NLM 0005^21 2 U.S. NATIONAL, LIBRARY OF MEDICINE NLM000599212 RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN medical department OF THE UNITED STATES ARMY IN THE WORLD WAR VOLUME XI SURGERY PART ONE GENERAL SURGERY ORTHOPEDIC SURGERY NEUROSURGERY PREPARED UNDER THE DIRECTION OF MAJ. GEN. M. W. IRELAND The Surgeon General WASHINGTON : : GOVERNMENT PRINTING OFFICE : : 1927 LIH, cT LETTER OF TRANSMISSION I have, the honor to submit herewith a portion of the history of THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR. The portion submitted is Part One of Volume XI, on the subject of SURGERY, and includes General Surgery, Orthopedic Surgery, and Neurosurgery. M. W. Ireland, Major General, the Surgeon General. The Secretary of War. hi \ Lieut. Col. Frank W. Weed, M. C, Editor in Chief Loy McAfee, A. M., M. D., Assistant Editor in Chief editorlvl board a Col. Bailey K. Ashford, M. C. Col. Frank Billings, M. C. Col. Thomas R. Boggs, M. C. Col. George E. Brewer, M. C. Col. W. P. Chamberlain, M. C. Col C. F. Craig, M. C. Col. Haven Emerson, M. C. Brig. Gen. John M. T. Finney, M. D. Col. Joseph H. Ford, M. C. Lieut. Col. Fielding H. Garrison, M. C. Col. H. L. Gilchrist, M. C. Brig. Gen. Jefferson R. Kean, M. D. Lieut. Col. A. G. Love, M. C. Col. Charles Lynch, M. C. Col. James F. McKernon, M. C. Col. R. T. Oliver, D. C. Col. Charles R. Reynolds, M. C. Col. Thomas W. Salmon, M. C. Lieut. Col. G. E. de Schweinitz, M. C. Col. J. F. Siler, M. C. Brig. Gen. W. S. Thayer, M. D. Col. A. D. Tuttle, M. C. Col. William H. Welch, M. C. Col. E. P. Wolfe, M. C. Lieut. Col. Casey A. Wood, M. C. Col. Hans Zinsser, M. C. o The highest rank held during the World War has been used in the case of each officer. IV PREFACEa I his part of Volume XI, Surgery, comprises three sections, devoted to general surgery, orthopedic surgery, and neurosurgery. This grouping of subjects is inevitable, since some changes in the original plan (which was to narrate in separate volumes general surgical activities and the surgical activities relating to injuries of the brain, spinal cord, and peripheral nerves) were necessitated by tiie tact that the anticipated quantity of manuscript on these subjects did not prove adequate for more than one book (part of a volume). Furthermore, though it was intended to have the subject of roentgenology in a separate volume, a chapter only has been given to it, and this appears in the section on general surgery herein. The statistical data in the section on general surgery, particularly those con- cerning the incidence of various kinds of battle injuries, are essentially general in character; that is to say, they are studies, made in the home territory and after the war, of records received from all sources. Though these data serve a very useful purpose, a far better purpose would have been served had studies been made along this line on special types of injuries in the theater of operations and by trained observers. Such a course of procedure was impracticable, however, in view of the fact that our available personnel was relatively very limited at the time when we were receiving in our hospitals in France the major portion of our wounded. Furthermore, it must be borne in mind that most of our battle casualties resulted from two military operations—the St. Mihiel operation and the Meuse-Argonne operation. The former began on September 12, 1918, and the latter ended on November 11, 1918. Thus it will be seen that relatively little time was available for other than the reception and care of the wounded. Much of the material of some of the chapters of the general surgery section was obtained from published sources and used as a basis for the chapters as they now stand. For the use of this material grateful acknowledgment is now made to Oxford University Press, American Branch, for permission to use such text and illustrations as were found to be desirable in the chapters on "Localization and extraction of foreign bodies under X-ray control';; "Wounds of the soft parts and wounds of the joints "; " Wounds of the chest';; " Wounds of the abdomen." Acknowledgment is also made to Paul B. Hoeber (Inc.), for permission to use certain parts of the United States Army X-ray Manual for the chapter on "Localization and extraction of foreign bodies under X-ray control." Grateful acknowledgment is made to the Bureau of Medicine and Sur- gery, Navy Department, for certain plates of the Report on the Medico-Military ° For the purpose of the History of the Medical Department of the United States Army in the World War, the period of war activities extends from April 6,1917, to December 31,1919. In the professional volumes, however, in which are recorded the medical and surgical aspects of the conflict as applied to the actual care of the sick and wounded, this period is extended, in some instances, to the time of the completion of the history of the given service. In this way only can the results be followed to their logical conclusion. VI PREFACE Aspects of the European War, by Surg. A. M. Fauntleroy, I'nited States Navy, 1915, which are used partly to illustrate Chapter II of the first section of this volume. The section on orthopedic surgery is so arranged as to show, first the char- acter of treatment it was possible to give to the injured assigned to the care of orthopedic surgeons in the American Expeditionary Forces, and, second, the after care of such cases in the home territory. The section was compiled from the contributions of various officers of the orthopedic division whose names are as follows: Col. Elliott G. Brackett, M. C; Col. Joel E. Goldthwait, M. C; Col. Nathaniel Allison, M. C; Lieut. Col. Clarence B. Francisco, M. C; Lieut. Col. George W. Hawley, M. C; Lieut. Col. Hiram W. Orr, M. C.; Lieut. Col. Robert B. Osgood, M. C; Lieut. Col. James T. Rugh, M. C; Lieut. Col. David Silver, M. C; Maj. Zabdiel B. Adams, M. C; Maj. Wallace Cole, M. C; Maj. Murray S. Danforth, M. C; Maj. Norman T. Kirk, M. C; Maj. John L. Porter, M. C; Maj. Edward A. Rich, M. C; Maj. Philip O. Wilson, M. C; Maj. Carl C. Yount, M. C; Capt. Horace Morison, San. C; Capt. John H. Morse, San. C. Col. Elliott G. Brackett, M. C, who edited the section on orthopedic surgery, was chief of the division of orthopedic surgery, Surgeon General's Office, during the war. The section on neurosurgery was edited by Lieut. Col. Charles H. Frazier, M. C. Shortly after the war began, Colonel Frazier was placed in charge of the Army neurosurgical school of instruction, which was established in Phila- delphia at that time. When General Hospital No. 11, Cape May, N. J., was instituted, Colonel Frazier became its chief of neurosurgical service. Here he remained for the greater part of the war period. General Hospital No. 11 was one of the special hospitals designated to receive from overseas, cases of periph- eral nerve injuries, and wounds or injuries of the skull or brain and spinal cord. Subsequent to his service at this general hospital, Colonel Frazier was on duty in the subdivision of surgery of the head, Surgeon General's Office, and became a member of the peripheral nerve commission, appointed by the Surgeon General on January 29, 1919. It was upon the advice of the peripheral nerve commission that the periph- eral nerve register was distributed with the view of recording thereon the results of the examination of every peripheral nerve case. Since duplicate peripheral nerve registers of the cases examined were furnished the Surgeon General's Office, the hope was entertained that uniform data of a large num- ber of cases of peripheral nerve injuries might lead to a determination of the end results of such cases. However, with the wide dispersion of these cases throughout the country, following their discharge from military hospitals it would have been necessary, in the subsequent reexamination of them to relv upon medical men inexpert in neurological examinations. In consequence efforts to determine the end results necessarily were abandoned. TABLE OF CONTEXTS Preface___________ __________________ Introduction___ ____________________ xxix Section- I.—General Strgery Chapter I. Helmets and body armor—The medical viewpoint. By Maj. Bashford Dean, O. D________________________ 1 II. Firearms and projectiles; their bearing on wound production. Bv Col. Louis B. Wilson, M. C__________________________________."____ 9 III. Statistics. By Lieut. Col. Albert G. Love, M. C______ 57 IV. Surgery at the front. By Col. George De Tarnowsky, M. (Z S(i V. Collective surgical experiences at the front and at the base___________ 130 VI. Anesthesia. By Col. George Crile, M. C_______ ________________.. Kit; VII. Wound shock. By Lieut. Col. \\ alter B. Cannon, M. C. ____________ IS.'i VIII. Localization and extraction of foreign bodies under X-ray control. By Lieut. Col. James T. Case, M. C_________ _______ _____________ 214 IX. Gas gangrene. By Maj. Ellsworth Eliot, jr., M. C_________________ 205 X. Tetanus. By Lieut. Col. Frank W. Weed, M. C______ 2S4 XL Trench foot. By Lieut. Col. Frank W. Weed, M. C. . 290 XII. Wounds of soft parts. By Lieut. Col. Eugene H. Pool, M. C____ 294 XIII. Wounds of joints. By Lieut. Col. Eugene H. Pool, M. C_______ _ . ._ 317 XIV. Wounds of the chest. By Lieut. Col. John L. Yates, M. C._ 342 XV. Wounds of the abdomen. By Lieut. Col. Burton J. Lee, M. CZ 443 XVI. Wounds of the genitourinary tract. By Col. Hugh H. Young, M. C 470 XVII. End results, fractures of long bones. By Col. John B. Walker, M. (Z 401 LIST OF TABLES Table 1. Some German guns and howitzers------------- --- .. 11 2. German trench mortars----------------------- ---- 12 3. Shrapnel shell used in light field guns---------------- 15 4. Characteristics of the principal rifles used in the World War. 29 5. Automatic pistols and their cartridges------------------ 39 6. Various dissected rifle cartridges and their ballistic data----- ----- _ _ 40 7. Various dissected pistol cartridges and their ballistic data----------- . _. 43 S. Battle injuries, admissions, officers and enlisted men, United States Army, 1917 IS___________________________________________ :--- 5s 9. Battle injuries, deaths from injuries, officers and enlisted men, United States Army, 1917-18_____________________________________________________ *>* 10. Battle injuries, discharge for disability, officers and enlisted men, United States Army, 1917-18___________________________________________ 59 11. Battle injuries, days lost in hospital, officers and enlisted men, United States Armv, 1917-18___________________________________________________ 60 12. Battle injuries, duration of treatment (fatal cases excepted), classification by cases under 29 and over 29 days, officers and enlisted men, 1917-18-------- 60 13. Battle injuries by diagnosis, deaths in hospital, showing the day of treat- ment on which death occurred, officers and enlisted men, United States Army, 1917-1S_____________________________ 61 VII VIII TABLE OF COX TEXTS Fage Table 14. Battle injuries by diagnosis, wounded returned to the United States for further treatment, officers and enlisted men, United States Army, 1917-18. 02 15. Battle injuries by military destructive agents, admissions, officers and enlisted men, United States Army, 1917-18--------------------------- <>2 16. Battle injuries by military destructive agents—deaths from injuries, officers and enlisted men, United States Army, 1917-18---------------------- 63 17. Battle injuries by military destructive agents, discharges for disability, officers and enlisted men, 1917-1S---------------------------------- IS. Battle injuries by military destructive agents, days lost in hospital, officers and enlisted men, United States Army, 1917-18---------------------- 64 19. Battle injuries by missiles, admissions, deaths, and case fatality, officers and enlisted men, United States Army, 1917-18---------------------- 64 20. Battle injuries by anatomical part and by military agent, admissions, deaths, and case fatalities, single and multiple wounds, officers and enlisted men, 1917-1S_________________________________________---- G5 21. Fractures (all), battle and nonbattle, of long bones, officers and enlisted men, 1917-1919. Case fatality and average days lost. Percentage rates___________________________________________________________ 70 22. Battle fractures of the long bones, admissions, deaths, recoveries, and case fatality, annual admissions, deaths and noneffective. Rates per 1,000. _ 71 23. Summary of definite physical disabilities which resulted from battle injuries, officers and enlisted men, 1917-18-------------------------- "2 24. Associated physical disabilities (fatal cases excepted), resulting from battle injuries, in 19,768 officers and enlisted men, 1917-18------------------ 73 25. Physical disabilities, resulting from wounds (excepting fatal cases), by military agents, officers, and enlisted men, 1917-18; absolute numbers and percentage of each disability to the total number of cases wounded by the military agents_____________________________________________ 80 26. Measurements for use in connection with Hirtz compass---------------- 250 27. Depth of anatomical landmarks--------------------------------------- 251 28. Battle fractures, including single and associated fractures--------------- 491 29. Battle fractures, long bones, showing both single fractures and those in association, and deaths--------------------------------------------- 492 30. Nonbattle fractures-------------------------------------------------- 492 31. Battle and nonbattle fractures of long bones, showing immediate result— 493 32. Fractures of long bones of United States veterans of the World War, by type of fracture, showing bone or bones involved, and deaths, as of January 1, 1926___________________________________________________ 498 33. Fractures of long bones of United States veterans of the World War, by age group and bone or bones involved, and deaths, as of January 1, 1926. 499 34. Fractures of long bones of United States veterans of the World War, by con- dition on first examination, by location of fractures, and deaths, as of January 1, 1926___________________________________________________ 500 35. Fractures of long bones of United States veterans of the World War, by character and degree of disability, bone or bones involved, and deaths, as of January 1, 1926---------------------------------------------- 501 36. Fractures of long bones of United States veterans of the World War, by bone and joints involved, showing condition on first examination, as of January 1, 1926___________________________________________________ 503 37. Fractures of long bones of United States veterans of the World War, show- ing bone involved, location and character of the fracture, and ampu- tation and deaths, January 1, 1926__________________________________ 504 38. Amputations as a result of fractures of long bones of United States vet- erans of the World War, by bone or bones involved, amputation levels and interval elapsing between injury and amputation, and deaths, January 1, 1926___________________________________________________ 505 TABLE OF CONTENTS IX Page Table 39. Amputations as a result of fractures of long bones of United States vet- erans of the World War, by character and degree of disability, bone or bones involved, amputation levels, and deaths, January 1, 1926_______ 506 40. Fractured femur, United States veterans of the World War, rated less than 10 per cent on first examination; showing interval elapsing between injury and last rating, and degree of disability on last rating, as of January 1, 1926___________________________________________________ 510 41. Fractured femur, United States veterans of the World War, rated 10-29 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926___________________________________________________ 511 42. Fractured femur, United States veterans of the World War, rated 30-49 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926________________________________________________ 512 43. Fractured femur, United States veterans of the World War, rated 50-79 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926___________________________________________________ 513 44. Fractured femur, United States veterans of the World War, rated 80-99 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926___________________________________________________ 514 45. Fractured femur, United States veterans of the World War, rated 100 per cent disabled on first examination; showing interval elasping between injury and last rating and degree of disability on last rating, as of Jan- uary 1, 1926______________________________________________________ 515 46. Fractured tibia, United States veterans of the World War, rated less than 10 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of Jan- uary 1, 1926______________________________________________________ 510 47. Fractured tibia, United States veterans of the World War, rated 10-29 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926___________________________________________________ 517 48. Fractured tibia, United States veterans of the World War, rated 30-49 per cent disabled on first rating examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926---------------------------------------------- 518 49. Fractured tibia, United States veterans of the World War, rated 100 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926__________________________________________________ 519 50. Fractured fibula, United States veterans of the World War, rated less than 10 per cent on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of Jan- uary 1, 1926___________________________________________________-- 520 51 Fractured fibula, United States veterans of the World U ar, rated 10-29 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of Jan- uarv 1, 1926----------------------------------------" ' ~~~'"""-_- 52 Fractured tibia and fibula among United States veterans of the V> orld V> ar rated less than 10 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last ^ rating, January 1, 1926------------------------- X. TABLE OF CONTEXTS Page Table 53. Fractured tibia and fibula, United States veterans of the World War, rated 10-29 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926______________________________________ 523 54. Fractured tibia and fibula, United States veterans of the World War, rated 30-49 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926________________________________________ 524 55. Fractured tibia and fibula, United States veterans of the World War, rated 50-79 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926________________________________________ 525 56. Fractured tibia and fibula, United States veterans of the World War, rated 100 per cent disabled on first examination; showing interval elaps- ing between injury and last rating and degree of disability on last rating, January 1, 1926___________________________________________________ 526 57. Fractured humerus, United States veterans of the World War, rated less than 10 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926______________________________________________ 527 58. Fractured humerus, United States veterans of the World War, rated 10-79 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of Jan- uary 1, 1926______________________________________________________ 59. Fractured humerus, United States veterans of the World War, rated 528 30-49 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926_________________________________________________ 529 60. Fractured humerus, United States veterans of the World War, rated 50-79 per cent disabled on first examination; showing interval elapsing be- tween injury and last rating and degree of disability on last rating, as of January 1, 1926___________________________________________________ 530 61. Fractured humerus, United States veterans of the World War, rated 80-99 per cent disabled on first examination, showing interval elapsing be- tween injury and last rating and degree of disability on last rating, as of January 1, 1926_________________________________________________ 531 62. Fractured humerus, United States veterans of the World War, rated 100 per cent disabled on first examination; showing interval elapsing be- tween injury and last rating and degree of disability on last rating, as of January 1, 1926_______________________________________ 532 63. Fractured ulna, United States veterans of the World War, rated 10-29 per cent disabled on first examination; showing interval elapsing be- tween injury and last rating and degree of disability on last rating, as of January 1, 1926_______________________________________ 533 64. Fractured ulna, United States veterans of the World War, rated 30-49 per cent disabled on first examination; showing interval elapsing be- tween injury and last rating and degree of disability on last rating, as of January 1, 1926_____________________________________ -34 65. Fractured radius, United States veterans of the World War, rated less than 10 per cent disabled on first examination; showing interval elapsing be- tween injury and last rating and degree of disability on last rating, as of January 1, 1926________________________________ -..- Fractured radius, United States veterans of the World War rated 10-29 per cent disabled on first examination; showing interval elapsing be- tween injury and last rating and degree of disability on last rating, as of January 1, 1926_______________________________ „fi 66. TABLE OF CONTENTS Pa- Fractured radius, United States veterans of the World War, rated 30-49 per cent disabled on first examination; showing interval elapsing be- tween injury and last rating and degree of disability on last rating, as of January 1, 1926________________________________________________ 53 ON. Fractured radius, United States veterans of the World War, rated 100 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of Jan- uary 1, 1926______________________________________________________ 53 69. Fractured radius and ulna, United States veterans of the World War, rated less than 10 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926_______________________________________ 70. Fractured radius and ulna, United States veterans of the World War, rated 10-29 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926---------------------------------------------- " 71. Fractured radius and ulna, United States veterans of the World War, rated 30-49 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating as of January 1, 1926--------------------------------------- ----- 54 72. Fractured radius and ulna, United States veterans of the World War, rated 50-79 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926________________________________________________ 54 7'A. Fractured radius and ulna, United States veterans of the World War, rated 100 per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926------------ -------------------------- 74. Fractures of the long bones, United States veterans of the World War, showing the number and percentage of cases which reached their sta- tionary level after periods of 2, 3, 4, 5, or more years, as of January 1, 1926_________________________________________________________ ;-- 5 75. Fractures of the long bones, United States veterans of the Wrorld War, showing the change in per cent of impairment on first examination by the United States Veterans' Bureau, and on the last examination prior to January 1, 1926--------------------------------------------------- 76. A study of 4,647 single femur fractures among the World War veterans, showing the change in ratings by 6-month intervals from the Veterans' Bureau's first examination after injury, as of January 1, 1926.. 5 LIST OF CHARTS v I The effect of intravenous ether on the pulse and blood pressure---- 1 IL Comparative effects of ether and nitrous oxide in thigh amputations, as indicated by the pulse and blood pressure-------- --- 1<_ III Effect of special anesthesia on pulse and blood pressure------------ - - 1 < IV. Comparative effects of ether and of nitrous oxide in operations for the repair of extensive abdominal wounds------------ ----- V. Comparative effects of ether and of nitrous oxide in thigh amputations as indicated by the pulse and blood pressure------ ------ ---- VI. Incidence of cases of tetanus. Ratio of cases per thousand wounded, by ^ months__________________ ------ XII TABLE OF CO NT?: NTS LIST OF PLATES • ,, . .:ic-ing page Plate I. Multiple high explosive wound. Marked comminution of cortical section of tibia, showing mixed and pure infection____________ ■-- "*)S II. High explosive shell wound; gas gangrene________________ "'"* III. Gunshot wound; gas gangrene------------------------ - --- 2?4 IV. Experimental splenization in a dog's lung______________ 3/4 V. Lacerated wound of lower lobe of lung___________________ ---- 390 LIST OF FIGURES Figure PaKe 1. Mushrooming of bullets upon impact with armor-------------------------- 1 2. Diagram showing larger degree of protection of American helmet, Model 2A, contrasted with standard British model________________________________ 3 3. Diagram showing areas of danger--------------------------------------- 6 4. Diagram showing anterior portion of chest-------------------------------- 7 5. Diagram indicating by small dots entry wounds in chest and abdomen as recorded in about 1,000 cases (163 thoracic, 834 abdominal)--------------- 8 6. United States 14-inch railway artillery___________________________________ 9 7. United States 12-inch rifle on sliding-type railway mount------------------- 10 8. British 9.2-inch howitzer, model 1917____________________________________ 10 9. United States 240-mm. howitzer, model 1918______________________________ 11 10. United States 155-mm. howitzer, model 1918 (Schneider)-------------------- 12 11. United States 7-inch Navy rifle mounted on a pedestal on a railway car------- 12 12. United States 4.7-inch gun and carriage, model 1906_______________________ 13 13. United States 75-mm. field gun, model 1917 (British)______________________ 13 14. French 75-mm. field gun______________________________________________ 14 15. Types of shrapnel in modern use_______________________________________ 15 16. A type of high-explosive shrapnel_______________________________________ 15 17. French 75-mm. high-explosive, nose-fuse shell----------------------------- 16 18. Fragmentation of 10-inch common steel shell weighing 221 pounds------------ 17 19. Smaller fragments of high-explosive shell_________________________________ 17 20. Fragment of high-explosive shell removed from lower jaw___________________ 18 21. Shrapnel and rifle bullets removed from wounds___________________________ 18 22. Shell fragments removed from wounds___________________________________ 19 23. Portion of casing of 210-mm. high-explosive shell, with pieces of olive-drab cloth still adherent, removed from wound___________________________________ 19 24. Piece of shell (above) and two pieces of cloth (below) removed from a shell wound of the back, having some fibers of cloth still clinging to piece of shell. _ 20 25. Trench mortar, 240-mm. (9.45-inch)_____________________________________ 21 26. Stokes 4-inch trench mortar, and ammunition_____________________________ 21 27. Trench mortar, shell, 240-mm__________________________________________ 22 28. Regulation French bracelet type of hand grenade and a number of extemporized types, such as the "racquet" and "jam-tin"____________________________ 29. German combination grenade for hand or rifle use_________________________ 30. English combination grenade used in the rifle_____________________________ 31. English combination grenade___________________________________________ 32. Longitudinal section of an English grenade_______________________________ 33. United States hand grenades___________________________________________ 34. Demolition bomb, 25-pound, carrying 125 pounds of explosive and having heavy cast-steel nose and pressed sheet-steel rear body, for airplane use___________ 35. Fragmentation bomb, 25-pound, carrying 3 pounds of explosive, designed for use by airplanes against troops__________________________________________ 36. Incendiary bomb, 40-pound, of the intensive type with steel nose and fusible zinc rear casing for airplane use____________________________________ 37. Italian Mannlicher rifle, model 1891________________________________ 38. Austrian straight-pull Mannlichei rifle, model 1895__________________ TABLE OF CONTENTS XIII Figure Page 39. German Mauser rifle, model 1898________________________________ 20 40. German short rifle, model 1898....________________________________________ 26 41. English short Lee-Enfield rifle, model 1907________________________._______ 20 42. Canadian Ross magazine rifle, Mark III, model 1916________________________ 27 43. French Lebel rifle, model 1886-93_________________________________________ 27 44. French Lebel rifle, model 1907-15________________________________________ 27 45. French automatic rifle, model 1917________________________________________ 27 46. American Springfield rifle, model 1903_____________________________________ 27 47. American Enfield, model 1917____________________________________________ 28 48. Japanese Arisaka rifle, model 1907, officially known as the "Thirty-eighth year model"_____________________________________________________________ 28 49. Russian Mouzin rifle, model 1901, officially known as the "3-line Nagant"_____ 2s 50. Belgian Mauser rifle, model 1889_________________________________________ 28 51. Browning automatic rifle, model 1918, caliber .30__________________________ 30 52. Chauchat machine rifle, model 1915, caliber 8 mm__________________________ 31 53. Maxim machine gun and tripod (American), model 1904, caliber .30___________ 31 54. German Maxim machine gun on mount________________________________.. _ 32 55. Fiat (Italian) machine gun and tripod_____________________________________ 33 56. Browning heavy machine gun, model 1917_________________________________ 33 57. Hotchkiss machine gun, model 1914, 8 mm________________________________ 34 58. Vickers' machine gun, model 1915, caliber .30______________________ 34 59. Vickers' aircraft machine gun, model 1918, caliber .30----------------------- 35 60. Lewis machine gun, model 1917, caliber .30, ground type____. .. ________ 35 61. Lewis aircraft machine gun, model 1917, caliber .30--------- --------- 35 62. Marlin tank machine gun_____________ -------------------- --------- 36 63. Marlin aircraft machine gun, type 8 M. (L_ --------------- -------- 36 64. German 08/15 (Spandau) machine gun—-------------------- ---- ... 36 65. Colt .45 automatic pistol___________________________________ 37 66. Colt double action revolver, model 1917, caliber .45------------ .. ... 37 67. Smith and Wesson double action revolver, model 1917, caliber .45. 38 68. German Luger automatic pistol, caliber 7.65 mm---------------- --------- 38 69. German Mauser automatic pistol, caliber 7.63 mm----------- ----------- 38 70. Photographs of various dissected rifle cartridges-------------- --------- 39 71. German antitank rifle cartridge, compared with the United States Springfield model 1906 cartridge. Full size------------------------------------- 42 72. Photographs of sundry dissected automatic pistol cartridges----- _..-------- 44 73. Various deformed rifle bullets removed from wounds----------- --- ------- 47 74. Sundry bayonets---------------------------------------------- 52 75. United States trench knives, models 1917 and 1918------------------------- 53 76. German coup stick or trench club---------------------------------------- 53 77. French steel darts which were dropped in showers from airplanes----------- 53 78. Front line packages Nos. 1, 2, and 3--------------------------------- s9 79. First-aid outfit, complete------------------------------------------------ 80. First-aid bandage, with hooks and tape----------------------------------- 90 81. Immobilization of upper extremity against patient's side--------------------- 82. Thomas leg splint applied over clothing; traction made on shoe--------------- 91 83. First aid in trench warfare----------------------------------------------- 92 84. Administering a hot drink to a shock case--------------------------------- 94 So. Regimental aid station, 321st Infantry, October 3, 1918--------------------- 97 86. Dressing station. Croix de Charemont, August 17, 1918-------------------- 97 87. Ambulance company dressing station, open warfare------------------------- 9s 88. Dressing station, Lahayville-----------V'TTTTVVr vr 89. Unloading severely wounded at Field Hospital No. 28, Varennes, Meuse, October 2, 1918--------------------------------------------- XIV TABLE OF CONTENTS Figure Page 90. Slightly wounded, awaiting readjustment of dressings, Field Hospital Xo. 28, October 2, 1918______________________________________ ... _ . . 100 91. Sorting wounded_________________________________________ _ . _ ._ 112 92. Wounded awaiting admission to hospital_______________________________ 113 93. Admission office of an evacuation hospital___________________ ______ 114 94. Recovery ward of an evacuation hospital_____________________ _ ________ 118 95. Heating chamber for shock cases__________________________________ . . _ _ 119 96. Fracture ward of an evacuation hospital_________________________________ 122 97. The splint room of an evacuation hospital___________________________ 122 98. Nitrous oxide manufacturing plant__________________________________ 107 99. Storage building, office and laboratory of nitrous oxide manufacturing plant__ 167 100. Motors of 25 horsepower, used to drive compressors______________________ 168 101. Detail of compressors___________________________________________ ___ 168 102. Partial view of retort room____________________________________________ 168 103. Drip bottles and wash bottles which were connected with the retorts shown in Figure 102_______________________________________________________ 169 104. Military balloon, used to store gas______________________________________ 169 105. Method of folding three blankets to provide four layers beneath and four above the patient_________________________________________________ 188 106. Transfusion apparatus_______________________________________________ 198 107. Transfusion apparatus_______________________________________________ 200 108. Graphic illustration of macroscopic agglutination test______________________ 202 109. Palpator made from a small wooden rod, with a screw and a screw-eye________ 217 110. Showing the positions of shadow of plumb bob on fluorescent screen when X-ray tube is properly centered, and when off center_________________________ 218 111. Screen appearance of a tumbler with the tube properly centered and not properly centered_________________________________________________ 219 112. Screen appearance of an intracranial foreign body_________________________ 222 113. Screen appearance which might lead to an erroneous diagnosis of intracranial foreign body_____________________________________________________ 223 114. Method of rotation of the part (Nogier)_________________________________ 224 115. Method of rotation of the part_________________________________________ 225 116. Diagrammatic representation of the parallax method______________________ 226 117. Screen appearance during different steps of the parallax method_________ 226 118. Schematic drawing of parallax localizer________________________________ 227 119. Apparatus shown in Figure 118________________________________________ 227 120. Orthodiagraphic method of localization_________________________________ 228 121. Measurement in two directions (right-angled planes)______________________ 228 122. Screen appearance of, and method of using, the ring localizer_______________ 229 123. Malleable band, and the six-point survey methods_________________ 229 124. Classical single-shift, triangulation method________________________ 231 125. Wall meter, or indicator, for tube-shift method, also showing method of using adjustable double-slider caliper_____________________________ 232 126. Apparatus shown in Figure 125______________________________ 233 127. Method of similar triangles (double-shift, fixed-angle method)___________ 234 128. Screen appearance at different steps in the double-shift, fixed-angle method___ 235 129. Screen appearance after notching the diaphragm leaves for the Roussel method 236 130. Hirtz compass guidance during a surgical operation______________ 238 131. Hirtz compass______________________________________ 2**s 132. Schematic drawing of Hirtz compass with legs adjusted at zero points and resting on a plane_______________________________________ 230 133. Arms and indicator of Hirtz compass_____________________ 939 134. Schematic drawing of Hirtz compass set up on skin of patient— . 240 135. Reason for shift of leg of compass from zero point by the amount stated 240 136. Accessory apparatus for flouroscopic work with Hirtz compass _ 241 TABLE OF CONTENTS Figure 137. Method of showing fluoroscopic adapter with Hirtz compass_________________ 138. Setting arms and legs of Hirtz compass directly from the auxiliary compass____ 139. Detail of holder for direct setting of Hirtz compass___________________________ 140. Direct setting of Hirtz compass_______________________ 141. Centering of tube above plate holder on cassette with small cross wires, photo- graphic method, Hirtz compass_________________________________________ 142. Skin markers, plate holder and tube holder in position for photographic method, Hirtz compass________________________________________________________ 143. Schematic representation of plate, cross wire marker and tube focus positions for radiographic use of Hirtz compass______________________________________ 144. Construction for finding one of the foot points from the shadows of a corresponding marker as shown at Mi and M2, and the shadow of the cross marker_________ 145. Complete chart for setting feet of Hirtz compass _ ________________________ 146. Equipment supplied for use with Hirtz compass________________________ 147. Head rest for use with the eye localizer_____________________ ___________ 148. Sweet eye localizer______________________________________________________ 149. Position for first exposure in localization of projectiles in the eye_____________ 150. Specimen plate of projectile in the eye illustrating the method of measurement. _ 151. Second exposure for localization of projectiles in the eye_____________________ 152. Schematic drawing of localizing chart illustrating the method of obtaining measurements________________________________________________________ 153. Chart used in eye localization____________________________________________ 154. Extraction of a foreign body under flouroscopic control. The open screen method in darkened room________________________________________Facing 155. This illustration represents the radiological step of the procedure of localizing foreign bodies under fluoroscopic control---------------------------Facing 156. Arrangement of the tube and table for the Bonnet method-------------- ... 157. Gas gangrene of arm before operation--------------------------------- _ 158. Gas gangrene of arm, colored man, after amputation--------- 159. Debridement. Excision of the external wound------ 160. Debridement. Excision of the aponeurotic layer---------- 161. Debridement. Excision of injured muscle---------------------- 162. Change of position of wound tract from changed position of limb------- 163. Wound by shell fragment two weeks after debridement and primary suture .. _ 164. Perforating shell wound, left thigh, the same missile penetrating right thigh and fracturing right femur---------------------------------------------- 165. Multiple, penetrating wounds of back, soft parts, closed by primary suture------ 166. Long perforating wound of thigh, with opening of knee joint, closed by primary suture---------------------------------------------- ------- 167.|This and Figure 168 show perforating wounds of forearm with fracture, two 168. j weeks after debridement and primary suture----------------- 169. Outline of X ray, Figure 167--------------------------------------------- 170. Large penetrating shell wound, internal aspect of leg, closed by retarded primary suture-------------------------------------------------- 171. Large perforating wound of thigh, closed by primary suture---- ------ 172. W'ound, posterior aspect, right thigh; compound comminuted fracture of femur. Two weeks after debridement------ --- ---------------- 173. Same wound as that shown in Figure 172, two weeks after secondary suture.. 174. Gunshot wound of knee _ ------ 175. Gunshot wound of knee------------------------------ 170. A convenient method of recording the range of motion .... ------ ... 177. The same method as that shown in Figure 176, of recording motion in the elbow___________------------------------ 178. Gunshot wound of the knee ... ---------------------- XVI TABLE OF CONTENTS Figure Page 179. Gunshot wound of the knee_________________________________________ ----- 329 180. Dunham's original model of the air cell capillary gear________________________ 352 181. Sheep's lung five weeks after ligation of the artery supplying the left upper lobe. 353 182. Sheep's lung five months after ligation of the artery supplying the left lower lobe, showing adhesions produced by simple thoracotomy_________________ 354 183. Patient in position for operation. Line of incision for a thoracotomy of election. 384 184. Method of exposing a rib for resection______________________________________ 385 185. Simple type of rib shears. Bone biting forceps for chest surgery_____________ 385 186. Tuffier's rib spreader. Thin bladed clamp used to secure hemostasis, and as a tractor________________________________________________________________ 385 187. Thoracotomy of election__________________________________________________ 386 188. Cow horn rib stripper. Tuffier's lung forceps. Periosteal elevatcr___________ 387 189. Incision for exposure of the phrenic nerve__________________________________ 388 190. Exposure of the phrenic nerve_____________________________________________ 388 191. Thoracotomy of election__________________________________________________ 391 192. Methods of reducing the number of stitches used in repair after a resection_____ 392 193. Closure of the visceral pleura with an exaggerated Cushing stitch_____________ 392 194. Inner aspect of the chest wall, obtained after death from purulent pleurisy with- out open pyothorax____________________________________________________ 394 195. Closure of the chest wall after thoracotomy_._______________________________ 395 196. Closure of the chest wall after thoracotomy_________________________________ 395 197. Closure of the chest wall after thoracotomy_________________________________ 397 198. Closure of the chest wall after thoracotomy_________________________________ 397 199. Closure of the chest wall after thoracotomy_________________________________ 397 200. Closure of the chest wall after thoracotomy_________________________________ 397 201. Trocar, cannula, and catheter for intercostal drainage. Flap valve used to secure automatic one-way drainage____________________________________________ 398 202. Form of trap to be attached to a catheter drain_____________________________ 399 Section II. Orthopedic Surgery Chapter I. Organization------------------------------------------------------ 549 J II. The foot and its relation to military service___________________________ 591 ( III. Fractures caused by projectiles______________________________________ 602 f IV. Orthopedic surgery in embarkation hospitals, American Expeditionary Forces__________________________________________________________ 643 I V. Autogenous bone grafts for nonunion in atrophic long bones and in chronic } suppurative osteitis (osteomyelitis) following war wounds____________ 652 VI. Amputation service, American Expeditionary Forces_______________ 687 ' VII. Care of the amputated in the United States____________________ 713 | list of figures Figure 1. The Poliquen hitch. This and Figures 2 and 3 illustrate three practical methods of I applying traction to a fractured lower extremity over the shoe___________ 557 ( 2. The Collins hitch_________________________________________________'__ "_'_ 557 | 3. Special adjustable traction strap for saddle-girth hitch________________ 557 4. Adhesive plaster traction________________________________________ ggg | 5. Stocking traction____________________________________________ ceo ( 6. Sinclair skate______________________________________________ r-50 I 7. Mechanical drawing of Thomas traction arm splint______________ ccg ( 8. Thomas traction arm splint applied for bed treatment__________ 559 I 9. Thomas traction arm splint applied with rods in vertical place and arm slung from ( upper rod-------------------------------------------------------------- 560 J ( | TABLE OF CONTENTS XVII Figure 10. Thomas traction arm splint applied to obtain traction on the lower fragment and at the same time to allow flexion of elbow____________ 561 11. Treatment without splints due to extensive wounds_____ 5g-> 12. Mechanical drawing of hinged traction arm splint______________ 563 13. Hinged traction arm splint_______________________ r-fi4 14. Mechanical drawing of Jones humerus traction splint________________ 564 15. Jones humerus traction splint in use for fracture of the humerus at or "below the middle of the shaft in which flexion of the elbow is desired______________ 565 16. Jones "cock-up" or "crab" wrist splint and application__________________ 565 17. Mechanical drawing of hinged half-ring thigh and leg splint___________________ 566 18. Method of applying traction to fractured lower extremity in the field___________ 566 19. Method of applying traction to fractured lower extremity in the field___________ 566 20. Mechanical drawing of long Liston splint with interrupting bridge of iron wire_____ 567 21. Long Liston splint with interrupting bridge, applied for stretcher transport only._ 567 22. Long Liston splint with interrupting bridge, applied for stretcher transport only. 568 23. Mechanical drawing of Thomas traction leg splint____________________________ 568 24. Thomas traction leg splint with traction attached to end of splint and splint slung from cradle___________________________________________________ 569 25. Thomas traction leg splint applied with suspension to the Balkan frame______ 569 26. Use of Ransohoff "ice tongs" in conjunction with the Thomas traction leg splint, to secure skeletal traction________________________________________________ 570 27. Position for fracture of neck of femur or fracture into the trochanter___________ 571 28. Mechanical drawing of anterior thigh and leg splint. Hodgen type____________ 572 29. Wooden bed frame, for traction by weight and pulley and overhead counterweight suspension______________________________________________________________ 572 30. Mechanical drawing of Cabot posterior wire leg splint, to be used with or without side splints______________________________________________________________ 573 31. Cabot posterior wire splint applied with supination of the foot________________ 573 32. Mechanical drawing of ladder splint material________________________________ 574 33. Mechanical drawing of snowshoe litter______________________________________ 574 34. Maddox unit clamps, iron pipe and bed frame clamp_________________________ 575 35. Special use of Thomas traction leg splint____________________________________ 575 36. Hand and wrist splint_____________________________________________________ 576 37. Mechanical drawing of abduction arm splint--------------------------------- 576 38. Tomahawk wedge, the standard shoe alteration for ankle valgus, to shift weight- bearing to the outer side of the foot--------------------------------------- 595 39. The tomahawk wedge in place---------------------------------------------- 595 40. Anterior heel in position---------------------------------------------------- 596 41. Position of rocker shank on the outer sole----------------------------------- 596 42. Destruction of the head of the humerus, outer portion of the clavicle, head of the scapula, and comminuted fracture of the upper portion of the shaft of the humerus, by rifle missile------------------------------------------------- 6°3 43. X-ray picture showing fractured clavicle and lodged missile in the outer end of the clavicle_______________________________________________________________ 604 44. Fissure fracture of the greater tuberosity of the humerus by shell fragment, which is shown lodged--------------------------------------------------------- 45. Comminuted fracture of the upper portion of the diaphysis of humerus, with moderate dispersion of bone fragment------------------------------------ 605 46. Fracture of upper end of diaphysis of humerus by rifle missile, with much loss - , ____________________ 605 of bone-------------------------------------------- 47 Wound of the upper portion of the shaft of the humerus---------------------- 60b 48. Fracture of middle of shaft of humerus by shell fragment; moderate separation of bone fragments---------------------------------------------- 40997—27----2 XVIII TABLE OF CONTENTS Figure PaK« 49. Wound of diaphysis of humerus by rifle missile, with wide separation of bone fragments_______________________________________________--------- 607 50. Compound comminuted fracture, lower end of humerus, result of deformed rifle missile_________________________________________________________ 607 51. Rifle missile injury of shafts of ulna and radius and indirect fracture of lower end of shaft of humerus__________________________________________ 608 52. Fracture of upper ends of ulna and radius by rifle missile___________________ 609 53. Fracture of shaft of femur, juncture of middle and lower thirds, by rifle missile.._ 610 54. Same as Figure 53, taken three months after receipt of injury, showing progress of repair__________________________________________________________ 611 55. Fracture of shaft of femur by shell fragment, shown lodged__________________ 612 56. Rifle bullet wound, lower extremity, femur________________________________ 613 57. Same as Figure 56, viewed from front____________________________________ 613 58. Compound comminuted fracture, lower extremity of femur, with marked dis- persion of fragments________________________________________________ 614 59. Pistol-ball wound, head of tibia_________________________________________ 615 60. Same as Figure 59, viewed from inner side________________________________ 615 61. Penetration of upper extremity of tibia by rifle missile, with slight detachment of fragment of shaft_________________________________________________ 615 62. Same as Figure 61, viewed from front____________________________________ 615 63. Perforating wounds of upper portion of shaft of tibia by rifle missle___________ 616 64. Same as Figure 63, viewed from the back_________________________________ 617 65. Compound, comminuted fracture of shaft of tibia, showing typical "butterfly" arrangement of fragments____________________________________________ 618 66. Fracture or middle of diaphysis of tibia, caused by shell fragment_____________ 618 67. Extensive destruction of shaft of tibia caused by shell fragment______________ 619 68. Perforating wound of lower end of diaphysis of tibia_______________________ 619 69. Cloth gaiter, applied over shoe for extension______________________ _ _____ 620 70. Fracture ward, Base Hospital No. 41, St. Denis, Paris_______________ _____ 624 71. Treatment of fractured humerus______________________________________ 626 72. Compound, comminuted fracture involving shoulder joint___________ ___ 627 73. Compound, comminuted fracture involving shoulder joint_______________ 628 74. Method of treatment of fracture of both bones of forearm______________ 630 75. Compound, comminuted fracture, carpal and metacarpal bones_______ 631 76. Application of finger splint, showing extension applied_____________ 632 77. Balkan frame, showing suspension apparatus. Thomas splint______ 633 78. Fracture of femur, showing double extension. Inverted Hodgen splint 635 79. Pelvic lifter__________________________________________ ^oc 80. Method of using pelvic lifter___________________________ no- 81. Bridge transportation splint for fracture of tibia______________ 639 640 640 641 660 660 661 662 662 663 663 664 82. Delbet plaster splint for fracture of tibia 83. Plaster splint for fracture of tibia, permitting mobilization of ankle. 84. Bridge plaster splint for fracture of tarsal bones____________ 85. Case 1. Loss of bone substance, and bone atrophy______ 86. Case 1. Roentgenogram three and one-half months after graft______ 87. Case 1. August 1, 1922. Roentgenogram showing excellent bony union. _ 88. Case 1. Roentgenogram, May, 1924, showing hypertrophy of graft in tibia 89. Case 2. Marked deformity and eburnation of bone ends where the pseudarthrosis had occurred__________________________________ 90. Case 2. After resection of bone ends and removal of plate. Deformity corrected 91. Case 2. March 23, 1921. Excellent bony union and hypertrophy of radius 92. Case 3. Roentgenogram, December 10, 1921, showing bone being thrown across between graft and old eburnated bone_____________ TABLE OF CONTENTS XIX Figure _, _, Page 93. Case 3/ Roentgenogram, July 28, 1922, 14 months after operation. There is excellent bony union_______________________ 664 94. Case 4. Condition before operation________________________ 665 95. Case 4. Solid bony union January 17, 1922, five months after graft . _ _ 666 96. Case 5. Anteriorposterior view of both tibia, before bone graft_________ . .. 667 97. Case 5. Right tibia four months after graft_________________ _________ 668 98. Case 5. Left tibia four months after graft____________________________ 668 99. Case 6. Roentgenogram showing loss of bone substance before operation___ 669 100. Case 6. Good bony union six months after arthrodesis________ ...____ ... 670 101. Case 6. Photograph showing function______________________________ _ 670 102. Case 7. Roentgenogram before operation showing loss of substance______ 671 103. Case 7. Union five months after operation_______________________ _____ 671 104. Case 7. Photograph showing function______________________ 672 105. Case 7. Another view showing function____________________________ 673 106. Case 8. Loss of substance and atrophy present in humerus before graft___.. _ 673 107. Case 8. Excellent bony union at end of six months______________________ 674 108. Case 8. Another view showing excellent bony union at end of six months______ 674 109. Case 9. Lateral view showing comminuted fracture of patella and separation of fragments___________________________________________ _______ 675 110. Case 9. Union present January, 1924________________________ _ ____ 675 111. Case 10. Roentgenogram showing loss of substance and deformity________ 676 112. Case 10. Two months after graft-deformity corrected, with bony union___ . 677 113. Case 10. Showing function on completion___________________________ 67s 114. Case 10. Another view showing function on completion__________________ 678 115. Case 11. Roentgenogram showing loss of substance______________________ 679 116. Case 11. Roentgenogram three months after graft, showing excellent condition of bone_________________________________________________________ 679 117. Case 12. Roentgenogram showing loss of substance ___------------- 680 118. Case 12. Roentgenogram three months after graft____ ------------ 680 119. Case 12. Linear fracture ninth month____________ --- ---------- 681 120. Case 12. Note absorption two months later_____________ ------------- 681 121. Case 12. Solid bony union, 19 months after fracture--------------------- 682 122. Case 13. Roentgenogram November 17, 1921, fracture of first graft during fourth month and loss of substance bridged by graft---------------------- 682 123. Case 13. Excellent union in old fracture in original graft and in new graft----- 683 124. Case 14. Roentgenogram of graft six weeks after operation----------------- 683 125. Case 14. One year after Figure 124, or 13^ months after operation, showing proliferation which had occurred in graft which bridged loss of substance _. 6S4 126. Case 15. No attempt at union in old fracture. Note proximity to ankle joint. _ 685 127. Case 15. Lateral roentgenogram three months after graft------------------ 685 128. Case 15. Roentgenogram 11 months after graft. Outline of graft can barely be distinguished. Note union in fibula------------------------------- 686 129. Use of Thomas splint in application of fixed extension to an amputation stump to overcome soft part retraction----------------------------------- - 692 130. Use of a spreader in sliding extension applied to an amputation stump to over- come soft part retraction------------------------------------------- 131. Amputation of the thigh by the flapless method in various stages of healing under the influence of continuous extension---------------------------- 694 132. Amputation of the thigh by the flapless method in various stages of healing under the influence of continuous extension--------------------------- 694 133. Amputation of the thigh by the flapless method in various stages of healing under the influence of continuous extension--------------------------- 695 134. Amputation of the thigh by the flapless method with oblique section in order to save the maximum amount of soft tissue---------------------- 693 XX TABLE OF CONTENTS Figure PaSe 135. Short amputation of the thigh__________________________________________ 696 136. Short amputation of the thigh with marked retraction of the soft parts and protrusion of the end of the bone covered by granulation tissue------------- 696 137. Plastic closure of an open amputation stump with marked retraction of the soft parts____________________________________________________________ 696 138. Plastic closure of an open amputation stump with marked retraction of the soft parts_____________________________.______________________________ 697 139. Double amputation of both legs________________________________________ 697 140. Short amputation of the lower leg with marked flexion contracture of the knee. 699 141. Provisional appliance used in the American Expeditionary Forces for above- the-knee amputation_______________________________________________ 701 142. Provisional appliance used in the American Expeditionary Forces for above- the-knee amputation_______________________________________________ 702 143. Type of temporary appliance used for hip joint amputations________________ 703 144. Patients with above-the-knee amputation fitted with the temporary peg leg with plaster socket_________________________________________________ 704 145. Mechanical drawing of the provisional appliance for below-the-knee amputation used in the American Expeditionary Forces____________________________ 705 146. Application of the provisional appliance for below-the-leg amputation__________ 706 147. Application of the provisional appliance for below-the-leg amputation__________ 707 148. Application of the provisional appliance for below-the-leg amputation__________ 708 149. Application of the provisional appliance for below-the-leg amputation__________ 709 150. Application of the provisional appliance for below-the-leg amputation__________ 710 151. The temporary leg completed, ready to apply_____________________________ 711 152. Group of soldiers fitted with temporary peg legs___________________________ 711 153. Average sagittal stumps from four to eight months after trauma_____________ 719 154. Average sagittal stumps from four to eight months after trauma_____________ 719 155. Average sagittal stumps from four to eight months after trauma_____________ 720 156. Average sagittal stumps from four to eight months after trauma_____________ 720 157. Average sagittal stumps from four to eight months after trauma_____________ 720 158. Same as in Figure 157, after reamputation and healing_____________________ 720 159. Stump showing terminal edema and other evidences of latent infection________ 721 160. Typical ring sequestrum________________________________________ 722 161. Complete ring sequestrum surrounded by new bone formation_______________ 723 162. Excessive terminal bone production, "mushrooming"_________________ 724 163. Bony spur in below-knee amputation________________________ 725 164. Interosseous bony union in below-knee stump_________________ 726 165. Long thigh stump requiring secondary plastic operation_______________ 729 166. A typical sagittal Chopart stump__________________________ 732 167. Transcondylar reamputation____________________________ 704 168. Temporary appliance—plaster socket; stock metal bars; wooden foot______ 740 169. Original models of stock provisional appliances_________________ 741 170. Original models of stock provisional appliances_________________ 742 171. Provisional appliance used at Letterman General Hospital_________ 743 172. Letterman General Hospital leg; assembled and unassembled_____ 744 173. The final model of provisional leg with a plaster-of-Paris inset______ 744 174. Type of provisional arm used, and various attachments for work and plav. _ 746 175. Type of provisional arm used, and various attachments for work and plav. 746 176. Type of provisional arm used, and various attachments for work and plav _ " 747 TABLE OF CONTENTS XXI Section III. Neurosurgery Chapter I. Organization and activities of the Neurological Service, A. E. F. By Col. Harvey Cushing, M. C_______________ 749 II. Activities of the American First Army Hospital at Deuxnouds. Bv Maj. Samuel C. Harvey, M. C__________________ 759 III. Management of gunshot wounds of the head and spine in forward hos- pitals, A. E. F. By First Lieut. Adolph M. Hanson, M. C_________ 776 IV. Neurological aspects of the effects of gunshot wounds of the head. By Lieut, Col. Charles H. Frazier, M. C, and Capt. Samuel D. Ingham, M.C------------------------------------------ 795 \ . Late treatment of gunshot wounds of the head. By Maj. Claude C. Cole- man, M. C------------------------------------------------ 804 VI. A statistical analysis of gunshot wounds of the head. By Lieut, Col. Harry H. Kerr, M. C____________________________~__________ 841 VII. Experimental study of problems of infection of the central nervous system and the treatment therefor. By Capt. Lewis H. Weed, M. C_______ 848 VIII. Motor disturbances in peripheral nerve lesions. By Maj. Lewis J. Pollock, M. C_______________________________1_____________ 866 IX. Sensory disturbances in peripheral nerve lesions. Bv Maj. Lewis J. Pollock, M. C________________________________1_____________ 918 X. Electrical examinations in the diagnosis of peripheral nerve injuries. By First Lieut. Samuel Silbert, M. C___________________________ 942 XL Technique of nerve surgery. By Maj. K. Winfield Ney, M. C________ 949 XII. Results of peripheral nerve surgerv. Bv Lieut. Col. Charles Frazier, M. C____________________-"._—"______________________ 1081 XIII. Experimental observations on peripheral nerve repair. By Contract Surgeon G. Carl Huber, United States Army____________________ 1091 list of tables Table 1. Classification of gunshot wounds of the head, according to depth of injury, or its severity________________________________________________ S42 2. Symptoms____________________________________________________ 843 3. Primary operations performed_________________________________ 844 4. Secondary operations performed__________________________________ 845 5. Complications of head injuries__________________________________ 845 6. Disposition of head injuries______________________________________ 846 7. Persisting symptoms_______________________________________---- 846 8. Causes of death________________________________________________ 847 9. Data concerning time of operation in a series of 400 cases of peripheral nerve injury_________________________________________________ 10X2 10. Certain operated cases, observed in the peripheral nerve centers-------- 1085 11. Proportion of neurorrhaphies to neurolyses------------------------- 1086 12. The percentage of good, mediocre, and negative results after neurolyses. Indirect observation__________________________________________ 1086 13. The percentage of good, mediocre, and negative results in motor function after neurorrhaphy. Indirect observation------------------------ 1087 14. The percentage of good, mediocre, and negative results in motor function in the total series of operated cases, including neurorrhaphy and neurolysis. Indirect observation------------------------------------------ 1087 15. Percentage of end results of 497 operations, including 132 neurolyses, 350 neurorrhaphies and 14 transplants------------------------------- 1088 16. Percentage representing Tables 14 and 15 combined------------------ 108s XXII TABLE OF CONTENTS LIST OF FIGURES Figure PaSe 1. This and Figures 2 to 4, inclusive, illustrate the technique of the osteoplastic method with the wound near the center of the flap------------------------- 777 5. Sketch illustrating the method of suction of the tract of a penetrating wound while searching for foreign bodies_________________________________________ 77S 6. Grade II. Wounds producing local fractures of variable types, with the dura intact. Type A, without depression of external table. Type B, with depres- sion of external table__________________________________________________ - 779 7. Grade III. Local depressed fractures of various types, with the dura punctured. 779 8. Grade IV. Wounds, usually of gutter type, with detached bone fragments driven into brain_______________________________________________________________ 779 9. Grade V. Wounds of penetrating type, with lodgement both of projectile and bone fragments__________________________________________________________ 780 10. Grade VI. Wounds with ventricles penetrated or traversed (A) by bone frag- ments (B) by projectile___________________________________________________ 780 11. Grade VII. Wounds of craniocerebral type involving (A) orbitonasal (B) auri- petrosal region_____________________________________ ___________________ 780 12. Grade VIII. Wounds with craniocerebral perforation_________________________ 780 13. Grade IX. Craniocerebral injuries with massive fracture of skull_____________ 780 14. The indriven fragments of inner table (natural size)___________________________ 782 15. From a sketch at autopsy after removing calvarium___________________________ 783 16. Section through the contused area, showing position of bone fragments_________ 783 17. Trepanation block showing behaviour of thick skull to tangential wound________ 784 18. Bone block specimen on left shows interparietal suture and fissures radiating from gutter; on the right, a few fragments of internal table attached______________ 784 19. Example of lodged shell fragment, lodged in an oblique gutter wound___________ 785 20. Small gutter fracture in thin skull; complete dislodgement of fragments________ 785 21. Tripod incision for small irregular wound of vault. Dotted lines indicate area of reflection of flaps. (Cushing)__________________________________________ 786 22. Three-legged (Isle of Man) incision for larger wound of cranial vault. (Cushing). 786 23. Quadrangular trepanation__________________________________________________ 787 24. Diagram to show the insertion of a soft rubber catheter in the tract of a pene- trating missile to locate foreign bodies_________________________________ 787 25. Split shell fragments with separate tracts and fragments at varying depths. (Cushing)------------------------------------------------------------- 788 26. Split shell fragments in temporal lobe (Cushing)_____________________ 788 27. Method of opening dura________________________________________ 792 28. Exposing cord for removal of embedded shell fragment__________________ 793 29. Exposing cord for removal of embedded shell fragment; using nerve root as tractor______________________________________________________ 793 30. Conspicuous craniofacial defect with dense scar___________________ 805 31. Large right parietal defect__________________________________ oqc 32. Characteristic defect in the parietal region___________________ oqc 33. Characteristic defect in the frontal region_______________________ 8qc 34. Skiagraph of an irregular defect in the parietal region_____________ oqq 35. Skiagraph of a characteristic oval defect in the frontal region_______ cq6 36. Skiagraph of a rectangular defect, in the parietooccipital region, resulting from removal en bloc of area of skull in debridement______________ S(>fi 37. Large parietal defect. Roentgenogram before cranioplasty________ oq7 38. Roentgenogram of head shown in Figure 37, after repairs___________ 807 39. Posterior parietal defect. Roentgenogram before cranioplasty____ cq8 40. Roentgenogram of head shown in Figure 39 after autogenous cranial transplant" 808 41. Consecutive stages of operation____________________________ 42. Bagley's hinged-flap method______________________________ ' " 43. Bagley's hinged-flap method_____________________________ TABLE OF CONTENTS XXIII Figure Page 44. Cranioplasty by transplant from tibia______________________________________ 812 45. Cranial defect in right parieto-occipital region following loss of osteoplastic flap. 813 46. Roentgenogram showing osteomyelitis of osteoplastic flap and outline of bony defect_________________________________________________________________*_ 813 47. Cranial abscess___________________________________________________________ 816 48. Section of wall from b in Figure 47_________________________________________ 816 49. Pedunculated dural abscess___________________________________ ___________ 817 50. Section at x of wall of abscess shown in Figure 49________________ _ _______ 817 51. Higher magnification of a section from c in Figure 50______________ 818 52. A higher magnification of d in Figure 50 showing neuroglia fibrils.- - 818 53. Section at y of wall of abscess shown in Figure 49_______________ ____ 819 54. Higher magnification of section at e in Figure 53_______________ _______ 819 55. Frontal section of a brain with left temporal lobe abscess_________ ______ 820 56. A section from c in wall of abscess shown in Figure 55____________ 821 57. A section from b in wall of abscess shown in Figure 55____________ 821 58. Section from an abscess wall similar in type to that shown in Figure 56 _ — 822 59. Frontal view of brain with large abscess in right frontal lobe______ 822 60. A section from the wall of the abscess shown in Figure 59_______ ----- 822 61. A higher magnification of wall of abscess seen in Figure 60-------- — 823 62. Section of the innermost portion of abscess wall in Figure 60---------- 824 63. Upper surface of cerebellum, with abscess in left hemisphere---- 824 64. Cross section of cerebellum seen in Figure 63------------------- 824 65. Section from c in Figure 64_____________________________ S25 66. Section from d in Figure 64_____________________________ 826 67. A transverse section through occipital pole of brain-------------------- 826 68. Transverse section through the occipital pole of the brain shown in Figure 55.. 827 69. Section of the abscess wall at d in Figure 68-------------------------- ---- 827 70. Patient with hernia at the site of the frontal defect---- 829 71. Brain shown (a) enlargement of left hemisphere and hernia cerebri at site of cerebral defect; (b) horn of dilated ventricle in relation with tubular abscess cavity filled with inspissated pus; (c) bullet just beneath the cortex----- 829 72. Abscess from penetrating gunshot wound of left parietal and occipital lobes.. 830 73. Fungus following exploration from multiple right frontal abscess--------------- 834 74. Fungus complicating the drainage of a large abscess of the right frontal lobe.. 834 75. Case 1. a, Point of entrance; b, machine-gun bullet in right cerebellar hemis- , ____________ 835 phere______________________________________________________ 76. A "shower" of metallic fragments partly intracerebral and partly extra- .i _________________ ooD cerebral------------------------------------------------- 77. Large single metallic fragment, intrahemisphenc. 7s' Three metallic fragments at a distance from the defect; two bone fragments within the margin of the defect---------------------------------------- - - 79. One minute bone fragment, and three silver clips applied at operation overseas for control of hemorrhage-------------------------------------- 80. Lead tape and tracings---------------------------------- 81. Spring scales dynamometer-------------------------------- 82. Measuring pronation by spring scales---------------------- 83. Ulnar nerve lesions-------------- ----------- 85.' CarwithTpout'for measuring volume of extremity~by water displacement.. 877 86. Imprint in a case of ulnar nerve lesion---------- ' 87. Imprint in a case of median nerve lesion--------------------- ^ 88 Imprint in a case of radial nerve lesion---- ------------------ 89. Imprint in combined lesions of ulnar and median nerves .. _ _ 883 90. Musculospiral palsy---------------- - - - - - - - - - R8C- 91. Attempted flexion of fingers in musculospiral palsy---------- 838 838 807 869 870 871 876 XXIV TABLE OF CONTENTS Figure Page 92. Extension of wrist by supplementary movement of flexion of fingers----------- SSt) 93. Extension of wrist by supplementary movement of contraction of pronator radii teres_________________________________________________________________ 887 94. Extension of the distal phalanx of the thumb in musculospiral palsy---------- 887 95. Partial lesion of musculospiral nerve________________________________________ _°° 96. Sign of complete recovery of musculospiral nerve---------------------------- ^89 97. Median nerve palsy________________________________________________________ °'™ 98. Inability to completely close the fist in median palsy------------------------- 890 99. Imperfect clasping of fingers in median nerve palsy-------------------------- 891 100. Imperfect opposition of thumb in median nerve palsy------------------------- 891 101. Opposition of the thumb by the adductor pollicis and flexor brevis pollicis in median nerve palsy______________________________________________________ 892 102. Closure of fist in recovered median palsy_____________________________________ 894 103. Recovery of median nerve__________________________________________________ 894 104. Causalgie in median nerve lesion combined with ulnar lesion------------------- 895 105. Ulnar nerve lesion__________________________________________________________ 896 106. Ulnar "paper sign "________________________________________________________ 897 107. Extension of the distal phalanges of the index and middle fingers in ulnar palsy_ 898 108. Adduction of the thumb by the extensor longus pollicis in ulnar palsy__________ 899 109. Adduction of fingers by forced extension_____________________________________ 900 110. Adduction of index finger by extensor indicis with hand in ulnar deviation_______ 900 111. Pitres test for recovery from ulnar palsy_____________________________________ 901 112. Ulnar and median nerve lesion______________________________________________ 902 113. Flexion of the wrist by the extensor ossei metacarpi pollicis____________________ 902 114. Musculocutaneous paralysis_________________________________________________ 903 115. Circumflex nerve palsy. Greatest adduction_________________________________ 904 116. Complete adduction of arm by supplementary movement in circumflex nerve palsy------------------------------------------------------------------- 905 117. Erb's form of brachial plexus plasy analgesia (black) of fifth and sixth cervical segments_______________________________________________________________ 906 118. Brachial plexus lesion affecting common trunk of ulnar and median nerves______ 906 119. Partial lesion of whole brachial plexus affecting chiefly posterior and outer cords. 907 120. Sciatic nerve palsy______________________________________________________ 908 121. External popliteal nerve palsy_______________________________________ 910 122. Anterior crural palsy_____________________________________________ gi2 123. Facial palsy______________________________________________________ 913 124. Paralysis of trapezius_________________________ ______________ 914 125. Hypoglossal nerve palsy_____________________________________ 915 126. Syndrome of the posterior retroparotid space__________________ 91g 127. Sensory changes in ulnar nerve lesions_______________________ 922 128. Smallest composite area of analgesia in ulnar nerve lesions__________ 923 129. Sensory changes in median nerve lesions______________________ 924 130. Smallest composite area of analgesia in median nerve lesion.s______ 924 131. Senson- changes in radial nerve lesions______________________ 905 132. Sensory changes in external popliteal lesions________________ 99A 133. Smallest composite area of analgesia in external popliteal lesions_______ 926 134. Sensory changes in sciatic nerve lesions_____________________ 007 135. Smallest composite area of analgesia in sciatic nerve lesions______ 92« 136. Sensory changes in combined lesions of the ulnar, median, and internal cutaneous nerves ________________________________________ 137. Sensory changes in combined lesions of the ulnar, radial, and median nerve a b c and of the median and radial d,e,f,g_________________ 13x. Sensory changes in combined lesions of internal and external popliteal portions of sciatic nerve___________________________ TABLE OF CONTENTS XXV Figure Page 139. Sensory changes before and after resection and suture of the ulnar, median and ulnar, and median nerves_______________________________________________ 932 140. Sensory changes before and after resection of external popliteal and sciatic nerves. 933 141. Sensory changes in lesions of median, internal cutaneous, combined median and radial nerve, b, g, m, from which the residual sensibility of the ulnar nerve was obtained; and of the ulnar and internal cutaneous, radial, combined radial and median nerves, h, j, m, from which the residual sensibility of the median nerve was obtained__________________________________________ 934 142. Residual sensibility to prick pain of the ulnar nerve_________________________ 935 143. Residual sensibility to prick pain of the median nerve_______________________ 936 144. Residual sensibility to prick pain of the musculospiral nerve----------------- 937 145. Residual sensibility to prick pain of the musculocutaneous nerve------------- 937 146. Sensory changes of combined lesions of internal saphenous and internal nerves, /; small sciatic, external popliteal, popliteal, and internal saphenous and sciatic nerve lesions from which the residual sensibility of the external and internal popliteal nerves was obtained------------------------------------------- 938 147. Residual sensibility to prick pain of external popliteal nerve, b; sensory changes in an uncertified case of complete interruption of the internal popliteal, a---- 938 148. Residual sensibility to prick pain of the internal popliteal nerve-------------- 939 149. Residual sensibility to prick pain of internal saphenous nerve---------------- 939 150. Bundle or "cable" graft, using an autosensory nerve for repair of the defect.-- 957 151. Diagram showing the necessity of determining the intraneural location of a given branch______________________________________________________________ 961 152. Electroanatomic method of topographical identification---------------------- 962 153. Application of forceps to an immobilized nerve during section---------------- 964 154. Sectioning of nerve ends for removal of neuroma and scar tissue. Method of preserving sections in order of removal---------------------------------- 964 155. A, Technique of end-to-end suture, showing the placing of identification sutures ' before a nerve is removed from scar tissue. B, Exposed nerve before resection of neuroma and scar from its ends. C, Nerve resected, identification forceps applied, and three quadrant sutures placed------------------------------ 965 156 \ Rotation of the nerve for the purpose of placing the posterior quadrant suture. ' B, Intermediate sutures placed and all sheath sutures held in position to prevent rotation in placing a tension suture------------------------------ 966 157 \ \pproximation by tension suture. B, Order in which sheath sutures are tied 'after nerve is approximated by the tension suture. C, End-to-end suture ^_ completed--------------------------------------, " , ne_ 158. The V section of a small distal segment used for the same purpose as the 967 diagonal section in Figure 159------------------------------ --- - 159. Diagonal section of distal segment where it is smaller than proximal segment, for the purpose of securing accurate sheath approximation-- - ------- UbS 160 V Partial lesion of a nerve trunk. B, Isolation of the interrupted portion from the physiological normal portion. Quadrant sutures placed for approximation. C Approximation in partial suture such as a partial division of the sciatic nerve showing relaxed undivided portion of the nerve. - - - - - - --- - - 161. A, Paltll lesion of a nerve trunk, where gross -atomic Ration o func- tionally intact portion of a nerve can no be made as in Figure WOB Opening of the nerve sheath, showing involvement of bundle C, V-shaped Son of sheath by which approximation of the bundle is made possible.... 970 incision ot snear, y accomplished by relieving tension in 102' 'thf™ m tion olhe reeled sheath. B, The thickened sheath is not entirely closTd for fear of strangulation; the defect is^coveredI by a; fat trans-^ ^ plant----------------------------- XXVI TABLE OF CONTENTS Page Figure 163. A, Physiologic interruption of a nerve; nerves with this appearance are occa- sionally considered as having an "internal neuroma." B, Showing the enlargement to be due to a greatly thickened nerve sheath, producing com- pression or strangulation. C, Perifunicular adhesions following the prolonged use of a tourniquet______________________________________________________ 164. Plastic procedures and alcoholic injection to prevent the formation of amputa- ,- 982 tion neuroma__________________________________________________________ 165. Infraclavicular exposure of brachial plexus----------------------------------- 166. Infraclavicular exposure of brachial plexus----------------------------------- 989 167. Infraclavicular exposure of brachial plexus-------------------------------- -- 99° 168. Exposure of medial portion of musculospiral nerve in the axilla and upper portion of the arm____________________________________________________________ 997 169. Exposure of medial portion and internal part of posterior portion of musculo- spiral trunk through medial incision--------------------------------------- 998 170. Showing course of musculospiral nerve and relation of branches to triceps, as it passes behind humerus in musculospiral groove---------------------------- 1000 171. Landmarks for exposure of musculospiral nerve in its latero-ventral aspect------ 1002 172. Musculospiral nerve, latero-ventral aspect----------------------------------- 1002 173. Musculospiral nerve, postero-ventral aspect---------------------------------- 1003 174. Musculospiral nerve at elbow_______________________________________________ 1003 175. A, Supinator brevis exposed by separating extensor carpi radialis brevior and extensor longus digitorum. B, Intrasupinator portion of posterior interosseous nerve exposed by dividing superficial fibers of supinator brevis-------------- 1005 176. Exposure of median nerve in lower arm and upper forearm-------------------- 1017 177. Exposure of median nerve in the antecubital fossa; bicipital fascia divided, pronator teres mobilized from its attachment to flexor carpi radialis. B, Hu- meral head of pronator teres divided and retracted, exposing branches of the median nerve in this region______________________________________________ 1018 178. Intraneural dissection of median branches in the forearm_____________________ 1019 179. Median nerve lesion in middle third of forearm______________________________ 1021 180. Transposition of median nerve to a plane superficial to superficial head of pronator radii teres______________________________________________________ 1022 181. Median nerve transposed to overcome median defect and sutured_____________ 1022 182. Branches of median nerve in hand__________________________________________ 1026 183. Ulnar nerve, showing scar tissue as found at operation________________________ 1033 184. Ulnar nerve exposed above medial humeral condyle preparatory for transposi- tion anterior to the condyle______________________________________________ 1033 185. Ulnar nerve transposed; defect overcome by transposition and flexion relaxation- of elbow; branches preserved through mobilization_________________________ 1034 186. Branches of ulnar nerve in hand____________________________________________ 1036 187. Tendon transplant for restoring opponens position and function to the thumb in intrinsic hand muscle paralysis; exposure of palmaris longus tendon_________ 1042 188. Tendon transplant for restoring opponens position and function to the thumb in intrinsic hand muscle paralysis_______________________________________ 1042 189. Tendon transplant for restoring opponens position and function to the thumb in intrinsic hand muscle paralysis______________________________________ 1043 190. Tendon transplant for restoring opponens position and function to the thumb in intrinsic hand muscle paralysis________________________________ IO43 191. Diagrammatic explanation of viable neuroplastic transplant for filling of median defect in irreparable lesion of both median and ulnar nerves____ 1045 192. Exposure of sciatic trunk and branches to the hamstrings in gluteal region 1053 193. Exposure of the sciatic in the middle and lower thirds of the thigh by lateral retraction of the short head of the biceps____________________ JQC4 194. Diagrammatic cross section of sciatic trunk, showing its tibial and peroneal components----------------------------------------------- jq r 5 TABLE OF CONTENTS XXVII Figure Page 195. Method of alignment in physiologic approximation of the sciatic trunk, the intraneural septum between the peroneal and tibial portions of the trunk serving as a guide to alignment______________________________________ 1055 196. Exposure of the external and internal popliteal nerves in the politeal space_____ 1056 197. Exposure of external popliteal and its terminal divisions, as it swings around the neck of the fibula, the insertion of the peroneus longus having been divided to expose the terminal branches_______________________________ 1059 198. Viable neuroplastic transplant for repair of tibial portion of sciatic trunk in irreparable lesions of both divisions__________________________________ 1064 199. Viable neuroplastic transplant for repair of tibial portion of sciatic trunk in irreparable lesions of both divisions__________________________________ 1065 200. Dissection of temporal bone, showing course of facial canal in its vertical and tympanic portion—wdre directed through canal_________________________ 1067 201. Primary incision and exposure of the mastoid tip, suprameatal ridge, superior, posterior, and inferior bony meatal walls_____________________________ 1070 202. Auditory portion of the tympanic bone partially removed__________________ 1071 203. Bridge formed by the posterior meatal wall broken down over antrum, exposing the eminence of the lateral semicircular canal; suprameatal ridge not suffici- ently broken down________________________________________________ 1072 204. Facial nerve uncovered through a portion of its vertical and tympanic course, showing method of breaking down the wall with a fine, sharp chisel______ 1073 205. The sheath of the facial nerve is firmly attached to the periosteum of its canal; its attachment is severed with a cataract knife while the nerve is gently lifted from its bed______________________________________________________ 1074 206. The nerve removed from the facial canal throughout its vertical and tympanic course__________________________________________________________ 1075 207. Decompression of the facial nerve by opening its sheath------------------- 1076 208. Plastic procedure to protect the nerve from subsequent compression by turning down a flap of temporal fascia which is passed under the nerve, separating it from immediate contact with the bone; method of anchoring the flap------ 1077 209. The portion of the temporal muscle denuded of its fascia, turned over the nerve. _ 1079 210. Incision closed; points of drainage indicated. External auditory meatus lightly packed with iodoform gauze---------------------------------------- 1080 211. Diagrammatic cross section of the spinal cord showing on the right side the nerve roots and type nerve fibers------------------------------------ 1092 212. Microphotograph of a pyridine-silver preparation from a longitudinal section of the distal end of the central stump of the sciatic of a dog--- ------- 1104 213. From longitudinal section of a regenerating distal segment of a severed nerve several weeks after operation--------------------------------------- *105 214. Taken from the distal half of a neuroma, 21 days after severance of the sciatic nerve of a dog; pyridine-silver preparation---------------------------- 11Q6 215. From a longitudinal section of the proximal zone of a neuroma on the sciatic of a dog, 31 days after section; pyridine-silver preparation---- ------------- 1108 216. From'a longitudinal section of a neuroma on the sciatic of a dog, 31 days after nerve section; pyridine-silver preparation----------------------------- 1109 217. From a longitudinal section of a neuroma, removed three weeks after section of the sciatic of a dog; pyridine-silver preparation------------:"."",-----' 218. A longitudinal section of a typical neuroma removed from the sciatic of a dog 31 davs after section; pyridine-silver preparation---------- -- ---------- 219. Longitudinal section of an atypical neuroma from the sciatic of a dog, 18 clays after section; pyridine-silver preparation-------- - ------ - - - 220. Spiral formations of neuraxes from neuroma shown in Figure 219— _—. 114J 221 Cross section through the middle of a cable-auto-nerve transplant, Experiment No. 74, 11 days after operation; pyridine-silver preparation-------------- 1 lo2 XXVIII TABLE OF CONTENTS Figure PaS« 222. Cross section through the middle of a cable-auto-nerve transplant, Experiment No. 75, 26 days after the operation; pyridine-silver preparation------------- 1153 223. Longitudinal section through the central wound region, cable-auto-nerve trans- plant, Experiment No. 75, 26 days after operation; pyridine-silver preparation. _ 1154 224. From a longitudinal section of the central wound region in cable-auto-nerve trans- plant, Experiment No. 75, 26 days after operation; pyridine-silver preparation.- 1155 225. From a cross section of a cable-auto-nerve transplant, Experiment No. 75, 26 days after operation; pyridine-silver preparation________________________________ 1156 226. From a longitudinal section of the central third of a cable-auto-nerve transplant, Experiment No. 75, 26 days after operation_______________________________ 1157 227. Cross section of cable-auto-nerve transplant, Experiment No. 77, 152 days after operation; pyridine-silver preparation_____________________________________ 1159 228. Cross section of homo-nerve transplant, stored in liquid petrolatum, at 3° C, 8 days before use as transplant, Experiment No. 171, 12 days after operation; pyridine-silver preparation_______________________________________________ 1204 229. Cross section of homo-nerve-transplant, stored in liquid petrolatum at 3° C. for 39 days before use, Experiment No. 174, removed 23 days after operation; pyri- dine-silver preparation___________________________________________________ 1206 230. Cross section of homo-nerve-transplant, stored in liquid petrolatum 39 days at 3° C. before use; Experiment No. 174. Experiment terminated at 23 days after operation. Higher magnification of portion of the larger funiculus shown in Figure 229______________________________________________________________ 1207 231. From a longitudinal section of homo-nerve transplant, stored in 50 per cent alcohol for 10 days before use as transplant; Experiment No. 206. Nerve removed 62 days after operation_____________________________________________________ 1219 232. From a cross section of homo-nerve transplant, stored in 50 per cent alcohol for 10 days before use as transplant; Experiment No. 206. Nerve removed 62 days after operation__________________________________________________________ 1220 233. Cross section of auto-nerve transplant, wrapped with two layers of alcoholized Cargile membrane; Experiment No. 234; 44 days after operation_____________ 1237 234. Cross section of auto-nerve transplant, wrapped in alcoholized Cargile membrane; Experiment No. 236; terminated 272 days after the operation; pyridine-silver preparation_____________________________________________________________ 1238 235. Cross section of an auto-nerve transplant, wrapped in an auto-fascial sheath; Experiment No. 240; terminated 14 days after operation___________________ 1244 236. Cross section of auto-nerve transplant wrapped in auto-fascial sheath; Experi- ment No. 241; terminated 15 days after operation_________________________ 1245 237. Cross section of auto-transplant wrapped in auto-fascial sheath; Experiment No. 250; terminated 268 days after the operation______________ 1250 INTRODUCTION Considering the volume of surgery done during the World War, and the mass of literature resulting from surgical experiences in that war the nat- ural inference is, the developments were many. Each war of magnitude in the recent past, certainly within the period of modern surgery, has advanced to a greater or less degree the boundaries of our knowledge of military surgery; this, in turn, obviously has reacted beneficially on the practice of surgery in general. To determine how extensively the experiences of the surgeons of the World War have influenced the development of surgery, one must first know what, with the knowledge at hand, it was hoped to accomplish with surgery during that war. The practice of military surgery is inevitably circumscribed. Dis- regarding its primary purpose—that is, the conservation of combat troops- its scientific purpose is to preserve life, to prevent deformity, and to reconstruct physically. Since in the preservation of the life of the wounded the surgeon has been most concerned with preventing or combating wound infection, it is of present interest to determine not only how successful he was in this direc- tion during the World War, but also to trace briefly the steps which permitted the establishment of the modern principles of surgery along this line. It must be borne in mind also that changes which have been effected in the general treatment of gunshot wounds necessarily have followed changes in armament. Modern surgery had its beginnings in the sixteenth century, when Pare, no longer in the possession of the hitherto used cauterizing oils, hesitatingly made use of innocuous wound drainings, discovering, thereupon, not only that gunshot wounds were not poisonous in the sense previously held, but also that their healing was dependent upon the body itself. The period from Pare's time to our Civil War witnessed great strides in the technique of operative sur- gery, thus enabling it to become firmly established as a science; however, little or no improvement was made in respect to the general treatment of wounds. Except in so far as the greater array of surgical instruments and the variety of operations performed are concerned, a perusal of experiences of methods of general wound treatment during Civil War days might just as well apply to the sixteenth century. The inevitable pus of a wound was just as "laudable;" exploring fingers just as dirty. Keen, in comparing old and new war surgery, has this to say concerning his Civil War experiences: Our dressings in the sixties consisted of simple ointments, often only cold unboiled water followed later by constant poulticing to initiate and promote the abundant flow of pus., Little did we dream that our patients recovered as a result of a kind vis medicatrix naturae, and, as we now know, in spite of our encouragement of infection. * * ***** We used only the ordinary marine or toilet sponges. After an operation they were washed in ordinary water to cleanse them of blood and pus, and were used in subsequent operations In our ignorance of bacteriology we did not know that they harbored multitudes of germs which infected every wound in which they were used. If one fell on the floor it was squeezed two or three times in ordinary water and used at once! XXX INTBODUCTION The amazing advances of modern surgery were made possible by the teachings of Lister, which first appeared in printed form only two years after the cessation of our Civil War. Hitherto, unless a wound healed by primary intention, it was considered natural for it to go through the stages of granulation and suppuration. Since the stage of suppuration followed that of inflammation, during which there were the usual signs, including the "surgical fever," and was remarked as representing a relief of the fever, it was looked for as a desirable effect: hence the poultices. The Franco-German war of 1870-71 was the first war to occur after the begin- ning of the period of Listerism. At this time, however, antiseptic methods of wound treatment were but little known to many surgeons; they were also quite complicated and especially difficult of application in war time. The French in this war made no use of the new methods; the Germans attempted it and had some satisfactory results. Between this time and the occurrence of the Russo- Turkish War of 1877, greater opportunity had been afforded surgeons in general to try out Listerism and to be convinced of its merits, and in the war of 1877 we find successful though very limited efforts being made to combat surgical infection based on an intelligent conception of its real cause. In the application of this knowledge in the general treatment of gunshot wounds in the Russo-Turkish War, the surgeons at the front were given thoroughly to understand that there was to be only one line of treatment—to occlude the wound, to lay the wounded part in a suitable position on the litter, and to render it immovable; in other words, to practice conservatism. Coincident with these strides in the science of surgery, tacticians also were improving armament. In 1866, our slow-firing muzzle-loading rifle became a breechloader. Subsequently, between this date and 1892, improvements were made in the rifle by increasing not only the rapidity of fire but also the effective range. Other advances of the period, seemingly entirely remote from arma- ment, had a great influence on the startling improvements in armament soon to be made. Means of locomotion made it possible more rapidly to concen- trate large numbers of troops at weak points. Thus if a greater rapidity of rifle fire were effected than was afforded by the single-firing breechloader of 1866, this with more rapid means of concentrating troops might afford a superiority of rifle fire even to inferior numbers. So, with this in mind the magazine breechloader was devised, and adopted by the great military nations. Our first magazine rifle of reduced caliber was adopted in 1892 under the name of the Krag-Jorgensen, after its two Norwegian inventors. This is the type of rifle with which the opposing forces were armed in the next two wars—Spanish- American (1898) and South African (1899-1901). We now possessed what was generally looked upon as a humane military weapon, whose conoidal, jacketed missile when fired into soft tissue caused considerably less contusion and laceration than was true of the older rifle balls; and since there was less devitalization of the tissue surrounding the wound tract, the wound had the appearance of being clean cut, and proved in most cases to be relatively sterile. A suitable first-aid dressing, applied to such an injury on the field and shortly after its inception, effectively occluded it. INTRODUCTION XXXI First-aid dressings for wounds were used bv the British as early as the Crimean War Since this war occurred prior to the period of Listerism, these dressings made no pretense of accomplishing anything but the prevention of a gross soiling of the wound; they consisted merely of a calico bandage and four pins carried m the soldier's knapsack. It was not until the Sudan campaign of 1884 that a dressing of surgical utility was used by the British. This dress- ing was made of two pads of carbolized tow, a gauze bandage, pins, and a triangular bandage, all sealed in tin foil covered by parchment, In 1889, cog- nizance by us was taken of the desirability of having first-aid packets available for front-line dressings, but it was not until 1892 that they were officially .adopted. It is interesting to note here the difference in the present meanings of the words aseptic and antiseptic as applied to the treatment of wounds and that which obtained in the latter eighties. The following extract is taken from Smart's Handbook for our Hospital Corps, published in 1889: The object of aseptic treatment is to destroy germs that are present in a wound, and thereafter to effect their exclusion from its tissues. The object of antiseptic treatment is neither to kill nor exclude, but to suspend their vitality, and prevent fermentative changes. In 1892, as mentioned above, our Army adopted a first-aid packet com- prising two compresses of antiseptic gauze, each wrapped in a piece of waxed paper; an antiseptic roller bandage; a triangular bandage; and two safety pins. In 1896 it was required that each officer and enlisted man of the Army have one of these first-aid packets as a part of his equipment, Thus when the Spanish-American War began our military surgeons were in the possession of adequate knowledge as to the reasons for the occurrence of infection in gunshot wounds, and means for its mitigation, if not prevention. Experiences in the Spanish-American and South African Wars with wounds that were produced by the small-caliber, steel-jacketed missile and that were treated by the sublimated first-aid packet, showed that the vast majority of them healed by primary intention, thus giving rise to a sense of security as to the treatment of such wounds that was to be thoroughly shaken in the World War. In both the Spanish-American and South African Wars, injuries caused by the rifle far predominated over those caused by artillery, as had been true of previous wars. This was so to such an extent that in treatises concern- ing gunshot wounds of these two wars, shell wounds received relatively scant notice since they possessed small surgical interest. It may be noted, however, that they invariably were infected. Between the two wars just referred to and the World War two things occurred which should have set military surgeons thinking. These were change in the character of the rifle missile and a progressively greater tendency to make use of artillery. Tacticians, ever seeking for a lengthening of the range and an increased accuracy of fire, had in the period in question decreased the weight of the missile and made it pointed instead of ogival, with the view of having it offer less resistance to the air. Its center of gravity being now well back toward its base did away with its former stability when striking structures of even slight resistance; that is to say, resistance offered by such parts of the body as the chest and abdominal walls causes the bullet to turn on its short axis, thus resulting in wounds comparable to those inflicted by an exploding XXXII INTRODUCTION bullet. With the attendant destruction of tissue, it is easy to see that in such wounds the aseptic and conservative surgery of the beginning of the twentieth century would be totally inadequate. As to the progressive increase in the use of artillery during the period of aseptic surgery: In the Spanish-American and South African Wars shell and shrapnel wounds were between 5 and 10 per cent of the total gunshot wounds. In the Russo-Japanese War (1904-5) Lynch reported that in the Japanese First Army, engaged in field operations alone, shell wounds were 14 per cent. In the Turko-Balkan War (1912-13) shell and shrapnel wounds averaged about one-third of the whole. It is not the present purpose to give detailed consideration to statistical matter concerning the World War, but the fact remains that, though one would necessarily expect an increase in the proportion of shell wounds in siege warfare—the greater part of the duration of the European war 1914-1918 may be likened to siege warfare- no one evidently was prepared for the preponderant use of heavy projectiles in that war. Thus the ratio of gunshot wounds formerly obtaining, in which the wounds caused by rifle missiles were typical, became reversed and so found surgeons in a state of unpreparedness. Considering military surgery as a special branch of the science of surgery necessitates a few interpolative words here as to the evolution of the military surgeon himself. To revert to the fifteenth century, it is an incontrovertible fact that the importance of the surgeon to armies then was recognized as being great. Reference already has been made to the work of Pare in this connection, making him an outstanding figure. The poetry of war surgery was again written by the French in the days of Napoleon I when Percy, and especially Larrey, were competent surgeons, as well as exceptionally competent adminis- trative medical officers. Straub mentions, however, that this combination worked badly in our Civil War, as our doctors, unacquainted with war as they were, were all too prone, when charged with important administrative duties such as those of a division surgeon, to devote their energies exclusively to amputations rather than to exercise the supervision essential to their positions. This was all before the dawn of modern sanitation, and for centuries it was the surgeon who held the proscenium in the medicomilitary theater. In our earliest history as a nation the claims of surgery were not overlooked, for we had in the Revolutionary War a surgeon general as well as a physician general. Why the title "surgeon general" persisted is unknown. Perhaps because at that time the importance of surgery was recognized as paramount. Custom and not practice seems later to have dictated the title "military surgeon." As late as our Civil War, however, the surgeon still remained the important medical officer, though now some very competent medicomilitary administra- tors came to the fore. A change seems to have taken place in the medico- military hierarchy at a later period. With our next war—the Spanish-American —and the subsequent long military occupation of the Tropics, surgery from the military standpoint sank into insignificance and the thoughts in sanitation overshadowed everything else with our Army Medical Department. Nor did our small Regular Army afford much opportunity for specialization in surgery. Some good surgeons have developed therein, but this was not by virtue of but despite the system in vogue. The situation was quite otherwise INTRODUCTION XXXIII in our civilian medical profession, in which knowledge of surgerv had advanced by leaps and bounds since the beginning of the antiseptic and finally the aseptic eras; operations which would have been truly marvelous to the Armv surgeons of preantiseptic days were a matter of everyday occurrence now. These wonderful strides had resulted in a high degree of specialization which had to be taken into consideration in the plans of the Army to use most effectively civilian surgeons. But in this no great difficulty was encountered, since it was the general policy of the Government to secure the best talent available in all lines of activity for the care and welfare of the Army to be used in the World War, and committees representative of the many specialities of surgery as well as medicine were appointed by the general medical board of the Council of National Defense. Such committees were composed of the leaders in their respective specialties as well as representatives of the Medical Department, and soon after their organization many were gradually absorbed by the Medical Department, thus permitting them to continue as working components of our military machine. A plan was therefore perfected which enabled American surgeons to work in the Army along the lines of their civil experience, and there came into being the general surgeon, the orthopedic surgeon, and the neuro- surgeon. It is needless to say that the majority of our civil surgeons, regardless of their qualifications, were needful of adaptation to the practice of military surgery, encompassed, as it inevitably is, by the stress of circumstances, the very masses of material with which it is necessary to deal, and, in the advanced hospitals of the theater of operations, the practical impossibility of securing surgical cleanliness. Fortunately, when we entered the World War, we could take advantage of the several years of experiences of our surgical confreres in the allied armies and thus eliminate some of the mistakes which had been made by them. As explained above, prior to the outbreak of the war of 1914-1918, military sur- geons still considered the relatively clean wound made by the rifle missile the typical gunshot wound, and that its treatment would consist largely in the early application of a first-aid dressing, plus some means of prophvlactically antisepticizing the wound. With this thought in mind the first-aid dressing itself had been for some years prepared in a subliminated form, but a further step had been taken following the discovery of the high antiseptic value of tincture of iodine when applied to the skin and to ordinary wounds. Unfor- tunately, as has been made clear above, the new. pointed missile of the rifle frequently caused a wound whose tract was surrounded with devitalized tissue; also, there was now a preponderance of wounds caused by artillery missiles. Consequently, surgeons in the early part of the war were confronted with an overwhelming amount of wound infection; and since in the years immediately preceding the war prophylactic antisepticizing as a method had become so strongly entrenched among them, it was but natural that their efforts to treat the infected wounds should be directed toward securing efficacious antiseptics. In so far as the prophylactic antisepticizing of wounds in front areas was con- cerned, all efforts in this direction proved futile, because of the presence of 4(5007—27------'■"> XXXIV INTRODUCTION the damaged tissue in which the infecting organisms could readily propagate and where they were inaccessible to antiseptics. Surgeons now resorted to debridement, a practice in vogue centuries ago, consisting of opening up the wound so as to rid it of the foreign contained matter and the products of inflammation, the destroyed tissues being left to a natural process of elimination. This practice, and in conjunction with it, was followed by the use of such substances as the hypochlorites to dissolve the destroyed tissues, and, later, the actual excision of all devitalized tissue. Thus leaving only well-nourished tissues, which of themselves could overcome infec- tion, made it possible now to close the wound either by primary or delayed primary suture. To this practice the name debridement clung, though, as pointed out, it was a radically different procedure. The excision of gunshot wounds was a firmly established practice by the time we had any great number of wounded in our hospitals in France, so that we now had available to us a means which not only materially reduced the mortality of gunshot wounds but also materially reduced the average length of stay of the injured in hospital because of their wounds. The applicability to civil surgery of this sound method of treating wounds is measurably slight, perforce, nevertheless it has its field, particularly in industrial surgery; therefore, it represents a distinct contribution on the part of military surgery. Other advances, such as the treatment of shock, the handling of fractures, and the control of tetanus, will not be touched upon here, since to do so would be but anticipating what is given fully in the following parts of this volume. It was the policy of our Government to furnish the Army with the very best in the way of surgical personnel and to afford this personnel the opportunity to function best, by making available working facilities. Furthermore, the treatment of the wounded was not to be considered complete, in so far as our Medical Department was concerned, until after the wounded had attained complete recovery, or as complete as it could be, considering the nature of their respective disabilities. SECTION I GENERAL SURGERY CHAPTER I HELMETS AND BODY ARMOR—THE MEDICAL VIEWPOINT0 The nature of a projectile determines in no little degree the character and treatment of a wound. Bullets or fragments of shell of high velocity are less serious sources of infection than those of low velocity. A ball which mushrooms is eminently destructive—to such a degree, indeed, that bullets designed to mushroom have been forbidden in warfare. It follows that a breastplate of metal which tends to mushroom any impinging ball (fig. 1) Fig. 1.—Mushrooming of bullets upon impact with armor. The missile on the left is a copper- jacketed bullet of 230 grains; the one in the middle is a similar missile deformed upon contact with armor at a velocity of 800 foot-seconds; the remaining missile is a similar one mushroomed upon impact with armor at about 1,500 foot-seconds would be justly regarded as a source of considerable bodily danger to its wearer. Hence, from the general viewpoint, the use of armor would be sanctioned only when, on broad averages, the soldiers who wear it would be able to take a more effective part in warfare. In a word, any army could afford to lose one soldier, if by means of armor two soldiers were able to remain in active service. To discuss the nature of wounds produced by projectiles which had pierced a helmet or body defense is not the purpose of the present chapter; their nature and fate is considered in Chapter II of this volume. It is rather to show the findings of departments of war of various countries as to the use of armor as a practical means of saving "effectives". It has been shown« that: (1) Helmets and body armor were found, on broad averages, of distinct advantage to the wearers (2) A steel helmet became part of the regular military equip- ment of many nations; at the front its use was obligatory. (3) Body armor • The statement* fact appearing herein ar. based on " Heh^nd Body Armor in Modem Warfare," by Bash- ford Dean, Ph. D., N>w Haven, Yale University Press, 1920. . 2 SURGERY was used onlv for special service, e. g., for bombing parties, or for machine gunners. (4)" Its employment was limited partly or largely by the incon- venience which its weight caused its wearers, who on the first opportunity, disregarding the protection it afforded, were apt to throw it aside. Experiments to determine the protective qualities of helmets were first carried out bv the Intendant General Adrian (1914-15) of the French Bureau of Inventions, whose faith in his work led to the arming of soldiers in great numbers with the newly devised defense, half a million helmets having been placed in the field in the initial experiments. Had these been carried out on small groups, as an economical measure, a true result might not have been forthcoming, for it will be seen (1) that an innovation of this kind would have been resisted firmly bv already overequipped soldiers, whose neighbors were not thus additionally burdened, and (2) that the results of a small experiment would have failed to impress experts, medical and technical—who regarded the use of armor as "dead as Queen Anne." In fact, shortly after the experiment of General Adrian, many critical reports were filed showing that hospitals were crowded with head-wound casualties in helmet-wearing soldiers. It was only the more careful analysis of the data which showed that these men, although wounded, were men who were saved, for without their helmets most of them would have succumbed to cranial injuries. Effort was made by the writer to tabulate the practical results in the use of the helmet on different fronts, but no detailed statistics were to be had. Hospitals were usually crowded with cases, and their personnel could give little time or effort to determining the cause and the condition of the wounding. Of the French, however, the hospital records show that in 1915 (before the introduction of helmets) about one head wound in four proved fatal. After the introduction of the helmet, however, statistics in the same hospitals show that in head wounds, at the worst, but one case in four and a half proved fatal, and at the best one case in seven—a perceptible betterment of conditions. Evidence is abundant which shows that the same shrapnel helmet saved its wearer many times. In any event, the results in this direction were con- vincing—the shrapnel helmet had come to stay. HELMETS OF VARIOUS NATIONS The merits, from the medical viewpoint, of three types of helmets may be considered: (1) The French, adopted also by Belgians, Italians, and Slavs. (2) The British, which was adopted also, but provisionally, by the American Army. (3) The helmet of the Central Allies. The French helmet was a response to the need of producing quickly a metal head defense which would be reasonably strong and not so heavy as to cause serious discomfort to its wearer. It weighed 27 ounces was manu- factured of a mild steel with medium resistance and was built up; the parts often were separated by the shock of the projectile. Impact tests a demon- strated that the French helmet was perforated at a point pressure of from 674 to 756 pounds, indenting to a depth of from one-fourth to one-fifth inch. Such metal was easily penetrated by the Browning revolver of .25 caliber at a » Conducted by Dr. E. Dupuy, of the Chemical Laboratory of the Sorbonne. GENERAL SURGERY 3 6-foot distance, the ball then penetrating "hardwood" behind it to a depth of from 3J/£ to 5^ inches. The French helmet is therefore weak; it has. in fact, but half the strength of the British helmet, The wonder is only that the French helmet proved so great a success; it demonstrated, at least, that the soldier of 1915 was subject to injury from splintered missiles of low velocity, spent shrapnel, and the like. The British helmet, weighing 35 ounces, made practically of a single piece of 12 per cent manganese alloy, ruptured only, according to Dupuy's results, after a blow equivalent to 1,580 pounds had been given, the rupture following a point indentation of 0.28 inch—an indentation not extreme when it is recalled that the French helmet indented to 0.25 inch at half the pressure. The Ameri- can helmet, of similar model, was slightly heavier than the British, averaging about 1 ounce. It was made of a somewhat different manganese alloy, and was on the average from 12 to 15 per cent stronger (Dean's experiments). An improved steel (manganese-nickel alloy of Baker) produced a helmet with the same resistance to rupture as the German one at a saving of from 4 to 9 ounces in weight. Improvement in steel alloy which could be pressed into helmets was here noteworthy. The German helmet, weighing from 40 to 48 ounces, was admirably pressed in a silicon nickel steel; it was about 30 per cent stronger than the English helmet, but its greater weight was a distinct disadvantage. From the medical viewpoint, the matter of the form of a helmet proved of considerable moment. Strong rec- ommendations were made that an American helmet should be introduced which would cover in greater degree the back of the cranium, its sides and base. was seated too high up on the head. Its brim, it is true, was a strong defense from missiles approaching from above, but it was of no value as a ,protection from splinters or shrapnel from lower levels. The form of the helmet finally recommended to the American Army is shown in Figure 2. This protectee in best degree the region of collected nerve fibers, the thinner part of the cranial wall, and proximal cranial nerves. THE FREQUENCY OF INJURY FROM MISSILES OF LOW YELOCITY, WITH RESPECT TO THE WEARING OF ARMOR The statistics of European hospitals compiled through the year 1916 (later figures not accessible) demonstrate that three-quarters of the casualties were due to m.ssdes of low velocity-roundly, those trace mg at a rate of less than a thousand feet per second to which the hghtest type of helmets .ml Fit;. 2.—Diagram showing larger degree of protection of American helmet, Model 2A, contrasted with standard British model (less heavy line), the thinner cranial wall indicated by shading. The new model protects the sides and base of the cranium For it was clear that the British helmet 4 SURGERV armor used in the World War would have been proof.- And from French statistics there are similar results, 60 to 80 per cent of the cases having been wounded bv missiles of low velocity. The American statistics obtained from the assistant director, surgical service, A. E. F., show that wounds caused by missiles of middle and low velocity constitute about 80 per cent of all. The results of a review of the French hospital records (summer, 1918) show the following percentages: Percent Shrapnel or shell fragments----- ---- ------- ------ ----- Grenades------------------- --------- ------ Rifle or machine gun bullets---- --------------- ------- Bombs from airplanes--- ------ ---- Mine explosions--------------------- --- Accidental missiles, undetermined--------------------------- ----- 14. 00 A more careful analysis of these cases would probably show that as many as three-quarters were due to missiles included under the limit of velocity noted above—that is, the equivalent physically of a 230-grain bullet traveling less than 1,000 feet a second. In this connection the American surgeon, Dr. Walter Martin, who traveled on a special mission for the American Army, found on the Western Front (1916-17) a " large proportion of the wounds examined were due to missiles of low and middle velocity." And surgeons agree that it is nearly always possible to determine from the nature of a fresh lesion whether it was caused by a missile of this character. Summarizing the situation, it may be stated that the proportion of wounds due to middle and low velocity projectiles is not less than 60 per cent of all cases. This, in fact, is the least estimate the writer has been able to gather from medical experts in various services, some of whom declared emphatically that this percentage is entirely too small; that as many as 95 per cent of the wounds would usually fall within the limits given above. It is pointed out, for example, by Col. Joseph A. Blake, director of one of the largest American military hospi- tals (April 30, 1918) that the statistics as given above deal only with one class of wounded, for "a large number whose injuries are not infected are returned at the front and are not entered in the statistics of the hospitals." It is clear, therefore, that had armor been worn generally in the war a large number of the wounded would have been saved by its use; consequently its importance as a practical means of life-saving deserves full recognition. Moreover in nu- merous cases armor might have saved its wearers from missiles of high velocity which impinged obliquely, and were capable, therefore, of being deflected—an important consideration, since only a smaller proportion of missiles would be apt to impinge upon an object in a direct axial line. FREQUENCY IN THE LOCATION OF WOUNDS AND ITS BEARING ON THE ARMOR PROBLEM If it could definitely be established that a certain region of the body is particularly susceptible to injury, it is that region obviously which should be protected by armor. A curve of frequency in wounds with respect to their ° Two hundred and thirty data from English hospitals, obtained through the courtesy of Capt. I. S. St. C. Rose and of Captain Leeming, of the Trench Warfare Division, Ministry of Munitions, London. GENERAL SURGERY 0 location is to be examined, therefore, in order to determine the probable use- fulness of body defenses. The study of hospital statistics in this connection mighta furnish practical hints, and from this viewpoint the hospital records have been studied, especially of the French front. From an examination of the records of the French Medical Department (report from Col. Walter D. McCaw, M. C, United States Army, June 30, 1918), wounds have been classi- fied according to their anatomical situation and percentage of their occurrence as follows: Per cent Per cent Head___________________________ 11.90 Thorax_________________________ 7. 25 Spine___________ _____________ _ 2.20 Abdomen_______ ______-------- 3.97 Arm____________ ____________.__ 1-1.07 Forearm________________________ 10. 75 Hand____________________ 8.95 Thigh__________________________ 15. 62 Leg____________________________ 17. S4 Foot___________________________ 7. 45 This indicates that 41 per cent of the casualties suffered from leg wounds, 34 per cent from arm wounds, and head and trunk each about 12 per cent. A comparison of data obtained from various specialists has led to the belief that the following percentage tabulation of wounds with respect to their anatomical situation (hospital cases only) is not far wrong (up to 191S): Percent ; Percent Lower extremities__________________ 35 Head and neck--------- ---------- 20 Upper extremities__________________ 25 Trunk-------------------- ----- 20 In a worth over 50 per cent of the hospital cases suffered from wounded extremities, and rarely more than a fifth of the patients were wounded in the head. The number of patients wounded in the abdomen is usually small, at first sight unexpectedly so. Abadie (d'Oran) in his studies of wounds of the abdomen, offers the following table: Abdominal wounds----------- cases.,____ Due to low-velocity projectiles.. - 332 Due to high-velocity projectiles---- --- - cl<> ' rp, . _______________lung cases.. 15 Thorax____________________________________ ____ Due to low-velocity projectiles--------- ; Due to high-velocity projectiles-------- T_=,~ Extracted---------------------------- ---- ________ 33 Bullets--------------------------------- vjt) Shrapnel fragments------------------------- To describe the various forms of body defenses classified as to their pro- tective merits seems hardlv the function of the present discussion .heir use 4 special. Not more'than 2 per cent of the Bnt.sh soldier, at the front "ere provided with body armor. The French wore armor hardly in greater e^ree the Germans on a scale of two suits of armor per company. At danger poin s this armor was used in considerably greater numbers. In this con- nection reference is made, however, to the work carried on by the Bnfs , pTtal service as suggested in the '^^''^^ gathered toward the close ofjhe war." _ lheym<_c«_te_a.ea. of dange. ". '.. controversial- our figures are based upon hospital cases only, the location of wouM*^ Mini-try o .Munitions, London (Captain Rose). o These were furnished the writer uy iu_ 6 SURGERY which would, of course, govern in a degree the wearing of armor, from the frequency of entry wounds. The first diagram (fig. 3) gives the topographical areas. The second (fig. 4), showing the anterior portion of the chest, indi- cates by dots actual entry wounds in 163 cases. In the last figure (fig. .">) there are shown by small dots entry wounds in chest and abdomen as recorded 4.N.CK STRUCTURES LARGE BLOOD VESSEL TRACHEA , ETC. rtt»«T & ROOTS OF GREAT Bl.ob Vessel LYl*. JUST BENEATH CHEST ..all WHICH AT TMIS PART PRESENTS VERY LITTLE RESISTANCE TO SPLINTERS. TnE l»CST DANGEROUS AREA .UmjCaY----LINE . 2 LARGE BLOODVESSEL MARKED" -•- LYING IN AN UNPROTECTED POSITION. 8 MAIN VESSELS Or -IMS WHOSE ..JURY l/OU'LO ENTAIL SE'/Eft 4 C-CIC.R^u; HAlrtnMRMW BUT NOT NECESSARILY IMrlECHATE HEATH. HCRE T(lt L/Wrf VESSELS LIE AT TnE BACK Of THE ASPOMCN AND ARE THEREFORE BETTER PROTECTED. 5 IMPORTANT STRUCTURES (v'SCLS'-l) INJURY SY A SMALL SPLINTER HERE CAUSES A hish Remote but not necessarily a high Immediate mortality. Fig. 3.-Diagram showing areas of danger. This and Figures 4 and 5 were made available through the courtesy of Capt. I. S. St. C. Rose, Trench Warfare Division, Ministry of Munitions, London in about a thousand cases (163 thoracic, 834 abdominal), the deeper shading indicating the points of greatest danger. A final word should be said about the degree of protection furnished bv defenses a) of metal and (b) of textile. It has long been known that various fibers, notably silk, show high ballistic resistance. In fact, much " soft armor" made its appearance during the war. To this end the munitions bureaus of various countries made exhaustive experiments with silk, hemp, sisal cotton GENERAL SURGERY 7 hair, flax, kopak, balata, etc., with the rpsnlt tv.<.. .v. -n cv i ■t.-.,.»! .„ iT.v. . _r • result that the silk fiber was demon- b ard T T 'tlVe- AcCOrdlng t(> ^Ptain Lev of the munitions board in London, the experiments conducted at Wemblev in "fragmentation huts showed that sample pads of silks gave even better results than plates of helmet steel of even twice their weight, keeping out 74 degrees of '•medium shrapnel bullets at 600 foot-seconds." A British expert in this field (Mr. William A. laylor) declares that pure woven silk gives "materially better Cart showing entry wound or 165 p_.n_tfv.ing ^^T°_TTr_L_ ANTERIOR- riALf or THE CML5T. Fig. 4.—Diagram showing anterior portion of chest. Heart and roots of large vessels are indicated results than manganese steel against shrapnel bullets up to a velocity of 900- 1,000 foot-seconds, weight for weight.'' Also, "that silk weighing 10.8 ounces per square foot is proof against shrapnel at 800 foot-seconds, whereas steel to give the same resistance would weigh about 20 ounces. The relative ad- vantages and disadvantages of silk as compared with steel for body armor may be summarized as follows: Silk does not give nearly the same resistance as steel against high velocity pointed projectiles (e. g., rifle bullets) or bayonet thrusts, but, on the other hand, it does not deform the bullet which perforates it. The bullet which passes through steel is always deformed and causes the SURGERY Fig. 5.—Diagram indicating by small dots entry wounds in chest and abdomen as recorded in about 1,000 cases (163 thoracic, 834 abdominal). The deeper the .shad- ing as here indicated, the greater the danger the exploding bomb of shrapnel dictates. American tests, on the other hand, were made with ball of uniform weight which was shot directly at the object to be tested, with an explosive so graduated as to insure a definite impact. Hence we are firmer in our faith that the textiles are by no means better body defenses than plates of metal, weight for weight. We admit, however, that textiles have a definite value in preventing injuries from splash of lead or from smaller fragments produced by a crumbling projectile. CHAPTER II FIREARMS AND PROJECTILES; THEIR BEARING ON WOUND PRODUCTION The military surgeon, during the World War, had brought to his attention, in his treatment of wounds, many factors of which the experience of previous wars had furnished few or no data, and to which the experience of civil surgical practice had contributed almost nothing. The effects of direct shock and of secondary missiles from high-explosive shells, of multiple wounds from machine- gun fire, and the exaggerated effects of pointed rifle bullets of very high velocity were the chief factors of which previous military and civil experience had given little or no suggestion. It is true that considerable experimental data, par- ticularly concerning the effects of small-arm missiles, had been accumulated Fig 6 -United States 14-inch railway artillery. This type was evolved entirely by the United States Ordnance ' Department. It is an excellent weapon for coast defense and hurls a 1,200-pound projectile more than 18 miles which were corroborated bv battle-field experience during the war, but unfor- tunately the experimental data, prior to the war, had been regarded as largely theoretical or at least lacking confirmation either in military experience or m bi^-crame hunting. As a result, the surgeons of all armies, not only those drawn from civifmedical practice but also those with previous experience in military surgery found many conditions in the type and extent of the wounds encountered vvhich they were unprepared to meet and unable to explain. And thus early in the experience of ouch nation involved, the lives of many wounded men'undoubtedly were sacrificed which might have been saved had the men come under sun-ical treatment at a period after the attending surgeons had become more familiar with actual wound conditions. 10 SURGERY Fig. 7.—United States 12-inch rifle on sliding type railway mount. It is capable of hurling a 700-pound shell 25 miles. This is a modified Schneider type of carriage Fig. 8.-British 9.2-inch howitzer, model 1917. This gun shoots a shell weighing 290 pounds 8,690 meters GENERAL SURGERY 11 It is the purpose of this chapter to summarize the more salient facts, from the standpoints of weapons and missiles used by the several nations in their relation to wound production, and of pathology and physics which were learned trom a study of war wounds. ARTILLERY The artillery used by the belligerents in the World War underwent various changes subsequent to the beginning of the war in 1914, and in consequence of the varying conditions along the front.' In the earlier months of the war when the character of warfare was open, light mobile field guns were used almost exclusively on both sides, with the exception of the large siege guns and mortars used by the Germans to reduce Belgian fortifications.1 The subsequent use of intrenched positions necessitated resorting to additional heavier guns. The calibers commonly used by the Germans are given in Table 1. Fig. 9.—I'nited States 240-mm. howitzer, model 1918 Table 1.—Some German guns and howitzers" Caliber, centi- meters 9.0 10.0 10.5 12.0 13.0 15.0 21.0 Type Field gun.__ ....do..........____ Gun______________ Light field howitzer. Gun______________ Light howitzer....... Heavy field howitzer. Mortar____.......... Weight of high explosive shell (pounds) 13-17 16.5 39.5 34.5 36 89 92 1S4-262 Maximum percussion range (yards) 11.700 7,109 12, 085 11,210 7,984 15, 748 10,936 11,155 » Sources of information: (1) Data taken from S. S. 356, Handbook of the German Army in War, April, 1918. Issued bv the General Stall (British—Ed.), 6/18. (2) Notes on German Artillery Materiel, I, Divisional Artillery, second edi- tion, issued bv second section, General Staff, American Expeditionary Forces, Nov. 1, 1918. (3) Ordnance Data, VI, European Artilkrv, German, memorandum supplied to Gen. J. H. Rice, chief ordnance officer. A. E. F., by Colonel roles, and forwarded to Chief of Ordnance, Washington, D. C. Received Oct. 30, 1918. On file, Office of Chief of Ordnance, Ordnance Library, U F 520, XOO, Vol. VI. 12 SURGERY Fig. lO.-United States 155-mm. howitzer, model 1918 (Schneider). This weapon throws shell or shrapnel weighing 95 pounds. Muzzle velocity for shell is 1,420 feet per second Besides the guns listed in Table 1, various trench mortars were in use by the Germans, the principal ones being given in Table 2. Table 2.—German trench mortars " Caliber, centimeters Weight of high explosive Maximum favorable range, projectile, pounds yards Granatwerfer (stick bomb thrower) 3.9 7.6 17 24 ; I 25 4 1.7 9.9 92.6, 109.1, 123 220.5 207.2 208 700 1,422 1,750 1,312 1,094 « Source of information: S.S. 356, Handbook of the German Army in War, April, 1918. Issued by the General Staff (British—Ed ), B 18/145 4,000 6/18 H & S 5,586 wo, 103-105. rrrmtyMiR«M Fig. 11.—United States 7-inch Navy rifle mounted on a pedestal on a railway car. This rifle has a range of about 1' miles and throws a projectile weighing 165 pounds GENERAL SURGERY 13 Fig. 12.—United States 4.7-inch gun and carriage, model 1906. This gun throws a projectile weighing 45 pounds a distance of about 6 miles F,G. 13.-United States 75-mm. field gun, model 1917 (British). This gun throws a shell weighing 12^3 pounds a distance of 8,300 meters, with a muzzle velocity of 1,750 foot-seconds, and shrapnel weighing 16 pounds a distance of 8,900 meters, with a muzzle velocity of 1,680 foot-seconds 14 SURGERY The German 7.7-cnu, the French 75-mm., and the British 3.3-inch (1S- pounder), all of which wore relatively light field guns, were the most used by these three armies;2 the American forces used almost entirely the French 75-mm.3 field gun. In the later stages of the war, heavy artillery came more and more into use. Of the heavier types the French 90-mm., 105-mm., 120-mm., 155-mm., and the 220-mm.,1 and the British 5-inch gun and 6-inch, 8-inch, and 9.2-inch howitzers,4 together with a considerable number of large caliber naval guns usually mounted for land operations on railway carriages, came into general use.1 Fig. 14.—French 75-mm. field gun. This type of gun has been used by the French Army since 1897 and was the gun most used by the Allies in the Great War. This gun throws a shell weighing 12.3 pounds a distance of 8,400 meters, with a muzzle velocity of 1,805 foot-seconds, or shrapnel weighing 16 pounds a distance of 9,000 meters, with a muzzle velocity of 1,755 foot-seconds ARTILLERY PROJECTILES The shape and weight of artillery projectiles are determined largely by bal- listic factors which only remotely affect the wounding capacity. The thickness and tensile strength of the wall must be sufficient to prevent destruction or fracture by the firing and rotational stresses. Once this condition is attained the thickness and fracture-index of the walls and the amount and character of the shell contents are designed to produce the greatest destroying effect for which the shell is to be used. As used during the World War, artillery ammunition consisted of shrapnel, high-explosive shell, armor-piercing shell, or special shell such as gas shell, incendiary shell, smoke shell, and star shell. SHRAPNEL Shrapnel shell is usually made as thin-walled as possible and still withstand firing and rotational stresses.5 The largest number of bullets possible, of suf- ficient weight to maintain wounding energy, are packed within the shell cavitv.' GENERAL SURGERY 15 During the war the artillery ammunition of each of the armies showed a con- siderable variation in the size and weight of the shrapnel bullets used in shells of different calibers. Table 3 will give some idea of the number in the shrapnel shells in the three most used light field guns. Fig. 16.—A type of the high-explosive shrapnel Fig. 15.—Types of shrapnel in modern use Table 3.—Shrapnel shell used in light field guns ■• Caliber of gun Approxi mate A •my Milli-meters Inches weight of shell, pounds 75 82. 5 /7 2.95 3.30 3.03 15 IS. 5 15 Muzzle velocity, loot-sec- onds Approxi- mate weight of Vumber of bullets in shell 1. 755 150 285 1,635 170 340 1,555 150 300 France______ Great Britain Germany___ " Sources of infoimation: (1) The Story of the 75 (75 millimeter field gun), by W. N. Dickinson, Washington, Govern- ment Printing Office, 1920, 5, 116, U7. (2) Schneider & Cie.: Services de L'Artillerie, Ateliers du Crensot, Du Havre et D'Harfleur, Materiel de Campagne, a Tir Rapide de 75-mm., type L. D. P., 1908, 7. (3) Handbook for the Q. F. 1K- pounderGun, MK IV. on Carriages, Field, MKS. Ill and III*, Land Service, 1919, printed by His Majesty's Stationery Office (London—Kd.), 10, 64, 65. (4) Ordnance Data, VI, European Artillery, German. Report on the comparative characteristics of German ammunition for 77-mm. Gun, models 1896 and 1916, dated Oct. 31, 1918, source unknown, and French translation of a German document, Headquarters, A. E. F., January. 1918. On file, Office of Chief of Ordnance, Ordnance Library, UF 520, XOO, Vol. VI. (5) Notes on German Artillery Materiel, I. Divisional Artillery, second edi- tion, issued by second section, General Staff, American Expeditionary Forces, Nov. 1, 1918. Shrapnel shell is designed primarily for man-killing, although frequently it is employed for destroying obstacles such as wire, billets, and so forth.7 40111)7—27----4 79 16 SURGERY HIGH EXPLOSIVE NOSE FUSE SHELL FRENCH TYPE Defonafoi (explosive) Bourre/et- Explosive charge- Smoke/ess powder Primer (brass) Adapter (steel) Percussion fuse. Booster case, or Jacket, or Gaine. (cold drawn or pressed steel-machined) ■ Copper bond or rotating hand Cartridge case (drawn brass) Fig. 17.—French 75-mm. high-explosive, nose-fuse shell GENERAL SURGERY 17 In shrapnel fire against men the shell is made to explode in the air so as to discharge in a compact mass.8 The opening charge somewhat accelerates the velocity of the bullets (about 200 foot-seconds) at the moment of their release « 1 — _•- : _•'■_• :■_ _ ._•.-.'-: Fig. IS.—Fragmentation of 10-inch common steel shell weighing 221 pounds. Total number of fragments recovered, 4,078 The height and angle of descent of the shell at the moment it is opened deter- mines in large measure the angle at which men are struck and also accounts to some extent for the large proportion of wounds in the upper exposed parts of the body. The chief function of the steel helmet is protection from this overhead shrapnel fire. Shrapnel shells are generally made of forged steel with high tensile strength, and when used with bursting charges of low energy are not fragmented.5 HIGH-EXPLOSIVE SHELL The high-explosive shell, as its name implies, contains a large destructive charge of some high explosive.9 It is made in two general types. 10 either with m? Fig. 19.—Smaller fragments of high-explosive shell (actual size) thick stroncr walls and relatively reduced amount of explosive for the produc- tion of man-killing splinters, or with relatively thin walls and a very large ittino- wire entanglements, destroying dugouts, buildings. explosive content for cut IS SURGERY and so forth. The German 77-mm. high-explosive shell had a thick casing and contained a relatively small charge (about 1T> gm. of picric acid).11 On detonation about oOO fragments were produced, varying in weight from 10 to 200 gm., with an initial velocity of from 300 to 400 meters a second.11 The Fig. 20—Actual size of fragment of high-explosive shell removed from lower jaw French 7o-mm. shell had a thinner casing and carried a heavy charge, about S25 gm. of melinite.11 On detonation this shell burst into about 2,000 small splinters with a very high initial velocity of approximately 1,000 to 1,200 meters a second.11 * ■* «p • ~ • -«$ % * • • -_« s> Fig. 22.—Shell fragments removed from wounds Fig 23-Portion of casing of 210-mm. high-explosive shell, with piece of olive-drab cloth still adherent, removed from wound 21 SUKGERY high-explosive shell is about 25 gm.. although splinters lighter than 10 gm. mav be verv effective near the point of explosion.12 The German 7.7-cm. high explosive shell weighing about 15 pounds was designed to give 135 splinters of an average weight of 50 gm.1-' The French 75-mm. high-explosive shell, weighing "about 12 pounds, was designed to give only 50 splinters averaging 100 gm. in weight.12 The effectiveness of this shell depended on the high velocity near the point of explosion of the very large number of small splinters into which it was fragmented. This shell was highly effective over an area of about 25 square meters.12 The German 7.7-cm. shell was less thoroughly effective over a considerably larger area.12 Fig. 24.—Piece of shell (above) and two pieces of cloth (below) removed from a shell wound of the back, having some fibers of cloth still clinging to piece • of shell. Actual size Besides the steel splinters from high-explosive shells, the surgeon some- times encountered other metallic missiles from the same source which he was at a loss to explain. The shell fuses for igniting the bursting charge contained a number of cast or machined metal parts; on the bursting of the shell these frequently caused wounds of unusual type. In addition, when the annealed copper driving rings which surrounded shells were blown apart, they were likely to remain as long strands of metal with terrific wounding power. The Germans employed on their shells, behind the driving rings, various types of decoppering rings.13 These were of aluminum or tough alloys, such as zinc- aluminum or tin-lead, and they acted very much like the copper driving rings as wounding agents, although they were smaller and usually of lower specific gravity. GENERAL SURGKKY 21 Fig. 25.—Trench mortar, 240-mm. (9.45-inch) Fig. 26. Stokes 4-inch trench mortar and ammunition 22 SURGERY The common belief that poisonous gases were generated by the detonation of high-explosive shells was erroneous. Small quantities of carbon dioxide and carbonic oxide were generated. These were quickly dissipated by the terrific air currents following: detonation. Fig. 27.—Trench mortar shell, 240-mm. Though shrapnel and high-explosive shells were issued in equal propor- tions to the French artillery early in the war, as the war progressed high- Fig. 28.—Regulation French bracelet type of hand grenade and a num- ber of extemporized types, such as the "racquet" and "jam-tin" Fig. 29.—German combination grenade for hand or rifle use explosive shell was predominant.14 Efforts were made by all of the warrino- nations to develop a "universal" shell which would effectively deliver shrapnel ball and also produce wounding fragments by rupture of the casino-.« One such type of universal shell was so arranged that when the shrapnel balls were GENERAL SURGKRY 23 ! , Fig 30—English combination grenade used Fig. 31.—English com- Fig. 32.—Longitudinal section of an in the rifle bination grenade English grenade Fig. 33.—Inited States hand grenades. From left to right, defensive, offensive, gas, phosphorus 24 SURGKRY released in the air the head of the shell, which itself contained a high-explosive charge, was blown off and fragmented by explosion on striking any object.15 The consideration of armor-piercing, gas, incendiary, smoke, star, and other special shells is outside the scope of this chapter, since they were not primarily designed as wounding missiles. Shells fired from heavy trench mortars—for example, the 240-mm.—were thin-walled, of low velocity and short range. They had large charges of high explosive. Though the detonation of these shells produced serious concussion in their immediate vicinity, and their moral effect was very considerable, the penetration power of secondary missiles from them was small. HAND GRENADES Two kinds of hand grenades were used during the war: A defensive grenade, made of stout metal which would fly into fragments when the interior charge exploded; an offensive grenade made of paper, the purpose being to produce a deadly effect by the flame and concussion of the explosion itself." The defensive, or fragmentation, type of grenade was the most commonly used of the grenades, and ordinarily was thrown by men in the trenches, the walls of which protected the throwers from the flying fragments. On the other hand, though the offensive grenade was quite sure to kill any man within three yards of it when it exploded, it was safe to use in the open, there bein£ no pieces of metal to fly back and strike the thrower.16 The wounding effect of grenade fragments, especially at short ranges in trenches, was very considerable;17 however, the fragments rapidly lost their velocity and consequently their wounding energy. Grenade wounds were almost always infected.1* RIFLE GRENADES The rifle grenade, used both as a defensive and offensive weapon, fits in a holder at the muzzle of an ordinary service rifle.19 When the rifle is fired, the bullet passes through a hole in the middle of the grenade, and the gases of the discharge following the bullet throw the grenade approximately 200 yards.19 The effective area of an exploding rifle grenade is 75 yards.19 AIRPLANE BOMBS All of the bombs used by our aviators and by the aviators of other nations were of three distinct types: Demolition, fragmentation, and incendiarv bombs.20 The demolition bombs were for use in destroying materiel, and ail sorts of heavy structures where a high-explosive charge was desired- conse- quently they were of light steel, which was filled with some explosive of high destructive power.20 The fragmentation bombs differed from the demolition bombs in having a thick wall and a smaller charge of explosive.21 The shell walls were likely to separate into thin slivers, with very sharp edges, which produced lacerated wounds. GENERAL SURGERY 20 Fig. 34. -Demolition bomb, 25-pound, carrying 125 pounds of explosive, and having heavy cast-steel nose and pres.sed sheet-steel rear body, for airplane use Fig. 35.—Fragmentation bomb, 25-pound, carrying 3 pounds of explosive, designed for use by airplanes against troops Fig. 36. -Incendiary bomb. 40-pound, of the intensive type, with steel nose and fusible zinc rear casing, for airplane use 20 SURGERY Fig. 37—Italian Mannlicher rifle, model 1891. This rifle with 30.75-in. barrel weighed 8.41 pounds. The carbine shown here, with 18-inch barrel with which Cavalry and Alpine troops were armed weighed barely 6 pounds Fig. 38—Austrian straight-pull Mannlicher rifle, model 181).".. The bayonet for this rifle had a blade 10 inches in length Fig. 39.—German Mauser rifle, model 1898. The muzzle of this rifle was fitted with a cover which is not shown in the cut. The bayonet is " D" in Figure 74 Fig. 40.—German short rifle, model 1898. This rifle had the bolt turned down. The muzzle cover is shown in place. The sling passed through a loop on the left of the lower band and was fastened on the right side of the buttstock after passing through a recess just back of the grip Fig. 41.-English short Lee-Enfield rifle, model 1907. The hump over the receiver is a clip guide The heavv ears at the sides of the front sight were cumbersome but very useful as sight protectors GENERAL SURGERY 27 Fig. 42.—Canadian Ross magazine rifle, Mark III, model 1916. This was a straight-pull clip loader. was very fast, but had a tendency to stick under adverse conditions The action Fig. 43—French Lebel rifle, model 1886-93. This rifle, the standard arm of the French Army at the beginning of the war, had a tubular magazine under the barrel Fig 44-French Lebel rifle, model UW7-15. In this model a clip-loading magazine under the receiver was substituted for the cylinder magazine of the 1886-93 model; otherwise the gun was practically the same as the latter. The magazine holds three cartridges loaded in a clip F,g 45-French automatic rifle, model ,9.7. This weapon closely resembles to its barrel and fore end the model 1KK6-93. It is gas operated and self-loading in action Fig. 4f..-American Springfield rifle, model 1903 2S SUKGKRY Ki<;. 47.—American Enfield, model 1917. This gun was an adaptation of the British Enfield model 1911 design. It was substituted for the Springfield in equipping American troops because there was abundant machinery or its manufacture already in existence in the Inited States in the spring of 1917, while there was not sufficient ma- chinery in existence for the manufacture of a proper supply of the Springfield, model 1903 Japanese Arisaka rifle, model 1907, officially known as the "Thirty-eighth year model." Many of these rifles were sold by Japan to both Russia and England during the war and hence were in use in Europe Fig. 49.—Russian Mouzin rifle, model 1901, officially known as the "3-line Nagant." This was a heavy, clumsy weapon of doubtful accuracy and reliability. It was made in large numbers for Russia by manufacturers in this country. Many of them still remain in the United States ? aPf *:<^ -"* Z .' $*:~; Fig. 50—Belgian Mauser rifle, model 18X9. This model had a metal tube protector covering the barrel GKNERAL SURGERY SMALL-ARMS WEAPONS AND MISSILES RIFLES 21) The chief infantry arm of each of the warring nations in the World War was a rifle of a comparatively old model.22 The French Armv of 191S carried the Lebel model LSS(i-1893 rifle.22 The Italian Army carried the Mannlicher- Carcano rifle of the 1S91 model.22 The Austrian Army was armed with the 1X9.-) Mannhcher.22 The German Army carried the 1S9S model Mauser.22 The Russian 3-line rifle, model 1900, was only a slight modification of their old Xagant model.22 The American Springfield was of the 1903 model23; the American 1917 model, modified British Enfield, was the most modern weapon.22 The British Enfield model 1907 was slightly more recent than the American Springfield, but in 1914 the British Government considered it so obsolete that it had been planned to supersede it with a new model.24 However, though all of these guns, except perhaps the two American models, were regarded as obsolete before the war began, they all stood the severe test of war service in a most satisfactory manner.22 The chief characteristics of the principal rifles in use are shown in Table 4. Table 4.— Characteristics of the principal ritles used in the World War " Country Model Designation Magazine system Austria__________ 1895 Belgium_________ 1889 Canada <•____ .. _ 1907 France «... .. {*£»3 Oermany________ 1898 Great Britain_____{ Jyjjl Italy___ _______ isoi apan___ . ... 1907 l.ussia_______ ... 1894 r -, , _, , / 1903 ( mted states____< ,,,.- Mannlieher ________i Fixed vertical box_____ Mauser ___________ Detachable vertical box Ross__________ Lebel_________ Lebel (carbine) Mauser____. .. Lee-Enfield Mark 1. Lee-Enfield Mark 111. Mannliclier-Oarcann Year '38 pattern "3-line" Nagant- Springfield_____ Enfield ____ Fixed vertical box_____ Cylindrical in fore end.. Fixed vertical box___ ...do___________ Detachable vertical lio\ Fixed vertical box___ ._do_. ____ do. .do. with bay- onet, inches with out bay- onet, inches Length! Diam- of I eter of barrel, J bore, inches inch Num- ber of grooves in i rifling Depth of grooves. inch X um- ber of cart- ridges in mag- azine Charger ■ 1 Weight with-out Weight with bay-onet, or clip bay- pounds Clip.. 8. 34 8.98 Charger 8.03 9.59 Neither 8. 0G 9.08 ....do. 9.24 10.12 Clip____ Charger.. 9. 00 9.88 ..do____ 9.25 10.22 ..do____ 8.66 9.66 Clip.. S. 41 9. 19 Charger.. 8.63 9. 56 ..do____ s. 95 9.70 ..do..... \09 9.69 .do_____ s.87 9. 87 Twist of 1 groove rifling, inches Austria______________ 50.00 Belgium_____________ 50.25 Canada »____________ 52.00 France______________{ 5K12 Oermany__________ 49.40 ,,.„... / 49.50 Oreat Britain______< 44 50 Italy .. ________ Japan . ______ Russia__________ United States. 50. 75 50. 75 51.88 43.21 46.5(1 59. 50 ! 30. 12 59. 75 30. 67 58. 80 28. 00 71.81 31.50 69. 75 61. 50 61.70 62.38 65. 75 69. 00 59. 21 62. 50 29. 05 30.19 25.19 30. 75 31.30 31.50 24.01 26. 00 0. 315 .301 .300 .315 .315 .311 .303 . 303 .256 .256 . 300 . 300 .300 4 .0.0080 Concentric, beveled edge. 4 .0065 | Concentric______________ 4 .0055 _____do__________________ 4 .0059 ____do_________________ Concentric. _do. .do. .do. . 0065 .0065 .0058 .0060 . 0060 Segmental____ . 0070 Concentric, rounded edge: 9. 842 10.000 9. 450 ______I 9.390 ______ 10.000 ______ 10.000 --------- (■') _____ 7.875 _____ 9.500 .0040 Concentric________ ... _____ ____ 10.000 .0040 -.-do__________________________ 10.000 r ■ (nrmotinn' dl Tpvthnnk of Small Urns, 1909, London. Printed for His Majesty's Stationery Office l.y Har°risoCnS& SonI, 2M' (_> An.or^s Munmons! '(^'Training Regulations No. 320-10. War Department. Wash- irigton Mar. 12,T1;'- . ., disnlaced bv the British Enfield in the Canadian forces, principally to have all British .•nn.Va.m,", wrththe X.^ Hlle (W^S^wnsend: The American Rifle; New York, The Century . „.. ,9,8. 95., ■ See Figures 44 and 45 for further changes. ' Increasing from 19'4 to8,'4 inches. 30 SURGERY ANTITANK RIFLE During 1918, the Germans developed an antitank rifle. This was a single- shot 13-mm. rifle that had been developed pending the construction of a 13-mm. machine gun.22 The weapon was very heavy, weighing 37 pounds, and was nearly 5% feet in length, so it was necessary to provide it with a bipod for fixed position firing.22 The bullet, weighing f>7() gr., was pointed, and fired with an initial velocity of about 2,450 foot-seconds.22 The bullet was of armor-piercing construction, and a penetration of 20 mm. of the best steel was claimed for it at a range of 500 yards.22 AUTOLOADING AUTOMATIC RIFLE Besides those weapons listed in Table 4, a number of special rifles were developed and brought into military use for the first time during the war.23 Of those which were designed to be fired from the shoulder the Mondragon, semiautomatic rifle, the St. Etienne semiautomatic rifle, and the Browning automatic rifle deserve mention. Fio. 51.—Browning automatic rifle, model 1918, caliber 30 The Mondragon semiautomatic, in use in the Mexican Army before the World War, was adopted by Germany in 1915, chiefly for aviators' use.25 It was of 7-mm. caliber and provided with two types of magazines, one with a capacity of 10 rounds and the other with a capacity of 30 rounds.25 The French model, 1918, St. Etienne semiautomatic rifle, fired the Lebel S-mm. cartridge. The magazine had a capacity of five cartridges.23 The American Army had about 5,000 Browning automatic rifles in use during the last two months of the war.28 This gun, although handling the powerful 1906 United States rifle cartridge, had so slight a recoil that it could be fired continuously, without serious discomfort, at the rate of about 100 shots a minute.22 The magazines held either 20 or 40 cartridges.27 MACHINE GUNS Besides these autoloading automatic rifles designed to be fired from the shoulder, a number of automatic light machine guns were in use. The French used the Chauchat machine rifle,28 model,1915. This gun,weighing 19 pounds and firing the ordinary 8-mm. Lebel cartridge, had a magazine which held 20 cartridges.22 A bipod rest was attached to the fore end for fixed position firing. Hotchkiss light machine rifles firing the Lebel 8-mm. cartridge and weighing about lS}o pounds were also in use by the French Armv.22 GENERAL SURGERY 31 Fig. 52.—Chauchat machine rifle, model 1915, caliber 8 mm. F.g. 53.-Maxim machine gun and tripod (American), model 1904, caliber .30. This was the first automatic machine gun to be developed. It is of heavy type, recoil operated, water cooled, and belt fed. The gun is capable of sustained fire for long periods of time provided its water supply is properly maintained It is adaptable to indirect barrage fire. It was used by the British and United States forces and in mod.fied form by the Germans 46997—27----u 32 SURGERY The Madsen machine rifle weighing about 16 pounds was used by the Russians.22 The magazine held 40 rounds; when used as an automatic, the rate of fire was about 500 shots a minute.22 The British Army used the light Lewis machine gun, which was of the "ground type," weighing about 'l(\]/2 pounds.22 In this type the magazine held 47 rounds of the ordinary 0.303 caliber rifle ammunition.22 A somewhat heavier model, with the magazine holding 97 rounds, was used in aircraft by both the British and French.22 These guns were capable of firing 600 shots a minute.22 Fig. 54.—German Maxim machine gun on mount The Germans used two types of light machine guns.25 Early in the war the Bergmann, weighing 30 pounds, with a bipod mount, was much in use, although it was discontinued before the end of the war.23 The principal light machine gun used by the Germans in the later years of the war was the Maxim 08-15.25 This was a modification of the heavy Maxim machine gun with which the German Army was so abundantly supplied.25 GENERAL SURGERY 33 Fig. 55.—Fiat (Italian) machine gun and tripod Fig. 50.—Browning heavy machine gun, model 1917 34 SURGERY Fig. 57.—Hotchkiss machine gun, model 1914, 8-mm. This is the machine gun adopted by the French Army. It is of heavy type, air cooled, and gas operated. Its rate of fire is about 500 rounds per minute Fig. 58.—Vickers machine gun, model 1915, caliber .30 GENERAL SURGERY 35 ^ ^ Fig. 59.—Vickers aircraft machine gun, model 1918, caliber .30 Fig. 00—Lewis machine gun, model 1917. caliber .30, ground type Fig. 01 -Lewis aircraft machine gun, model 1917, caliber .30 36 SURGERY Fig. 02.—Marlin tank machine gun Fig. 63.—Marlin aircraft machine gun, type 8 M. O. Fig. 64.—German 08/15 (Spandau) machine gun MACHINE CARBINE PISTOLS In 1918 the Germans brought into use a "snail" magazine holding 32 cartridges for the Luger service pistol, thus bringing this weapon into a class related to the light machine rifle.29 This type of magazine, handling the 9-mm. cartridge, was used in the Luger with a long barrel and with a wooden buttstock attached to the hand grip as a shoulder piece.29 When the gun was fired from the shoulder the magazine served as a fore-end, hip-elbow rest, thus giving unusual stability and accuracy to the very light weapon.22 The Bergmann pistol gun (officially pistol 18 I) which was in reality a car- bine, fired the 9-mm. Luger pistol cartridge from a "snail" magazine holding 32 shots 29 at the rate of about 540 shots a minute.22 This carbine was heavy weighing about 91, pounds without the magazine; it was sighted to 200 m 22 GENERAL SURGERY Fig. 05.—Colt .45 automatic pistol used by the American Army and, whenever obtainable, by other armies also Fig. 66.-Colt double-action revolver, model 1917, caliber .45, with adapting clip to take rimless cartridges 38 SURGERY Fig . 67.—Smith & Wesson double-action revolver, model 1917, caliber .45, with adapting clip to take rimless cartridges Fig. -German Luger automatic pistol, caliber 7.65 mm. with "snail" magazine in place. The bridge from the receiver to the buttstock for mounting a Lyman sight is an American addition Fig. 69.-German Mauser automatic pistol, caliber 7.65 mm. The wooden buttstock is hollow and serves as a holster for the pistol GENERAL SURGERY 39 PISTOLS The autoloading military pistol, with calibers ranging from 0.30 to 0.45 inch, was used in practically all combat branches of the service of all armies not armed with rifles.3*) Table 5 gives the principal ballistic factors of these auto- loading pistols and their cartridges. Table 5.—Automatic pistols and their cartridges " Cartridge .63-min. Mauser. '.65-mm. Luger. 0.32 automatic Colt, Webley, Scott, Browning,"Ba\-ar(Y,\MausV_Vci.menV"stier' 9-mm. Luger_ Weight Muzzle Energy of bullet, ve'°£ty' : offbuJlet inerains foot" ' foot" in grains seconds pounds 0.38 automatic Colt, Bayard___________ 0.380'Colt automatic, Savage, Webley, BYow"ning".-mmV(7hor^Rlminiton7Bayard 0.45 Colt automatic, United States Government . 0.445 Webley naval automatic_____________ S6 1, 397 93 1,173 74 964 125 1,039 130 1, 146 95 887 I 230 S09 i 220 710 373 284 152 300 379 116 335 » Source of information: The Encyclopedia Brittanica, new volumes. XXXII, 107. The German Luger (Parabellum) was the standard German side arm,30 but owing to the great shortage of these weapons as many as 28 different models of pistols and revolvers were in use in the Germany Army.31 The Colt automatic pistol, caliber 0.45, was in use by the American Army.32 The regular magazine held seven cartridges. It proved to be the most effective side arm in use during the war; however, because it could not be produced in sufficient number to arm completely the American forces, Colt and Smith & Wesson revolvers of 0.45 caliber were adapted to use the rimless cartridge of the Colt pistol.32 They were as reliable, accurate, and effective as the pistol, but of course slower in functioning. Fie. 70— Photographs of various dissscted rifle cartridges. A. Italian Mannlicher (Carcano) (6.5 mm.); B. Austrian Mannlicher (8 mm.); C. German (Mondragon (7 mm.); D. German Mauser (8 mm.); E. British Lee-Enfield (.303 in.); F. French Lebel (8 mm.); G. Russian Nagant (.300 in.); H. U. S. .06 (.300 in.) SMALL-ARMS MISSILES RIFLE MISSILES In Table 6, data are given concerning various rifle missiles. It will be noted that, with the exception of the Italian and Japanese rifle cartridges, the bullets of the others were practically 0.3 of an inch in diameter (30 caliber, or S mm.); also, with the exception of the Austrian, the bullets were of approxi- mately the same weight, namely, from 150 to 198 gr. Likewise, their initial velocity did not vary greatly, running from 2,121 feet a second to 2,866 feet 40 SUROKRY a second. The initial muzzle energies of translation were also fairly close. being, except the Italian, from 2,216 to 2,685 foot-pounds. Table 6.—Various dissected rifle cartridges and their ballistic data a Country Rifle Kind Caliber Weight Grains 43 46 48 38 35 48-50 47-50 Powder Type Nitrocellulose____ ____do_____...... ....do___........ Nitroglycerine (cordite). Nitroglycerine (ballastic). Pyroxilin________ Py ro cellulose____ Length Inches 1.25 1.54 1.10 1.3 1.25 1.12 1.07 Bullet Dia-meter Inch 0.323 .320 .323 .311 .206 .308 .308 Weight Grains 241 198 154 174 101 149 150 Muzzle veloc-ity Foot-seconds 2,121 2,270 2,777 2,440 2,205 2,866 2,700 Muzzle energy Mannlicher....... Lebel____________ >.315 ".315 6.311 .303 '.250 .30 .30 Foot-pounds 2,408 2,266 2, 637 Great Britain....... Italy................ Lee-Enfield....... Mannlicher-Car-cano. 2,300 1, 857 2,685 Springfield, 1903. _ (1900 cartridges). 2,429 <■ Sources of information: (1) Table RN 471.842/45. On file, Infantry and Aircraft Armament Division, Manufacturing Service, Ordnance Department, unnumbered. (2) Table, Ballistic information and results of firing ammunition of the various countries. Fired at the experimental station. Ballistics Division, experimental station, E. I. Du Pont de Nemours & Co., Henry Clay, Delaware. On file, Infantry and Aircraft Armament Division, Manufacturing Service, Ord- nance Bureau, unnumbered. (3) Textbook of Small Arms, 1909, printed for His Majesty's Stationery Office. London, Harrison & Sons, 250. (4) Consolidated Data of Reports on Hand at Frankford Arsenal, Pa., British Small Arms Am- munition, May, 1920; source unknown. On file, Infantry and Aircraft Armament Division, Manufacturing Service, Ordnance Bureau, unnumbered. (5) Report on French Small Arms Ammunition, Frankford Arsenal, Pa., March, 1920, by W. L. Clay, lieutenant colonel, Ordnance Department, U. S. Army. On file, Infantry and Aircraft Armament Division, Manufacturing Service, Ordnance Bureau, unnumbered. (6) Collection of Reports on German Small Arms Ammunition, Frankford Arsenal, Pa., July 18, 1919, by W. L. Clay, lieutenant colonel, Ordnance Department, U. S. Army, commanding. On file, Infantry and Aircraft Armament Division, Manufacturing Service, Ordnance Bureau, unnumbered. (7) Training Regulations No. 320-10, W. D., Washington, March 12, 1924. (8) Handbook of Ordnance Data, Nov 15, 1918. Washington, Government Printing Office, 1919. (9) History of the Great War Based on Official Documents, Medical Services, Surgery of the War, London, His Majesty's Stationery Office, 1922,1. 7. b Eight millimeters. ' Six and a half millimeters. While all of these bullets possessed sufficient energy to be mankilling in the limits of all ranges at which they could be purposively directed, yet their shape, composition, and maintained energy varied so greatly as to produce widely different effects. It is therefore necessary to analyze each cartridge in detail. The .30-caliber United States Springfield bullet as fired from the 1906 model cartridge during the war weighed 150 gr.33 It was composed of a solid lead core surrounded by a cupro-nickel jacket of very high tensile strength. Its remain- ing velocity at 500-yard range was 1,668 foot-seconds and its remaining energy 932 foot-pounds.34 At the 1,000-yard range its remaining velocity was 1,068 foot-seconds and its remaining energy 382 foot-pounds.34 At the 1,500-yard range its remaining velocity was 853 foot-seconds and its remaining energy was 244 foot-pounds.34 The bullet of the .303-caliber British Lee-Enfield cartridge left the muzzle of the gun with 2,440 foot-seconds velocity and a muzzle energy of 2,300 foot- pounds.35 This bullet, however, weighed 174 gr.35 and therefore maintained its velocity and energy better than the lighter Springfield bullet. Its extreme effective ranges were practically the same as those of the Springfield. The base and body of the core of the bullet was composed of solid lead, but the point consisted of a small cap of lighter material, either aluminum or stalbite (hard- ened paper pulp) .36 The bullet of the Eussian cartridge, as made in America, was practically identical with that of the Springfield bullet, and had practically the same muzzle velocity and muzzle energy. GENERAL SURGERY 41 The bullet from the 8-mm. German Mauser cartridge weighed a trifle more than the Springfield bullet. It possessed about 200 foot-seconds more muzzle velocity and 200 foot-pounds more muzzle energy. Its range was longer and its maintained energy slightly higher at long ranges than that of the Springfield bullet. The core was of solid lead, the jacket of low carbon steel, nickel or copper plated.35 The French 8-mm. bullet was nearly one-third heavier and one-third longer than the Springfield bullet. Its muzzle velocity was much less than that of the Springfield, and its muzzle energy considerably less. Its maintained energies were greater at extreme ranges than those of the Springfield bullet.22 This was due not only to its superior weight but also much to its superior shape. The bullet was reduced in diameter from 0.320 inch at its middle to 0.270 inch at its base; its forward part (shoulder) was very sloping. Owing to these factors it encountered less resistance to the air than did any other military bullet. The French bullet was of solid bronze, containing neither core nor jacket to separate or split.7 Because of these factors when flying head-on this bullet produced clean-cut wounds.7 The Austrian Mannlicher rifle, model 1895, fired a bullet 0.323 inch in diameter (8 mm.) and 1.25 inches in length, weighing 241 gr., with a muzzle velocity of about 2,121 foot-seconds. Because of its relatively heavy weight, this bullet had a relatively high muzzle energy. However, since it had an ogival head, rather than a pointed one, the resistance of the air to its passage was relatively high,37 and its velocity and energy were both rapidly reduced. This bullet consisted of a solid lead core with a low carbon steel envelope similar to that of the German Mauser bullet.37 The Italian Mannlicher-Carcano rifle, 1891 model, fired a bullet 0.267 inch in diameter (6.5 mm.), 1.2 inches long, and weighing 162 gr. It had a velocity of about 2,400 foot-seconds and approximately 2,000 foot-pounds muz- zle energy. The bullet consisted of a lead core surrounded by a cupro-nickel envelope.37 This bullet had an ogival head with consequently high air resist- ance which caused it to fall off rapidly in velocity and energy.37 SPECIAL RIFLE BULLETS Besides rifle bullets referred to above, various special bullets for small arms (rifle and machine guns) were made. Practically all of these may be classified as armor-piercing, tracer, incendiary, wire-cutting, or explosive. Armor-piercing small-arms bullets consisted essentially of a hard steel core surrounded by a jacket composed of cupro-nickel alone or of a thin coating of lead covered with a cupro-nickel jacket of ordinary thickness.38 Bullets of this type not previously mutiliated by striking armor or other metal objects were likely to penetrate the human body, including bones, without deformation. On coming in contact with even fairly thick steel armor the relatively soft cupro-nickel jacket was split, permitting the passage of the steel core through the metal.38 These bullets were used by the Germans, chiefly against tanks and occasionally against armored adversary machine-gun operatives and airplanes.39 42 SUKGKRV Tracer bullets contained in a small cavity in the base a slow-burning com- pound which produced smoke, or more often a small speck of bright light visible even in the daytime.40 The forward part of the bullet consisted of a lead core and the whole was encased in a cupro-nickel or low-carbon steel jacket.40 During the later stages of the war the Germans devised an armor-piercing tracer bullet.39 However, in this the steel core was rather too small to be very effective. Tracer bullets were used almost entirely by air- planes.40 Incendiary bullets contained, within a chamber in the fore end, phosphorus, access to which was provided by a hole drilled on one side of the missile through the jacket and he lead core of the base.40 The passage of Aiq bullet through the gun barrel melted the solder with which the hole was closed and ignited the phosphorus within the chamber.40 The rotation of the bullet whirled the burning phosphorus out through the open hole.40 This bullet had an effective range of about 350 yards, beyond which the flame was extinguished.40 The smoke from the burning phosphorus served to make this bullet also of tracer character.40 These tracer incendiary bullets were produced by the French and the Americans in 11 mm.,41 as well as in the ordinary 8 mm. and .30 caliber. The flame from these large caliber bullets continued up to 1,200 yards range.42 Numerous attempts were made to im- prove the wire-cutting qualities of rifle and machine-gun bullets, either by cutting off the head of the ordinary pointed bullet with wire clippers or other wise mutilating them.43 These efforts were not successful. The Ger- mans developed a cylindrical steel bullet for the same purpose, but it also was not satisfactory.43 An explosive rifle bullet was made by the Germans which contained at the point within cupro-nickel and lead jackets a com- plicated firing mechanism consisting of a percussion cap, a suspension coil spring, and a striker.43 This mechanism was contained within a brass collar and was designed to explode a relatively large compressed bursting charge in the rear of the bullet to which the flame from the cap gained access by way of a channel through a brass Fig. 71.—German antitank rifle cartridge, com- pared with the United States Springfield model 1906 cartridge. Full size GENERAL. SURGERY 4.3 container in the middle portion of the bullet.43 This container was filled with a composition of potassium chloride and antimony sulphide.43 Experiments by the Allies with captured bullets of this variety showed that thev had con- siderable penetrative power before explosion and that thev must have been designed for their explosive effects only, since thev were valueless as tracers or for incendiary purposes,43 although the Germans stated that thev were intended lor ranging purposes.39 In the early years of the war many accusations were made by each of the warring nations that the enemy was using explosive and "dum-dum" bullets 3« While any bullet might be made into "dum-dum" pattern by mutilatino- its forward end in any way, the only "dum-dum" "mushrooming" bullet* which had evidently been manufactured in soft-point form which camo under the writer's observation were those in cartridges removed from the pockets of a German sharpshooter in the Chateau-Thierry operation.36 These were Ameri- can-made 0.256 Newton (6.5 mm.) bullets with soft-lead points, each with a small steel tack embedded therein. They were of pre-war manufacture (about 1912) ,36 loaded in German-made cartridge cases which had evidently been necked down from the ordinary 8-mm. size, and were being fired from a Mauser rifle of 6.5-mm. caliber. They probably represented a personal experiment of the sharpshooter on whose body they were found. The fact that "explosive," "dum-dum," and "mutilated" bullets were not more frequently used was probably due more to the difficulties of their manufacture, their inaccuracy, and their ineffectiveness. The ordinary bullets from rifle and machine gun were found to be sufficiently effective to satisfy military necessity. PISTOL BULLETS Table 7.— Various dissected pistol cartridges and their ballistic data " .38 Colt automatic pistol B .45 Colt automatic pistol. U. S. Gov- ernment Powder, grains_____________ Bullet: Length, inches_________ Diameter, inches________ Weight, grams............ Muzzle velocity, foot-seconds . Muzzle energy, foot-pounds... . 3oS . 450 130 230 1,146 | 802 379 329 C .30 (7.63- mm.) Mauser automatic pistol 7.5 .56 .300 1,397 373 D .30 (7.65- mm.) Luger automatic pistol 93 1,173 284 .56 .308 a Sources of information: (1) Table, Ballistic information and results of firing ammunition of the various countries. Ballistic Division, experimental station, E. I. Du Pont de Nemours & Co., Henry Clay, Del., Dec. 16, 1919. On file, Infantrv and Aircraft Armament Division, manufacturing service, Ordnance Bureau, unnumbered. (2) The Encyclo- pedia B'ritannica, 1922, xxvii, 107. (3) Training Regulations, No. 320-15, W. D., Washington, March 3, 1924, 5. 6 Bull's-eye. ' Flake. Figure 72 and Table 7 show the shell, powder, and bullet, together with the ballistic data of several of the more important cartridges used in automatic pistols during the World War. The bullet fired by the .45 Colt automatic pistol was the heaviest usedexcept that of the Webley automatic pistol in use in the British Navy. The Colt bullet weio-hed 230 grains and had a muzzle velocity of 802 foot-seconds and a muzzle 44 SUKOKRV energy of 329 foot-pounds.44 Because of their heavy weight and large cross section this bullet and that of the .45 Webley possessed greater man-stopping power than that of any other bullet used in pistols.45 The bullet of the .38 Colt and Bayard automatic pistols weighed 130 grains and was fired with a muzzle velocity of 1,146 foot-seconds and a muzzle energy of 379 foot-pounds.31 At close quarters this bullet was more likely to pass through the body than was the .45 Colt. Thus, although it possessed more muzzle energy than the .45,31 it did not have as much man-stopping power.46 The bullet of the .30 Luger automatic pistol (7.65 mm.) weighed 93 grains and was fired with a muzzle velocity of 1,173 foot-seconds and a muzzle energy of 284 foot-pounds.31 Its head was a truncated cone which served to reduce the air resistance to it but also reduced its man-stopping power.46 Fig. 72.—Photographs of sundry dissected automatic pistol cartridges. A. .38 Colt; B. .45 Colt; C. .30 (7.63 mm.) Mauser; D. .30 (7.65 mm.) Luger The bullet of the .30 Mauser automatic pistol (7.63 mm.) weighed 86 grains and was fired with a muzzle velocity of 1,397 foot-seconds and a muzzle energy of 373 foot-pounds.31 This bullet had an ogival head similar to that of the .45 and .38 Colt bullets.31 Its velocity and energy were well retained at relatively long ranges, but its small caliber and relatively high velocity contributed to reduce its man-stopping power.46 As a whole the experience of the World War bore out the previous experience of the United States Army in the Philippines, that a pistol bullet of large size (.45 caliber), heavyweight (230 grains), and relatively low velocity was much more effective as a "man stopper" at close quarters than any other yet devised of smaller caliber.47 BOAT-TAIL BULLETS The most recent development of rifle bullet designing has been in so modi- fying the base of the missile as to reduce the negative pressure set up by its passage through the air.48 Double-pointed bullets of all sorts have been experimented with, but, in general, nations now are apparently settling down to the so-called "boat" shape; that is, with a long pointed front, a cylindrical center, and a base which is a truncated cone. This boat-shaped bullet, first tried out by the French and later perfected by the Swiss, was adopted early GENERAL SURGERY 45 in the war by the French, and later by the British, Germans, and Americans.49 Properly designed these bullets are said to have less than one-half the resistance to the air that is offered by missiles with ogival heads of \y2 diameters.50 GENERAL CHARACTER OF WOUNDS FROM VARIOUS CAUSATIVE AGENTS Relatively large, smooth missiles of low velocity, such as shrapnel balls near the end of their flight, produce wounds of little depth, with but slight tearing, and with considerable contusion of the tissues. Large missiles of irregular shape and low velocity, such as large shell fragments near the end of their flight, produce ragged wounds with considerable bruising and little pene- tration. Large or small missiles of very high velocity, such as fragments from high-explosive shells in the first portion of their flight, and modern rifle missiles in the first mile of range, produce "explosive " wounds, with the wound of exit larger than the wound of entrance. Shape and velocity remaining the same, doubling the weight of the missile doubles its wounding power. Shape and weight remaining the same, doubling the velocity quadruples its wounding power, since it quadruples its energy. When weight and velocity remain the same, increase in sectional area either regularly or irregularly, as in a bullet with flattened point or one with the deformity of a split jacket, produces addi- tional wounding capacity, and especially its "shock" effect, which can not be stated mathematically since it will vary so greatly with the character of the tissue affected. With these general principles in mind, though all of them are subject to innumerable modifications, some general conception of the types of the wounds produced from various missiles may more readily be understood. The effects of shrapnel bullets and shell fragments from the older types of explosive missiles have been so well described by La Garde,51 Stevenson,52 and others that there is no need of repeating them here. It was supposed that the very greatly increased velocity and the very much greater comminution of shell fragments, due to the use of much higher explosives in the shells during the recent war, would eliminate in large measure the type of wound from shrapnel and shell fragments so com- mon in previous wars. This has not proved to be the case. Very many wounds from shrapnel ball and shell fragments were of the old type, namely, with slight penetration, much contusion, and incidentally much infection with foreign matter. A large number of the shrapnel and shell-fragment wounds among the American Expeditionary Forces must have been produced Ir- relatively low velocity missiles. This explains why the surgeons with the American Expeditionary Forces so seldom stated the causative agent as from high-explosive shell.53 On the other hand, in close quarters, as in trench fighting, where men were struck by missiles from exploding bombs and grenades, the character of the wounds often indicated that the missiles were of relatively high velocity. In general it may be said that shell fragments and shrapnel bullets, what- ever their primary velocity, rapidly become slow and depend less for their wounding effect on velocity than on their weight and shape.54 Thus they have but small power of penetration and frequently lodge in the body. They are likely to carry clothing and other foreign matter into the wound. On the other 40 SURGERY hand, rifle missiles and secondary missiles of all kinds from high-explosive charges, striking the body while still having a high velocity, produce effect< from their kinetic energy in penetration, "explosive" exits and injury at relatively large distances from the tract of the missile, which are quite different from all low-velocity missiles; also they are less likely to carry foreign matter into the wound. WOUNDS FROM EXPLOSIVE MISSILES Sufficient has been said above to indicate to the surgeon the very great variety, both in extent and character, of the effects on human tissue of shrapnel and shell fragments from exploding artillery missiles. Occasionally steel shell splinters of needlelike fineness were hurled with such tremendous velocity that striking end-on they penetrated the body wall either from the back, the front, or the sides and caused ultimately fatal hemorrhages by injuring large arteries, or the heart itself. In some instances the wound of entrance of these missiles was almost imperceptible. On the other hand, large masses of metal, weighing as much as 2 or 3 pounds, had frequently so little remaining velocity when they struck the bod}' that they did not rupture the skin or at most barely buried themselves in the flesh. It was surprising, however, what large masses of metal were found occasionally lodged in the human body. Between these two extremes of light weight with high velocity and heavy weight with low velocity every conceivable variety of weight and velocity of missile existed and likewise every conceivable variety of wound effects. If the missile lodged in the body, study of its shape and size, together with consideration of the tissues met with, gave some indication of its remaining velocity at the point of entrance. If the wounding missile had passed out of the body, unless both wound of entrance and wound of exit were small, it was impossible even to estimate the ballistic data. To these uncertainties was added the possibility that the wound might not have been produced by artillery fire but by a rifle or machine-gun bullet of unusual shape or flight, a subject which will be discussed below. WOUND PRODUCTION BY SMALL-ARMS MISSILES The World War afforded uprecedented opportunity to study the effects of high-velocity rifle bullets in human wound production. Leaving aside for the moment the unusual wound effects produced by deformed bullets and by bullets of irregular flight, the causes and effects of which have already been hinted at in the preceding analysis of the various types of bullets, we may examine the causes of the wound conditions produced by the normal-shaped bullet which struck human tissues while it was in normal flight. The wounding effects of a bullet depend on (a) the amount of energy it transmits to the tissues, (6) the velocity of the transmission, (c) the direction of the transmitted energy, and (d) the density of the tissues. The first three of these factors depend almost entirely on the energy, velocity and shape of the bullet, * ' H All rifle bullets used in the World War were several (three to five) times longer than they were thick. (See Table 6.) All except the Austrian and Italian GENERAL SURGERY 47 had very sharp-pointed forward ends and cylindrical bodies. Their surfaces were smooth except for the spiral longitudinal grooves, about 0.004 inch deep, cut by the lands of the rifle barrel through which they were fired. They left the gun muzzle with a velocity usually somewhat more than twice that of the velocity of sound (from 2,200 to 2,800 feet a second) and they were rotating on their long axes in most instances more than 3,000 times a second, with a surface speed of about 260 feet a second. The muzzle energy of their forward motion (translation) was about 2,400 foot-pounds and that of their motion of rotation was about one two-hundredths as much, or 12 foot-pounds. The different bullets used varied greatly in the rates in which their velocities of translation were reduced. The rate of reduction of the velocity of rotation is almost Fig. 73—Various deformed rifle bullets removed from wounds impossible of calculation, but it is not as great as the rate of reduction of velocity of translation, since we know that a bullet will continue to spin after it has ceased to move forward. The amount of energy transmitted to the animal body by a bullet is the amount with which the bullet enters less that with which it leaves the body. If the bullet does not pass out of the body it transmits to it all of its energy. If it does pass out, it obviously does not transmit to the body the energy it retains after exit The proportion of energy transmitted depends on the sectional area of the bullet, the shape of its head, the character of its surface, and the relative densities of the tissues struck. This is why a blunt-pointed, large-caliber revolver bullet, like the Colt .45, lodging in the body, may cause more tissue destruction and more shock than a sharp-pointed small caliber 46997—27---6 4S SURGERY way sive e eussion bullet carrying much more energy but passing through and out of fleshy struc- tures with but slight loss of energy. When the modern high-velocity, sharp-pointed military rifle bullet enters the human body it may produce terrific destruction of tissue at very consider- able distance from its line of passage. It may do this without being in any deformed in shape or flying erratically. The cause of the so-called explo- ffects of the modern rifle bullet has been the subject of prolonged dis- ,_on and experimentation by many careful students. It can not be said that the solution of the problem is yet entirely clear. However, from long experi- mentation and consideration of the laws of physics the following consideration derived from observations of wounds in man and animals would appear to bo of most weight in the explanation of the phenomena: When the sharp-pointed rifle bullet enters the body pomt-on and passes through it without tumbling, its wound production is the result of the transmis- sion of energy from the bullet's two motions, first, of translation, and second, of rotation. If the bullet were a cylinder it would act much like a punch, but though the body of the bullet is a cylinder the forward end has long, sloping shoulders which act as wedges. As a consequence of this, the energy of the bullet is transmitted not directly forward but at oblique angles with that of the path of the bullet. The energy is thus transmitted through an area of tissue which is represented roughly by a broad-base cone having its apex at the point of entrance and its base surrounding the point of exit. Besides the motion of translation, a small amount of force is no doubt exerted by the motion of rotation. The energy of the bullet from its motion of rotation is trans- mitted centrifugally at right angles to the track of the missile. It is probable that the energy of rotation is reduced less in proportion than the energy of translation by the passage of the bullet through the tissues; thus the energy of rotation of the bullet may be a relatively greater factor in the resultants representing the total transmitted energy of the bullet at the exit than at the entrance point. This transmission to the tissue of the energy of the bullet at decided angles to its path explains the dissemination of foreign bodies, and incidentally bacteria along with them, to points in the tissues at considerable distances from the path of the projectile. Dense particles, as, for example, charcoal used experi- mentally on the skin at the point of entrance of the bullet, are not driven into the tissues but are scattered widely through the tissues along the track of the missile. This is a most important point for the surgeon to remember in his primary treatment of wounds made by high-velocity bullets. But the physics of dense particles driven through soft tissues will not explain the phenomena encountered in "explosive" wounds of soft tissues. When the particles of a plastic body are set in motion by being struck by a missile the distance to which the motion is transmitted is determined by the freedom with which the particles move. Experimentally the energy of a high-velocity rifle bullet is transmitted approximately four times as far in 5 per cent gelatin as in 10 per cent gelatin and approximately nine times as far in 5 per cent gelatin as in 15 per cent gelatin. In other words, in plastic bodies the distance to which the energy is transmitted by a rapidly moving bullet is approximately GENERAL SURGERY 49 inversely proportional to the squares of the densities of the masses penetrated.38 On the other hand, the velocity with which tissues of greatly differing densities move when set in motion by transmitted bullet energy is apparently, though roughly, in direct proportion to their densities, and may result in shattered parts of a more dense tissue, as bone, being driven through a less dense tissue, as muscle. Apparently when tissues approximate each other in densities, none of which are sufficiently great to permit of angular fragmentation, as, for example, the several coats of the wall of an artery, particles of the one are not driven through the other by transmitted bullet energy. Probably both are moved but at somewhat different velocities. It may be assumed that these different velocities may produce unequal stresses. This possibly may be the cause of the frequently observed ruptures of the intima of large arteries by the passage near, but not in contact with them, of high velocity budets. On the whole, then, it seems reasonable to assume that the "explosive" effects produced by high velocity rifle bullets, either experimentally or in war wounds, in their passage through liquid or plastic substances may be due to the angular and lateral transmission of the energy of the bullet to the mass as a whole, thus setting up violent motion in the particles of the mass which are trans- mitted throughout the whole mass from particle to particle. In homogeneous fluids and plastic structures of low density all particles move together wavelike. In composite tissues of varying densities irregular stresses are developed which tear or even comminute the tissues. IRREGULAR MOVEMENTS OF BULLETS IN TISSUES There is a great tendency for the modern pointed bullet to tip on striking tissue of any considerable density. This is most noticeable, of course, with bullets of reduced velocity. These sometimes follow most eccentric paths in the bodyz Not infrequently; they follow the curve of a rib for considerable distance without puncturing it. The amount of actual tumbling within the body which a bullet is capable of making is a question of considerable dispute. It is doubtful, however, if any bullet turns completely over more than once or twice in passing through the human body. Of course, even this amount of tumbling would transmit an enormously increased amount of energy to the tissues. At all except extreme ranges the straight-flying modern military bullet should pass completely through the human body. However, a great many bullets fired at comparatively short ranges were known to have remained in the body. It is probable that some bullets remaining in the body after wounding at short range may have previously encountered other obstacles which reduced their energy. Others may have been fired from worn-out rifle barrels. SITE AND CHARACTER OF INJURY IN THE BATTLE DEAD The military surgeon is concerned only with the wounded soldier. The military pathologist is concerned also with the dead soldier; the site and charac- ter of injury of men killed in action involve problems in which the military pathologist is much concerned. 50 SURGERY The number of men killed in action constitutes a very appreciable share of the total casualties. Prior to the World War, it was generally accepted t hat the ratio of those killed or found dead on the field to the number wounded was 1 to 4.55 This ratio, of course, is verv much influenced by the mode of attack. In the American Armv during the World War, this ratio was slightly less. The total number killed or missing on battle fields in the American Expeditionary Forces was 36.7S().5e Tne totai number of wounded was 153,537,53 comprising only those wounded by military destructive agents, excluding poisonous gases. Thus the ratio was about 1 to 4.2. Information is not available as to the total number of men killed in action in the French Armv during the war. The total number of dead and missing was computed to be 1,357,800.57 The total number of wounded from 1914 to 1918 was 2,052,9S4.58 Although it is impossible from these figures to determine the ratio of killed in action to the total number wounded in the French Army, the general statement has been made that in the trench fighting on the western front, during the earlier years of the war, the ratio of killed to wounded was as 1 to 3; also, in the Battle of the Marne the ratio of killed to wounded was approximately 1 to 4.5.59 The total number of men in the British Army killed in action has been reported to be 464,049 f the number of missing (including prisoners) was 320,944.57 The total number of wounded from August, 1914, to November, 1918, was 2,036,75().57 Allowing 100,000 for the "presumed dead," the ratio of killed to wounded in the British armies was thus about 1 to 2.9. In that part of the German Army opposite the French-Belgian-British front the total number killed in action was 789,400 and the number missing in action 96S.197.57 The number of wounded was 3,088,743.57 Thus, assuming two-thirds of the missing were prisoners, the ratio of those reported killed to the total wounded was 1 to 2.8. It would seem that the preponderance of trench warfare, especially on the western front in the World War, tended to increase the ratio of killed to wounded, while the preponderance of shell and other explosive missiles tended to decrease it. That these two factors did not offset each other—for in the war in France and Belgium as a whole the general ratio of killed to wounded was greater than that of previous recent wars, namely, about 1 to 3 or even more— is accounted for by the deadliness of the pointed rifle missile with which most of the contending armies were equipped. This deadliness had already been deter- mined in the Turko-Balkan War of 1912-13, during which, though but 20 per cent of wounds were attributed to shrapnel, the ratio of killed to wounded was 1 to 2.5.60 The careful hunter of big game learns from a study of the effects of his bullets on the relatively few animals which fall to his fire more than he can possibly learn from years of experimental work on the rifle range. From a purely military standpoint it is greatly to be regretted that the military pathol- ogist has hitherto been unable to make a similar adequate study of the site and type of the injury and the character of the missile in the bodies of men killed on the battle field. So far as the writer is aware, this phase of military pathologic research, which it may readily be seen would probably have a most important GENERAL SURGERY 51 bearing not only on military medical problems but also on the planning of body armor and the revising of weapons and missiles, was scarcely if at all touched on by any of the nations involved in the World War. In oniy relatively isolated instances did physicians, usually in first-aid service, have opportunities to make such examinations. These physicians were seldom trained pathologists, nor were they interested in the problems which might have been solved by careful study of the dead. Most of all, their duties to the living did not permit time to be given to such study. Although, because of lack of observation and lack of records, most of our conclusions concerning the character of injury and the probable missile causing it in the battle dead have been drawn from inferences chiefly on conditions in the badly wounded, yet some of these inferences are worth recording. While no accurate figures of the proportion of deaths on the battle field from primary hemorrhage are available, we are probably safe in estimating that from 80 to 85 per cent of such deaths were due to this cause. Relatively few wounded with central chest injuries or with injuries involving the abdom- inal aorta ever reached first-aid stations. Immediate fatalities from head injuries, chiefly from snipers' fire, were very common in the early stages of trench warfare. These fatalities, however, were rapidly reduced to a minimum as men learned "to keep their heads down." Long-range sniping was largely at men whose entire bodies were exposed Here the sharpshooter aimed at the chest. The total number of men reported as "missing," who were not captured and who were not deserters, but whose bodies had been blowm into unidenti- fiable fragments, was relatively very much larger than in any previous wars. This was due to the great increase in number and size of high-explosive mis- siles. Compared with previous wars, a relatively" large number of instantaneous deaths occurred in action, particularly in trench warfare, without any sign of external injury to the body. In a few such bodies examined by pathologists many minute and occasionally large hemorrhages were found, usually in the central nervous system or lungs. Crile's experiments at Rouen, in 1917, on animals showed the lungs to be the seat of massive hemorrhages.61 Crile found the central nervous system also involved. Durante and Mairet,62 in similar experiments, found the central nervous system most affected. The exact physical condition producing these lesions has been much discussed. The most plausible hypothesis is that the very great instantaneous reduction of air pressure immediately following its very great increase from the gases of explosion causes such rapid displacement of gases and fluids inside the body as to rupture blood vessels with weak support, as in the lungs, and probably also to disintegrate cell membranes, particularly of the central nervous system. RATIO OF WOUNDS FROM MISSILES FROM SMALL ARMS In the open wars of the last 75 years prior to the Turko-Balkan war, approximately 90 per cent of the wounds were reported as having been caused from the fire of small arms, with approximately 10 per cent of the wounds -)_. SUHGKRY from bursting missiles from heavv gunfire.83 The proportion of wounds from bayonets, sabers, and other piercing instruments has never been large and is rapidly decreasing, though the bayonet has been and still remains the cause of a considerable number of battle-field fatalities. Fig. 74—Sundry bayonets. A, United States;]B, Great Britain; C, France; D, E, and F, Germany; G, United States Springfield, 1886 model In the American Army during the World War the causative agent of wounds was either not designated or designated as "gunshot missile," with the kind not specified in approximately one-half of the battle wounds, by military destructive agents (76,076 of the 153,537 total ^missions).53 Of the remaining admissions the causative agent was stated as ^nail-arms missile (rifle, machine gun, or GI.XERAL SURGERY z3 Fig. 75.—United States trench knives, models 1917 and 1918 Fig. 76.—German coup stick or trench club Fig. 77.—French steel darts which were dropped in showers from airplanes 54 SURGERY pistol ball) in 20,(562 admissions.53 Missiles from shell, shrapnel, bombs, hand grenades, exploding mines, etc., were noted as the causative agent in 53,183 admissions.53 Thus, secondary missiles from exploding projectiles in the World YA ar effected a much greater proportion of wound injury than in any previous war, while injury by direct missiles from the fire of small arms was proportionately greatly reduced. Taken as a whole, the percentage of wounds from exploding missiles probably varied, from 50 to 80 per cent being highest when battle conditions were most stabilized, as in trench warfare, thus resembling those of a siege, and lowest when the action became one of movement. The great increase in the proportion of wounds from fragments of exploding missiles was due to the fact that not only in the barrage accompanying major engagements was there an unprecedented number of large-caliber weapons, each firing an unprecedented amount of high-explosive ammunition, but also under the daily siegelike conditions of trench warfare, long-range artillery fire was supplemented as never before by trench mortars,hand grenades, and rifle grenades and by aircraft bombs, almost all of which were charged with high explosives. Although the missiles from these soon dropped to relatively low velocities as compared with the velocities of missiles of small arms, their wound- ing energies were most effective. The American military surgeons'refusal to hazard aguess as to the character of the causative agent of approximately/ half of all wounds needs no word of apology. The character of the wounds in a large share of instances was such as not to permit of even a reasonable guess as to the causative agent. Indeed, it is probable, on theoretic grounds, that many of the wounds of which the causa- tive agent was described as secondary from an explosive missile may have been due to deformed direct missiles from small arms. REFERENCES (1) Fauntleroy, A. M.: Report on the Medico-Military Aspects of the European War. Washington, Government Printing Office, 1915, 17. (2) Dickinson, W. N.: The Story of the 75 (75 Millimeter Field Gun). Washington, Government Printing Office, 1920, 5. (3) America's Munitions, Report of Benedict Crowell, the Assistant Secretary of War. Washington, Government Printing Office, 1919, 69. (4) Ordnance Data, VI, European Artillery, British, table "British Gun Data." On file, Ordnance Bureau, Reference Library, UF 520, XOO. (5) Bethel, H. A., Brevet-Col., R. F. A. : Modern Guns and Gunnery, 1910 Woolwich F. J. Cattermole, 1910, 76. (6) Ibid., 154. (7) La Garde, Louis A., Col. U. S. Army Medical Corps (Retired): Gunshot Injuries, How They are Inflicted, Their Complications and Treatment. New York William Wood and Company, 1916, 33. (8) Bethel, Op. cit., 201. (9) Ibid., 159. (10) America's Munitions, 120. (11) History of the Great War Based on Official Documents, Medical Services, Surgery of the War. London, His Majesty's Stationery Office, 1922, I, 31 32. (12) The Encyclopedia Britannica, new volumes, 1922, xxx, 263. GENERAL SURGERY 00 (13) Ibid., 119-122. (14) Fauntleroy, Op. cit., 25. (15) Ibid., 24. (16) America's Munitions, 202. (17) Snow, Chester R., Maj., Trench Art.: Ordnance and its Effects. The Military Surgeon, Washington, 1919, xlv, No. 1, 23. (IS) Fauntleroy, Op. cit., 15. (19) America's Munitions, 208. (20) Ibid., 303. (21) Ibid., 305. (22) The Encyclopedia Britannica, xxxii, 277 285. (23) America's Munitions, 178. (24) Ibid., 180. (25) Handbook of the German Army in War, April, 1918. Issued by the General Staff (British), 57, 60, 61. On file, Library, Army War College, General Staff, D 609, G 3, G 71 (1918) 48,628. (26) Ayres, Leonard P., Col., G. S., Chief of the Statistics Branch of the General Staff: The War with Germany, a Statistical Summary. Washington, Government Printing Office, 1919, 68. (27) The Encyclopedia Britannica, xxxi, 819. (28) America's Munitions, 162. (29) Pollard, H. B. C, Capt., The London Regt,: Automatic Pistols. London, Sir Isaac Pitman and Sons, Ltd., 1920, 94, 95. (30) Ibid., 17-27. (31) The Encyclopedia Britannica, xxxii, 105-107. (32) America's Munitions, 188. (33) Training Regulations No. 320-10, War Department, Washington, March 12, 1924, 44. (34) Description and Rules for the Management of the United States Rifle, Caliber .30, Model of 1917, October 8, 1917, Revised January 16, 1918, Revised May 7, 1918. Washington, Government Printing Office, 1918, 65. (35) British and German Small Arms Ammunition, memorandum communicated by the War Office respecting British and German ammunition. British Medical Journal, London, 1914, ii, 895. (36) Wilson, Louis B., Col., M. R. C, U. S. Army: Dispersion of Bullet Energy. The Military Surgeon, Washington, 1921, xlix, No. 3, 241. (37) La Garde, Op. cit., Table I. (38) America's Munitions, 197. (39) Handbook of the German Army, 50. (40) America's Munitions, 196. (41) Ibid., 198. (42) The Encyclopedia Britannica, xxx, 136. (43) Historv of the Great War, 10-12. (44) Training Regulations No. 320-15, War Department, Washington, March 3, 1924, 5. (45) La Garde, Op. cit., 75. 146) Ibid., 74. (47) Ibid., 69. (48) Textbook of Small Arms, 1909, printed for His Majesty's Stationery Office. London, Harrison and Sons, 187. (49) Wilhelm, Glenn P.: Long Range Small Arms Firing. Army Ordnance, Washington, 1922, ii, 299-303. (50) Bethel, Op. cit., 14. (51) La Garde, Op. cit., 96-115. (52) Stevenson W. ¥., Surgeon-Colonel, Army Medical Staff: Wounds in War, the Mechan- ism of Their Production and Their Treatment. New York, William Wood and Company, 1898, 77-85. (53) Based on Sick and Wounded Reports made to the Surgeon General, I . S. Army. 56 SURGERY (54) Bethel, Op. cit., 29. (55) La Garde, Op. cit., 412. (56) Based on reports made to The Adjutant General of the Army. (57) Special Report No. 178, Statistics Branch, General Staff, W. D., February 25. 1924. Copy on file, Historical Division, S. G. O. (58) Ministere de la Guerre, Direction du Service de SantS, Etude de Statisque Chirurgicale. Guerre de 1914-1918. Paris, Imprimerie Nationale, 1924, Tome Premier. (59) La Garde, Op. cit., 422. (60) Ibid., 61. (61) History of the Great War, Op. cit., 46. (62) Mairet, A., and Durante, G.: Etude Experimentale du Syndrome Commotionnel. Paris, Presse medicate 1917, xxv, No. 46, 478. (63) La Garde, Op. cit., 414. CHAPTER III STATISTICS The statistics presented in the following pages for the American Expedi- tionary Forces, unless otherwise stated, include only data for the United States Army (not including marines), exclusive of troops in North Russia and in Siberia. Revised statistics for battle casualties were published in the Surgeon General's Annual Report for 1920, Tables 1-43, inclusive (pp. 27-104, inclusive). As stated in that report, 5,768 military patients, whose admission had been caused by injuries received in battle in our expeditionary forces (exclusive of Russia and Siberia), remained in Army hospitals in the United States at the close of the calendar year 1919. Data for battle casualties published in the Surgeon General's Annual Report of 1920 could not include final disposition and time lost subsequent to January 1, 1920. Here, the later date of publica- tion has resulted in more complete data. Circular No. 87, W. D., March 29, 1921, required that all patients from the war army, officers excepted, remaining in hospital on Jul}- 2, 1921, should be discharged from the military service, thus separating them finally from Army records or military status. In consequence of these instructions it has been possible to include all military data for battle wounded, including those for the men whose military service terminated between January 1, 1920, and July 2, 1921, and these will be found included in the final statistical tables for battle casualties which appear here. Some of the tables which appear in this chapter are reproduced from the 1920 Annual Report of the Surgeon General, but no subsequent reference will be made here to that report. If any differences in the tables contained in this volume and in those published in the Surgeon General's Annual Report of 1920 are detected,0 preference should be given to those published here, as every opportunity possible has been taken to perfect the tables and to eliminate any errors which might unavoidably have been included in the earlier tables. No attempt is made to include killed in action. Reports were made to the Surgeon General's Office of only a small percentage of killed in action, and the information so furnished was too meager in character to be of any present value. battle injuries ADMISSIONS Lacerated wounds caused the admission of 46,549; penetrating wounds 42,374, and fractures 25.272. _______________ .E.e«D7in. tables 23 and 24, casualties from gases have been excluded from the tables herein. It was not possible to d.S%Cbles 23 and24 D_ta on wounds from gases are given in Chaper VIII, Volume XIV of this history.-*,*. 57 f)X SURGERY Table 8.—Battle injuries, admissions, officers and enlisted men, United States Army, 191, -IS « ABSOLUTE NUMBERS Diagnosis D islocation-------------------------------- Contusion--------------------------------- C oncussion____________________.....------- Crushing_________________________________ Decapitation.......------------------------- Exhaustion and exposure-------------------- Foreign body, traumatic-----.......--------- Gunshot wound, character of wound not specified Sprain of j oint------------------.....------- Strain______________......----------------- Traumatic amputation.......---------------- Wound: Contused------------------------------ Incised________________________________ Lacerated------------------------------ Punctured____________________________ Extensive........----------------------- Multiple___________________.....------- Penetrating.....------------......------- Perforating-----.....---------........— Character and cause not stated------------- Others, traumatic-----------------.....----- Total. a Source of information: Medical records sent to the Surgeon General's Office. DEATHS The total number of deaths from wounds received in action (not including deaths on field) was 12,470, a rate of 11.92 per 1,000 per annum; for enlisted men 11,881 deaths, rate 11.88; and officers 589, rate 12.57. (Table 9.) The deaths from penetrating wounds amounted to 4,976 or 4.75; multiple wounds 3,202, or 3.06; and fractures 2,751, or 2.63. Table 9.—Battle injuries, deaths from injuries, officers and enlisted men, United States Army, 1917-18 " ABSOLUTE NUMBERS Diagnosis Contusion--------------------------------- Concussion________________________________ Crushing---------------------------------- Decapitation_____.....--------------------- Exhaustion and exposure-------------------- Foreign body, traumatic........-------------- Fractures_________________________________ Gunshot wound, character of wound not specified Traumatic amputation---------------------- Wound: Contused______________________________ Lacerated----------------------------- Punctured----------------------------- Extensive----------------------------- Multiple------------------------------ Penetrating---------------------------- Perforating-----------------------...... Character and cause not stated------------ Others, traumatic.....---------------------- Officers Total- 142 245 46 3 Enlisted men White 2 4 3 1 1 1 1,686 55 45 4 249 1 2 1,650 2,566 392 11 52 Colored Color not stated 924 70 37 144 2 4 1,394 2,135 182 72 90 5,076 Total 3 11 16 2 2 1 2,634 125 82 4 398 3 6 3,060 4,731 577 83 143 11,881 Total officers and men 3 11 25 2 2 1 2, 751 128 5 410 3 6 3,202 4,976 623 12,470 •Source of information: Medical records sent to the Surgeon General's Office. GENERAL, SURGERY 59 DISCHARGES FOR DISABILITY The number of discharges for disability among the enlisted men as the result of battle injuries amounted to 21,822; among officers, 508; with a total of 22,330 for the two. (Table 10.) Penetrating wounds caused the discharge for disability of 4,982; multiple wounds, 3,130; and fractures, 11,740, 46.6 per cent of the total discharges. Table 10.—Battle injuries, discharge for disability, officers and enlisted men, United States Army, 1917-18 a ABSOLUTE NUMBERS Officers Enlisted men Total Diagnosis White Colored Color not stated Total 10 5 20 8 11,479 2 3 118 11 79s 6 4 3,065 4,866 1,044 15 366 officers and men 10 5 19 8 10,935 1 3 113 11 2 753 5 3 2,898 4,522 1,017 9 342 10 1 6 1 20 1 261 9 116 42S 1 11, 740 2 3 1 2 3 119 Wound: 11 2 20 1 15 30 1 1 124 293 12 6 15 818 7 4 65 116 22 43 51 15 3,130 4,982 1,066 15 20 50* 9 386 Total ______________.....-- 20,656 251 915 21,822 22,330 <■ Source of information: Medical records sent to the Surgeon General's Office. DAYS LOST The total number of days lost in hospital, including all time to July 1, 1921, amounted to 14,544,536 days. (Table 11.) The amount of time lost as the result of penetrating wounds was 3,697,759 days; multiple wounds, 2,017,208 days; fractures, 5,125,220 days, 29.3 per cent of the total. This does not really represent the total amount of time lost as the result of fractures, for as will be seen from Table 20, page 65, a number of fractures were tabulated as penetrating or perforating wounds. 60 SURGERY Table 11.—Battle injuries, days lost in hospital, offieers and enlisted men, United States Army. 1917-18 « ABSOLUTE NUMBERS Enlisted men Diagnosis Contusion_____________________ Concussion____________________ Crushing_____________________ Dislocation____________________ Exhaustion and exposure--------- Foreign body, traumatic________ Fractures____________________ Strain_______......__________ Traumatic amputation__________ Wound: Contused______________. ... Incised____________________ Lacerated__________________ Punctured_______________ . E xtensi ve__________________ Multiple___________________ Penetrating_________________ Perforating_________________ Character and cause not stated Others, traumatic......_________ Officers 962 2. 569 4 203 284 2 216,347 342 810 White 23, 560 24,467 2,370 4, 985 4, 376 2, 109 4, 542,472 5,825 54, 301 Colored 607 265 197 56, 250 140 851 Color not stated 3, 972 6,410 607 475 1,577 59 310,151 557 6,000 Total 1,302 33, 753 637 4,088 219 3,169 218 420 68,018 1,854,006 33, 541 253, 246 563 12,548 214 1,683 528 1,750,856 3 74, 421 23, 520 168,411 129,732 3,216,466 45, 361 306, 200 40, 661 962,405 13,067 111,849 624 18,615 546 3,713 4,510 113,610 1,889 15, 774 541,573 12,630,421 | 177,347 1,195,195 28. 139 21.142 3, 174 5, 468 5, 982 2, 175 4, 908, 873 6, 522 61, 152 38, 478 3,807 2,140, 793 14, 445 531 1, 942, 787 3, 568,027 1,087, 321 22,874 131, 273 Total officers and enlisted men 29,101 33,711 3,178 5, 671 6, 266 2,177 5,125,220 6,864 61,962 39,780 4,026 2,208,811 15,008 531 2,017,208 3, 697, 759 1,127, 982 23,498 135, 783 14.002,963 | 14,544,536 Total........___________________ <• Source of information: Medical records sent to the Surgeon General's Office. DURATION OF TREATMENT Of the 141,067 wounded who were treated in hospital, whose wounds did not result in death, the duration of treatment for 36,922 was 29 days or less, the average time per such case being 14.82 days. One hundred and four thousand one hundred and forty-five cases were treated in hospital for over 29 days, the average time for each such case being 133.25 days. (Table 12.) The average time in hospital for all cases that did not result in death was 102.26. Fractures required the longest treatment the average time being 225.50 days. Only 1,530 fractures in a total of 22,521, not resulting in death, were returned to duty in 29 days or less. Table 12.—Battle injuries, duration of treatment (fatal cases excepted), classification by cases under 29 and over 29 days, officers and enlisted men, 1917-18 a ABSOLUTE NUMBERS AND AVERAGE DAYS PER CASE Battle injuries Dislocation_______________ Contusion________________ Concussion_______________ Crushing_________________ Exhaustion and exposure____ Foreign body, traumatic____ Fractures.....____________ Strain___________________ Traumatic amputation_____ Wounds: Contused_____________ Incised_______________ Lacerated______..... Punctured____________ Extensive_____________ Multiple______________ Penetrating___________ Perforating____________ Character and cause not stated_______________ Others, traumatic_________ Total_______________ Under 29 days Num- | Number ber of : of days cases , lost 21 370 435 5 118 21 1,530 74 54 668 41 19, 264 146 1 2,379 8,034 2,383 19(1 1, 188 252 4,938 6,144 94 1,227 202 21,946 1,193 803 9,726 525 285, 854 2,233 9 34,864 117, 776 48, 803 1,613 14,990 Aver- age time 12.00 13.35 14.12 18.80 10.40 9.62 14.34 16.12 14.87 14.56 12.80 14.84 15.30 9.00 14.65 14.66 17.96 8.49 12.62 Number of cases Over 29 days Number of days lost 42 327 376 19 75 17 20, 991 77 552 453 41 26, 875 143 3 12,711 29,364 10, 265 229 1,585 36,922 547,192 14.82 104,145 5,419 24,083 27, 522 2,955 5,035 1,955 5, 056, 573 5,671 60,783 30, 033 3,501 1, 917,122 12, 579 518 1, 957, 558 3, 544,379 1,078, 286 21, 077 121, 972 Aver- age time 129.02 73.65 73.20 155.52 67.13 115.00 240.89 73.65 110.11 66.30 85.39 71.33 87.97 172. 67 154.00 120. 70 105.04 94.66 76.95 Total ------ Aver- Number Number age of of days time cases lost 63 5,671 90.02 697 29,021 41.64 811 33, 666 41.51 24 3,049 127.04 193 6,262 32.45 38 2,157 56.76 22, 521 5, 078, 519 225. 50 151 6,864 45. 45 606 61, 586 101.63 1,121 39, 759 35.47 82 4,026 49.10 46,139 2, 202, 976 47.75 289 14, 812 51.25 4 527 131.75 15,090 1,992,422 132.04 37, 398 3, 662,155 97.92 12, 648 1,121, 089 88,64 419 23,290 55. 58 2, 773 136.962 49.39 13.877.621 ( 133.25 | 141.067 14,424,813 102.26 ° Source of information: Medical records sent to the Surgeon General's Office. GENERAL SURGERY 61 DAY OF DEATH For the 12,470 who died in hospital as the result of wounds, the day of death was not stated in 930 instances. (Table 13.) Of the 12,707 deaths, for which the day of death was stated, 4,742 died on the first day. The propor- tional number who died on each day in hospital as the result of battle injuries is shown in Table 14. Table 13.—Battle injuries by diagnosis, deaths in hospital, showing the day of treatment on which death occurred, officers and enlisted men, United States Army, 1917-18 ° ABSOLUTE NUMBERS Diagnosis Day not stated_________________ First day______________________ Second day_____________________ Third day_____________________ Fourth day____________________ Fifth day______________________ Sixth day______________________ Seventh day_____________........ Eighth day_____ _________________ Ninth day________________________ Tenth day________________________ Eleventh dav_____________________ Twelfth day.. ___________________ Thirteenth day____________________ Fourteenth day----......----------- Fifteenth day_____________________ Sixteenth day_____________________ Seventeenth day___________________ Eighteenth day____________________ X i neteenth day____.....----------- T wentieth day____________________ Twenty-first day----------.....---- Twenty-second day.......---------- Twenty-third day_________.......... T wenty-fourth day-------.......--- Twenty-fifth day__________________ Twenty-sixth day__________________ Twenty-seventh day--------------- Twenty-eighth day________________ Twenty-ninth day_________________ Thirtieth day......._______________ Thirty-first to thirty-fifth day------- Thirty-sixth to fortieth day__________ Forty-first to forty-fifth day--------- Forty-sixth to fiftieth day----------- Fifty-first to fifty-fifth day.........—. Fifty-sixth to sixtieth day.. - ------- Sixty-first to sixty-fifth day------------ Sixty-sixth to seventieth day---------- Seventy-first to seventy-fifth day------ Seventy-sixth to eightieth day--------- Eighty-first to eighty-fifth day-------- Eighty-sixth to ninetieth day---------- Ninety-first to ninety-fifth day......- Ninety-sixth to one hundredth day---- One hundred and first day and over... Total. 2-= & 131 762 316 167 109 88 85 55 53 59 47 18 53 38 25 17 23 32 25 25 25 25 16 14 20 19 15 17 II 4 46 44 30 32 21 17 21 20 23 23 15 10 13 10 101 29 104 32 20 1 11 4 1 3 SI 10 6 1 1 1(1 1 1 11 2 1 1 2 8 8 3 1 4 1 1 ___ 5 6 2 3 2 4 1 1 3 1 4 2 3 3 3 3 5 3 1 2 2 2 1 2 ___ ___ 9 253 1,344 418 205 112 83 36 32 34 21 33 21 15 22 17 23 12 12 16 16 15 9 5 17 14 9 4 5 39 25 20 15 12 14 8 11 10 3 3 2 6 2 33 374 2, 086 665 292 170 102 128 101 82 76 114 53 53 33 46 37 31 40 32 25 12 23 19 15 '.9 16 19 13 84 i 410 . 3,202 4,976 • Source of information: Medical records sent to the Surgeon General's Office. 3 a£ 33 178 84 37 25 19 20 11 18 17 4 63 69 60 3 12 3 5 1 0 1 3 5 2 3 1 1 3 4 2 3 i | 3 1 i 14 11 ___ 2 5 8 l 3 l l 1 _____ i 4 1 ____1 1 930 ,742 , 553 735 445 310 329 250 210 200 172 153 155 146 102 90 101 92 96 80 68 63 63 57 47 49 54 57 33 2<; 59 49 47 51 44 36 29 19 29 21 189 INVALIDED HOME Forty-five thousand three hundred ninety-nine wounded were returned to the United States for further treatment. (Table 14.) Of this number 12,897 had received penetrating wounds and 15.542. or 34.23 per cent, had received 62 SURGERY fractures. Of the total number of fracture cases (25,272) 61.5 per cent were returned to the United States for further treatment. It should be explained here that all cases returned to the United States were not unfit for further military duty with the American Expeditionary Forces, for after the armistice, November 11, 1918, many cases were sent to the United States which otherwise would have been retained for treatment in Europe and ultimately returned for duty there. Table 14.—Battle injuries by diagnosis, wounded returned to the United^ States for further treatment, officers and enlisted men, United States Army, 1917-18" ABSOLUTE NUMBERS Diagnosis Dislocations____.............______ Contusions__________.....________ Concussion______________________ Crushing_______________________ Decapitation____________________ Exhaustion and exposure___.....___ Foreign body, traumatic___________ Fractures__________________...... Gunshot wound, missile not specified Strain_________________________ Traumatic amputation___________ Number of cases Per cent of total cases 17 11 15, 542 137 15 265 31.75 4.71 7.54 20.41 8.72 28.21 61.50 17.10 9.94 38.41 Diagnosis Number , Pft«j« °fcases ^es Wound: Contused___________________ Incised--------------------- Lacerated------------------ Punctured__________________ Extensive__________________ Multiple------------------- Penetrating----.....-------- Perforating_________________ Character and cause not stated. Others, traumatic--------------- 71 10 5,164 7,047 12, 897 3,392 138 462 Total. 45, 399 6.31 12.20 11.09 19.52 38.53 30.44 25. 56 27.33 20.52 » Source of information: Medical records sent to the Surgeon General's Office. MILITARY DESTRUCTIVE AGENTS The effectiveness of the military agents used by the enemy in inflicting wounds in battle is of great interest and importance to the medico-military student. Tables 15, 16, 17, and 18 show the number of cases, deaths, discharges for disability, and days lost, for officers and enlisted men, and for the total, which occurred as the result of the various military agents. Table 15.—Battle injuries by military destructive agents, admissions, officers and enlisted men, United States Army, 1917-18 « ABSOLUTE NUMBERS Causative agent Not stated_______....._______________ Aerial bombing_______________________ Airplane_____________________________ Explosion____________________________ Crushing____________________________ Cutting and piercing instruments (others). B ayonet_____________________________ Saber. Gunshot missile, kind not specified. Pistol ball______________..... Rifle ball______________________ Shell and shrapnel______________ Hand grenade__________________ Falling objects__________________ Indirect result of military agent--- Others, traumatic_______________ Officers Total. 2,758 12 816 1,683 31 8 60 66 75, 595 Enlisted men White 767 94 30 674 70 119 180 11 56, 540 196 16, 352 39, 490 672 115 994 1,388 117,692 tiered i Coj-not 956 12 289 631 33 18 18 41 2,059 346 8 9 140 4 13 50 1 14, 629 22 2,963 9,422 144 27 187 226 28,191 Total 1,130 120 39 829 79 136 232 12 72,125 230 19,604 49, 543 849 160 1,199 1,655 147, 942 Total offi- cers and enlisted men 1,193 124 74 879 82 139 235 12 74,883 242 20,420 51,226 880 168 1,259 1,721 153,537 » Source of information: Medical records sent to the Surgeon General's Office. GENERAL SURGERY 63 Table 16.—Battle injuries by military destructive agents—deaths from injuries, officers and enlisted men, United States Army, 1917-18 " ABSOLUTE NUMBERS Officers Enlisted men Total officers and enlisted men Causative agent White Colored Color not stated 82 7 1 4 1 Total Not stated....._________________ . . 10 1 9 1 49 8 2 9 2 1 2 2 4,033 7 592 36 3 6 30 1,943 131 15 3 14 3 1 4 3 7,112 13 910 54 13 8 55 3,542 141 Aerial bombing_________________ Airplane......._______________________ _____ 1 12 15 3 Explosion..........__________________ Crushing________......________________ Cutting and piercing instruments (others). . 2 1 3,035 3 312 16 9 2 24 1,577 4 3 Gunshot missile, kind not specified____________ 362 44 3 6 2 1 Pistol ball_________________........... Rifle ball_____________.......________________ 51 2 1 1 5 146 Hand grenade_______......______________ Falling objects_________________........... Indirect result of military agent................... 9 Others__________________......______________ 1 22 60 Shell and shrapnel_______.....____________ 3,688 Total_________________________........... 589 6,725 80 5,076 11. SSI 12,470 0 Source of information: Medical records sent to the Surgeon General's Office. Table 17.—Battle injuries by military destructive agents, discharges for disability, officers and enlisted men, 1917-18 " ABSOLUTE NUMBERS Causative agent Not stated______________________________ Aerial bombing__________________________ Airplane.....____________________________ Explosions______________________________ Crushing________________________________ Cutting and piercing instruments (others) . Bayonet_________________________________ Saber___________________________________ Gunshot wounds, kind not stated--------- Pistol ball_______________________________ Rifle ball________________________________ Shell and shrapnel____..........--------- Hand grenade___________________________ Falling objects___________________________ Indirect result of military agents---------- Others...........____.....—.....-------- Total. Officers 99 165 1 508 Enlisted men White Colored 107 38 7 162 5 9 2 6,732 26 3,972 9,206 176 5 117 83 82 41 111 3 20,656 251 Color not stated ' Source of information: Medical records sent to the Surgeon General's Office. 46997—27---7 152 471 IS Total Total officers and enlisted men 118 39 7 171 9 5 9 2 7,065 26 4,165 9,788 197 5 128 89 21,822 133 40 10 173 9 5 9 2 7,280 26 4,264 9,953 198 5 131 92 22,330 64 SURGERY Table 18. -Battle injuries by military destructive agents, days lost in hospital, officers and enlisted men, United States Army, 1917-18 " ABSOLUTE NUMBERS Causative agent Not stated________________............ Aerial bombing____________......_____ Airplane__________________............ Explosions....................__________ Crushing_____..........______________ Cutting and piercing instruments (other). Bayonet___.............._____________ Saber________________........_______ Gunshot missile, kind not specified_____ Pistol ball........................______ Rifle ball___________________________ Shell and shrapnel______________....... Hand grenade_______________________ Falling objects______.......__________ Indirect result of military agent_________ Others_________.....--------.......... Total..............._______________..... 541,573 12,630,421 177,347 Officers 2,663 1,079 3,722 3,708 36 285 369 Enlisted men White Colored Color not stated 197, 447 1,915 106, 639 207, 930 4,144 133 7,518 4,015 47, 359 12,930 4,170 33, 756 5,940 5,626 8,137 1,451 365, 341 18, 873 063, 902 815,191 68,021 5,490 65, 795 108, 439 877 529 1,073 533 126 182 122 69,848 1,035 29, 387 65,576 2,509 915 983 3,652 10,959 1,147 385 6,019 398 130 1,296 4 524,815 1,330 173, 764 448,416 7,270 1,017 7,560 10, 685 1,195,195 Total --------! officers and j enlisted Total men 59,195 14,606 4,555 40,848 6,871 5,882 9,615 1,577 5, 960, 004 21,238 2, 267,053 5,329,183 77, 800 7,422 74,338 122, 776 14,002,963 61, 828 15, 685 8,277 44,556 6,907 6,167 9,984 1,577 6,157,451 23,153 2,373,692 5, 537,113 81,944 7,555 81,856 126,791 14, 544, 536 ° Source of information: Medical records sent to the Surgeon General's Office. GUNSHOT MISSILES There were 147,651 men wounded by missiles. Of this number, the kind of missile was not specified in 74,S83 cases. In the 72,768 cases for which the missile was specified, rifle balls caused 20,420 wounds, or 28.06 per cent; shell and shrapnel 51,226, or 70.41 per cent; hand grenades 880, or 1.21 per cent; and pistol balls 242, or 0.33 per cent. The cases and deaths from missiles, with the case fatality for each, was shown in the following table: Table 19.—Battle injuries by missiles, admissions, deaths, and case fatality, officers and enlisted men, United States Army, 1917-18 ABSOLUTE NUMBERS AND PERCENTAGE RATES [Admissions and deaths from Tables 8 and 9, p. 58] Gunshot missile, kind not specified Pistol___________________________ Rifle____________________________ Shell and shrapnel-----------..... Hand grenade____________________ Deaths Case fatality (percent) 74,883 7,474 9.98 242 13 5.37 20,420 961 4.71 51, 226 3,688 7.20 880 56 6.36 ALL CAUSES As shown above, a very large percentage of the wounds received by Amer- ican officers and soldiers during the World War, which resulted in admission to hospital, were caused by artillery missiles. In addition to the wounds caused by the artillery missiles, there were no doubt many wounds by machine-gun missiles, though these would be shown in the various tables as rifle wounds. As a result, a large percentage of the men wounded received multiple wounds. Considering only two wounds to one individual, there were 42,023 more wounds than wounded men. Many of the multiple wounded were from artillery missiles and consequently of a more severe type; which factor, combined with their multiplicity, resulted in a much higher fatality rate—9.7 per cent, as compared with 5.3 for single wounds. GENERAL SURGERY 65 ANATOMICAL PART AND MILITARY DESTRUCTIVE AGENTS; CASE FATALITY RATES Table 20 shows, by the more important anatomical organs and parts, the number of wounds, deaths, and case fatality rates from rifle ball (including machine-gun bullet), shell, and shrapnel, and from other military agents (including the gunshot missiles not specified). In this table multiple wounds are included as well as single wounds; consequently, a death may be shown with a wound of a certain location or part, which would ordinarily not have resulted fatally, the patient at the same time having actually received a wound of another part, which caused the death. Therefore, the case fatality by re- gions, as here shown, is by no means literally true. For long bones it is fair to presume that when a wound is reported this necessarily implies a fracture. Such an inference, however, should not be made for wounds of the joints or for those of the extremities. With wounds of the joints, or of the extremities, wounds were sometimes described as pene- trating or perforating wounds, rather than fractures, even though fractures actually existed. Consequently, in Table 20, the number of cases shown as fractures for the joints or extremities do not necessarily include all of the fractures which were actually sustained. Table 20.—Battle injuries, by anatomical part and by military agent, admissions, deaths, and case fatalities, single and multiple wounds, officers and enlisted men, 1917-18 ° ABSOLUTE NUMBERS AND PERCENTAGE RATES Locations and tissues Admissions Rifle ball Abdomen and pelvis: Organs- Anus______________ Appendix__________ Bladder____________ Cecum_____________ Colon______________ Diaphragm--------- D uodenum......---- Gall bladder________ Ilium______________ Intestine, small______ Jejunum___________ Kidney____________ Liver______________ Mesentery__________ Omentum__________ Pancreas___________ Peritoneum_________ Rectum____________ Sigmoid____________ Spleen_____________ Stomach___________ Ureter_____________ Bones and muscles- Ilium________......- Ischium___.........- Pubic bone-------- Rectus abdominus--- Sacrum____.......... Regions— Epigastric.....------ Hypochondriac-...... Hypogastric-------- Iliac..........-......- Inguinal------....... Umbilical.....------- » Source of information: Medical Shell and shrap- nel 92 149 15 35 11 11 5 11 15 37 13 11 14 31 1 2 117 168 13 Others and not speci- fied 7 4 67 21 130 37 6 6 55 152 16 65 131 2 19 2 90 51 9 31 104 191 34 39 15 33 22 8 144 253 17 Total 15 5 125 31 222 67 10 11 103 272 33 129 258 13 38 4 162 102 17 51 144 4 432 84 61 31 100 57 67 11 340 511 36 Deaths Case fatality Rifle ball Shell and shrap- nel Oth- ers and not speci- fied 2 1 40 15 105 28 5 5 44 120 13 40 95 2 14 2 65 27 7 20 74 Total Shell Rifle and ball shrap- nel Others and not Total speci- fied 3 2 28.57 100.00 25.00 67 42.42 52.01 59. 70 20 50.00 50.00 71.43 171 72.00 71.65 80.77 45 36.36 68.43 75.68 8 100.00 50.00 83.33 7 33.33 50.00 83.33 75 1 55.56 70.00 80.00 205 63.27 76.05 78. 95 26 77.78 75.00 81.25 75 60.00 51. 28 61.54 173 56.82 63.85 72.52 6 40.00 33.33 100. 00 22 | 14. 29 58.33 73.68 4 !______ 100.00 100. 00 109 59.26 62.22 72.22 48 45.45 37.93 52.94 12 50.00 66.67 77.78 34 77.78 63.64 64.52 99 50.00 64.71 71.15 2 --- 66.67 111 14.13 22.15 34.03 17 26.67 14.29 23.53 16 27.27 45.46 20.51 6 20.00 27.27 13.33 39 26.67 48.65 35.42 7 • 7.69 18. IS 12.12 10 7.14 19. 30 13.64 9 25.00 8.33 25 8.86 5.13 82 12.22 15.48 17.79 8 15. 38 35.29 records sent to the Surgeon General's Office. T '> ,-ifc 20.00 40.00 53.60 64.52 77.03 67.16 80.00 63.64 72.82 75.37 78.79 58.14 67.05 46.15 57.89 100.00 67.28 47.06 70.59 66.67 68.75 50.00 25.69 20.24 26.23 19.35 39.00 12.28 14.93 18.18 7.35 16.05 22.22 66 SURGERY Table 20.—Battle injuries, by anatomical part and by military agent, adnrissions, deaths, and case fatalities, single and multiple wounds, officers and enlisted men, 1917-18 Continued ABSOLUTE NUMBERS AND PERCENTAGE RATES-Continued Locations and tissues Back: Bones and muscles- Coccyx_________ Rectus spinae___ Regions- Cervical________ Dorsal_____...... Interscapular____ Lumbar________ Lumbo-sacral___ Sacral.......____ Face: Bones- Malar........___ Maxilla- Inferior_____ Superior____ Nasal bone_____ Vomer_________ Zygoma-------- Parts— Chin___________ Cheek__________ Eye.............. Facial nerve____ Lip- Lower______ Upper______ Lips, both______ Mouth_________ Nose___________ Parotid_________ Tongue_________ Regions— Infraorbital_____ Orbital_________ Genital organs: Parts and location— Penis........____ Perineum_______ Scrotum.....____ Testicle________ Urethra.....____ Head: Bones- Frontal_________ Mastoid________ Occipital_______ Parietal________ Skull- Base________ Vault_______ Temporal_______ Parts- Auricle.....____ Brain__________ Ear..........___ Scalp__________ Ventricle_______ Regions— Forehead_______ Frontal.....____ Mastoid_______ Occipital_______ Parietal________ Supraorbital____ Temporal______ Lower extremity: Bones— Acetabulum____ Astragalus______ Calcaneum...... Cuboid.......... Rifle ball 7 3 25 94 1 209 1 24 3 5 35 246 141 7 7 15 33 7 23 43 14 47 24 24 24 31 133 Admissions Shell and shrap-nel Others and not speci-fied 4 5 1 24 53 171 229 12 26 664 855 3 15 66 61 23 31 387 548 107 154 33 35 6 11 9 15 178 216 1,137 1,487 854 1,189 11 15 52 67 126 154 11 20 34 54 274 335 9 4 11 25 45 53 22 38 62 63 23 17 101 170 90 112 8 19 151 191 31 29 98 130 159 206 93 219 145 268 86 134 79 140 136 1,065 197 310 888 1,158 1 1 351 462 137 174 144 157 307 373 247 311 176 196 353 413 7 6 74 123 123 164 15 27 Total 16 4 102 494 39 1,728 19 151 64 1,123 323 77 20 29 429 2,870 2,184 33 126 295 31 101 670 14 45 104 146 49 336 230 37 375 67 251 326 460 244 243 1,225 538 2,179 2 865 341 328 734 624 401 842 15 253 362 52 Deaths Case fatality Rifle ball shrap- not nel i speci- I fled Shell and Oth- ers and Total 4 1 35 100 3 153 2 10 104 23 1 1 1 12 53 85 Rifle ball 28.57 Shell and shrap- nel 36.00 18.09 9.09 100. 00 4.17 4.26 4.84 29.17 17.54 7.23 33.33 3.03 4.35 8.79 3.74 3.03 _____ 2.81 2.44 , 1.32 4. 96 ] 2. 81 4 49 76 163 165 51 2 266 4 31 1 1.92 3 11.11 10 6 22.22 29 3.08 17 7.14 7 20.00 103 27.27 7 14.29 70 13.04 123 I 23.26 230 42.86 259 40.43 77 16.67 2 375 5 47 2 58.33 3.23 2.26 3.23 4.35 9.90 7.78 12.50 18.54 6.45 18.37 23.27 65.59 51.72 25.58 69.85 1.85 6.06 10.53 1.79 1.46 100.00 2.85 3.65 3.47 3.26 4.05 1.71 3.12 42.86 8.11 2.44 GENERAL SURGERY 67 TKBr?JinZi?r!UC£J?™UhV Tati°mical ?art and ^ military aaent> admissions, deaths, arid case fatalities, single and multiple wounds, officers and enlisted men, 1917-18—Continued ABSOLUTE NUMBERS AND PERCENTAGE RATES-Continued Admissions Deaths Locations and tissues Lower extremity—Continued. Bones—Continued. Cuneiform— External_________ Internal_______ Middle__________ Femur___....._____ Fibula______________ Greater trochanter____ Malleous___________ Metatarsus__________ Patella_____________ Scaphoid (tarsal)_____ Tarsus (not specified).. Tibia___........_____ Location— Ankle— Fractures____..... Others "_________ Total. Hip- Fractures. Others <■-. Rifle ball 10 9 9 710 418 12 50 278 67 15 51 709 1 246 Shell and shrap- nel 14 7 10 1,143 882 30 93 357 163 13 74 1,425 Other; and not speci- fied 24 22 13 1,918 1,397 34 184 638 222 21 123 2,245 6 1,395 Total Shell Rifle and ball shrap- nel Oth- ers and not speci- fied Total 663 369 Total. Knee- Fractures. Others »__ TotaL Leg- Fractures. Others «.. Total. Thigh- Fractures . Others ".- 1 1,083 2 501 10 2,162 2,172 2,748 Total_____....... 2,756 Other locations- Foot_____________ Great toe_________ Heel_____________ Popliteal space---- Toe, not specified.__ Blood vessels- Femoral artery..... Popliteal artery---- Saphenous vein- External______ Internal______ Tibial artery- Anterior______ Posterior______ Nerves: Popliteal____.......--..... Sciatic nerve, great_______ Tibial nerve, anterior------ Tibial nerve, posterior----- Muscles and tendon: Adductor muscles.....---- Biceps femoris___________ Gastrocnemius----------- Gluteal__________.....---- Quadriceps extensor femoris. Tendo Achillis.-........--- 159 134 56 182 1,856 1,865 20 6,422 6,442 31 8,153 8,184 589 2 11 1,801 186 263 136 236 25 12 2 2 15 15 2 86 13 2,034 6 20 1,401 1,656 1,665 48 38 32 3,771 2,697 76 327 1,273 452 49 248 4,379 12 2,299 111 22 3 2 1 5 277 111 1 4 564 223 4 9 14 31 952 356 8 15 23 50 Case fatality Rifle ball Shell °^s\ s"aP-|sZi-'!TOta' 15.63 5.26 25.00 4.00 .36 24. 24 29. 41 12. 58 15.96 3.33 11.76 4.30 4.89 2. 24 2.19 7. 46 8. 59 13. 96 25.25 13.20 10.53 4.59 1.81 11.06 39 7 188 2,311 10 3,108 90 3,118 90 2,720 2,728 32 9,442 9,474 40 10,140 5,07 11 2 183 15 615 9. 46 li. 50 13.19 17. 28 16.67 1. 86 li. 05 14.04 8.33 2.00 2 300 302 22.22 11.06 7.32 I 8. 30 I 11.11 1 126 6 [______' 55.56 i 12.50 217 2.20 4.31 14.63 5,096 11 62 18,026 18,088 79 21,041 3,106 313 448 155 475 40 6 18 7 4 144 14 12 5 3 10 2,477 11 30 21,120 5,703 658 845 347 893 78 293 27 26 13 10 32 5,100 19 61 5 384 448 6 56 1 4 1 2 6 1 2 3 S 1 2 2 --- 4 1 3 1 1 1 1 30 131 -- 1 223 2.19 4. 56 | 4. 66 13 735 11 677 116 2 1,161 2.31 1,174 i 2.30 25.00 5.98 19 1,192 1,211 17S 25.81 5.40 3.11 2.15 1 250 1 2 1 2 411 1 1 3.57 .55 23.08 4.41 .85 32.00 8.33 100.00 13.33 26.67 1.59 3.49 5.09 11.11 12.50 20.00 7.69 6.44 5.00 25.00 7.70 6.76 3.73 .64 1.79 7.10 1.47 37.50 37.50 50.00 44.44 25.00 6.25 14.29 8.33 20.00 10.00 10.09 9.09 20.00 9.65 31.58 4.27 20.97 6.44 24.05 5.67 5.73 3.12 1.06 1.07 5.48 1.12 33.33 3.70 41.67 25.00 22.22 15.38 12.50 4.44 7.41 7.69 15.38 10.00 6.25 8.06 5.26 1.64 « " Others" properly include some fracture cases. 68 SURGERY Table 20.-BatUe injuries, by anatomical part and by military agent, °*™sf™sA*°^£nd case fatalities, single and multiple wounds, officers and enlisted men, 191, -18 con ABSOLUTE NUMBERS AND PERCENTAGE RATES-Continued Admii sions Deaths Case fatality )thers and not speci-fied Locations and tissues Rifle ball Shell and shrap-nel Dthers and not speci-fied Total Shell Rifle ' and ball | shrap-nel Oth-ers and not speci-fied Total Rifle ball Shell ( and >hrap-nel Total Neck: Organs- 2 11 2 8 4 3 9 17 8 9 9 10 3 11 7 10 36 114 1 8 324 2 171 6 32 227 13 18 10 331 32 12 25 12 14 12 9 3 14 137 194 3 23 564 10 263 6 49 389 8 32 14 40 110 2 342 . 60 22 42 25 27 15 25 11 25 220 378 4 33 1,115 15 559 15 99 729 23 62 33 104 229 9 4 5 6 8 7 4 1 1 1 99 91 3 9 345 7 109 3 110 1 3 2 14 1 4 10 7 14 11 13 2 2 1 1 176 158 3 13 602 9 196 1 6 189 2 5 3 1 20 1 1.21 15.63 50.00 32.00 58.33 28.57 8.33 11.11 33.33 1.17 3 1 2 1 2 2 4 3 7 1 1 27.27 50.00 25.00 25.00 66.67 11.76 44.44 33.33 70.00 33.33 9.09 16.67 31.82 33.33 Blood vessels- 44.00 48.15 Muscles and bones— 13.33 8.00 9.09 Sternocleidomastoid---- Locations— 5 1 1 47 70 41 25 1 36 42 --- 10.00 ...... 4.00 Spine: Parts and location- 87.23 100.00 33.33 1 36.84 72.26 46.91 100.00 39.13 61.17 70.00 41.44 6.12 28.28 12.50 9.38 14.29 12.73 50.00 80.00 41.80 Thorax: Organs or parts— 75.00 2 227 3 125 3 18 113 2 12 9 87 1 26 27 i 3 4 170 1 61 1 3 52 1 2 1 3 38.33 33.33 20.80 23.89 11.11 6.52 50.00 52.47 50.00 35.67 16.67 9.37 22.91 7.69 11.11 2.04 4.11 39.39 53.99 60.00 Muscles and bones— 6.67 6.06 Rib _______..... 25.93 Region- 8.06 9.09 15 | 49 46 73 4, 3 .96 8.73 Mediastinum__________ 11.11 14 : 27 10 1 13 18 i 16 223 1 550 | 35 14 13 633 242 114 13 2,007 949 108 6 1,230 27 363 7 7 1,014 10 76 37 47 1,406 497 201 23 4,020 1,851 240 9 2,475 54 806 17 13 2,150 19 2 2 2 24 18 4 2 5 3 44 32 7 5.71 14.29 1 3 6 3 17 8 3 5.56 1.35 7.14 23.08 13.51 ______ 15.38 3.09 | 3.79 6.38 3.13 Upper extremities: Bones— 84 28 4 724 393 47 171 59 6 1,289 509 85 3 770 16 306 6 4 699 4 4.68 5.08 7.44 3.51 6.44 Carpus (not specified)... Cuneiform (carpal)_____ 3.48 29 3 3 137 18 5 233 21 7 399 42 15 4.01 .76 6.38 10.63 3.54 5.88 11.61 2.21 6.48 9.93 2.27 6.25 475 11 137 4 2 | 437 5 8 2 42 1 24 68 36 118 1 62 1.68 1.46 5.46 6.25 7.84 5.53 9.92 4.77 1.85 7.69 1 39 1 76 1 14.29 3.85 33.33 6.03 7.69 Ulna________________ 9 28 1 2.06 4.01 25.00 3.53 5.26 Location— Arm- 3 . 1,482 22 4,734 24 6,668 49 12, 884 40 7 224 8 402 15 666 2.70 31.82 4.73 30.61 5.17 Total___________ . 1,485 4,756 6,692 12,933 40 231 410 681 2.69 4.86 6.13 5.27 Elbow- 1 168 4 557 784 13 1,509 1 11 2" 1 38 25.00 . 1.99 3.44 7.69 2.52 Total__________ 16. 561 795 1,522 Yi 2" 3S ______1 2.14 3.41 2.56 _l----- -. — » "Others" properly include some fracture cases. GENERAL SURGERY 69 Table 20.—Battle injuries, by anatomical part and by military agent, admissions, deaths, and case fatalities, single and multiple wounds, officers and enlisted men, 1917-18— Continued ABSOLUTE NUMBERS AND PERCENTAGE RATES-Continued Admissions Deaths Case fatality Locations and tissues Rifle ball Shell and shrap-nel 7 2,085 Others and not speci-fied Total Rifle ball Shell and shrap-nel Oth-ers and not speci-fied Total Rifle ball Shell and shrap-nel Others and not speci-fied Total Upper extremities—Continued. Location—C ontinued. Forearm— 6 764 12 2,781 25 5,630 5 2 46 1 87 3 138 .65 28.57 2.21 8.33 3.13 12 00 Others a____....... 2.45 Total_____ _____ 770 2,092 2,793 5,655 5 48 88 1 291 141 1 471 .65 2.29 3.15 25.00 6.06 2.49 Shoulder joint— 2 1,169 4 3,317 4 4,801 10 9,287 10.00 Others °.........-.. 32 148 2.74 4.46 5.07 Total___________ 1,171 3,321 4,805 9,297 32 148 292 472 2.73 4.46 6.08 5.08 Wrist- 2 205 4 631 9 999 15 1,835 1 16 1 27 11.11 1.60 6.67 11 1.74 1.47 Total...... .____ 207 635 1,008 323 1,207 579 840 551 4,717 1 571 3 39 2 5 25 10 49 9 119 249 38 212 43 302 18 104 24 3 152 23 189 648 107 80 27 1,850 658 2,219 1,088 1,525 1,073 8,447 2 1,034 5 86 9 3 7 40 27 102 20 238 455 80 421 78 654 49 228 54 4 266 34 376 1,169 229 150 58 --- 1 3 2 3 4 11 17 28 1.73 1.69 1.51 Other locations— Finger, not specified . Finger, index______ Finger, little_______ Finger, middle_____ Finger, ring________ Hand___.....----- Radiocarpal__._ .. Thumb - _______ 97 402 182 287 224 868 1 138 1 21 238 610 327 398 298 2,862 325 1 26 2 1 1 5 13 32 65 4 9 2 8 1 96 8 16 9 11 4 165 1.03 1.65 .70 1.34 .46 1.26 1.15 1.22 .25 ~~2.~27~ 1.24 . 35 . 95 . IS 2.04 1.22 .72 .83 .72 .37 1.95 2 1 8 1 5 11 2 6 1.45 .31 100. IK) 3. 85 1.40 33. 33 12. 82 1.06 Blood vessels— Axillary artery----- Brachial artery----- 40.00 6.98 Median cephalic _____' 1 1 100.00 --- 33.33 1 10 4 21 Radial artery....... 1 1 1 1 2 7.69 3.13 2.04 3.70 Nerves— Brachial plexus---- Circumflex nerve--- Median nerve------ Musculospiral nerve. Radial nerve_______ Ulnar nerve________ Muscles and regions— Acronial region----- 1.96 48 | 71 76 ' 130 14 ' 28 80 129 16 | 19 108 . 244 3 2 I 3 4 1.41 2.31 1.68 .40 1.26 .88 2 » 5 1 28 7 2 42 1.85 1.55 5.26 4.92 2.36 2.33 9.27 1.66 2.56 6.42 Biceps cubiti.......-Deltoid muscle----- Suprascapular------ 48 6 76 24 1 1 2 1 1.32 4.17 .96 .KS 1.85 Suprasternum------ Definite region not given: 45 i 69 7 , 4 66 , 121 295 ! 226 75 : 47 1--- 9 1 5 1 1 26 4 i i i 7 64 4 4 1 14 99 3 9 9 3 1 22 20.00 1.52 1.69 1.33 1 14.29 37.68 25.00 3.31 2.13 2.00 29.17 42.11 8.70 2.12 .62 .93 51.85 8.99 37.22 .67 20 7 ■>3, 625 50 24 60, 485 90,186 174,296 1,167 k 191 8,111 13, 469 4.94 6.93 7.73 - • "Others" properly include some fracture cases. 70 SURGERY BATTLE FRACTURES Since fractures of the long bones of the extremities caused such a large percentage of the total deaths from wounds (2,019 out of 12,192, or 16.56 per cent) and such a large number of days was consumed in convalescence (3,582,248 days out of 14,444,536, or 24.8 per cent) it is desirable to make a special study of them. Tables 21 and 22 are devoted to the study in question. In Table 21 a comparison is made by case fatality and loss of time, both for fatal cases and for those that did not result fatally; for the battle fractures, and for the simple and compound fractures, which occurred in the military serv- ice, but not as a result of injuries received in battle. In Table 22 battle fractures involving the long bones of the extremities are summarized. In this table only the six long bones of the extremities are considered, and when any fracture of one of these bones was associated with a fracture of any other bone of the body or with a wound of any other tissue of the body, the secondary lesions are omitted from consideration. This table shows the number of cases involving only one of the six long bones, those involv- ing two of them and lastly the total number of involvements of any of them. In this last section the excess number of cases, days, etc., is due to fractures involving two of these bones. For each of these classes, detailed information is given. The greatest number of patients was for the humerus, 3,549; and the great- est number of fractures was also for the humerus, 4,069. The largest number of deaths among patients was for the femur, 804; and the greatest number of deaths for fractures was also for the femur, 971. The highest case fatality was for fractures involving the fibula and radius. Since, however, this rate was based on only three cases, it is not significant. The highest case fatality rate (based on a significant number of cases) was for the fractures involving the femur and the humerus, 35.05 per cent. Table 21.- -Fractures (all), battle and nonbattle, of long bones, officers and enlisted men, 1917- 1919. Case fatality and average days lost. Percentage rates a Fractures Femur... Fibula— Humerus Radius.. Tibia___ Ulna___ Fatality Fractures, not in battle Simple 3.49 .24 .20 .16 .30 .10 Com- pound 19.50 5.04 5.05 3.38 4.24 Gun- shot battle frac- tures 25.22 13.20 10.17 4.77 14.04 3.53 Days lost per case Total Died Recovered Fractures, not in battle Simple 178.2 73.7 85.5 47.9 99.6 45.3 Com- pound Gun- shot battle frac- tures Fractures, not in battle 230.6 157.3 173.7 150.9 196.5 130.4 249.1 222.3 218.6 198.2 229.9 192.2 Simple 6.9 37.0 39.0 47.4 32.4 19.0 Com- pound 11.0 56.1 42.0 5.3 26.3 6.0 Gun- shot '__ battle frac- | tures ] Simple Fractures, not in battle 18.6 9.5 14.6 16.2 11.5 6.0 184.4 73.7 85.6 47.9 99.9 45.3 Com- pound Gun- shot battle frac- tures 283.8 162.6 180.7 155.9 204.0 131.5 326.9 254.6 241.7 207.3 265.6 205.3 •> Source of information: Medical records sent to the Surgeon General's Office. GENERAL SURGERY 71 Table 22.—Battle fractures of the long bones, admissions, deaths, recoveries, and case fatality, annual admissions, deaths and noneffective. Rates per 1,000 Cases Days lost Fractures Fractures involving only one of the following long bones: Femur......_____________ Fibula.........__________ Humerus________________ Radius______.....______ Tibia________________ Ulna___________________ Fractures involving two of the following long bones: Femur and fibula_________ Femur and humerus_______ Femur and radius_________ Femur and tibia__________ Femur and ulna__________ Fibula and humerus______ Fibula and radius_________ Fibula and tibia___.....___ Fibula and ulna__________ Humerus and radius.....___ Humerus and tibia________ Humerus and ulna________ Radius and tibia_________ Radius and ulna__________ Tibia and ulna___________ Total and average_______ Fractures involving the follow-- ing bones alone or in conjunc- tion with one of the others named. Femur__________________ Fibula__________________ Humerus............._____ Radius__________________ Tibia___________________ Ulna____________________ 3,296 1,013 3,549 1,492 2,471 1,237 46 194' 73 177 64 27 3 1,6001 81- 132 83 84 33 742 15 804 55 304 48 251 26 278 16,339 2,019 3,850 2,697 4,069 2,475 4,379 2,150 971 356 414 118 615 76 Total and average________19, 620 2,550 Excess of fractures over j patients________________I 3,281 531 o ■ar- « -H ~ 2,492 24.39 958 5.43 3,245 8.57 1,444 3.22 2,220 10.16 1,211 2.10 30 34.78 126 35.05 56 23.29 119 32.77 56 12.50 22 18.52 1 66.67 1,322 17.38 8 122 7.58 <2> C3 £ O c 859, 547 16, 053 106,536 779,602 4,847 257,131 1,477 521,701 3,709 208, 162 182 24.10 8. 33 21.21 4.58 6.67 14, 320 2,879 2,341 3,655 2,357 3,764 2,074 17, 070 12.36 25.22 13.20 10.17 4.77 14.04 3.53 13.00 6,179 31,449 13, 07* 37, 084 11, 866 4, 524 476 419,121 2,413 2, 661 . 34, 683 15, 171 24, 209 9, 796 175, 347 3, 925 3,582,248 31,971 959,203 18,041 599,497 3,369 889,638 6,044 490,511 1,906 1,006,7981 7,047 426,170 459 4,371,817 36,806 3,569 4,i 843,494 165,728 774,755 255,654 517,992 207,980 6,069 30,639 12,928 36,304 11,728 4,490 472 416,708 2,661 34,510 15,040 24,160 9,783 175, 258 3,924 Average days lost Annual rates per 1,000 260.8 164.4 219.7 172.3 211.1 168.3 134.3 6.9 162.111.9 179.2 8.8 20.0 33S. 5 14.7 173.0 15.9, 23S.8 30.8 177.0 14.8 233.3 7.0 171.7 3 15 0 -- 97 05 3 39 29 1 43 05 2 36 24 1 18 02 209.5 185.4 167.6 158.7 262.0 8.7 332. 61.... 262.8 17.3 13.4 17.3 6.8 2.(1 182. 8 288.2 296.8 236.3 261.7 202.3 243. 2| 230.9 305.1 209.4 204. ] 472. (I 315.2 332. 6 282. 9 238. 7 313.8 376.3! 247.51 280.3 2.25 .44 2.04 .67 1.37 .54 .02 .08 .03 .10 .03 .01 .00 1.10 .01 .09 .04 .06 .03 .46 .01 3, 550, 2 PHYSICAL DISABILITIES FROM WOUNDS Tables 23, 24, and 25 show the definite physical disabilities, which resulted from wounds received in battle, for cases in which the information furnished was definite and not too general in character to catalogue. Physical disabilities are catalogued for 19,768 men of the 25,1ST who were discharged for disability. Thus in 5,419 the definite disabilities were not tabulated, but in many they were shown as associated diseases. Amputations.__In Table 25 some of the more interesting final results of definite disabilities are considered. From this table it will be seen that the total number of soldiers who lost part of one or more extremities was 4,403. So far as the Surgeon General's Office has been able to determine, only one soldier who recovered lost both legs and one arm; 11 had amputations through both thighs, 1 through both legs at the knee; 9 had both legs amputated below the knee; 1 had both feet amputated; and 3 had one arm amputated above the elbow and one leg through the thigh. 72 SURGERY Loss of eyes or eyesight.—If traumatic cataract is counted as the loss of the sight of an eye, 66 men lost either both eyes or the sight of both eyes. In 44 the loss of sight of both eyes was partial, and 644 men lost one eye or the sight of one eye. Anlcylosis.—Four thousand nine hundred and seventy soldiers had a partial or complete ankylosis of one or more joints. Table 23.—Summary of definite physical disabilities which resulted from battle injuries, officers and enlisted men, 1917—18" ABSOLUTE NUMBERS Injuries Loss of extremities Upper extremity: One arm above elbow......_________ One arm at elbow__________________ Both forearms_____________________ One forearm_______________________ One hand at wrist__________________ Both hands_______________________ One hand___________...........____ Part of both hands_______............. Part of one hand___________________ One arm and one forearm____________ One arm above elbow and part of hand. One arm below elbow and part of hand. One forearm and one hand......._____ One hand and part of hand........____ Total. Lower extremities: Both thighs_________________ One thigh__________________ Both legs at knee________..... One leg at knee______.......... Both legs below knee............ One leg below knee___________ Both legs at ankle____________ One leg at ankle_____________ Both feet....._______________ One foot____________________ Part of both feet_____________ Part of one foot______________ Thigh and leg at knee_________ Thigh and leg below knee_____ Leg at thigh and leg below knee. Leg at knee and part of foot____ Leg below knee and foot_______ Leg below knee and part of foot. Total__________________ Upper and lower extremities: Arm above elbow and one thigh....... Arm above elbow and leg below knee. Arm above elbow and one foot______ Arm above elbow and part of one foot. Arm below elbow and one thigh_____ Arm below elbow and leg below knee. One hip and part of hand__________ Leg at thigh and part of hand_______ Leg at knee and part of hand.......... Leg below knee and part of hand_____ Total. Grand total.......____ Injuries to eyes Loss of both eyes.......... Loss of one eye_________ Loss of sight of both eyes. Loss of sight of one eye... Amaurosis____________ Amblyopia......------- Cataract, traumatic____ Num- ber 550 41 3 212 26 1 18 4 1,481 1 4 1 2 2 Injuries 2,346 11 1,137 1 95 9 327 3 131 1 20 3 280 2 4 1 2 2 3 2,032 4,403 14 447 30 170 4 37 27 Injuries to eyes—Continued Loss of eye and loss of sight of eye.....----- Loss of eye and amblyopia________________ Loss of eye and cataract, traumatic________ Loss of sight of one eye and amblyopia_____ Loss of sight of one eye and cataract, traumatic Total_______......____________ Ankylosis of joints Ankylosis: Bony, of— One hip....._____________________ Both knees______________________ One knee________________________ Both ankles______________________ One ankle.....____________________ One shoulder____________________'.. One elbow__________________....... One wrist________________________ Spine___________________________ One knee and one ankle____________ Total__________________________ Fibrous, of— One hip................____________ Both knees_____________.....____ One knee________________________ Both ankles______________________ One ankle.....____________________ One shoulder_____________________ Both elbows__________....._______ One elbow__________________...... Both wrists______________________ One wrist_______________......____ Foot, joints of________............... Hand, joints of_______.....________ Hip and knee____________________ Hip and hand_____________.......". Knee and shoulder..........________ Knee and wrist_________________ Knee and hand___________________ Knee and ankle___________________ Ankle and shoulder____________ Ankle and foot________________ Ankle and hand________________" Foot and wrist__________________ Shoulder and elbow_____ Shoulder and wrist_____________ Shoulder and hand__________ Elbow and wrist___________ Elbow and hand___________ Wrist and hand______.........__...! Total__________________________ Partial, and deformities of— One hip......______..... Both knees____________"" One knee_____________"". Both ankles___________~ One ankle______________ Both shoulders________'.'.'.""" One shoulder________ Both elbows_____ Num- ber 15 4 104 1 69 52 101 37 64 1 83 1 407 5 272 237 1 352 1 177 218 712 2 2 3 1 4 9 3 1 2 2 9 1 1 5 3 5 2,519 92 13 478 5 363 1 330 « Source of information: Medical records sent to the Surgeon General's Office. GENERAL SURGERY 73 Table 23.—Summary of definite physical disabilities which resulted from battle injuries, officers and enlisted men, 1917-18—Continued Injuries Num-ber 407 1 207 2 3 3 1 1 1 1 2 4 1 7 Injuries Num-ber Ankylosis of joints— Continued Ankylosis—Continued. Partial, and deformities of—Continued. One elbow... Ankylosis of joints—Continued Ankylosis—Continued. Bony, and partial deformities of— 1 Both wrists. 1 One wrist_____ 1 Hip and knee... 1 Hip and ankle_______ Total Knee and ankle_____ 4 Knee and shoulder .. Fibrous, and partial deformities of— Knee and elbow......... Knee and wrist_____ 1 Ankle and elbow_______ 2 Ankle and wrist________ 1 Shoulder and elbow____ 1 Shoulder and wrist_______ 1 Elbow and wrist________ 1 3 2 5 6 Total.....__________ 1,925 Bony and fibrous— 1 1 1 1 2 1 1 Hand and elbow___________________ . Knee and ankle______....... 20 Total . ________ Shoulder and knee______ ______ 43 Elbow and ankle____________ 10 Wrist and shoulder__________ ________ 12 Wrist and hand______________________ 1 Total.....__________ 8 4,970 Table 24.—Associated physical disabilities (fatal cases excepted), resulting from battle injuries in 19,768 officers and enlisted men, 1917-18" Amaurosis_______________________________ and paralysis of facial nerve_____________ Amblyopia______________________________ and adherent scar____________________ and disfigurement, facial-------------- and loss of eye________________________ Aneurism, abdominal_____________________ Aneurism, aorta thoracic___________________ Aneurism, arm Qocation not given)_____...... and fracture, faulty union______________ Aneurism, arteriovenous___________________ Aneurism, artery, axillary__________________ Aneurism, artery, carotid__________________ Aneurism, artery, femoral__________________ Aneurism, leg, right.....___________......... Aneurism, thigh (location not given)----..... Aneurism, unclassified____________________ Ankylosis, bony, ankle, right--------------- and fracture, faulty union-------------- and loss of leg at thigh----------------- Ankylosis, bony, ankle, left---------------- and ankylosis partial and deformity, shoulder. Ankylosis and adherent scar---------------- and fracture, faulty union-------------- Ankylosis, bony, ankle joints, both.....----- Ankylosis, bony, elbow joint, right---------- and ankylosis, fibrous, ankle--------..... and ankylosis, partial and deformity, wrist and adherent scar--------------------- Ankylosis, bony, elbow joint, left.........---- and ankylosis, fibrous, ankle------....... Ankylosis, bony, hip joint, right------------ Ankylosis, bony, hip joint, left-------------- Ankylosis, bony, knee joint, right.....------- and ankylosis, bony, ankle-------------- Ankylosis, bony, knee joint, left.........----- and amaurosis..............------------ Ankylosis, bony, knee joints, both...-------- Ankylosis, bony, shoulder joint, right.....---- and ankylosis, fibrous, knee------------- « Source of information: Medical records sent to Ankylosis, bony, shoulder joint, left___________ and adherent scar------.....------------- Ankylosis, bony, spine............------------- and adherent scar____.......----.....----- Ankylosis and fracture, faulty union----------- and loss of leg at knee________.....-------- and neuritis, following injury----............ Ankylosis, bony, wrist, right.....-------------- and ankylosis, partial and deformity, shoulder. and adherent scar____.....--------------- Ankylosis, bony, wrist, left--------............. Ankylosis, fibrous, ankle, right---------------- and ankylosis, fibrous, shoulder----------- and adherent scar----------......-------- Ankylosis, fibrous, ankle, left----------------- and ankylosis, fibrous, shoulder------------ and arthritis, chronic, ankle-------------- and adherent scar------------......-.....-- and fracture, faulty union----------------- Ankylosis, fibrous, ankle, both---------------- and adherent scar----------------------- and fracture, faulty union...........-------- Ankylosis, fibrous, elbow, right--------------- and amblyopia------------------------- and ankylosis, fibrous, shoulder------------ and ankylosis, fibrous, wrist-------------- and adherent scar----------------------- and fracture, faulty union.....------------- and paralysis of limb-------------------- Ankylosis, fibrous, elbow, left---------------- and ankylosis, fibrous, elbow-------------- and ankylosis, fibrous, shoulder------------ and ankylosis, fibrous, wrist-------------- and adherent scar----------------------- and fracture, faulty union.....-------------- Ankylosis, fibrous, foot, one or more joints (not q r» jrl*A_____________„___. -__-___- -_______- ■ and ankylosis, bony, knee---------------- and ankylosis, fibrous, ankle.......-------- and ankylosis, fibrous, wrist...........----- 16 1 59 3 1 1 1 11 1 1 17 90 1 4 126 1 1 5 1 3 1 1 119 1 1 3 5 3 1 120 1 1 1 6 1 205 1 1 2 the Surgeon General's Office. 74 SURGERY Table 24.—Associated physical disabilities (fatal cases excepted), resulting from battle injuries, in 19,768 officers and enlisted men, 1917-18—Continued Injuries Num- ber Injuries Num- ber Ankylosis and ankylosis, partial and deformity, ankle____.......------------------..... and ankylosis, partial and deformity, shoulder. and arthritis, chronic, ankle_________________ and adherent scar_______.....______________ and flail joint, ankle________________________ and fracture, faulty union__________________ and loss of sight, one eye____________________ and tendon, severed and contracted_________ Ankylosis, fibrous, hand or finger, one or more joints___________________________________ and ankylosis, bony, wrist_____......_______ and ankylosis, bony, shoulder_______......._ and ankylosis, fibrous, ankle________________ and ankylosis, fibrous, elbow......___________ and ankylosis, fibrous, hip__________________ and ankylosis, fibrous, knee............______ and ankylosis, fibrous, shoulder_____________ and ankylosis, fibrous, wrist________________ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, elbow.. and ankylosis, partial and deformities, knee.. and ankylosis, partial and deformities, shoul- der______.....__________________________ and ankylosis, partial and deformities, wrist.. and adherent scar__________________________ and disfigurement, facial____.....___________ and fracture, faulty union___________________ and fracture, nonunion_____________________ and loss of leg at thigh_____________________ and loss of sight, one eye____________________ and paralysis of facial nerve.....____________ and paralysis of limb_______________________ and tendon, severed and contracted_________ and loss of leg below knee___________________ Ankylosis, fibrous, hip, right___________________ and ankylosis, fibrous, knee_________________ Ankylosis, fibrous, hip joint, left________________ and ankylosis, fibrous, knee_________________ and adherent scar__________________________ and fracture, faulty union__________________ Ankylosis, fibrous, knee, right....._____________ and ankylosis, fibrous, ankle________________ and ankylosis, fibrous, shoulder_____________ and adherent scar________....._____________ and fracture, faulty union___________________ Ankylosis, fibrous, knee joint, left_______________ and ankylosis, bony, knee......._________..... and ankylosis, fibrous, ankle________________ and adherent scar__________________________ and fracture, faulty union___________________ Ankylosis, fibrous, knee joints, both_____________ Ankylosis, fibrous, shoulder, left________________ and ankylosis, fibrous, elbow.....____________ and ankylosis, fibrous, knee_________________ and ankylosis, fibrous, wrist.....____________ and adherent scar__________________________ and facial disfigurement____________________ Ankylosis, fibrous, shoulder joint, right__________ and ankylosis, bony, wrist__________________ and ankylosis, fibrous, ankle________________ and ankylosis, fibrous, elbow________________ and ankylosis, fibrous, knee_________________ and adherent scar__________________________ and fracture, faulty union__________________ Ankylosis, fibrous, shoulder, both_______________ Ankylosis, fibrous, wrist, right__________________ and ankylosis, fibrous, elbow________________ and adherent scar__________________________ Ankylosis, fibrous, wrist, left___________________ and ankylosis, fibrous, knee_________________ and adherent scar__________________________ and fracture, faulty union.....______________ Ankylosis, fibrous, wrist, both__________________ Ankylosis, partial and deformities, ankle, right___ and ankylosis, bony, knee_______......______ and ankylosis, partial and deformities, knee... and ankylosis, partial and deformities, wrist.. and adherent scar__________________________ and tendon, adherent in scars____......_____ Ankylosis, partial and deformities, ankle, left____ and ankylosis, partial and deformities, wrist.. and arthritis, chronic, knee.......___________ and adherent scar__________________________ 169 Ankylosis and fracture, faulty union------------- and hernia_____________.....--------........ Ankylosis, partial and deformities, ankle joints, both________________.....--------------- Ankylosis, partial and deformities, elbow joint, right_____________________________________ and ankylosis, partial and deformities, knee... and ankylosis, partial and deformities, shoul- der__________________........------------- and ankylosis, partial and deformities, wrist.. and adherent scar__________________.....--- Ankylosis, partial and deformities, elbow joint, left_______.....__________________________ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, wrist.. and arthritis, chronic, shoulder______________ and adherent scar__________________________ and frature, faulty union______....._________ and loss of leg at knee_______________________ and paralysis of facial nerve_________________ and paralysis of limb, lower, from cord injuries. Ankylosis, partial and deformities, elbow joints, both_____________________________________ Ankylosis, partial and deformities, hip joint, right. Ankylosis, partial and deformities, hip joint, left. and ankylosis, fibrous, elbow________________ and adherent scar_________________________ Ankylosis, partial and deformities, knee joint, right_____________________________________ and ankylosis, fibrous, elbow________________ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, hip___ and ankylosis, partial and deformities, wrist.. and adherent scar____________.....__________ and fracture, faulty union___________________ Ankylosis, partial and deformities, knee joint, left. and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, hip... and adherent scar___________________........ and fracture, faulty union___________________ Ankylosis, partial and deformities, knee joints, both___________________________________.. Ankylosis, partial and deformities, shoulder joint, right_____________________________________ and ankylosis, fibrous, wrist________________ and ankylosis, partial and deformities, elbow. and adherent scar__________.....____________ and tendon, adherent in scars_______________ Ankylosis, partial and deformities, shoulder joint. left.. ______________________T___ and ankylosis, partial and deformities, elbow. and ankylosis, partial and deformities, knee.. and adherent scar___________________________ Ankylosis, partial and deformities, shoulder joints," both_____________________________________ Ankylosis, partial and deformities, wrist joint," right_____________________________________ and ankylosis, fibrous, ankle____________II" and ankylosis, partial and deformities, elbow and ankylosis, partial and deformities, shoul- der______________________________________ and adherent scar_______________________ and fracture, faulty union__________IIII.IIII and tendon adherent in scars_____________ Ankylosis, partial and deformities, wrist joint", left" and ankylosis, partial and deformities, wrist.. and adherent scar_________________ and aphasia___________________IIIIIIII" Ankylosis, sacroiliac joint_____......_."" and loss of sight, one eye___________ Ankylosis, temporomaxillary joint . ...... and amblyopia________________ and ankylosis, fibrous, wrist. 1. 11111111 and adherent scar_____________ and facial disfigurement____IIIIII and loss of eye________________ Arthritis, chronic, ankle, right.. and ankylosis, partial and deformitiesVankYe" Arthritis, chronic, ankle, left.. Arthritis, chronic, elbow, right Arthritis, chronic, elbow, left____ and ankylosis, partial and deformities," "elbow" Arthritis, chronic, hip, right Arthritis, chronic, hip, left 1 5 3 162 1 1 1 7 1 1 1 1 2 33 36 1 1 212 1 3 1 1 7 1 206 2 1 1 1 133 1 1 4 1 138 2 1 5 GENERAL SURGERY /O Table 24.- ■ Associated physical disabilities (fatal cases excepted), resulting from battle injuries, in 19,768 officers and enlisted men, 1917-18—Continued Injuries Arthritis, chronic, knee, right___________________ and adherent scars__________________________ Arthritis, chronic, knee, left_____________________ and ankylosis, bony, wrist.......____________ Arthritis, chronic, knees, both__________________ Arthritis, chronic, shoulder, right________......_. Arthritis, chronic, shoulder, left_________________ Arthritis, chronic, spine________________________ Arthritis, chronic, wrist, right.....______________ Arthritis, chronic, wrist, left____________________ Arthritis, chronic, wrists, both__________________ Asthma_______________________________________ Atrophy of muscle, lower extremity. - _.....______ and ankylosis, bony, knee___________________ and ankylosis, fibrous, ankle________________ and ankylosis, fibrous, knee_________________ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, hip___ and ankylosis, partial and deformities, knee... and adherent scar__________________________ and fracture, faulty union___________________ and neuritis following injury_____.......____ and paralysis of limb_______________________ Atrophy of muscle, upper extremity_____________ and ankylosis, bony, elbow_________________ and ankylosis, fibrous, elbow________________ and ankylosis, fibrous, shoulder....._________ and ankylosis, partial and deformities, ankle. . and ankylosis, partial and deformities, elbow. and ankylosis, partial and deformities, knee... and ankylosis, partial and deformities, shoul- der______________________________________ and ankylosis, partial and deformities, wrist.. and adherent scar_____.....________________ and fracture, faulty union___________________ and loss of hearing, one side____.....________ and loss of leg below knee------.....-------- and paralysis of facial nerve_________________ and paralysis of limb_______________________ and pleurisy, chronic----.....-------------- Bronchitis, chronic_____________________________ and amblyopia----------------------------- and ankylosis, fibrous, elbow________________ and ankylosis, fibrous, knee_________________ and ankylosis, partial and deformities, elbow. and ankylosis, partial and deformities, knee... and ankylosis, partial and deformities, shoul- der____.....----------------------------- and asthma___________________________.....- and adherent scar----------------......---- and fracture, faulty union------------------- and loss of hearing, one side.....------------- and ioss of sight, one eye-------------------- and neuritis following injury---------------- and paralysis of facial nerve----------------- and tendon severed and contracted---------- Bulbar palsy___________________________________ Cardiac arryhthmia, others--------.....-------- Cardiac dilitation______________________________ Cardiac disorders, functional-----------......... and adherent scar-------------------------- and synovitis, chronic---------------------- Cardiac hypertrophy ------------------------- Cardiac hypertrophy and dilitation------------- Cataract, traumatic---------------------------- and adherent scar-------------------------- and facial disfigurement--------------------- and loss of arm above elbow----------------- and loss of arm below elbow----------------- and loss of sight, one eye-------------------- Cataract and loss of eye------------------------- Chest, deformities of, from injury--------------- Conjunctivitis, chronic_________________________ and amblyopia........---.......----.....--- Contracture, arm, right------------------------- Contracture, arm, left.......-------------.....--- and fracture, faulty union------------------- Contracture, leg, right---------------r.—.------ and ankylosis, partial and deformities, knee... Contracture, leg, left--------.............------- and ankylosis, fibrous, knee.....----.....----- and ankylosis, partial and deformities, ankle.. and adherent scar...............-.....------- Num- ber 1 2 1 7 2 4 10 2 1 2 103 1 4 2 1 3 1 1 5 1 I 1 1 4 1 2,281 4 1 1 1 1 1 5 5 1 2 1 1 1 1 1 3 4 100 1 1 4 3 22 2 2 Injuries Num- ber Contracture, legs, both________________________ Convalescent from wounds____________________ and ankylosis, partial and deformities, ankle. and ankylosis, partial and deformities, elbow. and ankylosis, partial and deformities, knee.. and ankylosis, partial and deformities, shoul- der______......_________________________ and ankylosis, partial and deformities, wrist.. and adherent scar_________________________ and fracture, faulty union__________________ and fracture, nonunion........______________ and loss of sight, one eye___________________ and tendon, severed and contracted_________ Deformities, larynx___________________________ and ankylosis, partial and deformities, shoul- der_____________________________________ Disfigurement, facial__________________________ and amblyopia......__________....._______ and ankylosis, partial and deformities, knee _. and adherent scar_________________________ Disfigurement, head.......____________________ Epilepsy___________........__________________ Epilepsy, Jacksonian......_....._______________ False joint of femur, right side__________________ False joint of fibula, right side__________________ False joint of fibula and tibia, right side_________ Fistula, biliary_________.......________________ Fistula, fecal___________......________________ and ankylosis, fibrous, hip..........._....... Fistula, other_________________________________ and ambl yopia_____......__________.....___ and rectum, loss of control of sphincter______ Fistula, rectovesical_________________........... Fistula, retroureteral............________.....___ Flail joint, ankle joint, right_________________ Flail joint, ankle joint, left_____________________ Flail joint, elbow joint, right_______........_____ Flail joint, elbow joint, left_____________________ Flail joint, elbow joint, both___________________ Flail joint, hip joint, left_______________________ Flail joint, knee joint, right.........____________ Flail joint, knee joint, left______________________ Flail joint, shoulder joint, right________________ Flail joint, shoulder joint, left----------- ----- and fracture, faulty union__________________ Flail joint, wrist joints, both.......------------- Flat foot, traumatic, right.......--------------- Flat foot, traumatic, left......----------------- and fracture, faulty union_____________ Flat foot, traumatic, both________________ — Fractures, deforming________.....--------- . and ankylosis, bony, ankle________________ and ankylosis, bony, hip......------------- and ankylosis, fibrous, ankle--------------- and ankylosis, fibrous, elbow_______________ and ankylosis, fibrous, hip......----------- and ankylosis, fibrous, knee________________ and ankylosis, fibrous, wrist________........ and ankylosis, partial and deformities, ankle- Fracture and ankylosis, partial and deformities, elbow.......---------------------------- and ankylosis, partial and deformities, hip... and ankylosis, partial and deformities, knee.. and ankylosis, partial and deformities, shoul- der____________________________________ and ankylosis, partial and deformities, wrist. and adherent scar_________________________ and facial disfigurement------------------- and fracture, faulty union.......----------- and loss of hearing, one side---------........ and nerves severed and contracted__________ and paralysis of limb......------------..... and synovitis, chronic-----------......---- Fracture, faulty union--------.....----......-- and amblyopia........-......-------------- and ankylosis, bony, knee..............---- and ankylosis, fibrous, ankle-----........... and ankylosis, fibrous, elbow____.....------ and ankylosis, fibrous, hip------............ and ankylosis, fibrous, knee.....----------- and ankylosis, fibrous, wrist_______________ and ankylosis, partial and deformities, ankle. and ankylosis, partial and deformities, hip... 2 554 2 3 1 2 2 6 3 1 1 1 3 4 18 2 1 1 1 1 1 292 1 2 5 4 1 16 1 2 1 76 SURGERY Table 24.—Associated physical disabilities (fatal cases excepted), resulting fro tn battle injuries, in 19,768 officers and enlisted men, 1917-18—Continued Injuries Fracture and ankylosis, partial and deformities, knee......_______..................._____ and ankylosis, partial and deformities, shoul- der........___________________....._____ and arthritis, chronic, ankle_______________ and adherent scar________________________ and facial disfigurement___________________ and loss of hearing, one side____.........___ and paralysis of limb_____________________ Fractures, old, ununited_______.....__________ and ankylosis, fibrous, knee_______________ and ankylosis, partial and deformities, elbow. and ankylosis, partial and deformities, hip___ and ankylosis, partial and deformities, shoul- der___________________.....___________ and ankylosis, partial and deformities, wrist.. and adherent scar________________________ Glaucoma, secondary_____.........----------- Heel, painful____________.....-------.....___ Hemiplegia__________________________....... and adherent scar________________________ and paralysis of facial nerve--------------- and loss of eye___________________________ Hernia, cerebral________.......----............. and amblyopia__________________________ Hernia of muscle________________________..... and ankylosis, fibrous, elbow________....... and ankylosis, partial and deformities, elbow. and adherent scar________________________ and paralysis of limb--------------.....--- Hernia, ventral_____________________.....--- and ankylosis, fibrous, shoulder____________ and adherent scar------------------------ and loss of sight, one eye------------------ and loss of eye.....---------------------- Insanity, total______________________________ Intestines, adhesions of______________________ Intestines, fistula of_________________________ Intestines, obstruction_____......------------- Intestines, partial loss of..-------------------- Kidney, loss of one, sequelae__________________ and ankylosis, fibrous, wrist_______________ and adherent scar________________________ Laryngitis, chronic______.........------------ and amblyopia_________.....------------ and adherent scar________________________ Leucoma______________________________..... Leucoma and adherent scar__________....._____ and 1 oss of eye__________________________ Ligament, relaxation of______________________ Loss of arm, right....._______________________ and ankylosis, partial and deformities, shoulder and adherent scar__________.....__________ Loss of arm, left____________......___________ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, knee... and ankylosis, partial and deformities, shoulder and loss of hearing, one side_______________ Loss of arm above elbow, right________________ and loss of eye__________________________ Loss of arm above elbow, left_________________ and ankylosis, fibrous, knee_______________ and ankylosis, partial and deformities, shoulder and paralysis of facial nerve____......______ Loss of arm at elbow, right___________________ Loss of arm at elbow, left_____________________ and ankylosis, knee__________.....________ Loss of bone tissue__________________________ and amblyopia__________________________ and ankylosis, bony, elbow__________....... and ankylosis, bony, hip__________.....____ and ankylosis, bony, knee______......._____ and ankylosis, bony, shoulder______________ and ankylosis, bony, wrist________________ and ankylosis, fibrous, ankle_______________ and ankylosis, fibrous, elbow______________ and ankylosis, fibrous, hip___________....... and ankylosis, fibrous, knee.....___________ and ankylosis, fibrous, shoulder............... and ankylosis, fibrous, wrist___.......______ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, elbow.. and ankylosis, partial and deformities, hip___ and ankylosis, partial and deformities, knee... Num- ber 1 1 13 2 1 1 34 1 1 1 1 3 2 1 2 39 1 1 1 2 1 10 1 2 1 15 1 2 1 1 2 26 1 2 2 4 1 1 42 1 1 18 2 1 16 102 1 1 106 2 1 1 1 153 1 168 1 1 1 20 20 1 266 2 3 3 4 5 2 10 3 4 11 13 Injuries Loss of bone tissue and ankylosis, partial and de- formities, shoulder-------................ and ankylosis, partial and deformities, wrist.. and arthritis, chronic, knee---------------- and arthritis, chronic, wrist----......------ and adherent scars_______________________ and contracture limb, lower--------------- and facial disfigurement.....--------------- and head disfigurement------------------- and epilepsy____________________________ and fistula, fecal_______.....-------....... and fistula, urinary__________........----- and flail joint, elbow_____________________ and flail joint, shoulder------------------- and fracture, union.......---------------- and fracture, faulty, nonunion------------- and neuritis, following injury-------------- and optic atrophy________________________ and paralysis of facial nerve_______________ and paraiysis of limb--------------------- and pleurisy, chronic--------------------- and tendon adherent in scars______________ and tendon severed and contracted_________ and loss of eye.......___.....------------- and loss of leg below knee_________________ Loss of forearm above wrist .right------.....___ and ankylosis, bony, elbow________________ and epilepsy, Jacksonian__________________ and loss of arm above elbow_______________ and loss of hand.....____________....._____ and loss of leg below knee......____________ Loss of forearm above wrist, left_______________ and ankylosis, fibrous, knee_______________ and adherent scar________________________ and loss of eye___________________________ Loss of forearm and loss of hand________.....___ and loss of leg below knee_________________ Loss of forearms above wrist, both_____________ Loss of ear, right______........_______________ and loss of hearing, one side_______________ Loss of ear, left_____________________________ Loss of eye, right_______________________...... and amblyopia__________________________ and ankylosis, bony, elbow________________ and ankylosis, fibrous, knee_______________ and ankylosis, fibrous, shoulder____________ and adherent scar________________________ and facial disfigurement___________________ and loss of arm above elbow_______________ and loss of sight, one eye___________.....___ and optic atrophy________________________ Loss of eye, left_____________________________ and amblyopia__________________________ and ankylosis, fibrous, ankle_______________ and ankylosis, fibrous, knee_______________ and ankylosis, partial and deformities, knee... and adherent scar_____.....______________ and facial disfigurement___________________ and loss of hearing, one side_______________ and loss of sight, one eye__________________ and paralysis of facial nerve___________..... Loss of eyes, both___________________________ Loss of foot, right___________________________ and loss of arm, above elbow__________ . . Loss of foot, left___________________________ Loss of feet, both___________________ Loss of foot, part of right______________......... and ankylosis, fibrous, hip________________ and ankylosis, fibrous, knee_______________ and ankylosis, fibrous, wrist_______________ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, knee... and adherent scar______________......____ and loss of hearing, one side_______________ and loss of leg below knee_________________ and paralysis of facial nerve_______________ and paralysis of limb.........______......___ Loss of foot, part of, left______________________ and ankylosis, fibrous, ankle________....... and ankylosis, fibrous, knee_______________ and adherent scar_____________.....______ and fracture, faulty union________________ and loss of arm above elbow_______________ and loss of eye_________________..... Num- ber 5 4 1 1 41 1 11 3 1 2 1 2 3 19 6 1 2 3 4 1 1 2 1 2 79 1 1 1 1 2 131 1 2 1 1 1 3 1 1 6 200 3 1 1 1 4 7 1 3 1 199 2 2 2 1 2 6 1 7 1 14 12 1 8 1 127 2 2 2 3 1 1 1 1 1 1 129 2 1 1 2 1 1 GENERAL SURGERY I i fABLE 24.- - Associated physical disabilities (fatal cases excepted), resulting from battle injuries, in 19,768 officers and enlisted men, 1917-18—Continued Loss of foot and loss of hearing, one side........ and loss of leg, below knee______________ and loss of leg at knee__________________ and optic atrophy----------........----- and paralysis of limb___________________ Loss of feet, part of both___________________ Loss of hand, all, right____________...-------- Loss of hand, all, left_____......-------------- and adherent scar___________.....________ and loss of sight, both eyes_____........_____ Loss of hand, all, both________.....---------- Loss of hand at wrist, right------------------- and ankylosis, partial and deformities, elbow.. Loss of hand at wrist, left_____________________ and adherent scar________________________ Loss of hand, part of right-------------------- and ankylosis, bony, shoulder______________ and ankylosis, bony, wrist---------------- and ankylosis, fibrous, knee--------------- and ankylosis, fibrous, shoulder------------ and ankylosis, fibrous, wrist--------------- and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, elbow.. and ankylosis, partial and deformities, knee... and ankylosis, partial and deformities, wrist.. Loss of hand and adherent scar--------------- and facial disfigurement------------------ and fracture, faulty union----------------- and loss of arm above elbow--------------- and loss of arm below elbow.........-------- and ioss of eye__________________________ and loss of hand, side not specified--------- and loss of leg below knee----------------- and loss of leg at hip--------------------- and loss of leg at knee-------------------- and loss of leg at thigh----------......---- and loss of sight, one eye----------------- and paralysis of limb--------------------- and paralysis of limb, upper, from cord in- juries_______________________________ and tendon, adherent, in scars------------ Loss of hand, part of, left-------------------- and ankylosis, bony, shoulder------------- and ankylosis, fibrous, elbow------------- and ankylosis, fibrous, hip--------.......-- and ankylosis, fibrous, knee-------------- and ankylosis, fibrous, wrist-----.-------- and ankylosis, partial and deformities, elbow. and ankylosis, partial and deformities, hip... and ankylosis, partial and deformities, wrist. and adherent scar-------.....----------- and fistula, urinary--------------------- and fracture, faulty union---------------- and fracture, nonunion------------------ and loss of arm above elbow......---------- and loss of ear__________________________ and loss of eye.....--------------------- and loss of hearing, one side-------------- and loss of leg below knee------......-..... and loss of leg at thigh----------........... and paralysis of limb..............--------- and pleurisy, chronic-------------------- and tendon, adherent, in scars........--..... Loss of hand, part of both..............-------- Loss of hearing, right ear-------------------- and adherent scar----------------------- and paralysis of facial nerve-------------- Loss of hearing, left ear--------------------- and facial disfigurement----------......--■ and loss of sight, one eye-----........---- and optic atrophy------......-------..... and paralysis of facial nerve-------.......-■ Loss of hearing, both ears-------......------- Loss of hearing, partial--------.........------ and amblyopia—.....------------......' and asphasia.........----.....----........ and adherent scar----------............... and loss of arm above elbow......--------- and loss of sight, one eye------............ and paralysis of facial nerve----.........— Loss of leg, right--------------------------- and adherent scar-------.....-—.......... Loss of leg, left----.......---.....-----..... and adherent scar-----......------------ 5 3 4 1 3 836 1 1 1 2 2 3 1 3 12 1 5 1 1 1 3 1 1 3 3 1 4 74 1 5 77 1 1 1 1 29 101 1 1 4 2 1 2 14 1 22 1 Loss of legs, both________________________ Loss of leg at ankle, right.....______________ and adherent scar_____________________ Loss of leg at ankle, left_____________........ and ankylosis, bony, ankle_____________ and ankylosis, bony, knee-------------- and adherent scar_____________________ and loss of eye_______________________ Loss of legs at ankle, both_________________ Loss of leg at knee, right__________________ and ankylosis, fibrous, knee........------ and adherent scar_____________________ and fracture, faulty union-------------- Loss of legs at knee, left___________________ and ankylosis, fibrous, wrist------------ and adherent sear_____________________ and facial disfigurement---------------- and loss of arm below elbow------------ Loss of legs at knees, both----------------- Loss of leg, middle third, right------------- and ankylosis, fibrous, elbow.........---- and ankylosis, fibrous, hip------------- and adherent scar________ -------------- and loss of arm above elbow-------......--- and loss of arm below elbow----.......----- and loss of eye---------------.........— and loss of leg at thigh-------------........ Loss of leg, middle third, left.....------------- and ankylosis, partial and deformities, knee... and adherent scar________.....---------- and loss of foot_____________........--..... and paralysis of limb........----.....------ Loss of legs, middle third, both.......--------- Loss of muscle_______________________.....-- and amblyopia------------------------- and ankylosis, bony, hip.......----.......... and ankylosis, bony, knee..................... and ankylosis, shoulder------------------ and ankylosis, fibrous, ankle-------------- and ankylosis, fibrous, elbow-------------- and ankylosis, fibrous, knee--------........ and ankylosis, fibrous, shoulder------------ and ankylosis, fibrous, wrist-------------- and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, elbow.. and ankylosis, partial and deformities, hip.... and ankylosis, partial and deformities, knee... and ankylosis, partial and deformities, shoulder_______.....----------.....— and adherent scar........---------------- and facial disfigurement------------------ and fracture, faulty union----------------- and glaucoma-------------------------- and loss of arm above elbow--------------- and loss of hearing, one side--------------- and loss of leg below knee----------------- and loss of leg at knee-------------------- and loss of leg at thigh---.....------------ and loss of sight, one eye.......------------ and paralysis of limb--------------------- and pleurisy, chronic------------.......--- and synovitis, chronic-------------------- and tendon, adherent in scar-------------- Loss of ribs, part--------------------------- Loss of scapula, right side--------.....-------- Loss of sight, right eye---------------------- and emblyopia.....--------------------- and ankylosis, fibrous, shoulder------------ and adherent scar----------------------- and facial disfigurement--------------..... and head disfigurement---.....----------- and leucoma adherens----............----- and loss of eye-----------.....---------- and loss of hearing, one side--------------- and optic atrophy.........--------------- Loss of sight, left eye---- ....... and ankylosis, partial and deformities, el bow_________________________-7—----- and ankylosis, partial and deformities, hip.... and adherent scar----------------------- and loss of eye-------------------------- Loss of sight of both eyes-------------------- and ankylosis, partial and deformities, wrist. and facial disfigurement......-----......--- 2 41 5 SI 1 1 1 1 3 31 1 1 1 50 1 1 1 1 1 154 1 1 3 1 1 1 1 157 1 4 2 1 9 404 2 1 1 1 2 11 8 13 1 6 4 4 7 1 3 2 1 1 1 2 1 1 1 1 1 1 2 1 89 1 1 1 3 1 1 2 1 1 71 1 1 2 1 31 1 1 78 SURGERY Table 24.—Associated physical disabilities (fatal cases excepted), resulting from battle injuries^ in 19,768 officers and enlisted men, 1917-18—Continued Injuries Loss of teeth___________________.....______ and ankylosis, bony, elbow______________ and ankylosis, fibrous, hip_____........... and adherent scar________________.....__ and facial disfigurement_________________ and fracture, nonunion__________________ and loss of eye_____.....________________ and loss of hearing, one side______________ Loss of teeth, and loss of sight, one eye.....____ Loss of testicle____________________________ and ankylosis, fibrous, knee______________ and ankylosis, partial and deformities, knee. and adherent scar_______________________ and facial disfigurement_________________ and loss of eye_________________________ and loss of leg at thigh___________________ and paralysis of limb____________________ and tendon adherent in scars_____________ Loss of thigh, upper third, right______________ and ankylosis, fibrous, ankle______________ and ankylosis, fibrous, shoulder___________ and ankylosis, partial and deformities, wrist. and adherent scar_______________________ and loss of arm above elbow______________ and loss of arm below elbow______.....____ Loss of thigh, upper third, left_______________ and ankylosis, bony, elbow_______________ and ankylosis, fibrous, elbow_____________ and adherent scar_______________________ and fracture, faulty union________________ Loss of thighs, upper third, both______________ Loss of thigh, middle third, right_____________ and ankylosis, fibrous, ankle______________ and adherent scar_______________________ and loss of leg below knee________________ and loss of leg at knee___________________ Loss of thigh, middle third, left_______________ and ankylosis, fibrous hip_______________ and ankylosis partial and deformities, wrist. and arthritis, chronic, knee_______________ and adherent scar_______________________ and flail joint, wrist_____________________ and fracture, faulty union________________ Loss of thighs, middle third, both_____________ Loss of thigh, lower third, right_______________ and amblyopia_________________________ and ankylosis, bony, knee......___________ and ankylosis, fibrous, elbow_____________ and ankylosis, fibrous, shoulder___________ and adherent scar_______________________ and loss of leg below knee_________________ pleurisy, chronic________________________ Loss of thigh, lower third, left________________ and amblyopia__________________________ and ankylosis, bony, knee_____________I.I" and ankylosis, fibrous, wrist___________ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, elbow. and adherent scar_____________________ and fracture, faulty union__________IIIIII and loss of arm above elbow___________"_'_'" and loss of leg below knee____________ " Loss of thighs, lower third, both___________I" Lung, foreign bodies in______■___________III.II! and ankylosis, partial and deformities, shoul- der__________________________________ and fracture, faulty union___________ " Monoplegia_______________________"I "I Nerve complication__________________"~ and amblyopia____________________ " and aneurism______________________ I"~ and ankylosis, bony, elbow__________II.II" and ankylosis, bony, knee_____________" and ankylosis, bony, wrist______________H" and ankylosis, fibrous, ankle____________II" and ankylosis, fibrous, elbow____________"'_ and ankylosis, fibrous, hip______________I" and ankylosis, fibrous, knee....._________I.I and ankylosis, fibrous, shoulder___________I and ankylosis, fibrous, wrist_______________ and ankylosis, partial and deformities, ankle.. and ankylosis, partial and deformities, elbow. Num- ber 74 1 1 15 30 1 1 1 1 32 1 1 6 1 2 2 2 1 122 1 1 1 3 1 2 95 1 1 5 1 1 245 1 3 2 2 245 1 1 1 2 1 3 7 193 1 1 1 1 2 1 1 202 1 1 1 1 1 3 1 2 1 3 1 1 4 646 3 1 7 2 2 9 37 2 10 6 13 1 6 Injuries Num- ber Nerve complication, and ankylosis, partial and de- formities, hip_________________________ and ankylosis, partial and deformities, knee. and ankylosis, partial and deformities, shoul- der__________________________________ and ankylosis, partial and deformities, wrist. and aphasia____________________________ and adherent scar_______________________ and facial disfigurement__________________ and fistula, urinary___________......_____ and flail joint, elbow_____________________ and fracture, faulty union________________ and fracture, nonunion___________________ and hernia_____________________________ and loss of arm above elbow______________ and loss of eye____....._________________ and loss of leg below knee____.....________ and loss of leg at knee____________________ and loss of leg at thigh___________________ and loss of sight, one eye__________________ and tendon adherent in scars______________ and tendon severed and contracted_________ N erves severed_____________________________ Nerves severed and contracted________________ Neuritis following injury, arm, right. _....._____ Neuritis following injury, arm, left_____________ and ankylosis, fibrous, ankle_______________ and ankylosis, fibrous, elbow______________ and adherent scar________________________ and loss of eye___________________________ Neuritis following injury, arms, both___________ Neuritis following injury, forearm, right________ and ankylosis, fibrous, wrist_______________ Neuritis following injury, forearm, left__________ Neuritis following injury, leg, right_____________ and ankylosis, fibrous, wrist_______________ and tendon severed and contracted_________ Neuritis following injury, leg, left______________ and ankylosis, partial and deformities, ankle. Neuritis following injury, legs, both____________ Neuritis following injury, thigh, right____ Neuritis following injury, thigh, left_________ Neuritis following injury, thigh, both______ Optic atrophy____________________________ and ankylosis, partial and deformities, knee and adherent scar________________________ Osteomyelitis___________________________ HI and ankylosis, bony, elbow_____________" and ankylosis, bony, shoulder_________ I and ankylosis, fibrous, ankle___________ and ankylosis, fibrous, elbow________ and ankylosis, fibrous, hip___________ and ankylosis, fibrous, knee_____ I and ankylosis, fibrous, shoulder______ and ankylosis, fibrous, wrist_______ and ankylosis, partial and deformities, ankle and ankylosis, partial and deformities, knee and ankylosis, partial and deformities, shoul- der__________________________ and arthritis, chronic, ankle____IIIIII and adherent scar______________" " and facial disfigurement____ I and fistula, fecal______________""" and fistula, urinary__________I." I and fracture, faulty union_____III" " "" and fracture, nonunion__________----- and loss of arm above elbow____ and loss of sight, one eye______ and neuritis following injury Paralysis, arm, right__________ and ankylosis, bony, ankle." I and ankylosis, bony, shoulder and ankylosis, fibrous, elbow. and ankylosis, fibrous, knee and ankylosis, fibrous, shoulder Paralysis and ankylosis, fibrous, wrist and ankylosis, partial and deformities,"elbow" and ankylosis, partial and deformities, knee and ankylosis, partial and deformities, wrist" and aphasia. and adherent scar_____ and fracture, nonunion. GENERAL SURGERY 79 Table 24.- Associated physical disabilities (fatal cases excepted), resulting from battle injuries, m 19,768 officers and enlisted men, 1917-18—Continued Injuries Paralysis and hernia______________________ and loss of sight, one eye___________II II and paralysis, facial nerve______"II I and paralysis of limb____________ Paralysis of arm, left____________________ and ankylosis, bony, elbow__________II and ankylosis, bony, shoulder______ and ankylosis, fibrous, elbow____________ and ankylosis, fibrous, wrist_____________ and ankylosis, partial and deformities, elbow and ankylosis, partial and deformities, shoulder and ankylosis, partial and deformities, wrist and adherent scar___.....______________ and flail joint, elbow________________II I and hernia__________________________I... 1111 and paralysis of facial nerve_____________ I Paralysis of arms, both______________________ Paralysis of arm from cord injuries, left.______1.11 and ankylosis, partial and deformities, elbow Paralysis, facial nerve right side__________....... and adherent scar_______.....______________ and fracture, nonunion_____________________ Paralysis, facial nerve, left side....._____________ and fracture, faulty union___________________ Paralysis, foot, right___________________________ and adherent scar__________________________ and loss of leg at thigh_______.....__________ Paralysis, foot, left_____________________________ Paralysis, hearing (auditory nerve)_________..... and paralysis of facial nerve_________________ Paralysis, leg, right____________________________ and ankylosis, fibrous, ankle________________ and ankylosis, fibrous, knee_________________ and adherent scar__________.....___________ and fracture, faulty union___________________ and loss of leg at thigh______________________ Paralysis, leg, left______________________________ and ankylosis, fibrous, elbow________________ and ankylosis, fibrous, wrist________________ and ankylosis, partial and deformities, knee... and adherent scar______....._______________ and loss of eye_____________________________ Paralysis, legs, both____________________________ Paralysis, leg. from cord injuries, right__________ Paralysis, leg, from cord injuries, left____________ Paralysis, legs, from cord injuries, both---------- Paralysis, rectum, from cord injuries------------ Paralysis, speech_______________________________ and ankylosis, fibrous, shoulder_____________ and loss of arm above elbow----------------- Paralysis, taste (gustatory nerve)_______________ Paraplegia_____________________________________ and paralysis of limb, upper, from cord injuries. Pleurisy and adherent pleura____________........ and ankylosis, fibrous, knee..........-........ and ankylosis, fibrous, shoulder_____________ and ankylosis, partial and deformities, elbow.. andankylosis, partial and deformities, shoulder and adherent scar..........----------------- and facial disfigurement—.......----------- and fracture, faulty union___________________ and hernia.........-------------------.....- Num- ber 206 26 128 20 29 260 Pleurisy and intestines, adhesion______________ and loss of eye___________________________ and loss of kidney, one____________________ and loss of sight, one eye__________________ and tendon adherent in scars______________ Rectum, loss of control of sphincter___________ Rectum, loss of portion______________________ Scar adherent or painful____....._____________ and ankylosis, bony, ankle________________ andankylosis, fibrous, ankle______________ and ankylosis, fibrous, elbow______________ and ankylosis, fibrous, hip________________ and ankylosis, fibrous, knee_______________ and ankylosis, fibrous, shoulder____......_. and ankylosis, fibrous, wrist______________ and ankylosis, partial and deformities, ankle and anklyosis, partial and deformities, elbow.. and ankylosis, partial and deformities, hip___ and ankylosis, partial and deformities, knee... and ankylosis, partial and deformities, shoulder and ankylosis, partial and deformities, wrist... and facial disfigurement___.......__________ and fracture, faulty union__________________ and fracture, nonunion_____________________ and loss of eye........_____________________ and loss of leg at hip_____________....._____ and loss of sight, one eye____............____ and neuritis following injury________________ and synovitis, chronic____......___________ Spleen, infection______________________________ Stenosis, esophagus____........._______________ Stenosis, rectum______________________________ and loss of arm above elbow________________ Stenosis, trachea____....................._______ Swollen arm, left, from injured blood vessels_____ Swollen arms, both, from injured blood vessels___ Swollen leg, right, from injured blood vessels_____ Swollen legs, both, from injured blood vessels..... Synovitis, chronic, ankle, left.....______________ and ankylosis, partial and deformities, ankle.. Synovitis, chronic, elbow, left...........___...... Synovitis, chronic, knee, right_________......___ Synovitis, chronic, knee, left___________......___ and ankylosis, partial and deformities, elbow.. and adherent scar_____________.....________ and paralysis of limb, upper, from cord injuries. Synovitis, chronic, shoulder, right___....._______ Synovitis, chronic, shoulder, left_____......_____ Synovitis, chronic, wrist, left___________________ Tendon adherent in scars______________________ and ankylosis, fibrous, ankle_____............ and ankylosis, partial and deformities, ankle.. and anklyosis, partial and deformities, knee... Tendon severed and contracted_________________ and ankylosis, bony, wrist____________...... and ankylosis, partial and deformities, ankle. . and ankylosis, partial and deformities, wrist.. and adherent scar__________________________ and paralysis of limb.......----------------- Thrombophlebitis_____........---------------- Num- ber Total_____________________..........--- 19,768 4699. 80 SURGERY ical disabilities resulting from wounds (excepting fatal cases), by military 3, and enlisted men, 1917-18; absolute numbers and percentage oj cacti itisa- Table 25.—Physic agents, officers, bility to the total number of cases wounded by the military agent* Rifle Shell and shrapnel Hand grenade Other gunshot Others Total 20,420 51,226 880 \'um- Per ber i cent 75,125 T N'um- Per ber cent 6 ' 0.01 5,886 153,537 Results Num-' ber Per cent Num-ber Per cent 1 0.03 .07 . 11 .01 Num-ber Per cent Num-; Per ber j cent Ankle, right: 3 16 39 1 0.01 .08 .19 .00 13 37 56 7 1 22 0.01 41 42 3 1 12 51 49 1 1 .05 l .06 .00 .00 .02 .07 .07 .00 .00 6 1 0.10 .02 94 | .06 Ankylosis, partial and deformities, of. 1 ! 0.11 144 .09 12 ! .01 i 1 i .00 Ankle, left: 11 34 48 4 .05 .17 .24 .02 21 44 74 3 .04 .09 .14 .01 44 134 173 9 1 2 1 5 5 .03 1 .11 4 1 .07 2 I .03 1 .02 .09 Ankylosis, partial and deformities, of. .11 .01 .00 2 1 2 3 .00 .00 .00 .01 .00 Ankles, both: .00 1 2 .00 .01 2 | .00 i .00 Ankylosis, partial and deformities, of. . .00 Ankle, s. n. s.: 3 11 11 1 1 11 21 3 2 52 .01 .05 .05 .00 .00 .05 .10 .01 .01 .25 2 14 38 1 .00 .03 .07 .00 5 62 60 4 3 104 154 20 22 221 .00 1 1 :__ 35 , .05 10 I .01 2 ! .00 1 .02 .04 Ankylosis, partial and deformities of. .04 .00 Arm right: 2 18 14 2 17 71 .00 .02 .02 .00 .02 .09 .00 71 115 15 2 95 .14 .22 .03 .00 .19 1 3 .n .34 3 1 .05 .02 .07 .10 .01 1 1 .11 .11 .01 2 .03 .15 Arm, left: 1 12 31 3 4 73 .00 .06 .15 .01 .02 .36 3 80 112 14 7 97 1 1 .01 .16 .22 .03 .01 .19 .00 .00 1 .11 2 , .23 1 16 .00 .02 5 111 171 21 24 243 1 1 .00 2 3 1 1 1 .03 .05 .02 .02 .02 .07 25 .03 1 i .00 12 i .02 72 .10 .11 .01 .02 .16 .00 .00 Arms, both: Neuritis, following injury__________ 1 2 .00 .00 i 2 3 1 1 21 9 2 79 6 77 .00 .00 3 1 .01 .00 .00 Swollen from injured blood vessels ... " I.. .00 Arm, s. n. s.: Aneurism of (location not given).__ _. 1 ; .00 3 .00 1 | .00 .00 2 .01 13 7 2 22 5 18 .03 .01 .00 .04 .01 .04 2 .23 1 .11 1 .02 .01 Loss of, below elbow_____ ________ .01 Ear, right: Loss of.. .. ___.. . . __________ .00 Loss of hearing of. ... __________ 4 .02 7 1 .01 1 .00 8 .01 46 .78 .05 Ear, left: Loss of___ .. . ... ___________ .00 Loss of hearing of. . . ___________ 1 .00 .05 Ears, both: Loss of hearing of. ... __ ____. . 3 1 6 1 21 14 47 73 2 .01 .00 .01 .00 .04 .03 .09 .14 .00 26 .44 29 1 15 3 110 43 133 174 5 J 3 .02 Ear, s. n. s.: Loss of_________..........------ .00 Loss of hearing, one side___ Paralysis, hearing (auditory nerve). 3 1 1 10 34 39 1 2 .01 .00 .00 .05 .17 .19 .00 .01 2 .23 1 .00 3 .00 17 09 4 .07 .01 .00 85 2 1.44 .03 .07 Elbow, right: Ankylosis, bony, of___________...... .03 Ankylosis, fibrous, of__________ ___ 52 57 2 1 .07 .08 .00 .00 .09 Ankylosis, partial and deformities, of Arthritis, chronic, of______________ 3 .34 2 .03 .11 on Flail joint of--------------------- 1-- .00 ; Source of information: Medical records sent to the Surgeon General's Office. GENERAL SURGERY 81 Table 25.—Physical disabilities resulting from wounds (excepting fatal cases), by military agents, officers, and enlisted men, 1917-18; absolute numbers and percentage of each disa- bility to the total number of cases wounded by the military agents—Continued Rifle Total admissions. 20,420 Results Num ber Elbow, left: Ankylosis, bony, of________________ Ankylosis, fibrous, of______________ Ankylosis, partial, and deformities, of. Arthritis, chronic, of_______________ Flail joint of_____________________ Synovitis, chronic, of______________ Elbows, both: Ankylosis, bony, of.................. Ankylosis, fibrous, of Ankylosis, partial, and deformities, of Arthritis, chronic, of Elbow, s. n. s.: Ankylosis, bony, of. Ankylosis, fibrous, of Ankylosis, partial, and deformities, of. Flail joint of_____________________ Eye, right: Loss of_______________________ Loss of sight of Eye, left: Loss of. Loss of sight of___________________ Eyes, both: Loss of__________________________ Loss of sight of___________________ Eye, s. n. s.: Loss of__________________________ Loss of sight, one eye-------------- Amaurosis_____.....-------------- Amblyopia______________________ Cataract, traumatic--------------- Face: Disfigurement of------------------ Paralysis of facial nerve (right side)... Paralysis of facial nerve (left side)--- Paralysis of facial nerve (side not stated)________________________ Femur, right, false joint of.....----- Fibula, false joint of right side------ Fibula and tibia, false joint of, right side___________________________ Foot, right: Flat foot, traumatic--------------- Loss of_______________________ Loss of part of------------------ Paralysis of______________________ Foot, left: Flat foot, traumatic--------------- Loss of________________________ Loss of part of------------ --- - Paralysis of---------------------- Feet, both: Flat foot, traumatic--------------- Loss of________________________ Loss of part of------------------- Foot, s. n. s.: . . Ankylosis of one or more joints------ Loss of........-------------------- Forearm, right: Loss of, above wrist------------ Neuritis, following injury---------- Forearm, left: Loss of, above wrist--------------- Neuritis, following injury---------- Forearms, both, loss of, above wrist----- Hand, right: Loss of all---------......- ---...... Loss of at wrist............-.......... Loss of part of---.................--- Hand, left: Loss of all-----.........----------- Loss of at wrist---.....---.......... Loss of part of--------............... Per cent 0.02 .13 .26 Shell and shrapnel Hand grenade Other gunshot Others Total 51,226 ro,125 153,537 Num- ber .01 .00 .02 .00 .12 .02 .01 .01 .12 .02 .00 .00 .12 .00 Per JNum- Per Num- Per Num- Per Num- Per cent j ber cent ber ' cent ber cent ber ' cent 0.04 .09 .15 .00 .00 14 0.02 54 .07 42 .06 .02 .04 .04 .04 .01 .04 .04 .10 .03 .02 6 .68 5 .57 7 .Ml 1 . 11 1 .11 .11 .11 .45 4 .01 7 .01 2 .03 8 .01 1 .02 16 .02 3 .00 4 3 .07 .05 59 .29 9 .04 14 .07 .00 .00 .54 2 325 .00 .01 .13 .01 .00 .01 .12 .03 .00 .00 .00 .20 .00 .11 .00 .18 .00 .00 .00 .02 .51 .01 .00 .63 60 9 6 .01 1 .00 1 .00 1 .00 ____ 1 .00 ____ .11 4 .01 ____ .11 , 49 .07 | 2 li .01 , 1 1 .00 ____ 2 .00 :_____ 52 .07 | 4 9 .01 _____ .03 .02 .00 .00 .OS 14 1.59 1.82 .23" .34 .80 1.70 .07 .02 .02 1 224 .00 "."36" 2 I .00 ______ 5 .01 _____i- 351 ' .47 12 1 39 130 176 2 5 1 14 30 28 31 4 44 32 138 26 23 23 1 1 3 13 142 18 0.03 .08 .11 .00 .00 .00 .01 .02 .02 .02 .00 .03 .02 .09 .02 .01 .01 .00 .00 .00 .01 .09 .01 .00 .01 .09 .02 2 .00 1 .01 3 .00 -'_"■ .15 2 .00 85 .06 2 .00 137 .09 4 .00 3 .00 6 .00 11 .01 614 .40 12 .01 15 .01 885 . ",s 82 SURGERY Table 25.—Physical disabilities resulting from wounds (excepting fatal cases), by military agents, officers, and enlisted men, 1917-18; absolute numbers and percentage of each disa- bility to the total number of cases wounded by the military agents—Continued Rifle Shell and shrapnel Hand grenade Other gunshot Others Total Total admissions _____........ 20,420 51,226 880 75,125 5,KSfi 153 537 Results Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num-ber Per cent Num-ber Per cent Hands, both: Loss of all ______________ . . 1 0.00 1 0.00 Loss of, at wrist . . . Loss of, part of_____________ 3 335 2 3 3 11 9 1 1 12 20 1 1 .01 .65 .00 .01 .01 .02 .02 .00 .00 .02 .04 .00 .00 1 9 0.02 .15 4 767 4 5 30 33 3 5 35 38 2 1 5 22 24 27 1 2 2 6 41 185 226 21 2 21 50 149 211 15 2 17 4 1 13 2 17 94 56 3 1 7 15 46 34 163 13 131 2 2 12 23 85 54 165 13 134 3 00 Hand, s. n. s.: Ankylosis of one or more joints ___ Loss of_________________ 173 0.8." 6 1 0.68 .11 244 1 3 1 14 11 1 4 13 6 0.32 .00 .00 .00 .02 .01 .00 .01 .02 .01 .50 00 Head, disfigurement of. ________ 1 .02 00 Hip, right: Ankylosis, bony, of_____________ 1 5 13 .00 .02 .06 00 Ankylosis, fibrous, of ._____ 02 Ankylosis, partial and deformities of 02 Arthritis, chronic, of_____________ 1 .02 00 Hip, left: Ankylosis, bony, of ..- ______ 00 Ankylosis, fibrous, of.._____.. 9 10 1 .04 .05 .00 1 1 .02 .02 Ankylosis, partial and deformities of.. Arthritis, chronic, of_____________ 1 .11 .02 Flail joint of_______________ 00 Hips, s. n. s.: Ankylosis, bony, of____________ 2 4 4 11 .01 .02 .02 .05 3 10 9 5 .00 .01 .01 .01 00 Ankylosis, fibrous, of.. ________ 7 11 10 1 1 2 3 17 67 109 10 1 8 26 61 104 4 1 7 2 .01 .02 .02 .00 .00 .00 .01 .03 .13 .21 .02 .08 .02 .05 .12 .20 .01 .00 .01 .00 1 .02 01 Ankylosis, partial and deformities of 02 Intestines: Adhesions of____ _________ 1 .02 .02 Fistula of________ _ ____ Obstruction of____________ 1 .00 Partial loss of.._________ Kidney, loss of, one sequelae___ 3 20 63 61 5 1 7 11 52 55 7 .00 .03 .08 .08 .01 .00 .01 .01 .07 .07 .01 Knee, right: Ankylosis, bony, of_________ 4 50 49 5 .02 .24 .24 .02 .03 .12 Ankylosis, fibrous, of..___ 2 .23 3 7 1 .05 .12 .02 Ankylosis, partial and deformities of .01 .00 .01 .03 Flail joint of_________ Synovitis of ___________ 4 12 30 48 2 1 2 2 .02 .06 .15 .24 .01 .00 .01 .01 2 .03 Knee, left: Ankylosis, bony, of_____. 1 .11 Ankylosis, fibrous, of 6 3 2 .10 .05 .03 .10 .14 .01 .00 .01 .00 .00 01 Ankylosis, partial and deformities of.. Arthritis, chronic of ..____ 1 .11 Flail joint of______... Synovitis, chronic, of..____ 1 .11 6 .01 1 .02 Knees, both: Ankylosis, bony, of_____ Ankylosis, fibrous, of. ___ 1 .02 Ankylosis, partial and deformities of.. Arthritis, chronic, of_________ 2 .01 7 2 9 30 41 3 5 .01 .00 .02 .06 .08 .01 .01 4 .01 .00 01 Knee, s. n. s.: Ankylosis, bony, of______ 5 22 6 .02 .11 .03 3 39 7 .00 .05 .01 Ankylosis, partial and deformities of . Arthritis, chronic, of________ 1 1 .11 .11 2 1 .03 .02 .06 .04 .00 .00 .00 .01 .03 Leg, right: Aneurism of__________ Contracture of__________ 1 1 3 7 8 30 2 29 .00 .00 .01 .03 .04 .15 .01 . 14 Loss of. _________ .. Loss of, at ankle. ... 9 30 21 97 3 59 1 .02 .06 .04 .20 .01 .12 .00 2 1 4 .23 .11 .45 3 7 3 29 7 39 1 1 2 3 12 6 22 9 55 1 .00 .01 .00 .04 .01 .05 .00 .00 .00 .00 .02 .01 .03 .01 .07 .00 Loss of, middle third.. .. 1 3 1 3 .02 .05 .02 .05 .02 Neuritis of, following injury .11 .01 Paralysis of____________ I . 11 Paralysis of, from cord injuries- .09 .00 00 Swollen from injured blood vessels___ Leg, left: Contracture of___________ 1 2 2 15 10 26 2 27 1 .00 .01 .01 .07 .05 .13 .01 .13 .00 ' 7 17 55 38 114 2 50 .01 .03 .11 .07 .22 .00 .10 1 .02 1 1 . 11 .11 .01 .01 Loss of, at knee____________ 2 .03 ,0fi .04 Neuritis of, following injury____ ---; 3 .05 .11 .01 Paralysis of, from cord injuries.. i .11 i i l 1 .02 .02 .09 .00 GENERAL SURGERY 83 Table 25.—Physical disabilities resulting from wounds (excepting fatal cases), by military agents, officers, and enlisted men, 1917-18; absolute numbers and percentage of each disa- bility to the total number of cases wounded by the military agents—Continued Rifle Total admissions. 20,420 Results Num- ber Legs, both: Contracture of___________________ Loss of_________________________ Loss of, at ankle_________________ Loss of, at knee__________________ Loss of, middle third_____________ Neuritis, following injury__________ Paralysis of....._________________ Paralysis of, from cord injury______ Swollen from injured blood vessels... Leg, s. n. s.: Contracture of limb______________ Loss of, below knee........____..... Loss of, at hip......______________ Loss of, at knee__________________ Loss of, at thigh____....._________ Paralysis of limb_________________ Paralysis of, from cord injuries_____ Ligament, relaxation of______________ Lower extremity, atrophy of muscle of... Lung, foreign bodies in.....__________ Muscle: Hernia of_______________________ Loss of_________________________ Nerves: Complication of__........_________ Severed________________________ Severed and contracted___________ Ribs, loss of, part------------------- Rectum: Paralysis of, from cord injuries_____ Loss of control of sphincter---...... Loss of portion__________________ Stenosis of........_______________ Scapula, loss of right side_______........ Shoulder, right: Ankylosis, bony, of...............-. Ankylosis, fibrous, of_____________ Ankylosis, partial and deformities of Arthritis, chronic, of_____________ Flail joint of.........------------- Synovitis of----...................- Shoulder, left; Ankylosis, bony, of.......-........- Ankylosis, fibrous, of------------ Ankylosis, partial and deformities of . Arthritis, chronic, of------------- Flail joint of---------.....------- Synovitis of-----------........--- Shoulders, both: Ankylosis, partial and deformities of. Shoulder, s. n. s.: Ankylosis, bony, of--------------- Ankylosis, fibrous, of---------..... Ankylosis, partial and deformities of Arthritis, chronic, of-------------- Flail joint of.......--------.....- Spine: Ankylosis of_________.....------- Arthritis of_____________________ Spleen, infection of------------------ Teeth, loss of________...........----- Tendon: Adherent in scars---------------- Severed and contracted----------- Testicle, loss of.........-------------- Thigh, right: Loss of, upper third —.......----- Loss of, middle third-----......... Loss of, lower third.--.....-------- Neuritis, following injury--------- Thigh, left: Loss of, upper third......-.......... Loss of, middle third------------- Loss of, lower third------........— Neuritis, following injury.........--■ 131 2 Per cent Shell and shrapnel 50,226 Hand grenade Num- Per Num- Per ber cent ber i cent 2 | 0.00 2 .00 .00 .00 .02 .03 .64 .01 .01 38 .00 .11 .15 .00 .00 .05 .06 .00 .04 13 .03 2 .00 8 .02 12 .02 17 .03 1 .00 2 .00 52 .10 10 .02 ( 10 .02 334 .65 .01 ,_____ .00 _____ .01 1 .00 .01 .04 .07 .00 .16 81 19 174 .19 140 .00 a 10 66 23 176 .20 150 Other gunshot Others 75,125 Num- Per Num- ber cent ber 2 0.00 .00 .00 .00 .00 .00 .00 3 I .00 1 .00 8 .01 .00 .05 4 145 434 ..... .01 .19 .58 "66" .11 .11 2 .23 6 .01 41 .05 33 .04 1 .00 5 .01 1 .00 .00 .00 .01 .05 .04 .00 .00 .01 .03 .01 .00 .00 .00 .05 .01 .03 .01 .02 .04 .03 .00 .02 .04 .03 .00 Per cent .02 "!6_" "."02 .17 .03 .02 .12 1 .02 3 .05 Num- ber 1 .02 2 i . 03 .17 .03 .03 .02 .02 .02 .02 .07 .03 84 SURGERY Table 25.—Physical disabilities resulting from wounds (excepting fatal cases), by military agents, officers, and enlisted men, 1917-18; absolute numbers and percentage of each disa- bility to the total number of cases wounded by the. military agents—Continued Total admissions . Results Thighs, both: Loss of, upper third--------------- Loss of, middle third______________ Loss of, lower third_______________ Neuritis of, following injury-------- Thigh, s. n. s., aneurism (location not stated)___________________.....---- Trachea, stenosis of___________________ Upper extremity, atrophy of muscle of... Wrist, right: Ankylosis, bony, of--------------- Ankylosis, fibrous, of......-------- Ankylosis, partial, and deformities of Arthritis, chronic, of_______________ Wrist, left: Ankylosis, bony, of--------------- Ankylosis, fibrous, of......--------- Ankylosis, partial and deformities of— Arthritis, chronic, of_____________ Synovitis, chronic, of____.....---- Wrists, both: Ankylosis, fibrous, of_____________ Arthritis, chronic, of------------- Wrist, s. n. s.: Ankylosis, bony, of--------------- Ankylosis, fibrous, of------------- Ankylosis, partial and deformities of Arthritis, chronic, of______________ Aneurism: Not specified____________________ Abdominal.....----------------- Aorta, thoracic------------------- Arteriovenus____________________ Artery, axillary.----------------- Artery, carotid------------------- Artery, femoral------------------ Aphasia____________________________ Bone tissue, loss of_______........----- Bulbar palsy________________________ Bronchitis, chronic___________________ Cardiac dilatation___________________ Chest, deformities of, from injury______ Conjunctivitis, chronic-----------..... Convalescent from wounds____________ Deformities, larynx------------------ Epilepsy___________________________ Epilepsy, Jacksonian----------------- Fistula: Fecal___________________________ Other___________________________ Retrovesical.....------ --------- Retrouretal______________________ Urinary------------------------- Fracture: Deforming_______________________ Faulty union.-------- ---------- Old, ununited___________________ Glaucoma, secondary----------------- Heel, painful________________________ Hemiplegia------------------------- Hernia: Cerebral____________.......----.. Ventral_________________________ Not specified.___________________ Laryngitis, chronic___________________ Leucoma__------------------------ Leucoma, adherent------------------ Monoplegia_________________________ Neuritis, n. s...--------------------- Optic atrophy _ _------------......---- Osteomyelitis------------------------ Paraplegia__________________________ Pleurisy and adherent pleura... Speech, paralysis of Rifle 20,420 Shell and I Hand shrapnel \ grenade 51,226 Other gunshot Others 5,886 Num- Per Num ber cent i ber 0.00 .01 .00 .00 Per cent 0.01 .00 .01 Num- ber .00 . 12 .01 .05 .08 .00 .01 .05 .09 .01 .01 .04 .07 .00 1 i .00 2 ! .01 102 .50 2 191 .00 .01 .01 160 93 15 1 1 8 .00 .78 .46 .07 .00 .00 .04 .02 .01 .00 2 | .01 4 .02 Scar, adherent or painful_______________' 386 i 1. 4 1 280 1 3 1 4 3 1 278 161 32 1 20 101 11 103 5 1,041 .04 .20 .02 .20 .01 2.03 Per Num- Per Num- Per Num- cent i ber cent ber cent ber 0.11 1 0.00 1 .00 1 .00 .00 .05 .00 .03 .03 .23 .11 .01 .04 .05 .00 .00 .00 .01 .04 .02 .00 1 .00 2 .(H) 3 .00 175 .23 1 .00 30 .04 1 .00 1 .00 149 .20 .00 .00 1 2 172 197 15 1 1 16 1 6 .00 .00 .23 .26 .02 .00 .00 .02 .00 .01 .00 .00 24 I 2. 73 4 2 4 122 10 65 5 425 .01 .00 .01 . 16 .01 .09 .01 2 0.03 1 .02 2 .03 1 .02 6 .10 28 ~ ""."48 .02 .25 .17 .02 .02 .02 .02 Total 153,537 1 7 3 6 1 5 136 13 62 77 3 17 74 102 4 1 1 1 10 57 63 1 2 1 3 5 1 1 3 7 476 1 109 1 7 2 570 1 5 2 12 5 1 1 627 462 63 3 2 41 3 20 ] 4 4 31 275 30 245 17 GENERAL SURGERY 85 Table 25.—Physical disabilities resulting from wounds (excepting fatal cases), by military agents, officers, and enlisted men, 1917-18; absolute numbers and percentage of each disa- bility to the total number of cases wounded by the military agents—Continued Rifle Shell and shrapnel Hand grenade Other gunshot Others Total Total admissions. _______________ . 20,420 51,226 Num- Per ber : cent 880 Num- Per ber i cent 75,125 5,886 153,537 Results Num- Per ber i cent Num- Per ber cent 2 .00 Num- Per ber cent Num-ber Per cent Sacroiliac ankylosis------------------- Synovitis, chronic, n. s_____________ .. 1 .00 1 .00 4 .01 2 .00 1 j .00 4 .01 2 .00 6 .01 3 1 .05 .02 10 4 1 13 3 14 .01 .00 Taste, paralysis of____________________ .00 Temporomaxillary ankylosis - _____ 3 .01 6 .01 1 .00 2 .00 5 .08 .01 .00 1 .00 .01 9,060 17. 69 213 24.20 5, 579 7. 43 549 9.33 19,140 12.47 Note.—S. n. s. signifies, "side not specified." N. s. signifies, "not specified." PHYSICAL DISABILITIES BY MILITARY AGENTS The number of physical disabilities which resulted from military agents was 19,140 (not men, but disabilities). It should be noted that we are here speaking of disabilities, and not of individual men, although the number of the disabilities is less than the number of men disabled, which is shown in Table 24 as 19,768. The excess is due to the inclusion there of men disabled by gas. If disabilities from the latter were included in Table 25, the total would be 21,696. The percentage of disabilities from the various gunshot missiles was as follows: Shell and°shrapnel, 17.69; hand grenade. 24.20: rifle, 18.30; other gun- shot missiles, 7.43. From this we see that the highest proportion of disabilities resulted from the artillery missiles, with the exception of the hand grenades, where the number of cases was small. CHAPTER IV SURGERY AT THE FRONT GENERAL CONSIDERATIONS Medical Department plans for the surgical treatment of wounded at the front prior to our entrance into the World War, were essentially conservative.1 They were based almost purely upon a hypothetical war of movement; therefore, the maintenance of mobility of divisional Medical Department organizations (dressing stations, field hospitals) and of evacuation hospitals, which were intermediate facilities, was of paramount importance. The evacuation of wounded, with notable exceptions which will be referred to later, was to be of primary consideration. In effect, the provisions in question, from the front rearward, to and including evacuation hospitals, were as follows: With line organizations—regiments, trains, etc.; the sanitary train, comprising dressing stations, field hospitals; evacuations hospitals.2 The Medical Department equipment, provided for a regiment or other line organization operating as a part of a division, consisted of first-aid packets, individual equipment of the Medical Department personnel, and the combat equipment.3 In combat the duties that were to devolve on the sanitary per- sonnel were to render first aid to the wounded; to establish and operate an aid station, and to collect wounded thereat; to direct the trivially wounded to return to the line, and to direct others with slight wounds to the station for the slightly wounded; and in exceptional cases to transport the severely wounded to the dressing stations.4 Since the regimental medical personnel was to keep in touch with the regiment, no elaborate or fixed arrangements for the care and treatment of wounded were to be undertaken. Such treatment was to be imited ordinarily to first-aid and to the readjustment of dressings which previously had been applied either by medical personnel in advance of the dressing station, or by the wounded themselves. Activities at the dressing station (to be established by the ambulance company section of the sanitary train) were to be carried on under the following departments :5 Dispensary; kitchen; receiving and forwarding; slightly wounded; seriously wounded. Here, only such operations were to be performed as might be immediately required to save life or to render the patients fit for further transportation. Permanent occlusive dressings were to be applied, time per- mitting. The rules generally to be followed were that no operative or other nterference should be attempted under conditions unfavorable for asepsis or antisepsis, and that no wounded for whom transportation might be available should be delayed at the dressing station. Since the function of the field hospital was to keep in touch with the com- batant organizations, and to provide care and treatment as far as practicable for the sick and wounded of the division until taken care of by the sanitary 86 GENERAL SURGERY 87 service of the line of communications, it could meet these conditions only when relieved promptly by medical units to its rear. Under ordinary battle conditions surgical operations were to be such only as might be needed to fit patients for transportation to the rear.6 In the evacuation hospitals, which were to relieve the field hospitals of their sick and wounded, the treatment of wounded was to be hardly more extensive than that at field hospitals, viz, emergency operations and better preparation for transport. Particularly was this true during battle when many wounded would be received. On the other hand, in the absence of many wounded and of the probability of an early move, complete surgical treatment was permissible.7 When we entered the World War its character had for long been static; it was possible, therefore, to partially immobilize the units mentioned above. Such being the case, evacuation of the wrounded became less of an urgent neces- sity from a purely military standpoint and more or less subservient to the interests of the patients themselves. And whereas formerly no surgical inter- vention was to be practiced farther forward than base hospitals, except in times of quiet, it was found now that definitive treatment could not ordinarily be left until patients could reach hospitals in the rear: it had to be practiced in stages, and the preliminary stages must be accomplished as early and as near the front as possible. At this time, in contradistinction to former wars when rifle wounds were over 80 per cent and shell wounds in the neighborhood of 13 or 14 per cent,8 wounds caused by shell fragments were almost the rule (80 per cent); bullet wounds were rare.9 Since the wounds caused by the shell splinters were invariably infected with organisms whose period of incubation was extremely short, most severe complications, if not fatality, were to be expected unless surgical intervention could be practiced within a relatively few hours of the receipt of injury. Thus, though our earliest plans for surgery at the front had to conform to static warfare, this changed to open warfare at a time when our greatest numbers were involved, and though some general modifications in surgical treatment were possible, for example, delayed surgical treatment until patients in some instances could reach base hospitals located near the front, the treatment per se was essentially the same. GENERAL TREATMENT OF WOUNDS The subject of wound treatment at the front obviously must include all procedures from the application of the first-aid dressing on the battle field to the final dressing immediately preceding the evacuation of the patient from the zone of the advance to the base. The successive stages in which such treat- ment was given involved some or all of the following places or stations through which wounded men passed from the front line rearward: On the battle field, company aid stations, battalion aid stations, regimental aid stations, advanced dressing stations, dressing stations, field hospitals, mobile hospitals, evacua- tion hospitals. While it is essential in the interests of completeness to consider the sub- ject, in this chapter, from the viewpoint of the above enumerated places and stations, thus repeating some things which are given in greater detail in another 88 SURGERY volume of this history," it is not the purpose to dicuss herein special surgical treatment, except in so far as is necessary. Such special treatment is made the subjects of separate subsequent chapters. OX THE BATTLE FIELD Each soldier was provided, as a part of his individual equipment, with either a Medical Department regulation first-aid packet or a front packet. In addition, Medical Department enlisted men, assigned to line organizations, carried a liberal quantity of these packets and iodine swabs. The first-aid packet, in a metal case 4 by 2J4 by 1 inch, comprised 2 gauze bandages, 4 by 84 inches, 2 gauze compresses, 3^2 by 33/2 inches, 2 safety pins, and directions for application.10 FRONT PACKETS The following extract not only describes the kinds of front packets adopted for the American Expeditionary Forces, but contains as well directions as to the use of these packets:11 The dressings here described are intended for use in the dressing stations of the units in combat, in the field hospitals, the mobile hospitals, the evacuation hospitals, and the base hospitals. Surgical dressings should protect the wounded man from: (1) Trauma to his wounds; (2) loss of blood; (3) secondary infection, and should be so applied as to add to his comfort during treatment and transportation. In the manufacture of these dressings it is not essential that absolute accuracy in measurements be observed. Front packets.—-These packets are to be used by medical units in the area of combat. The outer covering is coated with paraffin to protect the contents of the packet against wet and vesicant gases. I. PACKET NO. 1. RED LABEL For small wounds. This packet contains the following supplies, the outer wrapper of which is made of kraft paper dipped in paraffin. It is marked with two red bands. On opening the outer covering there will be found: (1) 1 unbleached muslin bandage, 4 to 5 inches by 5 yards, cut on the bias; 2 safety pins, 1}4 inches long, attached to the bandage. (2) A muslin bag, which opens at one end. This bag contains sterile dressings wrapped in a special paper. These dressings should be handled with as much care as pos- sible to prevent contamination. The sterile dressings comprise: (1) 4 gauze sponges or wipes, 4 inches by 4J^ inches, for covering the wound; (2) 1 absorbent pad, 4 inches by 6 inches; (3) 1 gauze bandage, 4 inches wide. With these supplies the wound should be covered and the absorbent pad held in place by the gauze bandage. Finally the muslin bandage should be applied and firmly fastened with the safety pins to make the dressing secure or to apply the proper splint. II. PACKET NO. 2. WHITE LABEL For medium-sized wounds. This packet contains the following supplies, the outer wrapper of which is made of kraft paper dipped in paraffin. It is marked with two white bands. On opening the outer covering there will be found: (1) 1 unbleached muslin bandage, 4 to 5 inches by 5 yards, cut on the bias; 2 safety pins, \y2 inches long, are attached to the bandage. (2) A muslin bag, which opens at one end. This bag contains sterile dressings ° Vol. VIII, Field Operations, American Expeditionary Forces. GENERAL SURGERY 89 dressing* should be handled with as much care as pos- wrapped in a special paper. The: sible to prevent contamination. The sterile dressings comprise: (1) 4 gauze sponges or wipes, 4 inches by 4t^ inches; (2) 1 absorbent pad, 6 inches by 8 inches; (3) 1 gauze bandage, 4 inches wide. With these supplies, the wound should be covered and the absorbent pad held in place by the gauze bandage. Finally the muslin bandage should be applied and firmly fastened with the safety pins to make the dressing secure or to apply the proper splint. Fig. 78.—Front-line packages Nos. 1, 2, and 3 Fig. 79.—First-aid outfit, complete III. PACKET NO. 3. BLUE LABEL For large wounds. . This packet contains the following supplies, the outer wrapper of which is made of kraft paper dipped in paraffin. It is marked with two blue bands. On opening the outer covering there will be found: (1) 2 unbleached muslin bandages, 4 to 5 inches by 5 vards, cut on the bias; 2 safety pins V/2 inches long are attached to each bandage (2) ' \ muslin bag which opens at one end. This bag contains sterile dressings 90 SURGERY wrapped in a special paper. These dressings should be handled with as much care as pos- sible to prevent contamination. The sterile dressings comprise: (1) 6 gauze compresses, 4 inches by 8 inches; (2) 1 absorbent pad, 10 by 18 inches; (3) 1 gauze bandage, 6 inches wide. With these supplies, the wound should be covered and the absorbent pad held in place by the gauze bandage. Finally the muslin bandage should be applied and firmly fastened with the safety pins to make the dressing secure or to apply the proper splint. It was impressed upon the soldier that the first-aid dressing was for his individual use in the event of injury, and frequent inspections were made to insure the constant possession of these packets. Medical Department en- listed men assigned to battalions car- ried usually in a duffel bag or gunny sack a liberal quantity of these packets and iodine swabs. This was important because of the frequency of multiple wounds and of the frequent lack of a packet on the person of the wounded by reason of its having been either lost, or, contrary to instruc- tions, applied to a wounded comrade. Directions for the use of these dress- ings were given each combatant as a routine, and all Medical Department personnel were fully instructed in their application. In the light of our ex- perience particular attention in this instruction should be directed to: (a) The importance of applying the dress- ing directly to the wound without the interposition of either outer garments or underclothing, (b) The avoidance of the removal of clothing not neces- sary to uncover the wounds, thus lessening a tendency to shock, (c) The danger incident to tightly pack- ing a wound in the mistaken belief that complete cessation of hemorrhage is necessary, (d) Contraction of a dry dressing and bandage after their saturation with blood, water, or perspiration, with consequent circulatory interference, discomfort, and pain. Hemorrhage from fractured bone, lacerated muscles, or blood vessels of a limb inevitably results in swelling, and the earlier the application of a dressing and bandage to such a wound the greater should be the allowance for the consequent swelling. A dressing and bandage should be sufficiently snug to retain its position during transportation without causing constriction. («) The desirability of immobilization of a wounded area, even in the absence of fracture. Rest of damaged tissue enables nature to marshal her defensive forces for the localization of infection, and the degree of immobilization of a wound area, even though only the soft tissues are involved, largely determines Fig. 80.—First-aid bandage, with hooks and tape GENERAL SURGERY 91 ■■* *4."_t. '•*'--'-• - ■» ' • . ' Ic^ffr * ■v.'z^^.';-.' Fig. 81.—Immobilization of upper extremity against patient's side < 'j+±r J **><*', 4$r-v .^4§N3*£*»* «A'A--vT-9»* -'j_i& _*_&__ v*; €_^ • J?* __r #•• *:,*W vS- **:.. rvn u___H__^ ■*• f- * *_»I*H <*tn "T ' ,^ ^•.-Mk___3_*> ' .: -.:4. ____** Fig . 82.—Thomas leg splint applied over clothing; traction made on shoe 92 SURGERY the chances of the wounds healing without infection or with only localized infec- tion. Nothing tends to disseminate infectivematerial, particularly sand, dirt, par- ticles of clothing, and the like, more rapidly than muscle spasm in the vicinity of a wound, and the development of gas gangrene after an apparently thorough debridement of lacerated tissues is due, in all probability, to a dissemination of minute foreign particles beyond the zone of debridement. The immobiliza- tion of wound areas in regions having multiple layers of muscle with intervening planes of fascia, particularly the thigh and legs, should be equally thorough in both the presence and absence of frac- ture. (/) The imperative- ness of making no attempt to cleanse a wound on the bat- tle field, because of the in- sufficiently trained personnel, the time element, and the lack of essential facilities. A wound left alone rather than half cleansed is far more safe. Iodine, if available, was to be applied to the edges of the wound, but was not to be ap- plied within a deep wound, since nothing could be accom- plished in the way of antisep- ticizing, and the danger of setting up a new hemorrhage b\T dislodging a blood clot was to be in mind, (g) Immobili- zation, to begin on the battle field when possible, by the use of simple straight or impro- vised splints. The use of the Thomas splint for either arm or leg on the battle field is rarely possible because of the time required for its proper adjustment and the imprac- ticability of carrying on the person. Also, the Thomas splint is essentially a traction splint and does not afford complete immobilization unless reinforced with one or more straight splints. In the absence of any splinting material, for the purpose of transportation the up- per extremity may be readily immobilized by bandaging or strapping it against the body, and the lower extremity by splinting against the opposite limb. Efficient splinting invariably includes the j oints above and below the wound, whether or not fracture is present. Only by including these joints will muscle contraction cease Fig. S3.—First aid in trench warfare GENERAL SURGERY 93 and foreign particles remain in situ. Splints should never prevent free access to the wound and should be applied so as to permit changing the field dressing at the battalion aid station without removal of the splint. Adequate padding for all splints must be improvised on the battle field, and this is especially necessary over bony prominences, such as the elbow, wrist, iliac crest, great trochanters, femoral condyles, malleoli, and in the axilla. For this purpose articles of clothing, packing, leaves, grass, and the like can be utilized. The improper observance of this cardinal point predisposes to shock and the development of pressure necrosis of overlying tissues. The idea was to apply first aid immediately at the place where the wound was incurred, either by Medical Department personnel on duty with organi- zations in the front line or serving as litter bearers, or by litter bearers detailed from the line who were instructed in elementary first aid. Such application was usual in trench warfare, in which the casualties frequently occurred in the trench itself from desultory enemy fire, and special cover for dressing was not always essential. This applied also to a less extent to open warfare in periods of quiescence, but at times of great activity it was often impossible to apply dressings before transporting the patient to a company or battalion aid station, or even to reach the wounded for varying periods of time. THE COMPANY AID STATION In some instances stations subsidiary to battalion aid stations were estab- lished in the front line for each company, conducted by two dressers assigned from the battalion medical personnel.12 At these company aid stations emer- gency treatment was given the wounded brought thereto usually by line litter bearers. Such stations were more commonly used in trench warfare when it was possible to keep a small supply of surplus dressings and even splints, and some- times a battalion medical officer took station there; but in open warfare the only available dressings usually were those carried on the person, and often the only shelter was that afforded by a shell hole, consequently the wounded habitually were borne to the battalion aid station. THE BATTALION AID STATION With the increased strength of our battalions, the battalion aid station closely approximated in size the regimental aid station as prescribed in the Manual for the Medical Department, the regimental aid station then not being generally employed.12 In trench warfare, battalion aid stations usually were located in dugouts in the support line, 250 to 1,000 yards in rear of the front line, on or near an evacuation trench.12 The equipment, in addition to that enumerated in supply tables for a battalion, included at least two Thomas splints, and a shock table for warming patients. Light was supplied by simple petroleum lamps, and in some electricitv was present. Cooking was done belowr, when possible, coke or any available fuel being used and ventilators having dampers for excluding "•as led to the surface. Often the food was prepared in a separate adjacent 94 SURGERY dugout or improvised lean-to and in some sectors food was brought up in mar- mites at night time. The source of heat was small wood-burning stoves. The supplies w^ere usually brought up by the battalion medical carts or other vehicles, and replacements were made through a system of exchange by ambu- lances, trucks, or litter bearers. The supplies habitually included stimulants and ample facilities and material for the preparation of hot liquid foods, and other articles of food were also stocked, as often in periods of intense bombard- ment patients could not be evacuated until after dark, and preparedness for the bestowal of all possible attention, short of surgical intervention, upon the wounded for a varying number of hours was necessary.12 Fig. 84.—Administering a hot drink to a shock case In open warfare these stations were of necessity simple and even rudi- mentary both as to shelter and equipment.12 Proximity to the front and a location accessible to litter bearers both forward and rearward were absolute essentials, and frequently on account of the paucity of shelter and evacuation routes the stations of different regiments, even sometimes of those of different adjacent divisions in a narrow sector, consolidated. The distance from the front varied from 50 to 500 yards or more and was often in the support line. Advantage was taken of any possible shelter, such as a shell hole, quarry, culvert, cellar, or dugout, in locating the station. Supplies in addition to individual equipment consisted only of those that the personnel could carry up in gunny sacks and similar containers, and articles such as litters, splints, and GENERAL SURGERY 95 blankets, accompanying the evacuated patient were replaced by the bearers or ambulances by a system of exchange. The service simulated that of trench warfare in so far as possible. Immediate evacuation was the goal, but patients frequently had to be held until nightfall, and there were few or no facilities for treating shock. In attack the medical personnel with the front line usually applied first-aid dressings, and immobilized fractures when possible, leaving the wounded sheltered as far as practicable for collection, a few hours later, by the aid-station bearers, while they continued forward with the line. Similarly, if the movement was rapid the aid station, in moving forward to successive new locations, left the wounded, after administering to them as far as possible, at some centrally located " collecting point" for the facility of the following evacu- ation ambulance company.12 With respect to surgical treatment, the procedures which obtained in the battalion aid stations may be summarized as follows: (1) Kevision of the first- aid dressing. Pain, when present, was usually due to constriction of the wounded parts by gauze and bandage, which required changing or loosening. (2) Revision of splinting to insure proper immobilization for subsequent trans- portation. Application of the Thomas leg or arm splint when traction was indicated. To arrest severe hemorrhage, whenever the element of time, available surgical facilities, and good surgical judgment permitted, the bleeding aitery was sought in the wound and ligated above and below its laceration. If the primary search was unsuccessful and subsequent attempts necessitated material enlargement of the wound, it was often more desirable deliberately to seek and ligate the vessel beyond the wound margin, under conditions of strict surgical asepsis. Prolonged forcipressure—i. e., clamping artery forceps on the bleeding vessel or on the mass of lacerated tissue from which blood wras oozing—some- times succeeded in arresting the hemorrhage. It was possible thus for the forceps, properly padded with dressing, to be left in situ and the patient evacu- ated to the triage with this fact recorded on his field tag. Whenever, as a last resort, a tourniquet was used and left in situ, this fact was recorded and the ambulance driver or orderly instructed to loosen it for periods of five minutes at intervals of an hour. Only dire necessity justified the evacuation of a patient with tourniquet on arm or thigh. The duration of the journey from the ambulance head to the field hospital was so uncertain, and the pre- vention of intermittent loosening of the tourniquet because of inevitable traffic blockade, was so likely to occur, that every effort was to be made to ligate or apply forcipressure in all cases in which the rate of blood flow was sufficient to jeopardize the life of the patient. The maintenance of the body heat of the wounded by means of blankets, coats, hot-water bottles, canteens filled with hot water, and hot drinks (when not contraindicated by the nature of the wound) was vastly important. Any chilling of the body precipitates or aggravates shock, therefore every effort was made to have the wounded soldier leave the battalion aid station as thoroughly warmed as battle condi- tions permitted. Antitetanic serum was administered habitually, even in case of an apparently trivial wound, and the fact of administration recorded 46997—27---9 96 SURGERY on the field tag, and indicated on the patient's forehead by a cross painted with iodine. If the wound or dressings involved the forehead, the cross was painted on the dorsum of one hand. The standard dose of morphine, one-fourth grain, was given immediately to all severely wounded, and to those slightly wounded in whom the single element of pain wTas considered to be a factor in the development of shock. Often it was advantageous to repeat the dose: Pain frequently did not become marked until during the transit to the field hospital and a comfortable journey was to be insured by the use of sufficient morphine. Operative Technique In battalion aid stations, it was usually impossible for the surgeon to scrub his hands and change gloves for each wound treatment: Water and gloves were not always available, or the supply was very limited. However, instruments could be sterilized sufficiently by immersion in alcohol or ether, and by experi- ence the surgeon could easily learn to dress all wounds without having his hands make contact with septic tissues or objects. With two pairs of dressing forceps, or with one pair each of artery and dressing forceps, he could accom- plish any kind of dressing and continue with a series of cases without scrubbing his hands or changing his gloves after the completion of each. He usually had an enlisted assistant, previously trained to apply bandages and splints under his supervision. THE REGIMENTAL AID STATION As stated above, when we first entered the war the regimental aid station was the most forward unit aid station prescribed by field service regulations, but with the change of tables of organization increasing battalions to prac- tically the former size of regiments, it was succeeded by the battalion aid station and became almost obsolete, though maintained in a few instances.12 The term persisted but usually signified merely the station and office of the regi- mental surgeon and the liaison point of regimental medical service, where serv- ice was rendered the regimental headquarters detachment, which was usually at or near regimental headquarters. The function of the regimental aid station when employed, was similar in both trench and open warfare to that of the battalion aid station and it sometimes served, especially in open warfare, as a collecting point for both the walking wounded and those for ambulance evacua- tion.12 In the confusion of attack, bearers conveyed the wounded to any point at which a medical officer was known to be, consequently the station of the regimental surgeon frequently became an additional temporary battalion aid station. THE DRESSING STATION The number and locations of divisional dressing stations were dependent upon the roads, available shelter and the width and activity of the divisional sector; generally from one to three to a division, located from 3,000 to 6,000 yards from the front line.12 In trench warfare the dressing station, usually located in a dugout or in any available building, contained a greater amount and variety of equipment than was possible in open warfare, and had separate rooms for such purposes as GENERAL SURGERY 97 Fig. 85.—Regimental aid station, 321st Infantry, October 3, 1918 Fig. .ti.—Dressing station, Croix de Charemont, August 17,1918 98 SURGERY Fig. 87.—Ambulance company dressing station, open warfare Fig. 88.—Dressing station, Lahayville GENERAL SURGERY 99 receiving, recording, and dressing the wounded, for shock treatment, the serv- ing of hot foods, and for administration. Since more time was available for the care of men brought to the dressing station than was true under open-war- fare conditions, many who were merely exhausted were returned to duty after a few hours' rest during which they were given hot food; also, casualties depleted by hemorrhage or suffering from shock could be retained longer and conse- quently evacuated in better condition. The personnel usually worked in shifts. In open warfare, buildings or other shelter were not always available and the dressing station was frequently under tentage, which sometimes was but a tent fly. Each dressing station was placed as near the front as conditions permitted; the location selected being generally with a view to its subsequent occupation by a field hospital as the action developed. Occasionally an advance dressing station, with reduced personnel, was established 1,500 to 2,000 yards from the front line, or nearer when possible, as a relay between battalion aid stations and the main dressing station.12 Commonly, the dressing station sec- tions of two ambulance companies were utilized in the establishment of a main dressing station, one as an advance dressing station and the fourth held in reserve; often three were combined in one station and again each company operated its own station, the tactical situation being the decisive factor. Equip- ment was limited and in general consisted of dressings, splints, litters, blankets, antigas supplies, antitetanic serum, a few instruments, and drugs, including morphia, and kitchen equipment. The dressing station in a few instances was employed as a triage, in which event the division specialists were stationed here, but this was not habitual.12 The function of the dressing station in gen- eral was to receive casualties, to administer indicated emergency treatment, and to group and evacuate to designated destinations when conditions per- mitted, but habitually to field hospitals. The emergency treatment com- prised arresting hemorrhage, readjusting dressings, applying or readjusting splints, administration of morphia and of antitetanic serum when time per- mitted, stimulation by hot drinks and the retention and reviving of gassed and shocked cases as far as possible. Operations were limited practically to the closure of aspirating wounds of the chest, and to emergency ligations. Since casualties usually came or were brought to the dressing station in groups the personnel could not always work in shifts, otherwise the service in general was similar to that of trench warfare. Because all Medical Depart- ment activities here were to subserve the prime function of evacuation, profes- sional interference was reduced to the lowest possible minimum. Morphine was administered generally to the severely wounded; great importance was attached to the giving of hot food, for, as mentioned above, many with minor wounds required nothing more and after being fed voluntarily returned to the front line. THE FIELD HOSPITAL The field hospital was the last and largest divisional unit of the Medical Department in the chain of evacuation, the function of which in general was to receive casualties from the dressing station, and to institute all measures possible under varying conditions to best fit them for continued evacuation, 100 SURGERY Fig. 89.—Unloading severely wounded at Field Hospital No. 28, Varennes Meuse, October 2,1918 Fig. 90.—Slightly wounded awaiting readjustment of dressings, Field Hospital No. 28, October 2, 1918 GENERAL SURGERY 101 usually to evacuation hospitals. Field hospitals were located from three to eight miles from the front line, depending upon such factors as the enemy range of fire, roads, fuel, water, availability of buildings, and the locations of evacuation hospitals.12 Whenever possible they were grouped, preferably in a village or at the confluence of roads from the sector served, for convenience both in the interchange of patients and for the ambulances. In trench warfare and in some quiet sectors the field hospital was of a semi- permanent character and was often elaborately installed with modern equip- ment and conveniences in well adapted commodious buildings or well arranged dugouts.12 The equipment in addition to all surgical essentials included electric lights, portable radiographic and laboratory units, steam sterilizer, and other similar conveniences. In a few instances they, complete with equipment, were taken over from the French.12 Usually, under these conditions, one field hospital functioned as triage and cared for the wounded and gassed, one cared for the sick, one for skin and venereal cases, and the fourth was held in reserve frequently conducting a convalescent camp for transportable patients and supplementing the other three as required. All cases likely to become fit for duty in from 10 to 14 days were held. While no definitive measures were undertaken, greater latitude and freedom of action within the discretion of the staff was customary than usually proved possible in open warfare. In open warfare the situation presented all phases, from conditions obtaining in quiet sectors during periods of quiescence, simulating trench war- fare, to the intense activity of attack and advance in which improvisation and individual resourcefulness were the prime factors. When equipment was sparse and of the simplest, often no patients could be held, operations and professional work were reduced to a minimum and the work resolved into a problem of evacuation. On the other hand, in a few instances, as in the cases of the 2d Division at Chateau-Thierry,13 and the 3d Division at Chierry (August, 1918) and also at Verdelot,14 conditions obtained whereby the field hospitals were located in commodious buildings with clean, well-lighted operat- ing rooms in which modern aseptic surgical wrork wTas done by attached special surgical teams, which included nurses. The normal personnel of the field hospitals usually was augmented by the division specialists of the various branches and at times also by special operating and shock teams. In a few instances, their facilities for the care of nontrans- portable wounded were increased by the attaching of mobile surgical units.12 Also, additional enlisted men were attached, as occasion demanded, who were usually trained for and assigned to special semipermanent team duties. The equipment necessarily varied with conditions and ranged from that which was complete and even elaborate, including a portable X-ray outfit, which also supplied electric lights in trench warfare and in quiet sectors, to that which was scant and often in part improvised in periods of great activity and rapid movement. The following description of the surgical work of field hospitals extracted from a report of the 3d Division, in general terms, is fairly typical of that of other divisions, though there were so many differences in details, both in this 102 SURGERY division at various times and between this and other divisions, that it is illus- trative rather than of universal application:14 In operating the hospitals, officers and enlisted men were divided into two shifts, as far as possible, working from 7 a. m. until 7 p. m., although at times all were on duty for longer periods. Division specialists made regular visits to the field hospitals for purposes of consultation and supervision of cases in their own special branches. The receiving ward of the triage hospital of the 3d Division in the second battle of the Marne was located in an Adrian barrack; the surgical dressing room was in a smaller build- ing at the rear, and the shock and operating rooms were in a smaller building across the street. Near it were the ward tents. When patients were taken from ambulances at the receiving ward, litter cases were carried as far forward as possible, and litters set on the floor on one side of the building, while sitting patients occupied benches along the other side. The record desk at the far side of the building was passed by all patients as they left this room. The receiving officer examined litter cases, sorting out the nontransportable, those to be re-dressed, and those who were to be evacuated immediately. He designated proper wards for all others and designated those who could have liquid or other food. He checked diagnosis tags and especially the records regarding antitetanic serum. Those having no record or proper mark indicating that they had received serum were given the prophylactic dose here. When possible, the record of the case was taken at this time. This first exami- nation was quite thorough, for diagnosis tags were often written under shell fire and fre- quently failed to record all the wounds the patient had received. When additional wounds were found they were noted on the tag. The tags were also checked to verify nontrans- portable cases, especially those with active hemorrhage, which were given first consideration. Their records were taken at once, and they were sent to the dressing room or the shock ward. Many shocked cases were warmed in the receiving ward, given morphine, hot liquids, and other foods, and reacted so well that they were transportable. Morphine in large doses from a stock mixture was given in the receiving ward to many cases marked for evacuation, such as patients with joint lesions which were well splinted, fracture cases, etc. Injury to the hands and feet caused more pain in proportion to the amount of tissue destruction than any other classes of cases. Cases for re-dressing, not in a state of shock, were sent to the well-heated dressing ward, where care was exercised to reduce to a minimum the exposure of patients while being dressed and to perform accurate work. Many first-aid packet dressings applied on the field had slipped out of place; but this was seldom the case when two or three pieces of adhesive plaster were used to secure the bandage to the skin. Very few tourniquets were found tight enough to impede circulation. They had generally been loosened at some forward dressing station and bleeding controlled by adequate packing and well-applied bandages. Many of the tourniquets that had not been loosened cut off the venous flow only. In the rush of work, fracture cases with a good splint that looked comfortable, showed no evidence of shock or hemorrhage, and did not complain of much pain or tight bandages were considered transportable. When but few cases were being received, nearly all fractures were sent to the re-dressing ward for a careful examination. The most common defect in dressings was that bandages were too tight, especially on the forearm, the upper third of the leg, or about the ankle. Many patients complained of pain at the site of fracture or wound, which was relieved when a tight bandage at some distant point on the limb was loosened. Fracture cases were prepared for evacuation by the use of salvaged clothing packed loosely about the limb, and masks were used for pillows. Care was taken in case of fracture of the extremities that the Thomas splint was properly applied and that excessive bleeding was not taking place. When found necessary to hold fracture cases, they were sent to the appro- priate ward, kept warm and free from pain. There were very few that required active shock treatment after being prepared and classed as transportable. Sick patients whose condition was not serious were sent to the medical wards Usually a separate hospital received these cases. Those with trivial conditions who we're able to return to duty within a few days, were retained; the others were evacuated Transportable surgical cases awaiting evacuation and the slightly wounded who might be returned to duty GENERAL SURGERY 103 in a day or so were sent from the receiving or dressing wards to the surgical wards for slightly wounded, and they also were retained. ' Hot drinks, food, and water were available in the receiving wards and were given to practically all cases except those with penetrating wounds of the abdomen. Soup, coffee, and chocolate were the three hot drinks used, and when more than one was available patients usually preferred the first mentioned. Food of all kinds was served, including delicacies furnished by the Red Cross and articles taken from the regular ration. To keep hot liquids or other food, a two-burner kerosene stove was set on a block in the receiving ward, but during rush periods liquid nourishment was served direct from kitchen containers. On the whole it can be said that the condition of the patients received on the Marne was not as good as those received in the Meuse-Argonne offensive, where we operated close behind the lines. The trip of 17 kms. by ambulance from Chateau-Thierry to Verdelot was attended by considerable jolting and there was a longer interval between the time of injurv and hospital treatment. This was offset by the fact that better hospital facilities were afforded by good buildings, operating rooms, skillful nursing by trained female nurses, and freedom from the dangers of shell fire. The shock ward received all shock cases, whether the condition was present on admission, developed in other wards, or was subsequent to some surgical operation. All wet clothing was removed from the patient and he was wrapped in warm blankets, arranged on a litter in such a manner as to permit the heat from two primus stoves, or solidified alcohol cans, placed underneath, to circulate within the folds of the blankets and about the body of the patient. The blood pressure and pulse were taken frequently; and, in a case where collapse was threatened, intravenous injections of saline solution or 5 per cent acacia were given until the patient rallied. Some surgeons preferred the gum acacia to the saline solution, but from the small clinical experience obtained in field hospitals it was impossible to derive any conclusions of value. Blood transfusion was resorted to on a number of occasions. The technique of this procedure was fully explained and supervised several times daily by surgical consultants experienced in the method. The donors were classified and were usually obtained from among very slightly gassed patients. Most of the shock cases were caused by gunshot wounds of the abdomen, head, thigh, or knee, and in many of the last-mentioned wounds the shock seemed out of proportion to the character of the wound. When cases were admitted that required surgical treatment they were first revived by the above method and then sent to the operating room. On the Marne all cases from the operating room were sent to the shock ward for examination, and treatment if necessary, before they were sent to the surgical ward. The shock ward retained the majority of its cases about four hours and had a mortality rate of about 10 per cent. Re-dressing was done mainly in the surgical ward for slightly wounded. A medical officer was on duty here constantly to apply dressings, to detect developing shock and hemor- rhage, and to supervise generally the work of the ward. Feeding was of great importance in this ward. Many face cases required the use of a rubber tube. Morphine and codeine were practically the only drugs used. Hypodermic injections of sterile water were found efficient in many cases. As the use of Dakin's solution exercised a mental effect, it was used in most of the cases and was applied every two hours. In gunshot wounds of the extremities the elevation of the limb afforded great relief in many cases. Active hemorrhage was very infrequent in cases that were re-dressed; usually wnen found it complicated injuries about the hands and face. Tight packing with large shell-wound dressings and properly applied bandages left few cases requiring ligation. In the operating room most of the work consisted in controlling hemorrhage, removal of foreign bodies, debridement of wounds, adjusting fractures, and otherwise preparing the patients for evacuation. In the Marne battle, after July 15, most of the surgical work was performed by special surgical teams attached to the division for that purpose. From July 15 to 20 three operating teams operated continuously on head, chest, abdominal, and thigh cases, which had been classed as nontransportable. Beginning the first week of August, three teams were in constant operation at Chierry on the Marne, in Field Hospital No. 27, on this same class of patients. They rendered great service to the severely wounded, and brought to within a short distance from the firing line the skill of experienced surgeons and 104 SURGERY nurses. Both at Chierry and at Verdelot the surgical operating rooms were located in excellent buildings, with good light and clean surroundings, making thoroughly aseptic work possible. Before and after operations the shock teams with their surgeons and nurses, worked over many apparently hopelessly wounded men. The radiographic unit, operating in close proximity to the surgical room, proved invaluable. But few plates were made, as the fluoroscopic method, being rapid and accurate, was used almost exclusively. After fractures were reduced the work was checked up under the fluoroscope. The following discussion of the surgical service in the field hospitals of the 42d Division is also quoted,15 for it illustrates in many respects the methods employed and the conclusions reached. The methods differ in some respects from those of the 3d Division, w-hich are quoted above. The descriptions of the work of these two divisions are the most explicit that can be found: It was the universal policy to evacuate at once to the rear all cases capable of bearing the trip, so that operative surgery in the field hospital resolved itself into treatment of the seriously wounded; that is, of those whose condition was such that further transportation was both inadvisable and dangerous to life. Very early in the campaign it was realized that for the most part field hospitals must rely on their own resources in the care of such cases, for in an active fighting unit, moving rapidly from one sector to another, it was impos- sible to depend upon the arrival of specially trained operating teams from the rear. The hospitals had to be as mobile as the division and able at a moment's notice to care for the wounded. In spite of surroundings and regardless of whether units were working in well- equipped hospitals or in barns or tents, provision always had to be made for prompt action in those cases requiring immediate surgical intervention. At an early date, in order to be prepared for any contingency, six operating teams and four shock teams were organized from the personnel of the section. Operating room assistants, anesthetists, orderlies, and litter bearers were selected and given special training. Operating and shock teams worked in relays, thus allowing periods for rest. The mobile X-ray equipment was a valuable adjunct to operative work, making possible the location of foreign bodies and the demon- stration of the extent and nature of fractures. On several occasions it furnished light for the operating room. At times the drain on sterile dressing was so great that it was necessary for hospitals to do their own sterilizing. This was accomplished by a fairly large portable sterilizer of French design, which served the purpose admirably. Operating routine was essentially the same in all cases. On arrival at the field hospital cases were sorted and classified according to the nature of the wounds and also with regard to the condition for further transportation. Cases pre- senting symptoms of shock were taken at once to the shock room for special and immediate treatment. In the preoperative ward patients were again closely examined with a view to determin- ing which needed prompt attention. All such were picked up on the following special chart: GENERAL SURGERY 105 Name_________________ Condition: Good. Fair. Shock— Traumatic. Hemorrhagic. Nature of injuries: Physical examination: Conscious. Unconscious. Semiconscious. Chest wound: Open. Closed. Hemo- or pneumothorax. Urine: Amount. Blood or clots. Vomiting: Frequency. Amount. Character. Hematoma: Location. Pulsating. Bruit. Preopekative Ward ---- Date and hour received. Tourniquet: Paralysis: Location. Sensory. Motor. Abdominal wound: Location. Physical symptoms. Stools: Normal. Blood. Fractures: Location and description. Disposition: X-ray. Shock ward. Operating room. Died. (Signed) This chart was found to be invaluable from many standpoints, especially from the fact that it necessitated careful examination of all patients. Crowded and insufficiently lighted advance aid stations, rapid evacuation from these stations under shell fire, and divided responsibility at times resulted in failure to record the use of tourniquets or the detection of hemorrhage. In the same connection, one case of morphine poisoning was observed, but, fortunately, was discovered in time to prevent a fatality. * * * The case is cited to show the danger of failure to record the use of morphine, for as the patient was badly shocked as well as poisoned, it would have been pardonable for the entire syn- drome to have been attributed to shock alone. Of equal importance was the advisability of recording all obtainable data concerning the nature of the wounding agent as well as the manner in which the wound was sustained. It was a well-recognized fact that shell fragments or bullets entering the body might travel in any direction, leaving no external clue to their subsequent course, the final destination of a missile being determined by its nature, velocity, and angle of entrance. Given a chest wound, a bloody vomitus would be strong evidence that the missile had passed through the diaphragm and penetrated the stomach, and to omit this evidence from the records was a serious mistake, for, although a perfect operation might be performed on the chest wound, the complicating abdominal injury untreated would surely have been fatal. On the other hand, when a patient came to the operating room a carefully taken description of his wound saved valuable time for the surgeon and for the patients who were painfully, though patiently, waiting their turn. 106 SURGERY Every shock case upon reaching a field hospital was sent at once to the shock ward and the patient's record kept on the following report chart: Shock Ward Narne: Individual report. Nature of injury: Organization. Blood pressure: Date and time of injury: Date and time received: Condition of patient: Moderate or severe shock. Treatment: Tourniquet: Infusion, c. c. Location: Transfusion, c. c. Duration:---------hours. External heat. Morphine. Stimulants. Specify any other. Effect of treatment: Improved: Unimproved: No response: Disposition: Time. Operating room. Evacuated. Died. Was patient returned from operating room, and final disposition? This chart was adopted in order to permit a close study of the cases treated for the purpose of determining the relative value of the various forms of treatment. Upon arrival of a case in the shock ward the litter was placed on a pair of low trestles, one for each end. The officer in charge made a hurried examination for open or concealed hemorrhage. If none was found the patient was covered with warm blankets and heat applied beneath the litter. Solid alcohol was used for heating purposes, usually four cans to a single patient, these being protected by metal boxes open at one end only. Blankets were then dropped over the sides of the litter to the ground. Warm drinks were given in small quantities if the patient had no abdominal wound or was not slated for early operation. The only cardiac stimulants used were caffeine citrate and camphorated oil, used subcutaneously. Morphine was given, both for the relief of pain and for its general beneficial effect. Gum acacia salt solution was used extensively, with unsatisfactory results, and blood transfusion was not always feasible. The length of a patient's stay in the shock ward depended upon his condition. If re- action was prompt and there was no special need of an immediate operation he was evacu- ated. If operation was indicated it was performed as quickly as circumstances would permit. Anesthetics used were ether and ethyl chloride, preferably the latter, owing to the fact that it induced rapid anesthesia and was well borne. No untoward effects of any kind were observed from its administration. At the close of an operation the patient was returned to the shock ward for further treatment until full reaction had occurred. A study of shock cases treated by the field-hospital section of the 42d Division led to the following conclusions concerning the etiology of shock: During the early days of the division's participation in active campaign, when the weather was warm and the men were in splendid condition both physically and mentally, the number of shock cases was rela- tively small. It was observed during this period that even cases in severe shock responded readily to treatment. * * * In striking contrast was the clinical picture presented by the wounded during the closing weeks of the war. Not only was there a greater number of shock cases, running up to 17 to 20 per cent of the severely wounded, but they were far GENERAL SURGERY 107 graver in character, reacting very slowly to the most energetic treatment, Worn out bv long fighting, with little chance for rest, exposed to cold, with insufficient protection, con- stantly wet and insufficiently fed, with cold food—a condition necessitated bv the risk which fires close to the line would have entailed—the troops were at a low-water mark of fitness, mentally and physically. * * * The mortality in shock cases was, consequently, ex- tremely high in spite of every possible form of treatment, and the experience of all was that, no matter what the type of treatment, results were most unsatisfactory and discouraging, for the patients were not only wounded but exhausted. This experience coincided with that of other divisions. It was found that war surgery, like all traumatic surgery, constantly presented three great problems, viz, shock, hemorrhage, and infection. Shock has already been discussed. but it must be emphasized that this was materially lessened by the careful attention given the wounded at regimental and advance aid stations and by the rapid evacuation by am- bulance companies of all wounded to the field hospitals. Hemorrhage was controlled by the tourniquet or by direct ligature, which insured the delivery of patients to their destination without serious loss of blood. With regard to infection, it was noted in the early days of the war that the number of wounded men dying from tetanus was very large. Accordingly, a thorough system of immunization was carried out and every wound, no matter how trivial, was considered justifiable cause for the administration of antitetanic serum. So religiously was this plan followed that a wounded soldier rarely appeared at a field hospital without first having received his prophylactic dose of serum. Experience with infection caused by gas-forming bacilli was limited in the field hospitals, owing to the fact that in most instances cases were received promptly after injury and were evacuated before the development of this grave condition. This was true also of the pyogenic wound infections, but an effort was made to prevent all infection by the adoption of well-recognized preventive measures. In the 42d Division operations in field hospitals were limited to the following classes of cases: Thoracic aspirating wounds, abdomical cases where hemorrhage might be rapidly fatal or a peritonitis imminent, cases requiring amputation, joint injuries, and all hemor- rhagic cases. It was not intended that definitive surgery should be performed in field hospitals except upon certain nontransportable patients, as evacuation hospitals were provided for this purpose. The scope of professional activities in field hospitals varied greatly according to the intensity of the action, but during an offensive it was customary to evacuate all patients as soon as they could endure transportation. After the formation of the First Army its orders required that operations in field hospitals be reduced to a minimum, and similar orders were published in several corps. Though evacuation hospitals habitually were located well up toward field hospitals, an exception occurred when the 1st and 2d Divisions attacked toward Soissons. During this attack evacuation hospitals were not moved up because no advance information had been given the medical authorities concerned.10 Also they were at considerable distances from much of the front in the later stages of the Meuse-Argonne operation, on account of lack of rail- roads in the immediate rear of the divisions. Because of the accessibility of evacuation hospitals during the first part of the Meuse-Argonne operation, only two types of patients were operated upon in field hospitals, in the 5th Divisiou, viz, those with aspirating chest wounds and hemorrhage.17 Later, on account of the considerable length of time elasping from receipt of wounds until arrival at hospital, all types of cases were operated upon if thev could not be transported to the evacuation hospital within 15 hours after being wounded, except that patients with aspirating 108 SURGERY chest wounds and uncontrollable hemorrhage continued to be operated upon irrespective of this time limit. In the 5th Division, wounds operated upon under these circumstances were, relatively, as follow-s:17 Abdomen, 20 per cent; chest, 27 per cent; head, face, and neck, 9 per cent; upper extremities, 18 per cent; lower extremities, 26 per cent. No patients were operated upon who could possibly have been transported within the time limit—15 hours— except those whose wounds were so severe that operation was imperative.17 The operations performed most frequently in the 5th Division were trans- fusions and arrest of hemorrhage. In about 19 per cent of the patients ad- mitted to triage, antitetanic serum had to be administered, there being no record of its having been given farther forward.17 The following records pertaining to the 32d Division, A. E. F., indicate the plans which were promulgated in that division for the care of its wounded, more particularly in the field hospitals, and in addition show with what success they were carried out under battle conditions: [Memorandum] Headquarters, 32d Division, Office of Division Surgeon, August 31, 1918. To All Medical Officers, this Division: Instructions for Operation of Triage, Thirty-Second Division It is essential that all casualties from the front pass through the triage. The following plan of operation, with minor modifications, has been successfully followed by a field hospital of this division. No radical departure therefrom will be made, except by order of the division surgeon: 1. Functions.—The function of a triage is, in general: First, the grouping of casualties as to degree, which determines whether they are (a) transportable; (b) nontransportable. Second, their classification as to type of casualty, i. e., (a) G. S. W.-S, (b) G. S. W.-O, (c) psychoneurosis, (d) gassed, (e) injured, (J) sick. Other functions of a triage are: 1. The rendering of minor surgical aid and medical treatment in emergencies, to make transportable, if possible, cases that would otherwise be nontransportable. 2. The readjustment, or renewal of dressings and of splints where necessary. 3. The administration of antitetanic serum for immunizing purposes where it has not already been administered. (Accept no evidence that it has been administered other than a statement to that effect on the diagnosis tag or the presence of the characteristic sign on the patient's forehead. A statement by the patient that he has had a hypodermic injection must not be accepted as proof.) 4. The preparation of hot drinks and food, to be given when indicated. 5. The triage is not a collecting station, but a means of separating and evacuating with all possible speed, through proper channels to designated hospitals. 2. Operations, Records and Reports.—I. A medical officer shall examine each case as admitted, marking the disposition of case on the back of the diagnosis tag with colored pencil. A clerk will then follow to collect the necessary data; the completion of which he will indicate on tag by a fixed symbol or otherwise. (Cross in circle is suggested.) The noncommissioned officer in charge of litter detail will assure himself that each tag bears this symbol before evacuating such case from triage. II. Accurate and complete record of all patients will be made, listing casualties separately by, first, 32d Division; second, other United States units; third, allied troops; fourth, enemy. And giving in each instance name and Army serial number, rank, company and organization, nature of casualty, disposition. This in- formation will be recorded on Form 4, A. G. O. S. D., A. E. F.; two copies to be forwarded to the division surgeon's office by courier. The period of record thus compiled will be six GENERAL SURGERY 109 hours, 6 a. m. to 12 noon, 12 noon to 6 p. m., etc. III. The nontransportable wounded will be admitted to advanced operative field hospital immediately and directly from the triage receiving tent. IV. A daily summary for the 24-hour period ending 6 a. m. and known as triage report will be prepared and sent by courier to the division surgeon's office as soon after the closing of the period as possible. V. Only cases admitted to field hospitals will be carded on field medical card and reported on Form 22, A. G. O. S. D., A. E. F. Cases dying in triage or enroute to triage will be forwarded and admitted to a hospital, where the necessary records will be made and proper provision made for burial. 3. Personnel.—I. The personnel shall consist of two teams; each on a 12-hour tour of duty and composed of (as a minimum) 1 medical officer, 1 noncommissioned officer, 2 clerks, 1 stenographer, 12 litter bearers, 2 men for kitchen detail, 1 ward attendant for each tent in which patients are held, and 2 men for dispensary and dressing room. 4. Equipment.—The following equipment has been found adequate: I. One ward tent or other shelter as a receiving ward, with a capacity for at least 12 litter and 40 sitting cases. When feasible it should be well lighted. II. A second ward tent or other shelter for the tem- porary care and segregation of the seriously wounded transportables while awaiting evacua- tion. III. A third ward tent or shelter for the temporary care and segregation of slightly wounded sitting cases. IV. A fourth shelter for those cases classified as sick or as psychoneuro- tic; which are ordinarily sent to one of the division field hospitals. V. A small cover, such as is afforded by a 14 by 14 tent fly, for (a) storage of litters, necessary medical supplies, blankets, etc.; (b) office. VI. Equipment necessary for the preparation and serving of food. Enlisted personnel must be especially trained in their respective duties and instructed as to the function and purpose of a triage, namely, grouping of casualties, correct record, speedy evacuation. G. E. Seaman, Lieutenant Colonel, Medical Corps, Division Surgeon. Headquarters 32d Division, September 3, 1918. From: J. W. Vaughan, major, Medical Corps, United States Army. To: The Chief Surgeon, A. E. F. Subject: Surgical care of the wounded from the 32d Division during the drive from August 27 to September 2, 191S. 1. Since the report last made upon the surgical care of wounded from the 32d Division several changes have been made in the organization. These changes have been instituted as a result of the experience gained in the Fismes drive, and it is the opinion of those who have had to do the work that they have facilitated in the proper handling of the wounded. 2. The chief change was one put into effect by the commanding officer of Field Hospital No 127 This consisted in the placing of a triage, in compliance with an order of the divi- sion surgeon, a short distance in advance of the operating hospital for seriously wounded, thus separating it entirely from our advanced operative hospital, to which it was attached in our former drive All wounded were brought to this triage by the division ambulances. These ambulances were unloaded and immediately returned to the front stations for more wounded. In that way no serious blocking ever occurred at the advanced dressing stations 3 At the triage the patients were sorted out as to the degree of severity of their wounds. Accurate records were also kept of the wounded so that a report of the number, rank organi- zation, and severity of the wounds could be made every six hours. (It is imperative that the best aid most decisive medical men available should direct this work.) The severely wounded were sent to our advanced operative station, which was 12 kms behind the front line at the beginning of operations. Inasmuch as the distance between the two stations was only about STards, the mule-drawn ambulances were used for this purpose. The less seriously wounded were evacuated by truck and attached motor ambulance company to Evacuation Hospital No. 5, which was stationed 19 kms. farther in the rear. From here evacuation was carried out by train to Paris. 110 SURGERY 4. One train of wounded was also evacuated by train direct from La Vache Noire to Paris, the latter place being just about 1 km. from the triage, at a time when sufficient motor transportation to Evacuation Hospital No. 5 was not obtainable. 5. The placing of the triage entirely separate from and slightly in advance of the operat- ing station for seriously wounded enabled the officer in charge of the same to send only non- transportable cases to that station. Abdomens, sucking chests, serious heads, cases in shock or apparently standing transportation poorly, and those showing evidence of hemorrhage were the only ones sent. 6. The total number of wounded was 1,758 up to the time of writing this report. Ol these, 256 were sent to the hospital for seriously wounded. Of these 256, 41 were so seriously wounded that they died within a few hours after admittance. Blood transfusion, intravenous injections of gum, and other methods used to combat shock failed to be of benefit in these cases. In addition, seven deaths were charged to the hospital, the deaths occurring en route to the triage, the bodies being brought so that our burial squad could attend to them. 7. Operative treatment was given to the 215 cases remaining. Amongst these cases there were 34 deaths. The separate wounds encountered in the 215 cases were 419 in number, and were divided as shown in the following table. The wounds encountered in the cases that proved fatal are also tabulated. Soft parts____________.......______________ Soft parts associated with injury of large vessels. Fractures: Femur_______________________________ Humerus_____________________________ Radius, ulna, tibia, or fibula_____________ Other bones.........___________________ Knee joints___________________________ Elbow joints__________________________ Combined chests and abdomens_____________ Chests (sucking)___•------------------- Abdomens, with injury to hollow viscus______ Abdomens, without injury to hollow viscus____ Head and brain___________________________ A mputations_____________________________ Cord injuries: Partial_______________________________ Complete..........____________________ Symptoms present, but no injury to cord found Collapsed eyes____________________________ Total______________________________ Wounds Wounds in 215 in 34 cases deaths 170 17 7 1 14 fi 15 1 37 y 46 l 5 5 l 6 i 41 5 25 10 11 2 15 2 8 1 3 2 1 4 5 419 Cases showing evidence of fulminating gas gangrene totaled 8; of these, 2 died. Fig- ures were furnished by the adjutant of Evacuation Hospital No. 5 upon September 1, which showed that up to that time 1,635 casualties from the 32d Division had passed through their hands. Of these, 367 were gas cases and 122 medical, leaving 1,146 surgical cases. S. Of the latter, 676 were operated upon at No. 5, and amongst these there had been but 6 deaths, which showed that the sorting at the triage had been exceedingly well done These showed wounds of chest, abdomen, right and left femur, gas gangrene of right and left feet, and a case of hemorrhage from a neck wound. These cases had been sent on from the triage at a time when the advanced hospital was filled and it was thought that they might receive attention sooner if sent on. This probably should not have been done and was an error in judgment on my part, as possibly some would have been saved if attended to at the advanced station. 9. A good proportion of the cases which so far have survived operation at the advanced institution were in shock, or showed evidence of having suffered from considerable hemor- rhage, upon arrival. In fact, the percentage of these cases was so large that a rule was adopted that every case entering the hospital should first be seen by the head of the shock team, and that the order in which surgical attention was given was under the direction of the shock team entirely, inasmuch as through their constant observation thev were able GENERAL SURGERY 111 to estimate when a case should be operated upon much better than could the operating surgeon who was busy with many other things. 10. The shock team furnished was No. 116, and their work was of inestimable value. I would request that in the future two teams be assigned to this division, when in an active sector, so that it will be possible for one to relieve the other. It was found necessary to divide the last team and add one more officer from our own divisional personnel in order that this team could functionate in 12-hour shifts. 11. I would again request that two X-ray teams be furnished our advanced operating hospital, so that it will be possible to work 12-hour shifts there also. The team attached to us worked constantly without rest for over 48 hours and carried on with but little sleep for the full six days. 12. One operative team was furnished us by the surgical department for our advanced unit. This was Navy Operating Team No. 1. The work done by this team was excellent, and I would again suggest the necessity of more equipped teams for advanced hospitals during active times. 13. As in our former drive, it was found necessary to make up teams from the officers and enlisted personnel of the division. These were practically the same as those detailed in the report upon activities in the Fismes sector. Six such teams were used, and without such resources it would have been impossible to giye the seriously wounded the attention required. 14. An attempt was made to follow up the cases operated upon in our advanced insti- tution in order to ascertain what the ultimate outcome was. A total of SS cases were seen in the base hospitals in Paris. Of these, 14 had been operated upon at Field Hospital No. 127, and amongst these there had been one death from gas gangrene. 15. Some system of follow-up should be devised whereby a record of these cases can !>e kept and thus the ultimate value of advanced operative institutions for seriously wounded can be ascertained. It would appear, however, that there is a decided place for small mobile advanced institutions, which should be attached to each division, especially if our evacuation hospitals are to be stationed so far in the rear. Such institutions are abso- lutely essential in case of an advance of 10 kins, or more if our seriously wounded are to receive proper attention. (Signed.) J. W. Vaughan, Major. Medical Corps, United States Army, Con s u Iti n g S u rgeo n. THE EVACUATION HOSPITAL In both trench and open warfare the evacuation hospital is usually the first surgical formation reached by the wounded that is completely equipped and prepared for the treatment of all cases. At the evacuation hospital, which operated cither alone or in conjunction with one or more mobile hospitals, primary operations wore performed, emergency operations performed at the more forward stations were revised, the severely wounded were hospitalized until they cither succumbed or became transportable to the base, and all trans- port able wounded, after receiving appropriate treatment, were evacuated im- mediately in order to make room for other convoys of wounded. FUNCTIONS Evacuation hospitals which reached the zone of the armies were operated directly under the jurisdiction of the army surgeon and not under the chief simoon of the line of communications, as our regulations had stipulated pre- vious to our entry into the war." The army surgeon, cooperating with the 46007—27— -10 112 SURGERY deputy of the chief surgeon, A. E. F., at G. H. Q.. supervised their distribution, location, and expansion, coordinated their activities with the service of the front, and, through a medical officer assigned to the regulating station, effected their clearing by hospital trains. In the few instances, when evacuation hos- pitals were not located on a railway line, the army surgeon effected their evacuation to a railway by ambulance companies under his command.18 These evacuation hospitals, too, were supplemented by mobile hospitals, which per- formed similar functions but were smaller and more mobile. While in certain respects our field hospital continued to be an emergency hospital for the battlefield, it became more nearly a magnified and improved dress- ing station than a hospital. This made th e evacuation hos- pital the actual theater of our surgical effort there, especially during very active periods. The evacuation hospital, plus the mobile hospital and the mobile surgical unit, thus con- stituted the hospital for early surgery; upon it, to a very great extent, the patient's life and limb depended. It proved necessary to apply in this hos- pital with great rapidity, to the most urgent cases, the best treatment known to modern surgery, in order to secure satisfactory professional re- sults, and at the same time, in order to secure the best administrative service, it was likewise necessary to evacuate its patients as quickly as pos- sible to provide beds for in- coming wounded. To a cer- tain degree these needs con- flicted, and it was only by the utmost diligence and perspicacity that they could be reconciled in periods of stress, or, that, if this proved impossible, their conflict could be reduced to a minimum.19 It should be explained here that our medical service did not accept the tenet of our Allies that the more lightly wounded should receive preferential attention in the zone of the armies because of the greater probability of their return to active service, and also because a greater number could thus be cared for in a given period.20 Increased knowledge of surgery proved that removal of devitalized tissue and foreign bodies from slight wounds could be accom- plished successfully back of the zone of the armies, and that surgical interven- Fig. 91.—Sorting wounded GENERAL SURGERY 113 tion within 12 hours was not essential in the slighter cases in order to prevent infection by the gas-forming bacilli.21 The earlier belief that early operation was essential in all cases had an important influence, however, in causing the British and the French to locate so many large, relatively immobile hospitals so close to the front. Their entire evacuation hospital service was also pro- foundly influenced by the fact that shell wounds, so common in this war, were practically always infected by gas-forming organisms, and that, in order to get the best results, operation was advisable within 12 hours after injury.21 At such operations foreign bodies were removed, the wound debrided and left open until bacteriological examination showed that its closure was warrantable. This last procedure, in uncomplicated flesh wounds, was usually possible in four to five days and recovery was complete in from three to five weeks. No one questions the necessity for very prompt action in serious wounds, but it Fig. 92.—Wounded awaiting admission to hospital had also been believed that return to the colors would be expedited if the slightly wounded as well as the seriously wounded could be operated on within 12-hour limit of time. Later observations showed that practically the same results were obtained in the slightly wounded, without retained foreign bodies, if operation were delayed 24 hours or even longer. Upon this knowdedge was based the American policy of sending such cases farther to the rear for opera- tion if pressure was such that their numbers would overtax an evacuation hospital of approximately 1,000-bed capacity at the front.21 Our evacuation hospitals then sought especially to give surgical treatment to severely wounded patients whom it was not advisable to send, unoperated upon, farther to the rear, and then to hospitalize such patients until they were fit to'be moved, so far as might be necessary, but only, as circumstances per- mitted, to hospitalize here also the less seriously injured. As a rule, the treat- ment oiven the latter was temporary, though sometimes it was definitive, but 114 SURGERY this was onlv if the demand for beds was not pressing. In times of great st n-s> there were never enough evacuation hospitals at the front to give full surgical attention to all the wounded; nor was it proposed that there should be, for such provision would have required an excessively large hospitalization in tin- zone of the armies. Except for the small percentage of very seriously wounded who had to be hospitalized in evacuation hospitals because they could not endure transportation to the rear, our evacuation hospitals were merely relay or clearing stations in the hospitalization and evacuation chain. While the more seriously wounded properly required two weeks' hospitali- zation after operating before being transferred, sometimes the demand for beds was so great that the more seriously wounded had to be removed in less than half the time. Brain injuries, if operated upon here, were kept, if possible, at least 10 days. Knee-joint, abdominal, and chest wounds were retained from 10 days to two weeks when possible, but patients with these wounds sometimes were evacuated after five days, or, very rarely, in even less time. Patients Fig. 93.—Admission office of an evacuation hospital with compound fractures of the femur were kept as long as possible.21 It was estimated that about 10 per cent of the beds in evacuation hospitals would ordinarily be used for the severely wounded and the remainder for patients to be evacuated immediately. It was recognized, however, that this proportion, like many others pertaining to evacuation hospitals, was subject to radical modification in order to meet the constantly shifting military situation and it- hospital requirements.21 Elasticity of this hospital proved essential in both size and service.16 The capacity and organization of individual evacuation hospitals were based, to a certain extent, on an estimate of what the maximum daily admis- sions would be. With some exceptions these did not exceed 1,000, but on some occasions there were more than 1,400; for example, in Evacuation Hospital No. 9, on October 10, 1918, during the Meuse-Argonne operation.22 Excessive pressure, due to the intake of more patients than an evacuation hospital could care for, was controlled by sending patients out on ''preoperative trains," tliough GENERAL SURGERY 115 some hospitals objected to this practice on the ground that it indicated in- ability of the institution to handle patients properly. It was contended also that the time which must elapse before these patients could be delivered by train to hospitals in the rear would exceed the length of time they would have to await operation in the evacuation hospital concerned and that their chances of infection would thereby be increased. In any event, these patients were transferred from the evacuation hospital only after very careful examination and re-dressing. The transferable were held to include those with such injuries as fractures caused by rifle and machine-gun bullets, but without much bom- destruction; gutter wounds; and flesh wounds with retained bullets. But local demands and the resources available at the time really determined what classes of patients should be transferred. An important factor influencing the use of preoperative trains was the number and rapidity of operating teams available at the evacuation hospitals. The number of operating teams was increased in the evacuation hospitals; then work was speeded up. The number of unoperated patients it was necessary to evacuate from the evacuation hospitals during the Meuse-Argonne operation fell from above 1.370 in the first phase of that engagement to 293 in the second.-' When the 24-hour intake of patients at an evacuation hospital exceeded 1,000 the routine plan of work ordinarily had to be changed if all patients were to be cared for locally. The necessary speeding up of operating teams under such circumstances depended on their good organization. Shifts at the eleventh hour generally proved unsatisfactory, and it was found that sometimes, due essentially to inadequacy in number, experience, and speed of operation teams, preoperative trains had to be used. How severe the pressure was at times is indicated by the fact that in the six weeks subsequent to June 13, 19ls, Evacua- tion Hospital Xo. 7, at Coulommiers, near Chateau-Thierry, received and evacuated 27,000 cases. Between June 14 and November 11, 191S, it admitted more than 50,000 patients,24 while Evacuation Hospital Xo. 9 admitted more than 32,000 during the Meuse-Argonne operation, September 2(> to November 11, 19LS.22 Generally speaking, more than half the patients admitted to evacuation hospitals in the zone of the armies were surgical cases, and of these about half were operated upon. Data on this subject, however, are incomplete, and these figures apply only to those hospitals which reported on this subject. The quota of personnel on duty in the receiving ward also differed some- what in the several hospitals, but usually it consisted of 2 officers, 1 sergeant. S clerks, 2 guards, and S or 10 litter bearers. Officers on duty here gave emergency treatment in case of hemorrhage, supervised litter bearers' activities, the preparation of records, and the care of valuables, made appropriate note on the admission card of a patient if antitetanic serum had not been administered and distributed patients to wards for gassed and medical patients, to the dressing tent for walking wounded, to the preoperative ward or to the shock ward, as the case might be. Records were made here giving each patient's name', his military designation, diagnosis, and any other necessary data obtained from personal interrogation and from an examination of his field card and diagnosis tag.20 If the patient was unconscious these facts were obtained 116 SURGERY from other patients accompanying him and from his identification tag, as well as from the other sources mentioned.25 In some hospitals a nominal list was usually made on the admission of patients, and two copies of Form 52 were made out for each patient in the wards. One of these was sent to the sick and wounded office at once, and this furnished the data for reports called for from the hospital. The other copy was turned into the sick and wounded office when the patient was evacuated. In other units complete records were made, so far as this was possible, in the receiving ward, and these records were sup- plemented later by data from the operating room and wards. Walking wounded who were seriously injured were sent to the preoperative ward, tagged for immediate attention. Similar tags were placed on shock patients and on those with tourniquets. The dressing room for the slightly wounded was located near the receiving tent. Its equipment was simple, consisting of one or two operating tables, benches, a table for instruments, and dressings and utensils which had been sterilized in the main sterilizing room.25 One or sometimes two officers, as- sisted by one or two nurses and by two or three enlisted men, were on duty here. At this point a second sorting was effected. The officer on duty examined, dressed, and recorded patients admitted to this department, giving antitetanic serum to such patients as had not already received it. Patients requiring immediate operation or who might be evacuated at once (on litters, if the pressure was great) were properly tagged and sent to the preoperative ward. Patients whose conditions wrere not critical, requiring X-ray examination, were sent to the X-ray department. Since patients with very serious injuries— for example, injuries of the large blood vessels and even compound fractures of the skull—were sometimes ambulatory, careful attention was given every wound, however slight it might appear to be. At this point, too, careful search was made for injuries of nerves and blood vessels. Provisional diag- nosis and administration of antitetanic serum or morphine were noted on the patient's field medical card.25 Other patients than those already mentioned wore sent to the wards for slightly wounded, or to the evacuation ward, after their wounds had been dressed and they had received hot food or drinks if, as in some hospitals, these had not already been given in the receiving ward. Slightly wounded patients who had developed intercurrent diseases, such as pneumonia, dysentery, or the like, were sent habitually to the appropriate medical wards.25 Decision as to whether slight wounds should be operated upon was based on the rate of admissions, the number of surgical teams and their speed. It was found that an experienced team operating two tables often handled 35 or 40 minor patients during its shift; later this number was notably increased be- cause of better organization and improved skill, until many teams operated upon more than 60, some more than 80 patients, and one team more than 90 patients, during the daily shift.23 In periods of comparative quiet at first practically all surgical patients admitted were operated on, and toward the end of the war this was the case even during periods of great military activity. The chief of the surgical service kept his teams fully occupied, the number of preoperative patients transferred being limited only by the surgical facilities locally available.25 GENERAL SURGERY 117 The third major sorting of patients was effected in the preoperative or classification wards, which received the wounded admitted on litters and certain ambulatory patients sent from the dressing tent. Patients received here required 80 per cent of the professional skill available in an evacuation hospital. At this point, on alternating day and night shifts, were stationed the most experienced men on the professional staff, selected with regard to accuracy and rapidity of decision and adjustability to the constantly shifting standards which controlled the disposition of patients. The quota of nurses and orderlies in this department was large; usually there were 1 officer, 1 nurse, and 4 enlisted men to each ward. Day and night shifts were provided. Patients were undressed, bathed, if possible, and their wounds were examined and dressed. When possible they were undressed in one tent and their wounds were dressed in another.20 In some hospitals a sketch and description of the wound were made when patients were being bathed, and this record accompanied the patient to the operating room. If the patient's condition was critical, his clothing was not removed until he had been anesthetized, or, if he was badly shocked, not until rising blood pressure warranted it.20 In the preoperative ward waiting patients received morphine, if this was needed, and hot drinks and food if these had not already been administered or if desired.25 The success of an evacuation hospital's service was commensurate in very large degree to its methodical and successive distributions of patients. At the three points mentioned above—receiving ward, dressing room, and preop- erative ward—it was essential that there be prompt, accurate diagnosis and immediate distribution in conformity with very changeable demands for evacua- tions. Distribution from the preoperative ward was determined primarily by the number of patients to be cared for and by the facilities for operating, and not entirely by the patient's condition. When operating teams were limited in number, or were inexperienced, a rapid influx of patients would change the standard of selection of patients for operation from all-litter and the more serious walking cases into, for example, a very much more restricted class composed chiefly of patients with abdominal wounds, aspirating chest wounds, and fractures of the femur by shell fragments. Under such circumstances patients had to be sent out on preoperative trains until operating teams were furnished in sufficient number and had acquired sufficient speed to care for them.20 Only in exceptional cases were patients sent from the preoperative ward direct to the operating room. These included patients with active hemorrhage, or patients received with tourniquets in place, and with certain fractures without splinting.20 The preoperative ward, X-ray section, operating rooms, and wards for the severely wounded were grouped as near together as possible, for it was essential to reduce carriage by litter to a minimum. If this was not done, it was found that litter squads were exhausted after a week's offensive.20 Patients were distributed from the preoperative ward, according to rate of admission and available operating facilities, into (a) special wards for head, 118 SURGERY chest, and abdominal patients; (b) shock ward: (c) X-ray ward: ( that the I lrto WlUf,befCOnVe^d into a triage hospital or a specialized hospital. no "Z T , ' °Ur fidd h°Spitals Sh0uld be rained to do everything shouldd7™th IT "^ SUrgiCah TWe 1S danger that the ^ ^P^ should do nothing but gas cases and the surgical hospital nothing but surgery. Given a division that has a front of 30 or 40 km. there will be four or six hospitals for different cases. Another sector of 10 to 12 km. will have one hos- pital, with a gas hospital acting also as triage. We can not always pick cases and send them to specialized hospitals. With a division that is advancing, we should group hospitals and have them do the triage, but we should not tram field hospitals along any one line. It makes no difference whether you call it a mobile, field, or evacuation; all depends on the men and equipment, If there is a good surgeon at a field hospital, that hospital will do good surgery \ ,H t P the fi6ld ambulance as the British have it; our field hospitals should be generally trained, not specially trained only, and should be ready to do emergency work of any kind. General Makins (British). I think the last speaker has touched the great point—military surgeons must be general practitioners. It is quite true that you may have special units for special work, but the surgeon ought to be ready to take anything that comes into his hands. Colonel Cummins. I want to indorse the remarks made by the last two speakers. I feel quite certain that no divisional unit can avoid being ready to do anything that comes along; it must be general and not special. Certain points require special study. The best field ambulance I had had specialized in the immobilization of fractures, in the arrest of hemorrhage, in the feeding and warming of patients, in dealing with shock cases, and in triage and clinical work. I say clinical work because it is a most important matter to a divisional commander to know what becomes of the wounded and sick that come down the line. Those are the general subjects on which field ambulances ought to specialize. I believe our field ambulance ought to be identical with your field hospital. General Bowlby. I have listened to this discussion with the greatest inter- est, but I want to say that it is impossible to lay down hard and fast rules and regulations. Personal initiative is the thing to which a great deal must be left; conditions vary with the times. What is right one time is wrong another time. While fighting is going on it is most important to pass people through as rapidly as possible to the rear. In cases where the line is fixed and the fight- ing not very heavy, it seems to me that the arrangements made in the British, French, and American armies are very simple and good; the difficulty comes in where there is a very heavy crowd of wounded. Our feeling is that triage had better be done at the casualty clearing sta- tion. Don't let anyone worry the men and examine them too much; pass them on; give them to the casualty clearing station, or your evacuation hospital, and there let their fate be decided. Is a man to be retained for operation, or is he to be evacuated? The sooner you get the men to the evacuation hospital the better, and the heavier the fighting the more necessary it is to get the men there as quickly as possible. The object of the field ambulance is to have the 140 SURGERY patients dressed, examined, and passed on. There are cases where it is advis- able to do operations there, but the point of view to keep in mind is that when you have operated a man you have not finished with him, and if you have no way of caring for him afterwards it is better not to do anything; you are not doing him a kindness by operating him if you can not give him aftercare. It is necessary to have the man under favorable conditions and where he can be retained after operation. The field hospital may have to be moved and patients moved with it who are much better not moved. In a small manual published for the guidance of our surgeons it was advo- cated that no operations should be done at the field ambulance except arrest of hemorrhage and removal of badly smashed limbs. This is essential. Under these circumstances you may require resuscitation teams, and we have put them lately in field ambulances to enable these operations to be done more thoroughly; but whenever a patient can be evacuated he should be sent to a casualty clearing station. It is essential to free the field ambulances and not block them. On the 8th of August the Fourth Army began a large move, and within three weeks we had moved our casualty clearing stations thirty-four times. There is an idea that an evacuation unit is a fixed unit, but it is not. If you say you must move the whole hospital, it becomes an impossibility; but you can take a section of the casualty clearing station with operating teams and a suffi- cient number of staff to deal with 300 to 400 patients and put them forward. Put them in the field ambulance and there they can do the work, and while they are working the field ambulance can move up. There is too much of a habit of talking of the C. C. S. as an indivisible unit; some of the surgeons can be moved on to aid the staff of the field ambulance. If you supply operators from the C. C. S. and reestablish the C. C. S. in detail—not all at once—the thing is not impossible. One of the greatest difficulties in our advance was the transportation of the C. C. S. forward, or bringing patients back. Our chief difficulty came from the number of canals with bridges blown up. The C. C. S. was often ready to go, but had no opportunity of moving on because of the pushing up of military material. But when we could not move it as a whole we could move sections of it and reestablish it on the other side of the canal. If we look at other parts of the world where the war has been going on, we will find other difficulties which we have not encountered. Our conditions were entirely different from those of the Italians in mountainous regions. The general principle is to get wounded back from the forward areas as soon as you can. Do not operate unless you can look after the cases subsequent to operation. If you insist on operating a large number of cases, many of whom will have to be moved, you will lose many lives. Colonel Crile. Shall evacuation hospitals be specialized hospitals or not? General Wallace. As far as the front area goes, I think that on the whole every clearing station should be equipped in the same way to deal with every class of case. I quite appreciate the benefit of having hospitals for head cases, abdominal cases, etc., but this means great care in arrangements that the staff at the abdominal hospital has got adequate work; the same thing at the chest hospital, etc. In a battle you can never prognosticate the proportion of different GENERAL SURGERY 141 cases which you have; consequently, if you separate them, you are apt to get one hospital very hard worked while another has nothing to do at all. This is the surgical point of view. From the administrative point of view, the difficulties of evacuation in the front area are extremely great, and I don't think it is fair under those circumstances to put an extra burden on people who are already overworked. It is much better, therefore, to equip hospitals so that they can deal with every class of case and let evacuation go along on quiet lines, but from what I see I really think that at the base there is great scope for specialization, for there you can always assure an even flow of cases, and the personnel is always fully equipped. Lieutenant Colonel Cannon. The disadvantage that comes from specialized hospitals was demonstrated at St. Mihiel. There, one hospital was set aside for very badly wounded, that was not farther away than the other hospitals but was quite separate from them, with the result that no provision was made in the way of donors for blood transfusion. Blood was badly needed, and there were no slightly wounded or gassed men from whom blood could be obtained for these cases. General Wallace. It is not really a question of specialization, but a question of separating walking wounded from more seriously wounded. In the British Army w^e put aside one station for walking wounded; they can be dealt with by a small staff and quickly sent away. From a surgical point of view the great object is for a hospital with seriously wounded not to have too much work. One can't help being struck by the air of calm in a station dealing only with serious cases. Colonel Crile. Is it advisable to establish a pool of medical officers and nurses to supply emergency personnel when needed, and to render possible the utilization of all personnel at all times? General Wallace. Up to quite recently the fighting has only really in- volved one or two armies, and our armies were asked: "What is the minimum amount of personnel that you can do with, if the army remains quiet?" Di- rectly one or two armies got involved, the Medical Department knew what personnel was needed. Surgical teams were supplied and were moved into the fighting area. There was no definite pool, but they knew what other armies could spare. General Bowlby. I think the experience wre had at the front is that when everything is quiet there is no objection to establishing special hospitals, but when operations get active we can no longer separate head and lung cases, and every C. C. S. must be prepared to take, in heavy fighting, everything that comes along. In times of quiet it may be distinctly advantageous to the patients to have specialized hospitals. Colonel Crile. What is included among nontransportable cases? Suppose we say cases of hemorrhage, shock, wounds of the chest, as a beginning, what other cases should be included? General Bowlby. I think all completely smashed limbs should never be removed from the field ambulance. Colonel Crile. If there is a sufficient number of hospitals shall one mobile hospital be set aside for the care of the walking wounded? 142 SURGERY Lieutenant (Lionel Johnson. I think the mobile hospital is such a valu- able unit that it should not be used for this work; it should be put to the use for which it was intended, and not used for walking wounded. General Bowlby. In the recent advance of the First Army there was a walking-wounded hospital and three others. I think it very desirable to have a walking-wounded hospital in the same direction as, or beside, the other hos- pitals. It enables a string of ambulances to go in the same direction, and a given ambulance car might deposit the walking wounded at one place and other patients at another place. I remember seeing a walking-wounded officer with a small wound on the outer side of his thigh. I was asked to see him because of a swelling, and I found that he should become a lying patient. To distinguish between walking and lying wounded you need extremely competent surgeons. Out of 20 walking wounded, usually at least 1 ought to be taken to the hospital wliich deals with other cases. Often a large number of soldiers will crowd onto a light railway or van in order to get away, and if three or four lorries carry away walking wounded, men will get on who should be considered as lying wounded. In case of crowding a hospital for walking wounded should have a train attached to take away the men as soon as possible and relieve the C. C. S. Of course, the patient should not be taken a great distance. A large number of walking wounded are always the first to arrive, and they occupy the time and the operating theaters in such a way that when the seriously wounded arrive a large number of cases are in front of them. If walking wounded can be put in a particular train and sent to another area, you relieve you own staff and bring into work a large number of officers at base hospitals who otherwise would have nothing to do. With large numbers of wounded we have endeavored to have temporary ambulance trains and pass on the walking wounded to the base, where they will arrive soon enough for their wounds to be carefully treated. I think that when making provision for walking wounded you should also make provision for special cars. All cases of fractures should be sent to regular hospitals for treatment, and temporary ambulances should pass them on. You then bring into action a large number of medical bases, as well as hospitals at the front, and therefore deal with a much larger number of patients. Colonel Crile. Should mobile and evacuation hospitals be grouped in threes, in fours, or should they be isolated? Colonel Reynolds. Group all hospitals where possible. Colonel Lyle. From a transportation point of view, I agree. Group all hospitals as near together as possible. Colonel Crile. Is it advisable to establish a rotation of service between the personnel of advance and rear units? General Finney. It seems to me that it would be to the mutual advantage of every one concerned—those working in the forward areas, in base areas, in intermediate areas—if each knew something at least of the problems of the others. There would then be less tendency to criticize, to feel that the other fellow who had seen the case first was not quite onto his job. I find that the more a man knows other problems the more charitably inclined he is. There- fore it is desirable that we should institute some interchange of officers from general surgery 143 base to front. After consultation with the administrative authorities, it was decided to change at the rate of 10 per cent a month the personnel of base and front areas. That would take about 10 months to bring about a complete change of personnel. Perhaps it would not be desirable to have a complete change; it might not be possible, but it seemed eminently desirable to have a considerable change of personnel from the front to the rear and from the rear to the front. This scheme was being worked out when the war closed. I think it has many desirable features. I think a man really can do better work at the base when he has had front line experience; nothing can bring out a man more than front line work. I feel sure that for the morale of our profession, it would be to the advantage of every one concerned to say nothing of the care of the patient. The idea was to keep a continuous circulation of personnel. Whether it would work or not I don't know; we had no opportunity to try it. I myself believe that it would have worked satisfactorily. General Makins. I am very glad to hear General Finney raise that point. I have had large experience at base hospitals and I have always felt that it was desirable to have changes made. The most important reason is that it gives the individual medical officer a proper idea of the course of a surgical case. The majority of the men who have worked at one stage of the line have gained no experience of military surgery whatever. I have always felt that it was quite possible to have a definite arrangement by which a certain number of the men could move. The other point that I have felt so very strongly upon is that when the men are moved they should not really interfere very seriously with the composi- tion of the staff for the time being. The system with us was for new men who came out to be assigned to a base hospital, which served as a depot to supply medical officers at the front, I believe that is an extremely bad system, as these men interrupt the work of the hospital because they are not used to it, and in a few days they are shifted to the front. I believe there is one method which would make a very great difference. At a base hospital, vou get two classes of cases: Serious ones, and patients who stay a very short time, or slight cases. I think that all large base hospitals should be divided in two classes: (1) Serious cases, with a staff as permanent as possible. (2) Class of casualty clearing station. This is a very important point economically and medically. There is no harm in the latter hospital in changing the staff often; you can look after the patients without interfering with the work. Economically it is a very extravagant method to pass men from base hospitals into regular hospitals. They must have everything provided for them and some arrangement could be made by which hospitals of two classes could be a great advantage to the medical service with due economy. The idea of letting men see the progress of a case from beginning to end is very good and it engenders confidence of one set of surgeons in the other. It is often felt that the place of a medical officer at the base is not so important as that of the medical officer at the front. This is a mistake. When a patient goes home and verdict is passed on his case, it is never passed on the officers in the front line, 46997—27---12 144 SURGERY they are scot free of criticism. If a man is supposed to have been badly treated, the medical officer at the base is criticized, not the surgeon at the front. Colonel Lyle. There is the question of transportation. It is difficult to provide the necessary transportation. Colonel Crile. What is the best method to prevent introduction of infec- tious diseases into first-line organizations by replacements? Gen. Sir John Rose Bradford. It seems to me that the only method of doing that is to have some organization segregated for that definite purpose. At present, all cases of infectious diseases are sent to a field ambulance. Colonel Cummins. First of all one has to examine the means by which replacements are made. We have a base depot at which the troops join; from there they go to the divisional replacement battalion. We have on the other hand a corps depot through which replacements for the corps go, and in some cases a divisional unit of the same kind. All depends on close inspection. In time of disease this would be done more carefully than usual. Certain things always escape us. It is quite cer- tain that it is impractical to suggest swabbing of throats of the men in the depot to make sure that there are no carriers. A very important point is to have a medical officer make the inspection and pick out all men who look ill and examine them. Both at the base depot, divisional replacement units and corps replacements units, there must be a few tents put aside for the immediate isolation of any one suspicious. There must be close touch between the med- ical officer in charge of these units and the nearest mobile hospital. My scheme would be to have an empty isolation hut for suspected cases, an organization to separate and observe contagious cases with good sound rou- tine and inspections, but no elaborate system. Problems Relating to the Care of Patients Colonel Crile. Has our experience in the Argonne brought out any new points? Has anything new developed in the treatment of shock and hemorrhage? Lieutenant Colonel Cannon. I have had cases reported of men being brought back on stretchers with blankets over them and not under them. These men lose heat by sweat and by their wet clothing. They lose it by contact with stretchers which may be wet. It is very important to conserve the heat of the patients and see that they are properly blanketed. Report came in during the recent activity that patients in shock had four blankets over them and none under them. I have sometimes urged that shock teams be sent to the dressing station because of the time element and low blood pressure. It is desirable that shock teams be got to work as early as possible. As a matter of fact, I think shock teams have not been working so far forward in most places. Colonel Crile. What can be done for shock during the journey in the am- bulance? General Wallace. The heating of our ambulances is done by a system of running tube pipes under the seats and into the exhaust, but the exhaust is prevented from getting into the ambulance. It has been satisfactory on the general surgery 145 whole, but sometimes the ambulance gets too hot, which is bad for wounded men. Lieutenant Colonel Cannon. We had an accident in our armv which seemed to determine our action in this respect. A pipe burst, the gas leaked into the ambulance, and the patients were almost asphyxiated. We might have a pipe running from the hot-water system to the engine, when there would be no possibility of this accident occurring. Something of this sort seems desirable along with the provision of hot-water bottles in case the heating of the ambu- lance is not good or is lacking. General Wallace. We have had no question of poisoning, but I would prefer to bring the pipe underneath where the stretcher lies. Lieutenant Colonel Cannon. Another question is as to the arrangement for caring for these patients in mobile and evacuation hospitals, and whether it is really proper to have teams constituted of medical men rather than sur- geons. For future policy it seems very desirable to have some opinion on that point. General Bowlby. The question of warming patients comprises warm cars, warm admission rooms, and warm operating rooms. You must see that the men do not get cold in the operating theater. It is a good idea to put a small stove under each operating table so that the patient is kept thoroughly warm during the operation. Patients have often been kept w^arm until they got to the operating theater and not warm enough during the operation. A small stove burning under the table does a great deal to prevent patients getting chilled. Colonel Crile. What during operation? Captain Middleton. The question of warmth supplied by sand bags heated in the old-fashioned way will relieve the question of heat under the table. The question of donors for evacuation hospitals could be solved if we could have cooperation—if one case of slightly wounded was brought in to each five or eight cases of seriously wounded. In that way the unit has a constant supply of donors. Colonel Crile. This is a very valuable discussion. I wish to interrupt the program for a moment and say that the A. E. F. is fortunate in having as a part of its surgical personnel Lieutenant Colonel Cannon, who has done notable work. I will call upon him to speak of his work at the laboratories at Dijon. Lieutenant Colonel Cannon. There are certain things that have been brought out already as important matters in the treatment of shock, and which have been long recognized. Among the first is the question of heat. It has already been pointed out that a man suffering from a severe wound is likely to lose heat because of sweat and wet clothing. Another cause is low blood pres- sure and there may be a reduction of 50 per cent in heat production; therefore the patient has a "tendency to become cold and get into a worse condition surgically. Every effort should be made to keep up the heat of the man m all stages, from the time of wounding until recovery. There is danger in overheating because he is likely to have lost fluids by bleeding or sweating. If you overheat him he will lose more fluid because of sweating. 14(3 SURGERY In addition to the loss of body heat, and the necessity of keeping up body heat, there are several other points. A characteristic of a shocked man is that he has low blood pressure. However we may differ regarding the cause of shock, whether we regard it as primarily a matter of disturbance of the nervous system or as being caused by chemical causes, there is this consequence: The low blood pressure that prevails in the shocked man and which is likely to cause damage to the nervous system, because low pressure means slow circulation, and with slow circulation there is a lack of oxygen in the tissues, which makes them likely to suffer. When the blood pressure is lowered by shock there is a critical level in the fall of the blood pressure, below which it becomes inadequate to keep a suffi- ciently rapid circulation to supply the tissues with enough oxygen to keep them normal. If this inadequate oxygen supply is allowed to continue there is damage done to the organism which gets greater as long as the condition persists. If you allow a man who is in shock or who has had a severe hemorrhage to per- sist in a stage of low blood pressure, he suffers damage from which it is often impossible to recover. That is the reason why the operations of the resuscita- tion teams should be begun as far forward as possible. The question is asked as to what should be done during operation. If a man has suffered shock and had damage done to his central nervous system, he is extremely susceptible to ether and chloroform anesthesia. In a series of cases I worked on under General Wallace's auspices and help, we found that the average fall of blood pressure during operation was from 88 down to 62 in the course of operation. When a man has already had a low blood pressure or is suffering from low pressure, and you seriously lower the pressure still further, it is quite obvious that he is liable to undergo serious damage in consequence of that drop. If you have to use ether in these cases, a favorable condition is to make use of transfusion or other means of raising blood pressure during oper- ation. If possible, use nitrous oxide and oxygen, which gives exactly the same degree of anesthesia without diminishing the blood pressure, but it must be used in the ratio which gives the greatest amount of oxygen. If you use too much nitrous oxide you get lowered blood pressure as with ether. The ratio should be 3 to 1. I should say, therefore, that we have first of all: 1. Warmth as a cardinal point of treatment. 2. Prevention of prolonged persistence of pressure below a critical level. 3. Rest, both because of the effects produced on the nervous system and injury, because every movement a man makes requires oxygen, and with inade- quate oxygen supply it is necessary to reduce the demand* for oxygen. 4. Fluid to replace loss during shock, especially if attended by hemorrhage. Professor Barcroft. I entirely support what Colonel Cannon has said regarding loss of oxidation in low blood pressure. Colonel Crile. We will resume the practical side. As a basis for discus- sion let us say that the treatment for shock is: 1. Warmth. 2. Rest and sleep. 3. Fluids. 4. Morphia. GENERAL SURGERY 147 5. Transfusion and various methods of raising blood pressure. Colonel Crile. Is morphia contraindicated in abdominal perforations? In chest? General Wallace. I expressed my own opinion a long time ago. I don't think it right for any benefits to be got in the diagnosis to deny any man an adequate dose of morphia. I certainly always advocate it, and I do not think it complicates the diagnosis. Even if it takes away a man's sensi- bility, which I don't think it does, one has enough faith in one's self to operate if there are chances of recovery. In large doses morphia is bad. Major Castellani (Italy). I quite agree with General Wallace. Morphia is most useful. Lieutenant Colonel Yates.—Out of 130 chest cases, I have seen two in which morphia seemed to have a bad effect, and I am inclined to think it was not due to the fact that it had been given, but because the patients had been morphinized before and no record made on their cards. Therefore, I think there is no objection to giving morphia judiciously in chest cases. Colonel Crile. In battle conditions, are the tissues of the wounded desiccated? Is water of more value to the organism if it is absorbed through mucous membranes; from the subcutaneous tissues than when given intravenously? That is, should water have a biological pass? Professor Barcroft. I have something to ask. In gassed patients suffer- ing from shock we had been advised to give large quantities of hot coffee on account of the caffeine. I have wondered if it was not the water that was beneficial instead of the caffeine. Captain Robertson. I have seen men coming to a base hospital 24 hours to a week after a hemorrhage, and when we made a test of blood volume at that time we found it much reduced, even days after a primary hemorrhage, showing that circulation had not been restored. I have seen as much as 60 per cent reduction after a week. What was it due to. It is ordinarily known that after a hemorrhage the body tends to make up the loss by pouring fluid into the circulation. In these cases it had not made up the volume because the tissues had been desiccated and had no fluid in reserve. We began by giving these men large quantities of fluid—water by the mouth, and saline solution by the rectum. We gave as much as 5,000 c. c. The blood volume was quickly restored to normal. We found that these patients could take an astonishing amount of fluid by rectum. With the rise in volume there was a rise in blood pressure. By measuring the intake of fluid and the output of urine, which normally is 3 to'2 (3 of intake to 2 of output), we found that some of these patients took very large quantities of water for relatively small quantities of urine—5,000 to 6 000 c c. of fluid and onlv 600 to 700 c. c. of urine. ' V case came in with a blood volume of a little over 3,000 c. c. In 20 hours the man took 5 000 c. c. of fluid and the blood volume increased to 4.700 c. c, the output of urine being only 700 v. c, showing that the fluid was taken both bv the circulation and the tissues. Conditions at the battle front were favorable for a dryin- out of the tissues. The men in line have very little to drink; their fluid intake is very small; they work hard; they sweat a lot; and they drink 148 SURGERY little. When they are wounded they sweat and have hemorrhage. If a man has a hemorrhage when his tissues are dried out he stands it worse than when he has had enough fluid. General Bowlby. I think there is a great tendency to put the fluid directly in the man's veins instead of in his stomach. I have been asking lately if the man has had enough to drink. I believe that almost all these men who are admitted in a state of shock should have large quantities to drink, if they are able to drink. If they are unable to drink the next best is to give it them by the rectum. Very large quantities of fluids are absorbed by the rectum, and in many cases it does more good to give pint after pint through the rectum than 1 pint through the veins. The natural method of absorption will retain the fluids and utilize them better than if they are put into the blood, hence the necessity for giving the patient plenty to drink. Colonel Crile. How much injury to the donor is the taking of blood for transfusion? How many days' disability for duty should a man have? Captain Robertson. There is very little harm done from bleeding. The average amount of blood needed for transfusion is 500 to 600 c. c, and the average man stands that very well. If he lies down one or two hours he can go about his work without feeling any difference. The only instances when a donor is disturbed is when he has been in line three or four days with little sleep, when he has suffered from exposure, and been hungry and thirsty. Colonel Crile. How long may citrated blood be kept before using? Captain Robertson. I don't think it possible to say how long citrated blood may be kept before being used; it depends a great deal on the technic in which the blood was drawn. With good technic, very little change takes place and the blood may be kept some time, practically^ 24 hours, or even longer. If the inflow in the citrator has been rather slow and the transfusion not done very well, the blood will have undergone a change and you may get reaction. The aim in transfusion is to get the blood in the recipient as soon as possible. There is no objection to keeping it several hours. In regard to the use of preserved blood for transfusion, I will say a word or two. I have kept blood as long as 25 to 26 days, and the transfusion had the same effect and was just as good as with fresh blood. In using this pre- served blood there were several conditions which made the method seem quite practical. Warfare was then pretty stable, hospitals were pretty well estab- lished, and attacks were local. During such attacks large numbers of wounded came to the C. C. S., and for two or three days we would have a tremendous flood of wounded. The resuscitation ward was filled and it was impossible to give transfusion by the ordinary method. If you can store blood beforehand you can give a larger number of transfusions in the same time. Under those circumstances this method worked out very well, and we gave a great number of transfusions. In the last three or four months our hospital became mobile and this method was not of as much use. It was too much trouble to move a large quantity of bottles, etc., and it was easier to transfuse bv the usual method. If there was any difficulty in getting donors, the blood could be taken at a GENERAL SURGERY 149 central place and distributed. However, it seems more practical to regulate the donor supply. Colonel Crile. Are salines as good as blood? As good as gum salt? And in what class of cases, if at all, should gum salt be used instead of blood? Major Mixter. I have seen two cases in which gum salt did harm. One was a case of hemorrhage which had not been held for resuscitation at the dressing station, and while waiting for blood was given a transfusion of gum salt. The man died within half an hour. The other case was similar. These deaths were apparently caused, or at least hastened, by the gum salt. Lieutenant Colonel Wolsey. I have inquired of many evacuation and mobile hospitals what their opinion was of gum salt solution. In no single case did I get a favorable opinion. X. X. Without any hesitancy I should say that gum salt solution is absolutely contraindicated. Blood pressure is increased sometimes from 60 to 130, but almost invariably it drops to 40 or 50 after a short time. Lieutenant Colonel Lee. We have had one very excellent result from the use of gum salt; the patient was a man in a serious condition of shock after hemorrhage. The result following the introduction of gum salt was very re- markable and the man made a very nice recovery. On the other hand, two cases in a similar condition collapsed after the use of gum salt. Captain Middleton. We have had two experiences with gum salt. The results on patients received very early—3, 8, or 12 hours after being wounded— were uniformly good. In a second series of patients who were received three or four days after being wounded, the results were universally poor. The difference in results could be attributed to the difference in transportation, to exposure, and loss of body heat and fluids in the second series of cases. At Mobile Hospital No. 1 we proceeded to give citrated blood as a uniform method of resuscitation, and our results were just as disappointing with citrated blood as with gum salt. Out of 13 cases of transfusion in three days, 8 died and only 3 showed a normal effect. I should say that the results that have been obtained lately are due not to inferiority of methods but to the fact that you are dealing with conditions entirely different from those of summer months. In winter wTe are applying methods of resuscitation near the front. Captain Robertson. I was asked to look into the method of giving gum solution. I paid a visit to front-area hospitals and talked with a large number of men and got various opinions. Some of the workers were enthusiastic and had got good results, some were lukewarm, and some were against it. On looking over the records it seemed to me that the poor results reported from gum solution were largely due to the choice of unsuitable cases. There are about four classes of cases from which good results can not be expected: 1. Cases of shock for a long period—15 to 20 hours or more—with so much damage done the tissues and brain cells that blood pressure is very low and transfusion has no effect. 2. Cases treated immediately by gum salt; patients brought into the resuscitation ward and not given time to pick up with heat, morphia, and fluids. These do badly. 150 SURGERY 3. Cases suffering from very severe blood loss. Gum salt solution gives a temporary rise in pressure, but they have too little oxygen and the pressure is not maintained. 4. Gas bacUlus cases. We made a post-mortem of cases that did not do well after gum injection, and in every case we found gas bacillus. Where these various considerations are taken into account and gum solution used on that basis, results are good. Sir Walter Fletcher. It is a matter of great importance that the experience of the past months should be placed on record; I hope records have been col- lected. It is very important to have the clinical condition of the patients, the method of making the solution, and the method used for transfusion. There is certainly a wide variation in the quality used in France. In Italy experiences have been uniformly unfavorable because the solutions used were unsuitably prepared. Improvement in the solution changed the experience. altogether. Last week we received reports from Macedonia; the experience was bad, and it is clear that they had been using solution in the same form as in Italy. Alkaline solution of gum is very difficult to prepare; great attention should be paid to filtering. The point is not clear whether gum solution should be used; we have not yet received reports with enough detail to see if it should be used or not. General Finney. In going round various hospitals I was struck with one point. In several of the hospitals I was told that the solution from the central laboratory was not giving satisfactory results. Solution made fresh in the hospitals gave good results. This happened in several hospitals. The reason for the unsatisfactory results was the question of time; fresh solution gave good results. Lieutenant Colonel Cannon. There is evidence on both points that Sir Walter Fletcher has brought up. The first one was the clinical condition of the patient at the time the solution was used. I have had experience under two conditions. When the patient was received early, the result was good. When the patient was received late the result was unfavorable. In one sector of the British Army last spring in an advanced station excellent results were obtained from gum solution. Eighteen miles behind the front, with the same method, unfavorable results were obtained. So the clinical condition of the patient is one that will very largely determine the value of the method. I have a letter from one of the resuscitation officers who reports that in transfusion of blood he got chills in cases of low blood pressure from shock. There are differences in the gum used. The gum which has been used in the British Army was provided in clear lumps. In France, we had to get pow- dered gum and we found that it contained starch and * * * I have removed 60 per cent blood volume from an animal and given it gum salt solution; the animal recovered. So both conditions mentioned are important. From the very beginning I have urged that this solution be used as far forward as possible. Farther back I have found that in mobile units gum salt solution has been used instead of blood, because of the lack of donors, with bad results. general surgery 151 If an organism has been suffering from low blood pressure for some length of time it makes no difference whether you introduce blood or gum, von get unsatisfactory results. I would emphasize that it is the first essential to have these resuscitation measures applied as soon as possible, before damage due to low blood pressure has come to a point from which the patient can not recover. I would like to know whether persons who have used salt solution and think favorably of it have made blood-pressure observations to prove that it does anv good whatever. I believe that if you introduce salt solution you get a rise in the pressure, but I do not believe that it is permanent. Gum salt remains in the blood vessels and salt does not. Last Friday, at a meeting in Boulogne of men who had had experience in the British Army, the following statement was approved by the committee. "1. Provided that the gum solution is prepared from good gum, with a raised body temperature, and slowly injected, no seriously harmful results need be apprehended in its use. 2. The amount injected should be 700 c. c." Colonel Crile. In emergencies, may grouping be disregarded? Does any one object to answering "Yes"? Colonel Crile. In the anemia by a tourniquet, are damaging chemical compounds formed? Lieutenant-Colonel Cannon. Shock can be produced by shutting off the blood circulation for a time. We have had a number of cases of men who have had a tourniquet on for some time after being wrounded and who have gone in shock on removal. Colonel Crile. Is the blood of a gassed case as useful in transfusion as the blood from a normal one? X. X. (French). In the French Armv we use the blood of gassed cases for transfusion. What could oblige us to refuse transfusion from a gassed case!1 We may be sure, from experience, that there is no poison in the blood. Of course one will not use as a donor a man who is in an acute stage of gas poisoning, but I don't see why we should not take blood for the making of citrated blood from slight cases. There are many men in favor of keeping this blood, because it seems to be the best blood for transfusion, because it is concentrated writh a high percentage of red cells, and is very apt to take up oxygen. Lieutenant Colonel Cannon. I made use of blood from slightly gassed cases in July last, and called attention to the availability of these men as donors. There is no harmful effect but definite value to be got from this blood. Colonel Crile. What is the anesthetic of choice? What is the field of local anesthesia? Of spinal? Lieutenant Colonel Clinton. The American Army is obliged to use ether almost universally. A few operators have facilities for using nitrous oxide, but the standard has been ether through necessity. Xitrous oxide is preferred if available. General Wallace. We have found gas and oxygen by far the best anes- thetic in cases of shock. The worse a patient is, the easier it is to operate him by gas and oxygen, and it is the safest to give him. Apart from that, the usual anesthetic in the British*Army is warm ether. We have avoided chloro- 152 SURGERY form as a general anesthetic except for the purpose of conduction; still for a limited number of mouth and chest cases it can be used combined with oxygen. Spinal anesthesia has not been much used; it is not advisable to use it if one is not thoroughly educated in its use. Local anesthesia has been used in conjunction with gas and oxygen in particular cases; it is very useful in abdominal cases; it has been used by those who have been skilled in its use, and good results have been obtained. Gen- erally local anesthesia takes too long to act. We feel under a great debt of obligation to the American Army for their skilled anesthetists, especially in gas and oxygen. Gas and oxyrgen, as it has been given by skilled people, has saved many lives of patients under shock. Colonel Crile asked General Makins to comment on the influence of war surgery on the surgeon when he returns to civilian practice. General Makins. What effect will military surgery have upon civilian work at home? It can not be thought that it will have any marked influence on surgery at home. In civil life we should always open an abdomen, and in certain cases get successful results as in the Army. It is only in this war that facilities have been provided for taking the cases early enough. One thing in civil surgery which has been developed is surgery of the chest. When we come to surgery of the lung I think there is no doubt that there will be more of that; still, those who have only gained experience in military surgery will find lung surgery very different in civil life. As to the question of the develop- ment of the surgeon, it is quite clear that the work of a military surgeon must develop many qualities in a man; it develops quickness in making up one's mind, resourcefulness in meeting many great difficulties, etc. There is, how- ever, one side where military surgery is not good as an example for the civilian surgeon; the personal responsibility is much greater in civil life. Younger men will have to bear that in mind when they go home and operate. Colonel Crile. The program is now completed and there remain for me two pleasant duties to perform. The first is to express, though inadequately, our appreciation of the part taken in this meeting by our British, French, and Italian colleagues, who have given freely of their wider experience in elucidating our problems. My second duty is to say something on our own behalf. I have had oppor- tunity in the course of my duties to see the work at many mobile, evacuation, and base hospitals. In our first offensives, through lack of experience in military surgery on the part of some of our surgeons in certain instances, the work showed deficiency, but in the last offensive the work was uniformly of a high order. In view of the progress made during our brief experience, I feel that we have reason to be highly gratified with the results secured. AT THE BASE The Research Committee of the American Red Cross in France, desiring a record of the experiences of the surgeons of hospitals in the American Expedi- tionary Forces, concluded to devote one session of the Research Society of the American Red Cross to a conference on surgery at the base. Accordingly a questionnaire was prepared by Brig. Gen. J. M. F. Finney, M. D., and Col. GENERAL SURGERY 153 George Y\ . Crile, M. C, to be sent to the various base hospitals for replies for use as a basis for discussion. The questionnaire was quite comprehensive in that it dealt with a number of phases of some of the most important hospital problems, particularly those relating to war wounds. The questionnaire was sent to commanding officers of base hospitals for opinions based on the clinical experience of the surgical staffs. Many rephes were received, and the discussions on a number of problems, although neces- sarily brief, are a distinct contribution to the surgical literature of the war. Prior to the receipt of the responses, however, meetings of the research society had been discontinued. The responses, therefore, were summarized in the nature of a consensus of opinion, and published to the medical officers of the American Expeditionary Forces by the research society. Though the queries were propounded for surgeons at the base, their pertinence was in the majority of instances to surgery at the front; it is deemed desirable, therefore, to include the summary of responses to them in the present chapter. RESPONSES TO QUESTIONNAIRE ON "SURGERY AT THE BASE" Q. 4. How long should abdominal cases be held at the front before trans- portation? A. Consensus: Until danger from acute peritonitis is past—from ten days to two weeks, depending upon nature of wound and operation procedure. Q. 5. How do through-and-through chests travel? A. Number of votes: Badly, 8; well, 23. Expression of remainder: 1. Well after one week. 2. Shrapnel, poorly—perforating rifle bullet wounds, well. 3. Nonoperated cases without shock, well. 4. Operated cases before healing or those with severe intrathoracic condi- tions, badly. Remark: Difference of opinion evidently accounted for by results due to factors of transportation and sector conditions. Q. 6. What type of cases are most injured by travel? A. (a) Penetrating abdominal. (b) Muscle wounds in locations favoring developing of gas infection- buttocks, etc. (c) Compound comminuted fractures of femur, with or without knee-joint involvement. (d) Severely shocked cases. (e) Brain cases. (/) Sucking chest wounds. {g) Complicating pneumonias. (h) Fresh amputations. (i) All improperly splinted fractures. (/) High-explosive chest injuries. 154 SURGERY (k) Operated abdominal wounds. (.) All serious injuries with acute infections. (m) Wounds involving large vessels. (u) Recent hemorrhage. (o) Gassed cases. (p) Fractured spines. (q) All bad joint injuries. Q. 7. What is the comparative condition of wounds arriving at the base dressed with: (a) Dry gauze. (Jb) Dichloramine-T. (c) A protective. (d) Rubber tubes. (e) Carrel-Dakin. (f) Vaseline gauze. ig) Bipp. (h) Flavine. A. Votes expressing best results: Dry gauze, 13; Carrel-Dakin, 12; vaseline gauze, 5; flavine, 3; dichloramine-T, 1; rubber tube, 1; protective, 1; Bipp, 0. Remark: Nearly all observers emphasize the risk of packing the wound tightly with any dressing—lightly placed surface dressings necessaryz A thorough primary operation procedure associated with proper splinting much more important than any type of dressing used. II. Gas Gangrene Q. 1. To what extent, if at all, do the following predispose to gas gangrene? (a) Ligation of main artery of a limb. (b) Tight bandages. (c) Tight packing of a wound. (d) Insufficient debridement. (e) Low vitality from shock and hemorrhage. A. General concensus that all factors mentioned predispose as follows: (d) First cause. (a) Second cause. (b-c) Third cause. (V) Fourth cause. Q. 2. What is the indication for local operation? For amputation? A. Agreement that essential indication for local operation is: Involvement of definite muscle or small muscle group which can be completely removed without loss of function of limb. For amputation—evidence of massive gangrene of limb; where removal of involved tissue can not be acomplished without destruction of function of limb; when complicated by serious injury to main arteries of limb; when extensive fracture of large bones and joints co-exists; in doubtful cases in w-hich patient suffers from extreme shock and hemorrhage; and where there are other wounds requiring operation in which there is general constitutional evidence of a severe fulminating type of infection. GENERAL SURGERY 155 Q. 3. What is the value of antigas sera? A. Base Hospital No. 19: 15 cases with sera treatment previous to admit- tance; 4 of these developed gas infection, 2 died, and 2 recovered, the 2 dving requiring additional operation after admittance. Base Hospital No. 48: Enthusiastic over serum as prophylactic—Bull's serum, 40 c. c, intravenous, repeated in 30 c, c. dose, with rising pulse, the open wound being washed with hydrogen peroxide. One response: "Nil." Base Hospital No. 6: "Favors for both prophylaxis and early treatment." A. R. C. Military No. 2: Experience limited. In few cases used—not encouraging. Trouble to get best anerobic sera. Experimental evidence good, and practical tests show no prophylactic or therapeutic value of the gas bacillus antitoxin; other anerobic antisera in hands of certain French physicians show- evidence of possible value. Q. 4. Is it justifiable to base local operation or amputation on the bac- teriological findings alone? A. " No" sums up answer to this question. Q. 5. Is the general range of temperature high or low? Pulse rate high or low? A. General agreement that pulse runs high and temperature comparatively low-—pulse from 110-130 with temperature 101-102° F. in average cases. Q. 6. How frequently does gas gangrene attack tissues other than muscle? A. Responses: (a) Secondary involvement of subcutaneous tissue. (b) Chest involvement not uncommon. (c) Often begins in ecchymoses of fascia and in blood clots. id) In many autopsies gas found in liver. Remark: All other reports agree that tissue other than muscle is rarely affected. The above remarks are additional statements from four hospitals. III. Debridement Q. 1. What is included in a good debridement? A. Consensus: (o) Sparing removal of skin about wound margin. (b) Any necessary enlargement of wound and proper retraction. (c) Removal by sharp dissection of all contaminated, contused, devital- ized tissue lining wall of tract of missile, with avoidance of injury of any- important blood vessels and nerves. (d) Removal of foreign bodies including pieces of clothing. 0) Scrupulous hemostasis and drying by ether lavage (optional). (/) Fixation of remaining organisms by tincture of iodine (optional, but believed by some to be of value). _ (a) Especial care with regard to muscle tissue removed, with contraction, bleeding, and normal muscle color, the guides in reaching normal muscle tissue. (70 Guarded removal of unattached bone fragments. (i) Direct observation, by good headlight, of wound tract. 156 SURGERY Base Hospital No. 48 emphasizes great importance of transfixion suture (pig's-gate) in depths of posterior-tibial or similar wounds, believing it to save much secondary hemorrhage and many lives. Q. 2. What errors in debridement have you noted? A. Consensus: (a) Inadequate exposure of wound tract. (6) Incomplete removal of damaged and contaminated tissue. (c) Unnecessary transverse section of muscle. (c.) Undue sacrifice of skin (important). {e) Too firm packing with gauze and through-and-through drainage. (/) Unnecessary damage to important vessels and nerves. (g) Short cuts to foreign bodies without following wound tract. IV. Tetanus Q. 1. How many cases? A. Cases seen, 91; to total admissions, 0.018 per cent. Q. 2. Results? A. 37 deaths; rate, 61.66 per cent. Note.—Death percentage based on 60 cases with complete data. Thirty- one cases from one hospital not giving deaths not included in this percentage. Q. 3. Are there any contraindications to giving a second dose of anti- serum? A. Opinions: (a) Anaphylactic reaction following first dose. (b) If an anaphylactic individual is properly desensitized, no objection. (c) Unwise if full dose has been given and patient is profoundly septic. (d) No; if given before 10 days. (e) Yes; severe and dangerous primary reaction. Remark: With exception of above opinions, all observers agreed that there was no objection to a second dose. Q. 4. Have you seen local tetanus? A. Votes: Yes, 7; no, 27. Q. 5. Discuss late tetanus—cause—prevention. A. Expressions of cause: (a) Reopening of old wound in operation around rectum. (b) Mechanical trauma—operative or other. (c) Insufficient primary operation; secondary operation; insufficient drainage; improper dressing; insufficient serum. Prevention: Correction of above and always giving serum before secondary operation. Remark: Most hospitals stated that they had seen little or no late tetanus. V. Delayed Primary Closure Q. Bacteriological control or clinical judgment? A. Votes: Bacteriological control, 5 (Base 6 laboratory has once given 168 reports in 48 hours); clinical judgment, 10; both when possible, all. general surgery 157 Q. (2) Average time after primary operation? (3) Percentage of successes? (4) Has there been loss of life or limb following failures? A. 2 3 4 Days Per cent 10-12 98 U 10 65 0 (2) 94 0 3 3 95 0 2-5 3-4 0 <2 80 3 95 0 10 75 0 10 85.9 0 3-5 90 0 4-7 90 0 10 95 0 6 65 0 2-4 70 0 8 75 «1 1 Death tetanus. 2 Undetermined. 3 About. 4 Deaths gas infection. 5 Limb. Remark: It is noted that the first hospital, Base No. 6, relied, with special care, on bacteriological findings by culture methods. VI. Preoperative Cases Q. 1. What types of case need no operation? A. (a) Perforating bullet wounds (including machine-gun and rifle) of soft parts, exclusive of belly wounds, with no marked hematoma or other evi- dence of marked injury to important vessels, and with no evidence of serious nerve lesions; with small wound of entrance and exit, and without marked bone injury, provided there is no obvious infection present. (b) Minute foreign bodies in small penetrating wounds. (c) Nonsucking wounds (penetrating and perforating chest) without symptoms; or early cases of the same type without serious internal or external hemorrhage. (d) Certain head cases—extreme care in determining. Q. 2. How have cases evacuated without operation (preoperative) done? A. Ten reports; no experiences. Well (a) If within 24 hours; wounds of buttocks- (b) Perforating, except belly and head. (c) Slight superficial. (d) All. (e) All. (/) All. (g) All. (h) Superficial. (.) All. (j) All. (k) Except tarsal involvement. (I) All. (m) All simple perforated of chest and soft parts. (n) Majority. (0) All except calf, buttock, thigh, thorax, and subscapular. (p) All. Badly (a) Majority infected. (b) All serious wounds. (c) None as well as operated cases. (d) Infection except in perforating]wounds. (e) All. (/) 95 per cent badly. (g) All. (h) Higher mortality. (_) All except simple parts and chest. perforating of soft 158 SURGERY Q. 3. List the types of cases suitable for evacuation without operation. A. See heading No. 1. Many wounds of hands and feet, a few spine, and some head cases. Q. 4. What are the advantages and the disadvantages of the preoperative train? A. Ten reports; no experience. All others agree that properly scheduled trains (dear front area hospitals, in time of stress, of cases in which operation can be delayed without danger to life or limb or function. ATI. Chest Surgery Q. 1. What are the indications for operation in the front area? A. (a) Sucking chest wounds. (6) Serious hemorrhage. (c) Large effusions. (d) Driven-in bone fragments. 0) Large foreign bodies. (/) Collapsed lung—same side as wound. (g) Much rib comminution. (h) Infection. (i) Hemothorax with tension. (j) Pneumothorax with tension. (k) Foreign body in heart or pericardium. (I) Foreign body in mediastinum. (m) Simultaneous wounds—both sides of chest. (n) Hemothorax plus anerobic infection. Q. 2. What are the indications for operation in the base? A. (a) Empyema. (b) Lung abscess. (c) Secondary hemorrhage. {d) Sinuses due to foreign bodies. (e) Pus pockets. (/") Hemothorax with symptoms. (Repeated aspirations when necessary.) (g) Radical thoracotomy for infected hemothorax. Q. 3. Discuss the anesthesia—the operation technic. A. Anesthesia. Local, if possible, recommended by all. Stated first choice: Gas oxygen, 18; ether, 9;^ chloroform, 2; with morphine and atropine, 3; warm ether, 1. Operative technic. Definite opinions: For hemorrhage and removal foreign bodies, 6-inch incision, 5-inch of fourth rib removed. Begin incision at costal cartilage. Rib spreading. Split fibers pectoralis major. Lung delivered through wound. Palpation. Incision into lung to deliver f b Lung sutured by fine catgut, Hot sponge for oozing. Fine catgut for other bleeding. Gentle sponging of blood from chest cavity. Parietal pleura closed by continuous fine suture—catgut. Muscle and skin sutured to make air-tight. All these chest wounds to be closed primarily. Fluoroscopic table often used. GENERAL SURGERY 159 Always practice principle of thorough debridement and following of tract whenever possible m primary removal of foreign bodies-with radioscopic assistance. *tir cases—thoracotomy; suction drainage, positive pressure by blow- bottles as soon as possible Q. 4. Discuss the aftertreatment. A. (a) Sitting posture. (6) Morphine as indicated. (c) Aspirations of effusions after 48 hours for drainage and displacements. (d) Prompt radical drainage for infections (optional carreling of pleura when no open bronchus). (e) ('uses should not be evacuated. if) Rest essential. (g) Lungs expanded regularly as soon as condition permits. (James' bottle method satisfactory). (h) Warm and dry climate afterwards, if possible. Remark: Eight expressions, only, in favor of Carrel-Dakin or other irri- gation in infected chests. With these exceptions, general agreement in above principles. VIII. Secondary Hemorrhage Q. 1. In what type of case does it usually occur? A. Most commonly in extremities. Consensus: (a) Infected wounds with or without primary injury to vessels; usually primary injuries. (_») Infection after extensive debridement in presence of foreign bodies. (e) Prolonged use of drainage tubes. (d) Compound fractures with gas infection. (e) Follow-ing amputations. Base Hospital No. 2, B. E. F. Series of 46 cases: (a) Comminuted fractures, tibias and fibulas, 17 per cent. (b) Fractures of humerus, 13 per cent. (c) Wounds of thigh, without fracture, 13 per cent. (./) Buttock wounds, 11 per cent. (r) Wounds popliteal region, 11 per cent. Q. 2. Should first indication be ligation or temporizing? A. Stated preference. For ligation, 24; for temporizing, 3. A. R. C. Military Hospital Xo. 2: ''Ligation, if can be done in wound. Hesitate before ligating an arterial trunk to stop hemorrhage in an infected wound. Amputation often preferable, especially when complicated by gas." Q. 3. What are the predisposing causes of secondary hemorrhage? A. (a) Improper hemostasis. (b) Early transportation of amputations and hemophilics. (c) Faulty debridement. (d) Insufficient drainage. 0) Excessive restlessness. 4<;!>!)7—27-----13 160 SURGERY (f) Traumatic aneurism. (g) Rubber tubes in proximity to vessels. (I,) Faulty ligatures. . Remark: One definite expression that Carrel-Dakin solution favors hemor- rhage, by dissolving ligatures and loosening blood clots. Q. 4. What is the general treatment? A. General agreement: (a) Transfusion of blood after control of hemorrhage. (b) Fluids by mouth and rectum or subcutaneously, forced. (<:) Absolute quiet, (./) All general treatment of shock. (V) Intravenous saline inferior to transfusion. IX. Knee-joints Q. 1. In through-and-through machine gun or rifle wounds, how do non- operative compare with operative results? A. Definite opinions: Nonoperated cases—" Do as well as," 9; " Not so well," 4;"Do better," 17. Most qualify by remark, ''Unless extensive bone injury." Q. 2. In debridement do you advise— {a) Complete closure. (b) Closure of capsule and fascia . (c) Leaving the wound entirely open. A. Votes: (a), 15; (6), 20; (<•), 1- Seton drainage to capsule recommended by 2. Q. 3. Is shattering the head of the tibia or of the condyles of the femur the more serious? A. Votes: Head of tibia, 17; equally serious, 4; condyles, 10. Base Hospital No. 2, B. E. F.:" Injured condyles with joint-involvement, 40; infected, 19; amputations, 18; head tibia with joint-involvement, 15; in- fected, 7; amputations, 5." Q. 4. What type of knee injury demands immediate amputation? A. Consensus: (a) Extensive destruction both bones beyond limits of functional recovery. with associated injury to main vessels. (_>) Extreme destruction with fulminating infection. (c) With extensive comminution of lower third of femur or upper third of both bones of leg, or when popliteal artery is severed. Q. 5. What type of infection and what extent of involvement of the joint demands amputation? A. Consensus: Streptococcus infection of fulminating type with severe systemic symptoms, progressive, especially w-hen associated with much bone injury, or when infection extends to muscle planes, or when burrowing abscesses form. The gas bacillus and staphylococcus not as frequent agents as the streptococcus in necessitating amputations. Base Hospital No. 2, B. E. F.: "In general, panarthritis demands amputa- tion, though resection is sometimes possible in specially favorable cases." GENERAL SURGERY 161 Their figures are: Cases Amputa- tions Streptococcus,._ . . . . \\ 9 Staphylococcus_____ _____ y 3 B. welchii__________ _________ 7 5 Q. 6. In knee-joint injury and infection, has more error been made in con- serving or in amputating? A. Votes: Conserving, 21; amputating, 5. Remark: One expression that error has been in amputating too frequently at the front and conserving too much at base. Q. 7. What effect has excision of the patella on the function of the joint? A. Most observers agree that excision results in marked interference with function, the joint being weakened to such an extent that mechanical apparatus is necessary; that the patellar ligament serves, with difficulty, the function of extension unless the knee is throw-n in backward curve. Stiff joint also stated to occur. Definitive votes: Good function, 3; poor function, 9; little effect, 3. Q. 8. Compare mobilization with immobilization in the treatment of joints (Willem's method). A. Votes: For immobilization, 6; for mobilization, 16; remainder either no expression or misinterpreted question. Q. 9. What is your estimate of the value of antiseptic treatment of knee- joints? A. Votes: Desirable, 7 (Carrel-Dakin used by these); undesirable, 25. X. Antiseptics Q. 1. Compare the principle of chemical antiseptics with the principle of nonchemical treatment of infected wounds. A. Treatment by chemical antiseptics preferred by 28; nonchemical treat- ment preferred by 7. Remark: Carrel-Dakin method choice among those using antiseptics. Q. 2. List antiseptics in order of their availability for battle conditions at the front areas—at the base. A. Availability order At front Iodine. Carrel-Dakin. Alcohol. Flavine. Mercury Salts. Ether. Dichloramine-T. L.VM.l. Phenol. Bipp. Acetic Acid. Balsam Peru and Castor Oil. At base Carrel-Dakin. Alcohol. Iodine. Dichloramine-T. Mercury Sails. Boric Acid. Ether. Picric Acid. Lysol. Bipp. Acetic Acid. Burrow's Solution. Iodoform. 162 SURGERY XI. Anesthetics Q. 1. How do you value the nurse anesthetist? A. Votes: Very satisfactory, 25; satisfactory, 8; unsatisfactory, 1 (for prolonged operations); corps men, 1; none used, 1. Q. 2. In what cases and under what circumstances may local anesthesia be used? Regional? Spinal? A. Definite opinions: Local 1. Selected head cases. 2. Thoracotomy. 3. Dental surgery. 4. Small surface operations with superficial foreign bodies. 5. Face operations. 6. Secondary closures. 7. All chest where general anesthetic contraindicated. S. Selected abdominal cases. 9. Majority spinal cases. 10. Drainage of abdomen if general anes- thetic contraindicated. 11. Many brain cases. 12. Superficial abscesses. Regional 1. Maxillofacial surgery often. 2. Operations in orbit and about orbit. 3. Certain cases of skin-graft. 4. Certain spinal cases. 5. In clean surface operations, too extensive for simple local anesthetic, where general is contraindicated. Spinal 1. Certain shock cases, combined with gas oxygen or with morphine plus hyoscin. 2. Crushed legs plus bladder injury, if not too low blood-pressure. 3. Amputations of lower extremities in desperate cases. 4. Perineal wounds where general anes- thetic contraindicated. Q. 3. In what cases is gas and oxygen especially indicated? A. Consensus: (a) Chest cases frequently. (With acute bronchitis.) (&) With tuberculosis (pulmonary). (With gas complication.) (With influenza.) (V) Short debridement. id) All cases except brain and abdominal, especially chest and shock. (e) Septic. if) All lung operations. One expression that ether is preferred in all cases. Q. 4. Has the type of anesthetic influenced results? A. Votes: Yes, 30; no, 3: One states u Not as important as anesthetist." Q. 5. How do you value Depage anesthesia? A. 17 hospitals report ''No experience"; 7 hospitals report "Highly valued": 2 hospitals condemn; 1 hospital "No better than ethyl-chloride." Base Hospital No. 22, in 50 cases use very satisfactory. Base Hospital No. 60, most practical general anesthetic for front area; quick narcosis and recovery; easily transported; used in over 200 cases. XII. Fluids Q. 1. Compare sodium bicarbonate with normal saline in treatment of shock and hemorrhage. A. Votes: Normal saline superior, 11; sodium bicarbonate superior, 4; no difference, 10; no opinion, 8; both nonessential, 2. GENERAL SURGERY 163 Q. 2. Compare intravenous saline infusions with giving water by mouth or rectum, or subcutaneously. A. Consensus: That whenever possible water should be given bv mouth and rectum, as by the mucous membrane it is almost entirely absorbed, though comparatively slowly. A few prefer intravenous under all conditions, but most state a preference for its use when quick action only is desired after acute hemorrhage, or in shock, using subcutaneous method when less haste is desired. Q. 3. Compare gum-salt with saline; with blood. A. Votes: First place: Blood, 31; gum-salt, 0; saline, 0. Second place: Blood, 0; gum-salt, 13; saline, 10. Third place: Blood, 0; gum-salt, 9: saline, 10. Q. 4. Have you noted any ill effects from gum-salt? A. Votes: Yes, 13; no, 11. Base Hospital No. 20. Unfavorable reaction in 15 per cent of the cases. Three deaths attributed to solution. Base Hospital Xo. 6. XTothing to recommend it. Base Hospital XT 19. Two cases. Base Hospital Xo. 15. Considered dangerous. Base Hospital Xo. 48. Several deaths attributed to its use. Very positive against its use. XIII. Blood Transfusion Q. 1. What method preferred? A. Votes: Sodium citrate, 26; whole blood with paraffin tube, 3; Kimpton- Brown method, 1; syringe method, 1. Additional Expressions: Three votes for citrate in front area. Indirect tube method for base, 1 vote. One states paraffin tubes and citrate equally successful. Q. 2. Have there been any serum reactions when properly grouped? A. Votes: No, 29: yes, 0; slight and rare. 5. Q. 3. What results in prolonged infections? A. Ten hospitals report "No improvement:" 14 hospitals report "Definite improvement"; 2 hospitals report "Temporary improvement:" 7 hospitals re- port "X"o experience." Q. 4. Discuss available sources, difficulties encountered, etc. A. Sources: (a) Corps men; (b) prisoners (carefully selected); (c) slightly gassed and wounded, very carefully selected. Difficulties: (a) Length of time necessary to collect from donors; (b) clotting in needle when injecting blood; (r) inability to secure suitable donors; (d) corps men off full duty from 24-48 hours after donation; (e) keeping donors under careful control. XIV. Amputations Q. 1. What is the value of the guillotine operation? A. Votes: Favorable, 19; unfavorable, 7; no advantage, 3; speed only, 7. Reasons for favorable votes: Rapidity, drainage, little shock. Q. 2. Is the mediotarsal amputation justifiable? A. Yes, 11; no, 18; no observation, 2; noncommittal, 3. 164 SURGERY Q. 3. Compare the Symes's and the lower third amputation. A. Votes: For Svmcs's. 5; for lower third, 24; remainder either no experience or no preference. Q. 4. Is the rule that stumps of the lower extremities shall have no terminal scar a good one? On the upper extremities is the terminal scar always correct? A. Votes: (a) Yes, 15; no, 8. (6) Yes, 11; no, 8. Q. 5. Are amputations through the knee-joint recommended? A. (a) Yes, in emergency, 6. (b) No, 28. l k < 1 0 u-o o \ ^x S / N^ / f \ z A ui , / 1 BLOOD/ Z PRES-i I SURE/ 1 Z> I Q / 1 1 PULSt > 1 > 1 V) 0- _J uJ c_ t_ z o z -.z 0 ,"■*- \ -Uo id 4 ul _l H Z -J a RECOVERED I (0 1 1 \A / ""■"-. / 1 1 I / / i PULSE \ 1 / L BLOOD PRES-SURE . ^ / Q > O 5 1"3 X O a-uj 5 * Q o z z % s <_o a a i_ (0 of ■« < z 5 z UJ -O. z 2° OuJ 2$ -J S O _J o a (0 3 •4-1-« 01 3> z 3 2 *!_ o -£*> zS O "J 10 20 30 40 50 /l Htt- AFTER MINUTES OPERATION Chart IV.—Comparative effects of ether and of nitrous oxide in operations for the repair of extensive abdominal wounds. Note the greater extent of the trauma in the second case, which received nitrous oxide. (By courtesy of Capt. Goeffrey Marshall, R. A. M. C.) least possible length of time. Manipulations and exposure of the viscera should be reduced to a minimum; therefore, an ample incision should be made.9 If the patient is in deep shock, a transfusion of blood should be given at the beginning and again at the close of the operation. Operations on the Chest An extensive research was carried out by Gwathmey and his associates at the Central Medical Department Laboratory, A. E. F., at Dijons, France, for the purpose of determining the anesthetic method of choice.17 The findings in this study were in accord with the clinical experience of Marshall, of the GENERAL. SURGERY 179 writer, and of others, that nitrous oxide-oxygen under positive pressure is the method of choice. The following statements regarding the anesthesia in chest surgery were made by Lockwood:18 Paravertebral anesthesia is administered two or three spaces above and below the wound. A local infiltration at some distance from the wound is employed. Novocain 5 per cent and potassium sulphate 0.25 per cent in normal saline, prepared fresh and repeatedly autoclaved is injected with a Gray's syringe (10 mms. of adrenalin per ounce are added just before use). Gas and oxygen should be available for administration while the hand is inside the chest or when the patient is restless. The most serious cases may be operated on with a light nitrous oxide analgesia. Local anesthesia combined with gas and oxygen is the best means of preventing shock in extended operations. Neither ether nor chloroform should be used in chest surgery. An official report on intrathoracic surgery contains the following section on anesthesia: 19 A simple method of giving nitrous oxide and oxygen, utilizing tank pressure, to secure needed degree of inflation, was devised by Captain Gwathmey. A full preoperative dose of morphine made possible the induction of deep analgesia, without increasing the nitrous oxide and oxygen rates above 3 to 1, which Lieutenant Colonel Cannon's experiments had proved to be the limit of safety in the presence of shock. Lieutenant Cattell's observations had indicated that morphine thus given had value as a prophylactic agent against oncoming shock, and therapeutic value when given early in the presence of shock. Xo untoward result from depression of the respiratory centre was noted. Animal experiments showed clearly that administering anesthesia under tension, particularly when the chest was opened, was dangerous if the gas or ether was given in in- creased concentration. It also demonstrated that thoracotomy with all incidental manipula- tions, such as dislocation and operation upon lungs, should be performed under the primary stage of anesthesia. Manometric observations showed that when the pressure present in the mixing bag reached 8-16 mm. Hg. it sufficed to distend the lungs completely; that degree of pressure is present when the bag fluctuated little during inspiration. Since this degree of tension in the bag produced an intrapulmonary pressure that was well within the limits of safety for dogs, the manometer was not deemed a necessary adjunct for human use. A safe sequence in practice was found to be as follows: After the effect of the preopera- tive hypodermic of morphine was present, administrations of pure oxygen under no tension were started. Then very gradually the pressure was increased, and the administration of nitrous oxide started. Rapid induction of the anesthesia was undesirable. Avoidance of excitation and the producing of gradually increasing inflation were essential. During the operation the proportions of the gas-oxygen mixture and the pressure transmitted to the trachea were varied to meet conditions. After the parietal pleura was closed the amount of nitrous oxide was gradually reduced; last of all, oxygen under pressure was continued until the patient was conscious. The American Red Cross nitrous oxide apparatus, perfected by Captain Gwathmey and adopted by the Armv, fulfilled every requirement. This apparatus provides a mask that can be rendered relativelv air-tight by close approximation to the face, an escape valve, a mixiii-- bag close to the inhaler, and a rough gauge for estimating the proportion of the gases. fntrapulmonarv pressure was raised by increasing the rapidity of the flow of gases from the tank and bv increasing the pressure upon the face piece. It was lowered by decreasing the rate of flow of the gases or bv releasing the valve or decreasing the pressure which held the face piece in place. Thus, any degree of desirable inflation or deflation was promptly available to meet operative requirements. In general the degree of pressure utilized was that best suited to the animal or man under operation. This method gives all practical requirements for intrathoracic surgery without neces- sitating deep anesthesia for the introduction of intratracheal or oropharyngeal tubes. Moreover, its safety and ease of control has removed the chief obstacle to a wider applica- tion of surgical therapy. 180 SURGERY On the basis of his large experience in France and at the Walter Keed Hospital since the war, Keller makes the following statement:20 Nitrous oxide is, in my opinion, the anesthetic of choice in war-time general surgery and its general use in all formations from front to rear during the late war was limited only by lack of trained anesthetists and difficulty of transportation to some front line formations. Its use is also somewhat limited for mobile warfare such as during a rapid advance. In chronic chest surgery nitrous oxide is absolutely the inhalation anesthetic of choice, especially when combined with the Crile novocain block or paravertebral block, which enables the operator to do chest work without passing the stage of analgesia. Nitrous oxide used in the above manner has lowered the operative mortality in the chronic thoracic surgical derelicts to a degree not attainable with other inhalation anesthetics. It is of interest to note also that in the section on chest surgery in a ques- tionnaire sent by the Research Committee of the American Red Cross to base hospital staffs in France the following preferences as to the anesthetic were expressed:21 Local anesthesia if possible was recommended by all. For general anesthesia, the stated first choice was as follows: Gas oxygen, 18; ether, 9; warm ether, 3; chloroform, 2. To summarize, in intrathoracic surgery, if there is cy-anosis, oxygen should be given under pressure with enough nitrous oxide for analgesia until the gray- blue color or the ordinary cyanosis gives place to a pink color. This will usually require from 10 to 15 minutes. When the pink color has been restored the anesthetic may be deepened as required. With the gas and oxygen appa- ratus the lungs can be inflated under positive pressure, cyanosis overcome and anesthesia maintained; and under high pressure both anesthesia and sufficient lung ventilation can be maintained even when both sides of the thorax are widely and simultaneously opened. An adequate exposure should be made. Resecting a rib is better than work- ing in a cramped space. The lungs and heart and pleura should be handled precisely and gently. The patient should be moved as little as possible, the chest closed air-tight. Oxygen should be given under pressure at intervals during the first 24 hours, as the condition of the patient may indicate. Operations on the Extremities Nitrous oxide-oxygen is the anesthetic of choice, but if it is not available then low spinal anesthesia by Cabot's method may be given, but in such a case it is necessary to be prepared to give a blood transfusion to overcome the low blood pressure which will be caused by the anesthetic. When dealing with fractures under anesthesia, no less than without anesthesia, the limb should be orientated and handled so skillfully that little or no crepitus will be felt. In amputations the nerve trunks should be divided as lightly as possible and the limb handled as little as possible. In grave shock, if no nitrous oxide is available, low spinal anesthesia by Cabot's method may be used and preparations made to give blood transfusions to overcome the lowered blood pressure caused by the anesthetic. Large wounds should be covered and protected as much as possible. (Chart V.) (See also Chart II.) GENERAL SURGERY 181 Gassed Cases Oxygen under pressure should be given first, with just sufficient nitrous oxide to eliminate the worry due to the mask and to the oxygen inhalation. Alter the pink color is restored, light surgical anesthesia may be induced. The operation should be short and deft, As required, oxygen under pressure should be given during the post-operative period. In these cases if nitrous oxide is not available, local, regional, or spinal anesthesia should be employed rather than general anesthesia. WARM ETHER VAPOR AND OXYGEN SHELL WOUND, THIGH AND LEG-17 HOURS I60r AMPUTATION, MID-THIGH -40 NITROUS OXIDE AND OXYGEN NO REBREATHING SHELL WOUND, THIGH-21 HOURS PATIENT PALE AND VOMITING CIRCULAR AMPUTATION, MID-THIGH* 150 o — z o 1-< (_ UJ o u- REC T OVEF r n (ED \- PULSE a z UJ 1 1 0 100 90 SO — BLOOD PRES- SURE UJ > a: I t- 70 z ■ Z 1-o id -in — UJ >0 ___>_ o o IO — Z-o o Ul _i 10 < — ►--K o u. ___•_ o o o > 60 50 A-n u. O 10 o 3----■ _1 u. a UJ 1_ _j____ < --- id J O 10 20 30 MINUTES 12 3 4 HOURS AFTER OPERATION 0 10 20 MINUTES 30 12 3 HOURS AFTER OPERATION Chart V.—Comparative effects of ether and of nitrous oxide in thigh amputations as indicated by the pulse and blood pressure. (By courtesy of Capt. Geoffrey Marshall, R. A. M. C.) In cases of phosgene poisoning it should be borne in mind that phosgene poisons by reason of its interference with the passage of oxygen through the walls of the air vesicles, thus producing anoxemia. Cases of phosgene poison- ing, as is indicated by the rapid respiration, increased pulse rate, cyanosis, loss of mental and muscular power, sweating, etc., are in a state of acute acidosis— the same end effect as is produced by prolonged inhalation anesthesia, by- exertion, fever, emotion, shock, exhaustion, etc. Therefore, since the inhala- tion anesthetics themselves cause acidosis, their administration adds one acidosis to another; i. e., the acidosis of anesthesia intensifies the acidosis of phoso-ene asphyxia. Surgical shock also produces a state of acidosis. The 182 SURGERY acidosis of the surgical operation, therefore, if added to the acidosis of the phosgene and the acidosis of the anesthetic may kill the patient. Therefore, when an operation is required in a case of phosgene poisoning, it should be performed under local, regional, or spinal anesthesia, the patient meanwhile being kept pink by oxygen under pressure by means of the positive1 pressure mask of a nitrous oxide apparatus or a Haldane apparatus. If there is a phase of operation that can not be controlled by local or regional or spinal anesthesia, then one should give oxygen under pressure until the patient has a pink color, then switch to nitrous oxide for the briefest time required for the operative move, then switch back again to oxygen under pressure. Operations in* the Presence of Acute Infections Y\ bile narcotization with morphine is of value in all cases excepting in the presence of cy-anosis, in the acute infections, as has been proved by experiment and demonstrated repeatedly in civilian and war hospitals, morphine is of para- mount value. In such cases, therefore, the first requisite is deep narcotization with morphine, and if time permits the subcutaneous infusion of 1,000 c. c. of normal saline solution before operation. Nitrous oxide-oxygen analgesia should be used, the stage of full anesthesia being induced only as the exigencies of the operation demand. The morphine narcotization and saline infusions should be continued until the patient is safe. CONSENSUS OF OPINION AMONG BASE HOSPITAL STAFFS The questionnaire already cited contained, as would be supposed, special sections regarding the value of different types of anesthetics. For details in connection therewith consult the appendix of this volume. LIMITATIONS OF DIFFERENT TYPES OF ANESTHESIA The problems presented by anesthesia in war surgery-, as in civilian surgery, are in effect problems of limitations. Therefore, since in the exigencies of mili- tary surgery the anesthetic method of choice may not always be available, it is peculiarly essential that the limitations of each type of anesthetic be kept clearly in mind. Spinal Anesthesia In the low blood pressure of acute shock or hemorrhage the additional fall due to spinal anesthesia as a result of the interruption of so large an area of vasomotor nerves may cause dangerous, even fatal collapse. This may be pre- vented by blood transfusion. The psychic factor may be both distressing and damaging, but may be eliminated by very light ether anesthesia, Occasion- ally spinal anesthesia is incomplete. Such a failure must be met bv a General anesthetic. Nitrous Oxide In abdominal operations muscular relaxation may not be complete under nitrous oxide anesthesia. The condition should be met by regional anesthesia of the abdominal wall and by light handling. Xitrous oxide is a light anesthetic, demanding of the surgeon a lio-ht deft operative technique. Xitrous oxide must be given only bv experts- it is dangerous in inexpert hands. GENERAL SURGERY 183 Ether Ether tends to cause bronchopneumonia, especially in abdominal opera- tions during the winter. It diminishes, even temporarily abolishes, phagocy- tosis, and is therefore unsuitable in infections. There is a tendency to a fall in blood pressure after operation; hence it is unsuitable in shock. Ether causes a rather large diminution in the reserve alkalinity of the blood. THE ANESTHETIST If, as has been demonstrated, nitrous oxide-oxygen is the anesthetic method of choice in military surgery, then it is essential that corps of anesthetists espe- cially trained for its administration should be available. Safest of anesthetics in expert hands, nitrous oxide is the most unsafe in the hands of the inexpert. Since in military surgery the majority of patients are already grave risks on account of exposure, exhaustion, and infection, it is peculiarly- necessary that the anesthesia should be handled bv trained hands. REFEREXCES (1) Burlingame, C. C. Lt. Col.: Military History of the American Red Cross in France, 135. On file, Historical Division, S. G. O. (2) Conclusions adoptees par la Conference Chirurgicale Interalliee, 1st Session, 15th and 16th March, 1917. Archives de medecine et de pharmacie militaires, Paris, 1917 lxvii, 531. (3) Ibid., 2d Session, 14th to 19th May, 1917, lxviii, 451. (4) Letter from Major Harry L. Gilchrist, M. C, to The Adjutant General, .May 8, 1917. Subject: Departure of Base Hospital No. 4. On file, Record Room, S. G. O., 159444 (Old Files). (5) Burlingame, op. cit., 137. (6) Red Cross Reports on Nitrous Oxide and Oxygen Service. On file, Historical Division, S. G. O. (7) Cannon, W. B.: Acidosis in Case of Shock, Hemorrhage, and Gas Infection. Journal of the American Medical Association, Chicago, 191S, lxx, No. 8, 531. (8) Cattell, McKeen. Studies in Experimental Traumatic Shock. VI. The Action of Ether on the Circulation in Traumatic Shock. Archives of Surgery, Chicago, 1923, vi, No. 1, 41. (9) Marshall, Geoffrey. Anesthetics at a Casualty Clearing Station. American Journal of Surgery, Anesthesia Supplement, New York, 191S, xxxii, No. 4, 61. (10) Gwathmey, James T.: Personal communication. (11) Cabot, Hugh: Personal communication. (12) Desplas: Spinal Anesthesia. Medical Bulletin, Red Cross Research Society Reports, Paris, 1918, No. 6, 447. (13) Rocher, H. L.: La rachi-anesthesie en chirurgie de guerre. Journal de medecine de Bordeaux. 1919, xo, n.s., No. 1, 5. (14) Gwathmey, James T. and Karsner, H. T.,: General Analgesia by Oral Administration. British Medical Journal, London, March 2, 1918, i, 254. (15) Surgery in Relation to Shock. War Medicine, Paris, 1918, ii, No. 5, 785. (16) Gwathmey, James T.: Anesthesia. The Macmillan Company, New York, 1924, 153. (17) Ibid., 692. (18) Lockwood, A. L. Early Operative Treatment in Chest Surgery. Ttar Medicine, Paris, 1918, ii, No. 1, 7. 1S4 SURGERY (19) Official Report from Laboratory of Surgical Research, Central Medical Department Laboratory, A. E. F., to Brig. Gen. J. M. T. Finney, M. C, Chief Consultant in Surgery, A. E. F. Subject: Intrathoracic Surgery (Anesthesia). War Medicine, Paris, 1919, ii, Xo. 6, 1008. (20) Keller, Win. L., Lt. Col., M. C.: Personal communication. (21) Compilation of Responses by Base Hospital Staffs to Questionnaire sent out by Research Committee. Questionnaire prepared by Brigadier General J. M. T. Finney and Colonel G. W. Crile; Compilation of Responses made by Major T. W. Burnett, M. C. War Medicine, Paris, 1919, ii, No. 7, 12S1. CHAPTER VII WOUND SHOCK a .Wound shock occurs as a consequence of physical injury—the rupture, shredding, tearing, or crushing of large amounts of tissue. It is characterized by low venous pressure; low or falling arterial pressure; rapid thready pulse: diminished blood volume; normal or increased erythrocyte count and hemo- globin percentage in peripheral blood; leucocytosis; increased blood nitrogen; reduced blood alkali and lowered metabolism; subnormal temperature; cold skin, moist with sweat; pallid or grayish or slightly cyanotic appearance; thirst; shallow and rapid respiration; of ten vomiting and restlessness; and anxiety, changing gradually to mental dullness and lessened sensitivity. These features may appear at once or as soon after the reception of the wound as observations can be made, or they may develop only after several hours. The former type is called primary, the latter secondary, wound shock. The factors concerned in the development of shock may be divided into those that initiate the condition and those that sustain it after it has once been developed. INITIATING FACTORS The onset of early or primary shock is most reasonably accounted for as a consequence of some disturbance of the nervous system. A review of shock theories has shown that it is impossible to eliminate, as a consequence of wounds, a reflex relaxation of blood vessels similar to that w-hich occurs in fainting. Indeed, fainting is not infrequently seen after the reception of relatively slight wounds in warfare. Vincent * observed cases of this character, but the only instance which he described in detail is that of a man wounded in the abdomen who, through manifesting the syndrome of shock a few minutes after being hit, had a rise of blood pressure from 60 to 90 mm. Hg. within 45 minutes thereafter. It is possible, therefore, that an effect similar in character to fainting or syncope may be produced by a wound and that it may persist for a longer period than the usual fainting spell. For an explanation of the onset of delayed or secondary shock the theories wliich have been most commonly advocated in the past, such as inhibition, reduction of the carbon dioxide content of the blood (acapnia), fat embolism, and an exhaustion of nerve centers or certain glands, have all been shown to be inadequate. Their chief and common defect is that they fail to account for the occurrence both in clinical and experimental shock of a diminution of blood a This chapter is based largely on the writer's experience in cooperation with British investigators at a casualty clearing station at Bethune during the summer of 1917, and in London during three months of the winter of 1917-18, and thereafter on the work of a group in the Laboratory of Surgical Research of the American Expeditionary Forces, at Dijon, France, during eight months of 1918. The members of the group had opportunity to observe shock cases in forward areas, both during the summer and in the fall of that year. The experimental and clinical observations in France and England were supported by laboratory investigations conducted simultaneously in the United States. 185 186 SURGERY volume and either a local or general concentration of blood corpuscles. A group of theories which do take these facts into consideration, namely, theories wliich postulate a primary vasoconstriction with a consequent capillary congestion, arc defective in that they do not suggest how- a vasoconstriction w-ould occur capable of bringing about a reduction of blood volume. The theory of secondary shock which has the strongest support, both in clinical observations and in laboratory- experiments, is that of a toxic factor, arising from damaged and dy-ing tissue and operating to cause an increased permeability of the capillary walls and a consequent reduction of blood volume by escape of plasma into the lymph spaces. Thus the concentration of the corpuscles is also readily- explained. It is recognized that after a sufficient time infection may occur and be of such character in itself as to induce a persistent low blood pressure. According to this theory there might be no essential difference between the effects of toxins given off by damaged tissue and of toxins resulting from activity- of bacteria. Emphasis should be laid on the fact that toxic agents are usually not working alone to bring about the shock state. Complicating the wounds there is usually some loss of blood. Under battle conditions, especially, there may be cold and exposure. Likewise there may be prolonged lack ot food and water. Sweating is a regular accompaniment of severe trauma. All these factors are known to be capable of playing a role in producing a more or less permanent fall of pressure; such a loss, when combined with injury, may bring about promptly the signs of wound shock. Similarly, after a serious wound, with loss of blood, shock may not be present, but then ether or chloroform anesthesia and operation may quickly induce a calamitously low blood pressure. It is because the state of shock may be the result of a group of circumstances that improvement often follows when one easily controllable factor (e. g., cold) is eliminated. SUSTAINING FACTORS When a low blood pressure is developing in consequence of the action of initiating factors a critical level is reached at about 70 mm. Hg. Below this level the delivery of oxygen to the tissues becomes inadequate, the blood alkali begins to be reduced (i. e., "acidosis" appears), and the rate of chemical change within the organism becomes slower. There is a diminished heat pro- duction, so that the body temperature gradually falls below normal When there are defective circulation and insufficient oxygen supply tissues are damaged. Most sensitive to oxygen want are the nervous tissues. In addition to injury to these delicate structures there is likely to be a relaxation of the walls ot capillaries and perhaps also injury to the capillary endothelium. These disturbances in elements which are essential to the maintenance of an efficient circulation continue the state of shock which has been originated bv other .actors, and they may also still further reduce the already low arterial pressure. EARLY TREATMENT In the following suggestions tor the treatment of the wounded who are suffering from shock or who, because of their wounds, may pass into a state of shock, the facts above mentioned will be applied. It is necessary to keep in GENERAL SURGERY 187 mind at the outset that the early use of simple measures is of prime importance. Such measures will be described in relation to the conditions that have to be met m the course of treatment. Hemorrhage It is w-ell known that bleeding may sensitize the organism to factors which are likely to induce shock, and furthermore that men who have been severely wounded and are in an unstable condition therefrom may be reduced to shock by relatively slight hemorrhage. Moreover, in association with serious wounds there is likely to be a considerable loss of blood and consequently urgent need that no more be lost, All these considerations strongly emphasize the impor- tance of employing measures which will prevent a further bleeding that may be of critical importance to the life of the individual. The readiest method of checking hemorrhage when a limb has been wounded is by means of a tourniquet, and there is usually strong temptation to apply it promptly. As mentioned above, however, there is good evidence of a toxic factor in shock. Part of the evidence for the existence of this lactor was ob- tained in cases of a long exclusion of the circulation from a part of the body- especially a wounded part. When the blood flow was restored in the anemic region in these instances shock was promptly produced. Cases of this char- acter illustrate a definite danger which may arise if a tourniquet is used to con- trol hemorrhage and consideration is not given to the length of time it has been in place. The evils of thoughtless and indiscriminate use of the tourniquet became so prominent during the war that in certain parts of the British Army this method of hemostasis was definitely discouraged. Medical officers then found that in most cases the flow of blood could be stanched by applying com- pression to the wound itself. The advice of Wallace and Fraser,2 who had a vast experience with shock cases during the war, is as follows: Bleeding is to be arrested by pressure upon or ligature of the bleeding point itself and not by constriction of the limb above or by tying the artery on the proximal side of the injury. The systematic use of the elastic tourniquet should be limited, and its use, apart from during an operation, should be restricted to those cases in which a limb is completely smashed or blown away, or as a temporary measure while a patient is being carried to a regimental aid post. If the medical officer finds that a tourniquet has already been applied it is his duty to remove it at once and to examine the limb so as to ascertain whether there is actually hemorrhage, and, if so, to take measures for its arrest. A rule which is generally applicable is that the tourniquet should be avoided altogether if possible, and that if one is absolutely7 required it should be placed as far from the trunk as conditions permit and removed as soon as vessels are tied or snapped. If it must be left long in position a note should be attached to it stating when it w-as applied. The suggestion has been offered that if a limb has been so badly mangled that it can not be saved a tourniquet should be set close above the trauma and left in place until after amputation. The amputation should be performed proximal to the tourniquet, Thus the body is protected against toxic material which is present in the torn and smashed tissues and is likely to be absorbed. 1SS SURGERY Loss of Body Heat The well-established association between the incidence of shock and loss of body heat emphasizes the urgency of taking every precaution to conserve the store of heat which the body has and to give back to the body the heat that may have been lost. In accordance with this observed relationship the following principles of treatment should be applied. When a wounded man is being examined he should be subjected to as little exposure of the body as possible; only one part should be exposed at a time and it should be promptly covered again. These precautions are especially neces- sary in cold w-eather. As soon as possible the patient should be surrounded with blankets. Whether he is lying on the ground or on a stretcher, more blankets, if available, are needed under the body than over. The reason for this is that the blanket protects against heat loss by the air which it holds enmeshed in its fibers. The weight of the body lessens the air space in the fabric and consequently reduces the amount of protection. Under military conditions it is necessary to reduce the number of blankets to a minimum. By using the BIcmKet 3 Blanket Z v______________ Fki. 105—Method of folding three blankets to provide four layers beneath and four above the patient. The outer end. of blankets 1 and 2 are folded over the two layers of blanket 3, already in place above the patient method illustrated in Figure 105, three blankets may be made to provide four layers above and four below the patient. Of course the feet should be wrapped in warm covers. If the patient already- is cold or is likely to lose heat despite blanketing his body may be heated by means of hot-water bottles. If there are insuffi- cient bottles in the medical supplies for the purpose the ordinary canteens may- be used instead. Great care should be exercised to avoid a degree of heat which might cause burns. The bottles are more effectively employed if both sides instead of one are brought into contact with the body. Further, the physical fact should be remembered that heat passes faster from a warm to a cold object than to a lukewarm object, and, finally, heat is distributed throughout the body- by the circulating blood. In accordance with these considerations one hot- w-ater bottle should be laid on the abdomen, and the hands, which are likely to be cold, placed over it. The second bottle should be placed between the feet, which also are likely to be cold. If more bottles are available they should be placed between the thighs or pushed tow-ard the axilla between the arm and chest on either side. By such distribution the heat passes chiefly to the body rather than in large part to the layer of air in the surrounding blankets: further- BlanKet 1 j ___ i general surgery 189 more, it warms the parts which are most likely to be or to become chilled when the circulation is poor. Another highly effective mode of contributing heat to the body is by means of hot drinks. There are, however, limitations to the use of this method, for in case of wounds of the alimentary tract the taking of fluid w-ould be likely to wash material into the peritoneal cavity, and, besides, fluid taken by- mouth is sometimes not retained by the severely wounded. If the gastrointestinal canal has not been opened by7 injury and if the swallowed fluid is not vomited a hot drink is by far the best method of warming. All of the heat in it above the temperature of the body passes to the body itself. Moreover, the fluid helps to restore a reduced blood volume, It also satisfies the distressing thirst which is so constantly complained of by the wounded. The hot drink may be civen in forms which are relished, such as hot tea or coffee. Under military conditions these drinks may be provided at advanced stations and may be given repeatedly, when they are tolerated, in the course of the journey to a permanent hospital. Preliminary dressing of wounds should be done, if possible, in a warm place. In military activities this is a rare possibility, but provision should be made in advanced dressing stations for keeping the patient warm during the first care of his wounds. An arrangement w-hich has proved simple and satisfactory in military service is that of providing in these stations a rectangular support, the length and width of a stretcher and about 3 feet high, which is surrounded by blankets and heated by a lamp or oil stove placed on the floor. Over this warm chamber stretchers may be set and patients thus kept warm during the exami- nation of their wounds. If the layer of warm air which is ordinarily retained in garments is replaced by moisture the loss of heat through this better conduc- tor'may be rapid. During the preliminary dressing outer clothing which is wet should be removed and replaced by more blankets. If the patient can be kept warm, however, this need not be done. Durino- the World War an important improvement in the care of the wounded, especially in cold weather, was made when devices for warming the motor ambulances' were installed. Some accidents occurred from escape of gases into the car when the exhaust was used to supply the heat. Cars may be heated, however, bv hot water from the radiator. When on arrival at the hospital, the patient has a low temperature and cold skin his clothing should be promptly removed or cut away (with care not to lose more heat) and he should be put in a warm bed. A highly effective means of warming the patient while in bed is to set over him fracture frames wl^ :l covered wi/blankets and then to introduce heat m o^e covere bottle of liter capacity; F, glass tube; '7, rubber tube; H< glass tube for suction, with cotton in bulb * The present description is taken largely from "A Report upon the Transfusion of Blood for the Recently Injured in the United States Army," published by the Medical Division of the American Red Cross Society in France .4, Place de la Concorde, Paris, May ,1918. GENERAL SURGERY 199 Before the blood is collected a tube of sodium citrate is broken off at the file mark, the opened end flamed, and the contents poured into the bottle E. Normal saline solution (0.9 o/o) is then added up to 100 c. c, (i. e., to the top of the figure). When the bottle is filled to 700 c. c. the citrate present is 0.6 per cent. The apparatus (see fig. 107) is then assembled so that the rubber stopper fits snugly into the mouth of the bottle. Great care should be taken to keep all the open parts sterile. Bleeding.—The donor's arm is now extended at a right angle to the body. A tourniquet is applied to the arm high up—the cuff of a blood-pressure ap- paratus folded to half its width makes an excellent tourniquet with the pressure kept at 50-60 mm. of Hg. Choose a suitable vein in the bend of the elbow, remembering that the needle is best inserted tow-ard the hand. It is important to have as large a vein as possible. Opening and closing the fist and flicking the skin over the veins cause them to dilate considerably. The tourniquet is then released. The skin over the vein is scrubbed with soap and water and the sterilization completed with alcohol. At the point selected for venepuncture a small quantity of novocaine or cocaine is injected intracutaneous-}". A very- slight nick is then made through the skin with the point of a scalpel. The tourniquet is tightened and the means above described are again employed to dilate the vein. Do not touch the point of puncture. The bottle is placed on a stand close to the patient's arm in such a position that there will be no kinking of the tube B when the needle is in the vein. After drying the skin opening with a piece of sterile gauze the needle is inserted for a short distance beneath the skin; then by raising the base slightly it is pushed into the vein. It is es- sential to keep the needle immobile. The operator should hold it throughout the bleeding, steadying his hand against the donor's arm. AVith the free hand the bottle is given a rotary motion every-few seconds in order to insure thorough mixing of the blood with the citrate, which is very important. A moderate degree of suction is maintained either by means of the tube H, which is held in the operator's mouth, or more conveniently by using the adapted syringe pump. The donor continues to open and close his hand slowly, making a firm fist each time, care being taken that he does not move his arm. The citrated blood does not coagulate and consequently its introduction into the recipient need not be hurried. Under ordinary conditions the blood will be used immediately, but when occasion requires it may be kept for several hours before introduction. If in the course of drawing the blood clotting occurs and the blood ceases to flow, release the tourniquet, withdraw the needle, and obtain the blood through use of entirely fresh apparatus (needle, rubber, and glass tubing), which should be at hand, sterilized for such an emergency. It is usually better to take the other arm. Six hundred c. c. of blood is the limit to be removed, for a donor may lose this amount without distress. If more blood is required a second donor must he taken. The same donor must not be used twice within a single week. The bottle of blood should be placed in a receptacle containing water at about body temperature, where it should be kept during the transfusion. Transfusion.—The introduction of the blood into the recipient is accom- plished bv removing the first stopper D (fig. 106) with its connections and putting 200 SURGERY the stopper X (fig. 107) with its connections snugly into the mouth of the bottle. Air pressure is increased by blowing through the tube Q, and blood begins to rise in the tube M, which forms one limb of the siphon K, L, M (fig. 107). The tube K is held high as the blood passes into the rubber tube L and then is gradually- lowered. When K is completely filled a pincdicock closes the rubber tube L close to the glass tube K. A bandage or tourniquet is placed about the arm of the recipient sufficiently- tight to give the maximum venous pressure. Remember that the arterial pressure of the recipient is low; the arterial flow must continue if the veins are to be made prominent. The needle I with the short rubber tube J attached is then introduced, in the direction of the venous stream, into the vein of the recipient. As the blood begins to flow through the needle and tube the assistant quickly removes the bandage wiiile the operator immediately con- nects the rubber tube J with the glass tube K, the precaution being observed to have both tubes filled with blood. The bottle is then raised to the full height allowed by the rubber tube L, the pinchcock is opened, and the blood enters the recipient by gravity. The time allowed for the introduction of 600 c. c. of blood should not be less than 10 to 15 minutes. Any symptoms of dis- tress should indicate a checking of the flow. Such symptoms, which are usu- ally nothing more than a feeling of fullness and slight respiration diffi- culty, are ordinarily transient. At the completion of the transfusion a small amount of blood will remain in the bottle below^ the level of the glass tube M. If more convenient, the bulb of a Davidson syringe or of a blood-pressure apparatus may be connected with tube P (fig. 107), and the blood forced in by air pressure. If the veins of the recipient are very small or collapsed an incision may be made and a canula introduced into the vein. After use the apparatus must be cleansed with cold water immediately If not being frequently used the needles should thereupon be dried by running first alcohol and then ether through them, after which they should be stored in test tubes with a cotton plug in the bottom and the mouth of the tube. The needles must be kept sharpened. Selection of donors .—There exist in the plasma of animals certain bodies which will agglutinate or agglutinate and hemolyse the red blood cells of other individuals who are members of the same species. The transfusion of such incom- patible blood may be fatal to the recipient. Among human beings it is definitely Fig. 107.—Transfusion apparatus. J, Rubber tube; K, glass tube; _., rubber tube; M, glass tube; X, rubber stopper; O, glass tube; P, rubber tube; Q, glass tube for exerting com- pression (cotton in bulb) GENERAL SURGERY 201 known that all individuals fall into one of four groups. Knowledge of these groups has proved of practical value in blood transfusion. Hemolysis does not take place between individuals belonging to the same blood group, and practi- cally never takes place between certain definite combinations of different groups. Having determined the blood group, it is possible to select a donor whose blood is compatible, as regards hemolysis, with the blood of the recipient. The classification of these groups is as follows: Group I. Serum agglutinates no corpuscles. Corpuscles agglutinated by- sera of Groups II, III, and IV. Group II. Serum agglutinates corpuscles of Groups I and III. Corpuscles agglutinated by sera of Groups III and IV. Group III. Serum agglutinates corpuscles of Groups I and II. Corpuscles agglutinated by sera of Groups II and IV. Group IV. vSerum agglutinates corpuscles of Groups I, II, and III. Cor- puscles are not agglutinated by any serum. The incidence of the four groups is approximately: Group I, 5 per cent; Group II, 40 per cent; Group III, 10 per cent; Group IV, 45 per cent. The following table shows the relation of the four blood groups with respect to agglutination of corpuscles: Corpuscles Serum I o 0 0 0 II III + + o ! + + o 0 i 0 i IV I....... II________ III________ IV________ + + + 0 (+=agglutination; 0=no agglutination.) In order to determine the group of an individual, it is sufficient to test his corpuscles against known sera of Groups II and III. This is readily accom- plished by a macroscopic test, which in addition to the two known sera requires only a glass slide, a needle, and two small glass rods. Citrated sera for this test are furnished by the Central Medical Department Laboratory. These sera remain active indefinitely, as a rule, but they should be tested occasionally against blood of known groups to prove that thev are active and ready for emergency. The test is performed as follows: By means of the stopper in the bottle place a drop of Group II serum on the left half of the glass slide (slide need not be sterile, but should be clean and dry) and a drop of Group III serum on the right half of the slide. Puncture the ear or finger of the individual to be tested, and transfer in turn to each of the sera about one-third of a drop of blood, on the end of the glass rod, mixing the blood intimately with the serum. Avoid mixing too much blood with the serum; it wall prevent a clear result. Take care to transfer the blood before coagulation has commenced. Avoid mixing the tw-o 202 SURGERY sera; a separate glass rod or opposite end of a rod must be used for each transfer. Agitation of the slide accelerates the appearance of an agglutination. Within a few" seconds after mixing the blood and sera one may see a brick- dust-like appearance in one or both sera, or one may see only a homogeneous suspension of the cells in one or both sera. If the distinction between the SERUM _T SE.RUM SL Fig. 10S.—Graphic illustration of macroscopic agglutination test "brick-dust" and the homogeneous appearance should not be quite clear, tip the slide toward the vertical; a thin layer of blood will be left in the upper limits of the drop in which the difference, if present, will be evident. The brick-dust-like appearance denotes agglutination. Occasionally there is a tendency to rouleaux formation, which may be confusing. Rouleaux forma- tion appears more slowly than agglutination, and, contrary to agglutination, is GENERAL SURGERY 203 dissipated if the rouleaux are broken up by stirring the serum. In the rare instances in which the agglutination is questionable, the donor should not be used. Groups are indicated as follows: When agglutination occurs in both sera the individual belongs to Group I. When agglutination occurs only in III serum the individual belongs to Group II. When agglutination occurs only in II serum the individual belongs to Group III. When no agglutination occurs in either serum the individual belongs to Group IV. Except in cases where the risk of delay is greater than the risk of hemo- lysis, the compatibility of the blood of donor and recipient should be deter- mined before transfusion. It is not necessary that the donor belong to the same group as the recipient. The only practical consideration is that the recipient does not agglutinate the red corpuscles of the donor. From the above table it is seen that the red cells of Group IV are not agglutinated by the serum of any other group. Therefore, in practice it is simpler, whenever possible, to use only- donors of Group IV, in which case the patient's blood does not require testing. Group I recipients can take donors of any group, since the serum of Group I agglutinates the cells of no other group. Recipients of the other groups can take donors of their own group or Group IV only. Xo person should be used for a donor who has, or has had, syphilis, malaria, trench fever, or who has recently recovered from other infectious diseases. Lightly gassed patients, i. e., patients whose color is normal or nearly normal, may be used as donors if properly grouped and free from transmittable disease. Patients with scabies may be used as a source of blood for transfusion if they are otherwise satisfactory. In general, convalescent patients who are nonfebrile and in good physical condition constitute the class from which donors may be selected. No reward is to be offered a donor; his consent must be obtained without urging or compulsion. A list of donors, with their group, age, ward, and bed, must be posted in the operation room and in the resuscitation ward. When necessity arises, a donor is thus immediately obtainable. To avoid a possibility of error this list should provide every means for proper identification. For absolute assur- ance, small perforated metal tags should be provided, marked to indicate the group to which the man belongs. This tag must be attached to the man by the individual making the test at the time the grouping is determined. 204 SURGERY Transfusion- Equipment For A Hospital A. APPARATUS 1. Plain glass bottles of 1 litre capacity, marked 100 c. c, 400 c. c. and 700 c. c. at the proper levels________________________________________________ ----- 2. Rubber stoppers to fit the bottle (2 perforations).________________________ 3. Glass tubing. The glass tubing has a total diameter of 5 mm., thickness of wall 1 mm.; opening 3 mm. (for identification see interpretation of Figures I and II)." C. Long right angle tubes, one arm 10 cm. long, the other 6 cm. long------------ F.I q [Short right angle tubes, each arm 6 cm. long______________________________ H.^Tube for suction or compression (dilated in center for reception of small bit of Q.J cotton), 1 cm. long_________________________________________________ K. Straight tubes, narrow at the top, 10 cm. long____________________________ M. U tube, short arm 4 cm. in length, long arm 25 cm. in length_________________ 4. Rubber tubing. The rubber tubing has a total diameter of 6J^ mm., thickness of wall 1J^ mm., opening 3 mm. B. Short tubing for collection needle, 12 cm. long____________________________ G.\ p JTubh ibing for suction or compression 30 cm. long____________________________ J. Short tubing for introduction needle, 7 cm. long____________________________ L. Long tubing for introduction apparatus, 1 meter 30 c. long__________________ 5. Transfusion needles. These are made of steel. The total length of each needle is 4 cm.; the length of the shaft is 2}/2 cm.; the length of the point is 4 mm., the length of the base is \y2 cm. with a flat portion on two opposite sides. The size of the needles and the number required are: 25/10 mm., 2; 20/10 mm., 2; 16/10 mm., 2; 13/10 mm., 2. 6. Stone for sharpening needles______________________________ 7. Small infusion cannula.. The total length of the cannula, is 39 mm.; the length of the tip is 2 mm. and there is a small collar at the base of the tip, giving a diameter 1 mm. larger than that of the shaft; the length of the tip and shaft together is 33 mm.; the length of the base is 6 mm.; the sizes of the cannula. are: one of 20/10 mm., the other 30/10 mm___________ 8. Pinchcock_______________________________ 9. Test tubes for needles_______________________ 10. Small test tubes for cannula?____________________ 11. Paraffin 54° C____________________________________ kilo 12. Emery paper small sheets____________________ 13. Wooden box, well made and finished, to carry above apparatus, labeled: "Trans- fusion, Medical Dept., U. S. Army." B. LABORATORY TRANSFUSION SUPPLIES 1. Bottles of Group II and Group III sera, labeled as below: Serum U Serum III Sodium citrate---------- l. 5 Sodium citrate Tricresol--------------- .25 Tricresol... Date. Date. • Figures 106 and 107. GENERAL SURGERY 205 1 bottle of each serum 2. Sterile sealed tubes of sodium citrate solution with file mark for breaking point, labeled: "Sodium citrate in 0.9 saline, quantity sufficient to citrate 600 c. c. of blood to 0.6 per cent: date_____"______tubes. 48 3. Glass slides with II and III marked into the glass, in the upper'left and right hand corner respectively_______________ y> 4. Small tube containing small glass rods______________ 1? 5. Small bottle of alcohol for care of needles__________ 12 6. Small bottle of ether for care of needles_____________ 12 7. Bottle of blood counting fluid____________________ 12 8. Small metal tags (perforated) stamped to indicate the group of the patient: Blood Group I______________________________ 1Q Blood Goup II________________________________ Iqq Blood Group III______________________________ 20 Blood Group IV____________________________________ 100 9. Small ball of twine for fastening tag to the individual groups. 10. Wooden box, well made and finished, to carry the above supplies, labeled: "Laboratory supplies. Transfusion, Medical Department, U. S. Army." Precautions to be observed in intravenous injections.—Whether blood or an indifferent fluid is injected, careful attention should be given to the mode of procedure. The possibility of further loss of blood, as the pressure is raised, should be eliminated. The fluid should be introduced slowly and with little pressure. Zunz and Govaerts25 showed that blood transfusion after hemorrhage is effective in restoring normal blood pressure when 40 to 75 minutes are taken to replace about half the blood volume. But if this amount is introduced in .5 to 10 minutes a marked fall results which may last for hours. And they noted that the deeper and more lasting the circulatory failure before the transfusion the more slowly must the blood be injected in order to avoid a subsequent drop of pressure. The fluid should be given warmed to body temperature, or, better, slightly- above, in order to enter the body warm after passing through the connecting tubes. If any harmful or unfavorable effects are noticed as the fluid is entering the blood stream, the flow- should be checked at once. The amount injected usually need not be great; 500 or 750 c. c. may- be given at first, and later 500 c. c. more if circumstances seem to require it. This probably- will not restore the blood volume to normal, for, as Keith 21 and Robertson and Bock 8 showed, the volume is often reduced as much as 2,000 c. c. or more. Therefore, though an intravenous injection may raise the pressure satisfactorily, other and simpler means of increasing the circulating fluid should be continued—such as fluid by- mouth and rectum. On the basis of their Bethune experience in 1917, Cannon, Fraser and Hooper26 called attention to the unfavorable prognosis attending continued concentration of the peripheral blood, and to the disappearance or "dilution" of the blood as recovery occurs. Both Keith21 and Lee23 emphasized the significance of these blood changes, and suggested repeated hemoglobin determi- nations in order to learn whether "dilution " is occurring and whether the patient, therefore, is on the course toward improvement and recovery. 206 SURGERY OPERATION Operation on a man who has been greatly injured, or who is in shock, or who has been in shock for a considerable period and has to some degree recov- ered, is likely- to be hazardous because blood pressure barely sustained, or already low, or only recently restored, may- be reduced seriously by operative procedures. A number of conditions contribute to this danger, some of which can be avoided. Anesthesia The fall of blood pressure during or after operation in shock is probably due chiefly to ether or chloroform anesthesia. Sharply contrasted with the effects of these general anesthetics in shock cases is the action of nitrous oxide and oxygen or "gas-oxygen." During his extensive experience as an anesthetist in a casualty- clearing station in Flanders, Marshall4 found in a large series of very severe cases that gas-oxygen anesthesia was followed by no increase of shock whatever. And Bazett,27 who likewise had abundant opportunities to make careful observations, has testified: "One can only- say- that with nitrous oxide and oxygen anesthesia there is rarely- any sign of shock observed. The clinical contrast between cases anesthetized with nitrous oxide and oxygen and those receiving other general anesthetics is enormously in favor of the former." In this connection Dale's observation 28 on the relation of ether and gas-oxygon to histamine shock are highly- pertinent. He found 10 mg. of histamine per kilogram necessary to produce shock in the unanesthetized animal, whereas under ether 1 to 2 mg. were sufficient. But under gas-oxygen shock would be induced only by giving the dosage required in the unanesthetized state, i. e., 10 mg. Ether and the toxic agent cooperated to bring on the low pressure; with gas-oxygen anesthesia the cooperation was lacking. Bazett27 noted that after ether or chloroform there was a concentration of the blood, amount- ing at times to 20 per cent. With rapid operation under gas-oxygen, how- ever, very slight and only- temporary- concentration was seen. Gas-oxy-gen should be given with great care and by experts in its use. Cattell29 noted that high ratios of nitrous oxide to oxygen are quite as harmful as ether. A ratio of three parts nitrous oxide to one of oxygen caused no fall of blood pressure whatever. Gwathmey and Yates 30 found in their work on chest cases in battle areas that with a preoperative use of morphine, deep analgesia could be induced and maintained w-ithout increasing the ratio above three to one; Gwathmey31 stated that, with proper preliminary medication, complete relaxation of the patient for prolonged periods is easily maintained under gas-oxygen anesthesia, American and British experience during the war led to strong affirmation that in shock cases gas-oxygen is undoubtedly the anesthetic of choice, and this conclusion was accepted by the Interallied Surgical Congress at Paris in 1917.32 Whatever the general anesthetic employed, there should be avoidance of deep anesthesia and cyanosis. With the blood volume reduced and the nutrient flow inadequate or bordering on inadequacy, the organism is in danger from oxygen want. Shutting down the oxygen supply is certain to do harm. As Marshall33 remarked, cyanosis during operation causes a shocked man to lose ground which may be extremely hard to recover. GENERAL. SURGERY 207 An alternative to general anesthesia, particularly in operations on the lower extremities, is spinal anesthesia. There is the possibility that through the blocking of tonic vasoconstrictor impulses in the spinal nerves a fall of blood pressure may result. Indeed, according to Quenu,34 this is to be expected. The suggestion has been made that under such circumstances the pressure may be maintained by slow and continuous infusion of a weak solution of adrenalin. Theoretically this is an appropriate mode of procedure, but it is questionable whether there is a special advantage in its use. Time of Operation In 1917 Santy 35 observed 340 cases of nontransportable wounded, in 79 of whom the time between the reception of the wound and the surgical treat- ment was known. The mortality in these wounded was as follows: Hours inter-vening Number Mor- of cases tality Per cent 1 10 10 2 9 11 3 8 12 4 11 33 5 9 36 6 12 41 8 8 75 9-10 12 75 As the above figures show, the mortality was only 11 per cent in the first three hours; it rose to 37 per cent when there was a delay of between three and six hours (though infection was not marked until after six hours); it was 75 per cent in the eighth to the tenth hour. Although during the first hour the cases were not in complete shock, they were in grave condition, anemic and cold. A review of Santv's full description of his cases reveals that in all there were wounds of similar severity. For example, the lesions in the group operated on in the first hour included (1) mashing and pulping of the arm and leg; (2) of the leg and knee and of the forearm (in a diabetic); (3) of the right thigh and left leg; (4) of the thigh in the lower third; (5) of the mid-thigh, with laceration of the muscle above; (6) of the leg above the right knee, with tearing away of the calf; (7) of the elbow, with wounds of the face, loss of an eye, and two large wounds of the thigh; (8) double shattering of the left arm and forearm; (9) destruction of the popliteal space with section of the artery; (10) laceration of the muscles of both thighs and the calf. Of these 10 cases 1 died. Amputation was performed in 7 cases; in 2 cases double amputation. Six of the 7 amputations resulted successfully. In the last group, operated upon after nine or ten hours, the lesions were: (1) Extensive laceration of both thighs; (2) smashing of the knee with muscular lesions; (3) crushing of the shoulder; (4) wounds of both thighs with section of the left femoral artery and vein; (5) shattering of the right knee: (6) multiple wounds of the thighs; (7) fracture of the right thigh and the left leg; (S) tearing away of the left arm; ffl) muscular destruction of the right thigh; (10) smashing of the leg: (11) of 46997—27---16 208 SURGERY both legs; (12) of the right thigh. Of these 12 cases. 9 died. There were (i amputations with only 2 successes. Santv's observations are sustained by Gatellier36, who treated 13 serious cases, without waiting, by limited excision of injured tissues or by amputation, and had no deaths. The excellent results of prompt operation, performed on the severely wounded before the development of secondary shock, have been noted before this time. The great French military surgeon, Larrey37, who followed Napoleon's campaigns, laid down the dictum that crushing wounds of the extremities should be operated upon at once, for that treatment gives the only hope. The figures given by Santy point to action of some agency, w-hich, as time passes, brings on the state of shock and seriously jeopardizes the chances of recovery. The bearing of these observations on the toxic origin of secondary shock is obvious. The crushed and lacerated tissues become not only a source of danger to the body from processes of death taking place in them but they- are most favor- able sites for infection. Therefore, for both reasons, early clearing away of destroyed tissue, or debridement, is a prophylaxis against shock and other damaging conditions. If secondary shock is existent when the patient, cold and depressed, is brought under surgical care, there is general agreement that simple measures, such as warmth, rest, and fluids, should be applied in an attempt to improve his state before operative interference is begun. If, how- ever, there is continued hemorrhage accompanying and augmenting the shock, or if there is rapidly spreading infection (e. g., with gas bacilli), operation may be necessary- before full recovery has occurred. And if the surgeon must begin his work thus, a protective transfusion of blood before the anesthetization, or while the wounds are being attended to, will keep the blood flow adequate during the most critical time. The principle involved in the operative treatment of fully developed secondary shock is the same as that employed for prophylaxis against its devel- opment. As soon as possible there must be suppression of the trauma. This procedure is often the initial step in an extraordinary improvement in the patient's state. At the Interallied Surgical Conference, in 1917, TuffieT declared that we have too long submitted to the doctrine that shock absolutely contramdicates operation. Experience proves that the exclusion of the focus of injury, by short and radical procedures, causes the symptoms of shock to disappear. And the conference concluded: ''If true shock, without hemor- rhage, is severe, if the patient is cold and pulseless, the shock itself must be treated first. It is the same if the operation to be done must be long and difficult. But extensive destruction of parts necessitating amputation indi- cates operative attack." Quenu's advice is that in any case, long and complicated operation should be avoided; meticulous surgery is out of place; the principal lesion must be treated quickly and radically, and often less important wounds can be given only simple cleaning. GENERAL SURGERY 209 Precautions to be Observed During Operations The relation of cold to shock has been repeatedly emphasized. During operation every effort previously employed to prevent heat loss should be continued; needless exposure of the body should be avoided. The skin and protective coverings should not be allowed to remain wet, for both by evapora- tion and by more rapid conduction the escape of heat from the body thereby is promoted. Cavities and wounds should be washed out with w-arm solutions only. The operating room and the operating table should be warm; even under the rudest circumstances simple arrangements can be made for these desirable conditions. In the foregoing pages emphasis has been placed upon the sensitiveness of the badly injured and the shocked to hemorrhage. A small loss of blood, wholly- without permanent effect under ordinary circumstances, may cause a calamitous fall of pressure. Special care should be exercised during operation on shock cases not to lose a drop more blood than actually- must be lost. Marshall4 called attention to the fact that after larapotomy on a man who is or has been in shock, a turn of the body- laterally causes a sharp drop in blood pressure. He urged that if the back as well as the abdomen has been wounded, it be dealt with before opening the abdomen. Binders or many- tailed bandages should be applied by lifting the body, not by turning it free from side to side. Abdominal and thoracic viscera should not be exposed or pulled upon more than is absolutely- required for the satisfactory- performance of the operation. And all tissues should be handled with extreme gentleness. TREATMENT OF PRIMARY SHOCK The occurrence of primary shock of clearly nervous origin was so rare in the World War that almost no reference has been made to its treatment. It should be dealt w-ith symptomatically—by rest and quiet, and, if the blood pressure remains below- the critical level, by measures to increase the blood volume. Primary shock due to mortal wounds or to excessive and sudden hemor- rhage usually offers so little chance for treatment that nothing further need be said concerning it than that the principles developed in the foregoing pages should be applied when there is any hope of their being serviceable. AFTER-CARE It should be remembered always that the patient who has been in shock and resuscitated, and then operated upon, is in a precarious state. His nervous svstem has been disturbed not only by the original trauma, but also by the low- nutrient flow of blood and by the surgical procedures incidental to operation. Rest is therefore essential, and should be secured, if possible, in sleep. Yv armth should likewise be provided, but not to a degree which will induce sweatmg. It should be remembered that the blood volume has probably been reduced much more than the amount represented by the usual intravenous injection, and that the blood flow will not be normal until the volume is restored to the normal 210 SURGERY level. Fluids should be continued, therefore, by mouth or rectum until the urine output equals the water intake. Furthermore, the patient should be attentively watched for unfavorable developments, and if they arise should be promptly treated. SHOCK TEAMS, THEIR TRAINING AND DUTIES A contribution to military organization made during the World War by the American Army was that of giving special training to medical officers w-ho were assigned to the care of serious cases of shock and hemorrhage.28 During the months from May- to November, 1918, medical officers were sent to Dijon weeklyr and there received instruction regarding the nature of shock, the theories of its onset, its clinical manifestations, the conditions favorable to its development, and the principles of treating it, as outlined in the foregoing pages. Also they were disciplined in methods of matching blood and in the procedure of blood transfusion. The methods of instruction consisted of demonstrations of blood pressure measurements, the development of shock in a lower animal, and lectures and practical exercises in which the men determined their own blood pressures and their own blood groupings, and practiced trans- fusions on anesthetized animals. From these classes medical officers were selected who went to hospitals in battle areas and took charge of the shock wards. Their service to the surgeons has been highly commended. A number of valuable pertinent points resulting from this experience may be summarized as follows: (1) So far as possible, medical officers of field and evacuation hospitals should receive such instruction as is mentioned above and be detailed to take charge of shock wards in times of activity. At Dijon men from base hospitals, A. E. F., were given instruction, because it was believed that they could be called forward into battle areas in time of need. This proved, however, to be almost impossible, because base hospitals were quite as busy as forward hos- pitals during military engagements. (2) For each shock ward there should be at least two resuscitation teams, each consisting of a medical officer, a nurse, and an orderly. (3) Hopeless, moribund cases should not be sent to the shock ward; provision should be made for a separate place for such cases. The presence of a number of dying men in a crowded shock ward takes the time of the teams and interferes with efficiency and morale. (4) In the transfer of the wounded away from the front line, provision should be made, in wards close to the shock cases, for caring for at least some of the minor cases, and for men who have been gassed. Withdrawing 500 to 750 c. c. of blood from a man w-ho has been only slightly wounded does him no harm, and that amount taken from a man who has been gassed may be serviceable to him; the blood thus obtained may save the life of a comrade who is suffering from shock or severe hemorrhage. (5) Officers in charge of hospitals should understand that men badly wounded require special care and that medical officers who have been particularly trained to give that care should have, so far as possible, free rein in making proper arrangements. The duties of resuscitation officers are as follows: (1) To provide heating arrangements in anticipation of shock cases. These arrangements should GENERAL SURGERY 211 consist of hot-water bottles or canteens, means of getting hot water, and for applying hot air under fracture frames as described above. (2) To assure an adequate supply of transfusion equipment from the medical stores. (3) To arrange continually for an adequate number of donors, whose blood grouping must be determined. (4) To determine the blood grouping of all donors and recipients. (») To be available for consultation with any of the hospital staff concerning transfusion. (6) To perform or direct personally all transfusions. T When possible, to obtain records of the clinical condition of the shocked men, in order to add information regarding the onset and the course of events in wound shock. (8) To perform such clinical work as the surgeon in charge may direct (this duty is mentioned with the proviso that no assignment will be made that removes the resuscitation officer from his important service in the shock ward). service. Obviously, the shock team should cooperate closely with the surgical ice. Resuscitation officers who have followed the progress of shock cases from the time of admission and w-ho best know the limits of improvement in each case should give the surgeon their judgment of the optimum time for surgical intervention. Even apparently hnpeless cases should be given the chance which surgery offers, though the percentage of recovery of such cases mav be small. REFERENCES (1) Vincent, C.: Contribution a l'ctude de l'etat de shock promitif chez les blesses de guerre. Comptes rendus des Seances de la Societc. de Biologie, Paris, 1918, lxxxi (meeting of October 19), 1886. (2) Wallace, C, and Fraser, John: Surgery at a Casualty Clearing Station. Hemorrhage and Wounds of the Blood Vessels. A. and C. Black, Ltd., London, 1918, 241. (3) Crile, Geo. \Y., and Lower, William E.: Anoci-association. W. B. Saunders Co., Philadelphia, 1914, 115. (4) Marshall, Geoffrey: Anesthetics at a Casualty Clearing Station. Proceedings of the Royal Society of Medicine, Section of Anesthetics, London, 1917, x, No. 7, 2.K. {») Henderson, Y., and Haggard, H. \Y.: The Circulation in Man in the Head-Down Position and a Method for Measuring the Venous Return to the Heart. Journal of Pharmacology and Experimental Therapeutics, Baltimore, 1918, xi, Xo. 3, 189. (6) Gesell, Robert: Studies on the Submaxillar}- Gland. IV. A Comparison of the Effects of Hemorrhage and Tissue-Abuse in Relation to Secondary Shock. The American Journal of Physiology, Baltimore, 1919, xlvii, No. 4, 46S. (7) Rous, P., and Wilson, Geo. W.: Fluid Substitutes for Transfusion after Hemorrhage. Journal of the American Medical Association, Chicago, 1918, lxx, Xo. 4, 219. (Si Robertson, O. H., and Bock, A. Y.: Memorandum on Blood Volume after Hemorrhage. Special Report Series Xo. 25. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, August S, 1918, His Majesty's Stationery Office, London, 1919, 23. (9) Wright, Sir A. E.: Conditions which Govern the Growth of the Bacillus of "Gas Gan- grene" in Artificial Culture Media. The Lancet, London, 1917, January 6, i, 1. (10) Cannon, W. B., Fraser, John, and Cowell, E. M.: The Preventive Treatment of Wound Shock. Special Report Series Xo. 25. Reports of the Special Investigation Com- mittee on Surgical Shock and Allied Conditions. British Medical Research Com- mittee, December, 1917, His Majesty's Stationery Office, London, 1919, 125. (11) Bayliss, W. M.: Intravenous Injection in Wound Shock. Longmans, Green and Co., London, 1918, 75. (12) Meek W. J., and Gasser, H. S.: The Effects of Injecting Acacia. The American Journal of Physiology, Baltimore, 1917-ls, xlv, 54S. 212 SURGERY (13) Drummond, H., and Taylor, E. S.: The Use of Intravenous Injections of Gum Acacia in Surgical Shock. Special Report Series Xo. 25. Reports of the Special Investi- gation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, January, 191S, His Majesty's Stationery Office, London, 1919, 135. (14) McXee, J. W., Sladden, A. F., and McCartney, J. E.: Observations on Wound Shock Especially with Regard to Damage of Muscle. Special Report Series Xo. 25. Reports of the Special Investigation Committee on Surgical Shock and Allied Con- ditions. British Medical Research Committee, His Majesty's Stationery Office, London, 1919, 33. (15) Mixter, C. G.: Gum Salt Solution (Eleventh Session of the Research Society of the American Red Cross in France, Xovember 22-23, 1918, Hotel Continental, Paris. War Medicine, Paris, 1919, ii, Xo. 7, 1276. (16) Lee, Roger I., Ibid., 1276. (17) Robertson, O. H., Ibid., 1277. (IS) Ohler, W. R.: Treatment of Surgical Shock in the Zone of the Advance. American Journal of the Medical Sciences, Philadelphia, 1920, clix, No. 6, S43. (19) Stokes, J. H., and Busman, G. J.: Tubing as a Cause of Reaction to Intravenous Injec- tion, Especially Arsphenamin. Journal of the American Medical Association, Chicago, 1920, lxxiv, Xo. 15, 1013. (20) DeKruif, P. H.: Experimental Research on the Effects of Intravenous Injection of Gum-Salt Solutions. Annals of Surgery, Philadelphia, 1919, lxix, No. 3, 297. (21) Keith, X. M.: Blood Volume Changes in Wound Shock and Primary Hemorrhage. Special Report Series No. 27. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, His Majesty's Stationery Office, London, 1919, 25. (22) Erlanger, J., and Gasser, H. S.: Hypertonic Gum Acacia and Glucose in the Treatment of Secondary Traumatic Shock. Annals of Surgery, Philadelphia, 1919, lxix, Xo. 4, 389. (.23) Lee, Roger I.: Field Observations on Blood Volume in Wound Hemorrhage and Shock, American Journal of the Medical Sciences, Philadelphia, 1919, clviii, No. 4, 570. (24) Pike, F. H., and Coombs, Helen C.: The Relation of Low Blood Pressure to a Fatal Termination in Traumatic Shock. Journal of the American Medical Association, Chicago, 1917, lxviii, Xo. 25,1892. (25) Zunz, E., and Govaerts, P.: Recherches experimentales sur les effets de la transfusion dans les divers etats de collapsus circulatoire. Bulletin de VAcademie royale de medecine de Belgigue. Bruxelles, 1919, 4th s., xxix, Xo. 5, 796. (26) Cannon, W. B.; Fraser, John and Hooper, A. XZ: Some Alterations in the Distribution and Character of the Blood. Special Report Series Xo. 25. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, December, 1917. His Majesty's Stationery Office, London, 1919, 72. (27) Bazett, M. C.: The Value of Haemoglobin and Blood Pressure Observations in Surgical Cases. Special Report Series No. 25. Ibid., April, 1918, 29. (28) Dale, H. H.: Conditions which are Conducive to the Production of Shock by Histamine. British Journal of Experimental Pathology, London, 1920-21, i, 103. (29) Cattell, McKeen: Studies in Experimental Traumatic Shock. Archives of Surgery, Chicago, 1923, vi, Xo. 1, 41. (30) Gwathmey, J. T., Yates, J. L., Middleton, W. S., and Drane, Robert: Laboratory of Surgical Research, Central Medical Department Laboratory, A. E. F. A. P. 0. Xo. 721, France. Boston Medical and Surgical Journal, Boston, 1919, clxxx, Xo. 15, 410. (31) Gwathmey, J. T.: Anesthesia Reviewed. Xew York Medical Journal, Xew York, 1916, civ, Xo. 19, S95. GENERAL SURGERY 213 (32) Conclusions on Traumatic Shock adopted by the Interallied Surgical Conference at its 6th Session, November IS 21, 191S. Archives de medicine et de pharmacie militaires, Paris, 191 x, lxx, 705. (33) Marshall, Geoffrey: Modification of Technique. Special Report Series No. 25, Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, December, 1917. His Majesty's Stationery Office, London, 1919, 155. (34) Quenu, E.: De la toxemie traumatique a syndrome depressif (shock traumatique) dans les blessures de guerre. Revue de Chirurgie, Paris, 1918, lvi, November, 339. (35) Santy, P., Moulinier, and Marquis: Du shock traumatique dans les blessures de guerre. I. De la distinction dans les etats de shock chez les grands blesses, du shock nerveux hemorragique ou infectieux. II. Du role joue par l'hemorragie dans l'apparition du shock traumatique. III. Analyses d'observations. Bulletins et memoires de la Societe de chirurgie de Paris, 1918, xliv, No. 5, 205. (36) Gatellier,: Quelques considerations sur les plaies vasculaires. La Presse medicate, Paris, 1918, xxvi, 322. (37) Larrey, J. D.: Memoires de chirurgie militaire et campagnes. Tome i, J. Smith, Paris, 1812-1817, 70. (3S) Tuffier, T.: Shock Traumatique. Conference Chirurgicale InteraUiee, 2nd Session (14-19 May, 1917). Archives de medecine et de pharmacie militaires, Paris, 1917, lxviii, 123. CHAPTER VIII LOCALIZATION AND EXTRACTION OF FOREIGN BODIES UNDER X-RAY CONTROL LOCALIZATION EARLY HISTORY AND LITERATURE In reviewing the methods of localizing foreign bodies, one is immediately impressed with the fact that the publications of the year 1896 set forth the prin- ciples at the foundation of most of the localizing methods of to-day. This year saw the publication of Buguet and Gascar,1 setting forth the classical formula: Depth equals ~y when a represents the distance the tube is shifted; b the distance of shift of the shadow of the projectile; and h the height of the screen or plate from the focus of the tube. Early in this same year Thompson,2 in America, and Imbert and Bertin,3 in France, proposed stereoscopy in connection with X-ray localization. The method of making two exposures at right angles, the so-called method of right-angled planes, was proposed by White, Goodspeed, and Leonard.4 The following year marked the publication of Mackenzie Davidson and Hedley,5 on the triangulation method, visualizing in space the position of the foreign body by- means of crossed threads,and the method of Gerard 6 and Levy- Dorn 7 which utilized the same principle of triangulation, but without the cross- thread visualization. Stechow wrote further on the method of making two exposures at right angles.8 Exner described a method combining a ring local- izer with the triangulation principle, and later used the parallax principle.9 The parallax principle was also used by Levy--Dorn.7 Remy and Contre- moulins 10 described an elaborate apparatus which was apparently the fore- runner of the Hirtz compass as used to-day. In 189S, in addition to other methods, Morize used four small adhesive disks of lead; n two he placed at the points on the skin where the vertical ray passing through the foreign body entered and left the part; the other two were placed in a similar manner at right angles (or nearly so) to the plane of the first two. The intersection of the two diameters joining these four points gives the location of the foreign body. Galeazzi12 was apparently the first to publish description of the "pierced screen"'' the ordinary fluoroscopic screen with a small hole drilled through it and the lead glass cover, sufficiently large for the insertion of a small rod for estimating the depth from the screen surface to the skin in. those locations where it was not possible to bring the screen in actual contact with the part under study. He also employed the triangulation method with single tube shift, and added a direct-reading scale, obviating the necessity- of calculations. 214 GENERAL SURGERY 215 Sechehaye,13 in January of this year, published a review- of the literature on the subject and was able to summarize 32 methods and authors. The writer, in 1918, published a brief history of the development of foreign body localization by means of the X rays, with a bibliography containing more than 200 references.14 The more than 200 methods referred to in this review- were really sus- ceptible of classification under a few of the methods described in the first two years of the roentgen era. Few of the methods later published were anything more than rediscoveries or minor modifications of essential principles already- discussed and used. The Hirtz compass, though first used in 1907, was not referred to in litera- ture until 1914.15 Telephone probes and other localizers working on the magnet principle were innovations appearing shortly before the opening of hostilities in 1914.16 The most complete work on the subject of foreign body localization was written by Ombredanne and Ledoux-Lebard.17 Delherm and Rousset,18 and Xogier 19 also wrote booklets on the subject. The United States Army X-ray Manual was finally adopted as the working manual of the United States Army Medical Department, and in it a large section was given over to localizations.20 An effort was made to select the more valuable methods and to standardize the necessary instruments and the tech- nique for their operation under the methods selected. It was exceedinglv diflicult for those who had not actually participated in forward area surgery under battle conditions to realize how simple, direct, and quick the localizing methods had to be. It was soon recognized that any method involving the use of plate or film records was unsuitable because of the time and labor necessary to make the localization, and it soon transpired that the medical officers actually- doing localization work in forward hospitals exhibited a marked tendency to employ very simple methods capable of being used without accessory- instru- ments other than the fluoroscopic apparatus itself. METHODS Though civil surgery- affords relatively infrequent opportunity for the surgeon or the radiologist to put to actual test the methods of localization which are to be found in every textbook on radiology, the World War afforded an extraordinary multiplicity of occasions for study-ing foreigh body cases, and en- forced a careful analysis and modification of the more than 200 procedures which were described in the medical press early in the war. Some of the procedures described are complex, some are simple; some re- quire complicated apparatus or special instruments, while others may be car- ried out with any of the ordinary types of X-ray equipment; some required the aid of radiographic plates, while others are screen methods quickly per- formed and affording an instant answer to the surgeon's query as to the pres- ence or situation of the offending foreign substance. Out of the war have arisen systematized localizing procedures, with standardized apparatus espe- cially adapted to the expeditious handling of large numbers of wounded men. Some of the standardized types of apparatus developed for military- work are already bein°- used in our civil hospitals, and the general trend of manufacture 216 SURGERY of X-ray equipment is toward the simpler instruments developed during the war. It is the purpose to set forth briefly herein only those methods most readily learned and carried out with a minimum of accessory instruments. Explana- tions of geometrical propositions, for lack of space, are reduced to a minimum. Any reader interested in the details of such mathematical propositions will find discussions in the various excellent treatises on localization which have been prepared byT the medical departments of the various allied armies, already- referred to. Magnets, vibrators, and telephone probes have been variously- recommended by military surgeons but thev are limited in their usefulness. Magnets, for instance, are applicable only to the localization and extraction of such metallic foreign bodies as are responsive to magnetic attraction, whereas the radiologic method should discover all metallic foreign bodies (with the possible exception of aluminum), besides many nonmetallic substances, The radiologic method as a part of the surgical procedure lends itself admirably- to helping the surgeon during the extraction of any foreign body, whereas the magnet and vibrator methods above referred to have the same limitations in respect to nonmagnetiz- able substances. The person undertaking a localization should not confine himself to an esti- mation of the depth of the foreign body, but should acquire all possible informa- tion afforded by an X-ray study of the case. For the best results it is essential that the radiologic work be done by a physician, or, better still, the surgeon should be familiar with the radiologic procedures involved in foreign body locali- zation ; indeed, there is such temptation for the surgeon himself to go ahead with the radiologic part of the extraction procedures that unless he has a thorough technical knowledge of the subject he is likely to harm himself through inad- vertent overexposure to the rays. These dangers will not be discussed here as they are fully described in numerous textbooks. Localizations are usually accomplished by fluoroscopic methods, although there is no objection to radiographic methods other than that they involve more time and expense and are not so informing as the screen methods. Stereoscopic radiograms are more valuable than single plates. A localization should afford the following information: (1) Anatomical data, showing the relation of the foreign body to neighboring structures, such as a trochanter, a condyle, or some other well-known bony point, to a muscle; or to an artificial opaque marker affixed to the skin. The condition of any injured bones should be carefully recorded. (2) Mathematical data as to the depth of the foreign body in relation to marks or markers on the skin. (3) Directions which will guide the surgeon to the foreign body. This guidance is frequently afforded by the fluoroscope through observations made during the removal of the foreign body. The following localizing methods are considered herein: (1) Rotation of the part; study of the movements of the shadows of the projectile or other foreign body in relation to neighboring opaque structures or skin markers. (2) The '•nearest point" method. (3) The parallax method, wliich is often combined with the nearest point method. (4) The orthodiagraph^ method, which is GENERAL SURGERY 217 also often combined with the nearest point method. (5) The method of right- angled planes (four-point survey). (6) The multiple diameters method. (7) The single-shift triangulation method, with which may be included the stereoscopic method. (8) The double-shift fixed-angle methods. (9) Har- pooning methods, combined with reconstruction of the part by the aid of a cross-section anatomical atlas. There are numerous other methods which might be described, but these mentioned above are all very simple, easily learned, quickly- performed, and accurate to within a half centimeter, without the aid of plates. There is no reason why one or more radiograms of the part should not be made if the surgeon so desires, especially if he has not been present at the X-ray localization. If such plates are made, they should be stereoscopic plates. Apparatus Required In addition to the usual current-generating apparatus ol any- type supplying a milliampere or more, a tube of sufficient hardness and a horizontal a or ver- tical fluoroscope installed in a room capable of being completely darkened, the following items ot equipment are necessary: A ruler; a localizing rod or wooden stick the size and length of an ordinary lead pencil, with a metal ring, approxi- mately 2 em. in diameter, screwed into one end, and an ordinary screw- with a Fig. 109.—Palpator made from a small wooden rod, with a screw and a screw eye well-rounded head in the other; grease pencils, such as are used for marking on glass or chinaware; suitable skin-marking ink; an aniline dye may be used, or the Finzi ink;6 a cross-section anatomy, that published for Professor Symington, being highly satisfactory.21 The foregoing accessory articles permit the performance of most of the localizing procedures listed and described in this article, but the following inexpensive and simple accessories are often very useful: Large calipers, such as obstetrical calipers: a foot-switch for controlling the current through the X-ray tube; better still, a combination switch, controlling both the overhead light and the tube current; strips of flexible metal, such as composition tin, 1.5 • It is assumed that the majority of the work will be done with the standard X-ray table by fluoroscopic methods and with the tube below the table. The tube box is movable in two directions, as in the usual trochoscope and is pro- vided with a double shutter giving a diamond-shaped opening with the diagonals parallel and perpendicular to the length of the table and also with an adjustable slit, under separate control, parallel to the length of the table. The tube box runs freelv and may be locked in any position against both lateral and longitudinal movement, and is also provided with Sf£££ ^ fixing the amounLf tube shift for a particular purpose or for measuring any shift from a fixed pos.t.on. The fluoroscopeScreen is carried by a ball-bearing carriage mounted on the table rails, and proviso is made for a nio^^STllTta^ rotation about a vertical axis and also for a vertical shift. Each of these movements maXpreven ed by a suitable, convenient lock. The fluoroscopic screens are perforated wuh a small hole through which a markTng devL ly be inserted to mark the skin in the vertical ray. When th.s ray us spoken of it is assumed 2? he^ab e w.U besubstantially in a hori_ontal position and that a ^j^^^^^ZZ^Z . .„ , A■ -„i-_ f- tho nknp in which the tube may move. The opening in the screen also serves a very ^^J^SSS^X^^^ «» -les and other pieces of apparatus which it is desired to use on the fluoroscopic screen. semipermanent mark on the moistened skin. For » The writer prefers an ord nary ndelible pencil wh.c ^ ^ ^ ^ ^ ^ war surgery the indelible pencil would hardly satisfy tne neeu, uui. . v 218 SURGERY or 2 cm. in width, and of appropriate lengths for surrounding an arm. a leg. or the torso, and hinged together in pairs; a cannula and trocar, and a supply of fine piano wire cut into lengths somewhat longer than the trocar. Centering the Tube Accuracy in localization work requires an exactly centered X-ray tube. Some of the French manufacturers suppby a special device for centering the tube. Among the numerous groups of rays given off in the active hemisphere of an X-ray tube is one to which the term "normal ray'7 has been applied. It will be recalled that in geometry a line normal to a second line is one perpendic- ular to it, making with it two right angles. In radiology, therefore, the term Fig. 110.—Showing the positions of shadow of plumb bob on fluorescent screen when X-ray tube is properly centered, and when off center normal ray is applied to that group of rays perpendicular to the long axis of the tube. Lnless the tube is carefully centered beneath the diaphragm in such a way that when the diaphragm is closed down to a small opening the normal ray will pass through it, there will be a resulting error in the localiza- tion calculations. One may determine when the tube is centered by the following means: When the military type of table is not available, the screen is locked in position above the tube box and a plumb bob attached to a metal marker, such as a lead ball, is affixed by adhesive plaster to the underside of the screen some- where near its center (fig. 110). The opening in the diaphragm is reduced to about 1 cm. and the tube box moved until the pencil of rays emitted through the small opening casts the shadow of the plumb bob and the metal marker on GENERAL SURGERY 219 the screen. If the two shadows do not coincide, the tube is not correctly centered, and alterations in its position should be made and compared until the two shadows coincide. An ordinary tin cup or a glass tumbler may be placed accurately over the small opening in the diaphragm, care being taken to see that the cup or tumbler is on a level support, and that the opening in the diaphragm comes as near as possible to the center of the cup. Then the diaphragm is opened so that the shadow of the whole cup shows. One may judge by the symmetry of this shadow w-hether or not the tube is properly centered (fig. 111). With the table supplied by the United States Government during the war, the diamond-shaped opening of the shutter is reduced to about 1 cm. The tube box is locked in position and the screen moved so that the perfora- tion in its center will coincide with the center of the projection of the small Fig. 111.—Screen appearance of a tumbler with the tube properly centered and not properly centered diagonal opening of the shutter. The carrier is locked against longitudinal motion and against rotation, and the screen raised by the vertical movement of the carrier. If the perforation does not retain its symmetrical position the tube needs shifting until this condition obtains. It is important that this process of centering the tube be carried out each time a localization is attempted, unless a number of localizations are planned for the same day. Marking the teKiN For marking the skin in relation to foreign bodies, especially where there is only occasional need for localization work, the ordinary indelible pencil, dipped in water or used on the moistened skin, is quite satisfactory. This mark is not obliterated bv painting the skin with tincture of iodine. If a black mark is desired, which dries quickly and w-hich will withstand scrubbing the Finzi formula is useful: Pyrogallic acid, 1 gm.; acetone, 10 c. c; liquid chloride of iron, 4 c. c; wood alcohol q. s. ad., 20 c. c. This ink when made up fresh about once in 10 days, makes a black mark and dries quickly. It is best applied with a sharp stick or a fine brush If allowed to dry thoroughly the mark will resist alcohol, show through an iodine stain, and persist from two to seven days. 220 SURGERY In emergency eases a persisting mark can be made with a stick of silver nitrate on the skin moistened with a few drops of photographic developer. A match or toothpick dipped in a 10 or 20 per cent solution of silver nitrate will serve the same purpose without the irritation of the skin which sometimes results from the use of the silver nitrate stick. An aqueous solution of brilliant green has also been suggested for marking the skm. The method of marking will vary with the case. If multiple foreign bodies are present, it is sufficient to mark such of them as can be located by the " nearest point" method with a dot surrounded by a circle, the dot indicating the nearest point. In cases of a single foreign body it is well to make as many marks as mav be helpful to the surgeon; for instance, one mark perpendicularly- over the foreign body recording its depth, with two horizontal marks on either side of the part in the plane in which the foreign body lies. It is also highly important that the localization be carried out and the marks placed upon the skin in the position which the patient is likely to occupy while undergoing operation. Hence, when it is feasible, the surgeon or his assistant should be consulted as to the probable method and site of surgical approach. It should be stated as an axiom that in all localization work the patient should be carefully placed in the operative position before one begins to make the localizing marks. TECHNIQUE One of the first steps in the localization of a foreign body, after determining its presence, is an estimation of its approximate position—whether it lies in front of or behind a certain bone or other anatomical landmark, whether it lies within the substances of a great muscle, etc. This is termed the anatomical localization, and it often suffices to enable the surgeon to perform the extraction. Extraction of the foreign body is often one of the lesser considerations in dealing with a gunshot or other emergency case. The proper toilet of the wound, the removal of clothing and other foreign materials which may be carried into the part by the projectile or foreign body, as well as attention to damaged bone, nerve, or other tissue, are of paramount importance, and in many instances the extraction of the offending foreign body comes in for secondary consideration. Along with the data for localization the radiologist should supply all information possible regarding injury to bone, dislocations, blood or pus accumulations, gas infections, and other conditions relating to the wound. Anatomical Localization From the surgical standpoint, it may- be stated that it is more important for the surgeon to be informed of the anatomical situation of a foreign body than of the mathematical distance it lies perpendicularly below a given point on the skin. For example, the surgeon is more interested in knowing that a foreign body has penetrated the pleura than that it lies 4.5 cm. below a certain point on the back when the patient is lying prone; and whether a projectile recorded as being 7 cm. beneath a point just below the vertebra prominens is intrapleural or lies within the substance of the body of the last cervical or the first dorsal vertebra. In order to give this information it is essential that the GENERAL SURGERY 221 radiologist should possess an accurate knowledge of anatomv. It is here that the cross-section anatomies may lend considerable aid, though sometimes anatomical conditions vary in individual cases on account of unusual accumula- tions of fat and because of varying build in different individuals. The anatomical location can often be determined by requiring the patient to carry out some active movements, or the radiologist can himself move the part and observe the changing relations of the foreign body during these maneu- vers. The movements of the shadow during the contraction of muscular masses are significant. For instance, a foreign body in the forearm which exhibits considerable displacement when the patient closes his fist manifestly lies in one of the flexor muscles; if it ascends on flexion of the thumb and remains stationary during movements of the other fingers, it obviously lies in the flexor muscle of the thumb. Foreign bodies in the region of the eve may be more exactly localized by- causing the patient to open and close the eyes, to rotate the eyeball, and to carry out other movements w-hich bring into play the individual eye muscles. A method of localization of foreign bodies in the eye will be considered later in this discussion. By having the patient protrude the tongue, open and shut the mouth, perform movements of deglutition, swallow a capsule containing bismuth, etc., one is able to determine the relative anatomical position of a foreign body in the face or neck. For differentiation between intra- and extra-thoracic foreign bodies, it is usually- sufficient to cause the patient to practice several deep inhalations and exhalations. During inspiration the lung is displaced from above downward, while the thoracic cage is displaced in a contrary sense. Lateral or oblique fluoroscopy of the chest is very important, especially- when the patient's dia- phragm is immovable. Unless rather definite and extensive movement ol a foreign body in the lower half of the chest can be determined during respiratory- movements (save when the diaphragm is motionless), it should not be consid- ered to be intrapulmonarv: in the upper part of the thorax intrapulmonarv foreign bodies may exhibit very little respiratory movement, and in the middle of the lung on either side they may be quite stationary. As intrapulmonary^ and hilus calcifications have caused many errors in the study of intrathoracic foreign bodies, it is w-ell to have stereoscopic plates made in all doubtful cases. The pulsation imparted to intrathoracic foreign bodies by the heart or great vessels, especially to those lying near the midline, may occasionally cause great difficulty in exact localization. Foreign bodies lying within the pericardium are usually movable and gravitate to the most dependent point possible when the patient changes his position; in old cases, intrapericardial foreign bodies may be attached to the wall of the pericardium and render the diagnosis more difficult. Projectiles lying near the diaphragm, but just above it, should be easily- localized, provided one views the patient from a sufficient number of angles. Intraabdominal, subdiaphragmatic foreign bodies are not so easily localized. Stein and Stewart 22 have recommended the introduction of oxygen or some other gas into the peritoneal cavity, so that by changing the posture oi the patient it is possible to separate the subdiaphragmatic structures from the 222 SURGERY diaphragm itself. Many cases of wounds with intraabdominal projectiles will have developed sufficient gas in the peritoneal cavity to make the introduction of oxygen unnecessary. Careful palpation of the abdomen, inflation of the colon or stomach in selected cases, the use of the Trendelenburg position, etc., will usually be sufficient without an induced pneumoperitoneum. Mallet and Tan- ton23 have called attention to the possibility in certain cases, especially in wounds of the urinary bladder, of localizing a foreign body inside a hollow organ if, by localizing alternately from the anterior and the posterior aspect of the torso, results are obtained which disagree as regards the total thickness of the subject and are notably less. This is due to the displacement of the projectile from one position to the other. In considering foreign bodies in relation to the vertebral column, attention should be drawn to the great value of stereoscopic plates and to lateral radios- Fig. 112.—Screen appearance of an intracranial foreign body copy and radiography of the spine, too little practiced by the average radiologist. Lateral radiography of the spine is generally considered impossible without extraordinary apparatus; on the contrary, the average type of portable appa- ratus will suffice to make excellent radiograms if intensifying screens are used. Even the sacrum can be radiographed laterally in this manner. Foreign bodies in the pelvis should be localized with ease provided one makes stereoscopic radiograms. In occasional cases it may be possible to gain more information concerning a foreign body located in or near the rectum if an assistant makes intrarectal manipulations at the moment of the X-ray examination. In wounds of the head it is sometimes possible for the casual X-ray obser- vation to be very misleading. This is demonstrated in Figures 112 and 113. In Figure 112 a typical intracranial projectile is shown in the frontal and lateral GENERAL SURGERY 223 projection. Figure 1VA represents the actual position of a projectile which is extracranial and lies within the soft tissues of the temporal region, but w-hich with the usual frontal and lateral X-ray projection appears to be intracranial. This error would hardly occur during a fluoroscopic localization, but it w-ould be entirely possible with a radiographic procedure, and the possibility should be duly noted. Fi-;. 113.—Screen appearance which might lead to an erroneous diagnosis of intracranial foreign body In a routine examination the patient is first placed on the horizontal fluoroscopo and a brief fluoroscopic survey made to determine the presence of a foreign body. Of course, one may deal with foreign particles too small to be seen with tlie fluoroscopic sciven, but except in the eye and a few other similar critical locations, a metallic foreign body too small to be seen with the fluoro- 4 where a represents the distance the tube is shifted; b the distance of the shift of the foreign body shadow-; and ii the height of the screen or plate from the point of focus of the tube. The patient is placed upon the couch in the position he will occupy during operation and the screen fixed horizontally- above the part and resting on it. The tube is moved about until the foreign body shadow lies in the normal ray, and a mark is placed on the skin at the points of entry and exit of the normal ray. The position of the projectile is further marked upon the lead glass of the fixed screen. On opening the diaphragm the tube is shifted any distance, say 10 cm, without disturbing the position of the patient or screen, and the new position of the shadow of the foreign body is marked upon the screen. By measuring the height h from the screen to the point of focus of the tube, the distance a the tube is shifted, and the distance b the shadow of the foreign body was moved, we are able to work out the formula above stated and to arrive at the depth of the foreign body below the screen. In order to determine the exact depth below the skin, it remains only to subtract the distance from the screen to the skin, if the skin and the screen are not in contact. This method GENERAL SURGERY 231 may be worked out accurately- without arithmetical computation by simply redrawing the procedure to scale. In civil practice, where only the occasional localization case is encountered, there is no necessity for maintaining a fixed distance between the screen and the focus point, for all these distances and shifts can be easUy measured. In war, it will be better to adopt a standard focus-screen distance h (55 or 60 cm.) and a standard tube shift a (10 cm.), and to construct tables by which the depth of the foreign body below the screen can be instantly read from the shadow shift, Many such tables and many graphic devices were published during the war. The device intended for use by medical officers of the United States Army during the late war is illustrated in Figures 125 and 126. For use of this apparatus it is SCREEN Fig. 124.—Classical single-shift triangulation method better to employ: (1) A fixed tube shift of 10 or 15 cm. may be used or an image shift of an exact number of centimeters. (2) A fixed target-screen distance may be used. This is not, bow-ever, always convenient. (3) The exact setup of Figure 124 may be reproduced by use of a device shown in Figure 125, which may be supplied in case of a desire to use this method. This device consists of two straight bars, A and B, at right angles to each other. B carries an adjustable slider, R. A carries two sliders, E and G. E is not moved after one adjustment unless a new table is used. The slider, G, has notches, 0, 1, 2, etc., 1 cm. apart, and a slider, P1; with a latch engaging these notches. ' A scale, S, with its zero point at the upper end is carried by G. A lug at H is in line with the zero of G. If, now, DH-tube shift, GH-target- screen distance, PiO-image shift, then a straight line, PXD will cross the scale, S, at the depth of the foreign body below the screen. The instrument should 232 SUHOKKV be fastened to the wall in a convenient place and the measurements needed should be made by a caliper, thus avoiding any reading of scales except the final depth. If in the particular case illustrated, the image shift is 4 cm. and the zero point of scale. S, is set above II an amount equal to the target-screen distance, and D1I is the tube shift for an image shift of 4 cm., a string drawn as indi- cated will cross the scale at a point P. The scale reading at this point is the depth sought. When using the standard table the slider, E, is adjusted so that ii length measured on the screen- carrier support will show how- much above E we must place G in order that GH may represent the target-screen distance. It will be observed that this instrument serves to reproduce tube and image positions as actu- ally observed by the roentgenolo- gist; i. e., one vertical ray in which the skin is marked, and one ob- lique ray whose intersection with the former corresponds to the dis- tance of the projectile from the screen. An accessory device is also supplied, consisting of a strip of celluloid with a pin centering in the perforation of the screen, and having centimeter divisions clearly marked both ways from the cen- ter, making it quite easy to secure an exact number of centimeters displacement. There is a considerable ad- vantage in making the distance the image is shifted a definite number of centimeters, and meas- uring the tube shift, since the relative error in measuring the small length of image shift is greater than that in measuring the long tube shift. When supplied with the accessories indicated above, this method becomes as expeditious as others, and is as accurate as any of the depth methods. In the single-tube shift method there are various procedures which may- be used. They all require essentially- the same data, namely, (1) tube shift, WEIGHT Fig. 125.—Wall meter, or indicator, for tube shift method, also showing method of using adjustable double-slider caliner GENERAL SUROF.RY 233 (2) image shift, (3) target-screen distance. If these distances are measured to scale in centimeters, it is possible to compute the end result. The apparatus supplied for this method includes a scale w-hereby a definite image shift may be made, if that is desired by the operator. There is also a provision for a definite tube shift of either 10 or 15 cm. on the standard table and for the measurement of any tube shift, if the operator desires to make the shift of the image a definite amount—the procedure generally- advised. Fig. I2(i.—Apparatus shown in Figure 12.1 The complete equipment, including the reproducing device or wall meter and accessories, is shown in Figure 126. The stereoscopic method is really a single-shift triangulation method. During the war the United States Army Medical Department perfected an apparatus devised by the late E. W. Caldwell, of New York, permitting stereo- scopic fluoroscopy. This method, of course, requires special apparatus and the instrument is not yet generally upon the market. The stereoradiography method is the procedure of cdioice when plates are made. In civil practice it is well to make stereoscopic plates in addition to the ordinary screen localizations. 234 SURCERY DOUBLE-SHIFT FIXED-AXGI.K METHOD A number of single and double shift fixed-angle methods have been described, all, however, based upon the same principle. The method of Strohl,24 professor of physics at the Sorbonne, is as follows: At a convenient distance above the tube T (fig. 127), usually on the dia- phragm of the tube holder, it is easy to fasten a piece of cardboard or aluminum to which are affixed two bits of straight wire, W- and W3, placed parallel on either side of the midline W1, so that the distance between the wires will bear a SCREEN w2/ v—f—0 \ I / \ ' > \i/ w3 Iw1 w2 \ !•/ \i/ T Fig. 127—Method of similar triangles (double-shift, fixed-angle method) \W3 ^> fixed relation to the distance O from the cardboard or aluminum sheet to the focus of the tube. In other words, in the triangle TWAY3, the distance WAV3 bears a definite relation to the distance W'T. For convenience, let us say that the two distances are equal and that WAV3 equals W'T. If desired, a third wire may be added at W1, coinciding with the normal ray. WAY1, therefore, equals WAV1. It is a geometrical fact that the distance between the shadows cast upon the screen by the wires W- and W3 will, under these circumstances. always be equal to the distance from the screen to the focus point of the tube, GENERAL SURGERY 235 so long as the screen is held horizontal to the tube. With a small diaphragm opening the tube is brought directly beneath the foreign body P (fig. 127) and the position of the foreign body shadow marked upon the screen at P1 and upon the skin directly underneath. The screen appearance at this moment is shown at a (fig. 128). Two leaves of the diaphragm are then opened widely making a slit and giving the appearance illustrated in Figure 12S, b; the tube is then shifted to the left, during which movement the shadow of the right wire W2 will also travel toward the left while the shadow of the projectile will travel toward the right, until a tube position will be reached where the two shadows coincide (fig. 12,s, c). This point is marked upon the screen with a grease pencil. The Fig. 128.—Screen appearance at different steps in the double-shift, fixed-angle method tube is then shifted in the opposite direction until the shadow of the left wire, W3, and of the projectile coincide (fig. 12S, d). This point is also marked upon the screen with a grease pencil. According to the law of similar triangles, the distance betw-een the two marks upon the screen equals the distance from the screen to the foreign body; and to estimate the depth of the foreign body it only remains to subtract the distance from the screen to the skin, if the screen itself does not rest directly upon the skin. The distance between the wires W2 and W< may bear any given relation to the distance from the focus point to the plane in which the wires are fixed. It is only necessary to know- this relation in order to estimate the depth of the foreign body by this very rapid and accurate method. It is not necessary to 236 SURGERY know the focus distance of the screen or the distance of the tube shift. The wires may be placed upon any of the ordinary type's of fluoroscopic apparatus without interfering with the routine work; one must only know the ratio of the distance between the wires to their distance from the focus above referred to. In place of the wires, which are sometimes somewhat hard to see through the denser portions of the body, one may file upon the two leaves of the dia- phragm three notches (fig. 129), one directly above the focus of the centered tube, and one on either side of this central point at any given distance. The ratio may be varied, just as in the Strohl method. With the diaphragm closed, one has upon the screen, therefore, three diamond-shaped, illuminated notches (fig. 129); the two outermost notches correspond to the shadow- of the two wires shown in Figure 12S, b. The tube is shifted in the same manner, first to the left and then to the right until the foreign body shadow- is brought to the center of each of the diamonds; these spots are marked upon the screen with a grease pencil, and the distance betw-een them measured and translated into the depth of the foreign body. During the war the so-called " 26-degree method"—the distance from the middle notch to either of the outer notches being half the focus-diaphragm distance -was popular among French radiologists and w-as w-idely adopted by Fig. 129.—Screen appearance after notching the diaphragm leaves for the Roussel method our own medical officers. With this method, only one shift was made from the central notch to one of the outer notches, and the distance of the shadow shift multiplied by two to determine the depth of the foreign body below the screen. IIVRPOOX METHOD The harpooning method, the insertion of a sterile needle through the tissues to the foreign body, which serve as a guide to the surgeon in removing the projectile, requires no special apparatus not found in any hospital with a fluoroscopic X-ray- equipment. The instruments, the field of operation, and the surgeon's hands must be surgically- clean, and a sterile sheet or towel must be held between the operative field and the fluoroscopic screen. By rotation and manipulation of the part the approximate anatomical position of the foreign body is determined as nearly as possible. The needle when introduced will mark out the line of the surgeon's approach; if the track of the needle is likely to pass near vital struc- tures it is of importance that this line be determined in consultation with the surgeon. The path of attack having been determined and the surgeon having marked on the skin approximately- where he wishes to make his incision, the part is rotated under the screen so that the skin mark will lie vertically over GENERAL SURGERY 237 the foreign body. A needle of proper length having been selected, it is seized with forceps and held at such an angle that the fingers of the operator wall not he exposed to the rays. Under the fluoroscopic screen, the needle is pushed down upon the foreign body and left in situ. This method has been modified and improved under the name of the trocar and cannula method" by various surgeons of the allied armies. It should always be used under the direct supervision of a competent surgeon or of one who has the necessary anatomical knowledge and surgical judgment to use it without danger of infecting the patient or of injuring important struc- tures. In cases with encapsulated foreign bodies the trocar and cannula method is often of great value, but it is not useful as a routine procedure in recent wounds, where the surgeon usually approaches the projectile or foreign body through the path by which it entered. lTnder anesthesia, the skin should be punctured with a sharp scalpel, after which the cannula, with the obturator in place, is slowly passed into the tissues until it comes into contact with the projectile as determined by touch or bv fluoroscopic observation at varying angles. After contact is secured, the obturator is removed and a piece of piano wire, bent at the lower end in the form of a fishhook, is passed well through the cannula. The latter is then withdrawal, leaving the piano wire hooked into the flesh. If necessary, the external end of the wire may be clipped wnth forceps or cut off short, and bent down (dose to the skin. The length of wire introduced beneath the skin indi- cates to the surgeon the depth of the foreign body. It is very important that the introduction of the needle or trocar should be carried out with the instru- ment in the line of the normal ray; any attempt to insert it at any angle will result in considerable mutilation of the tissues. The harpooning method is not only a method of localization, but it is also a method of guidance for the surgeon during the operation of extraction. HIRTZ COMPASS METHOD The use of the Hirtz compass is foremost among the methods which serve to localize, and to guide the surgeon. This is an apparatus of which several types, all similar in principle, were employ-ed during the war. For clinics where there are frequent extractions of foreign bodies from the cranium and from the deeper structures of the shoulders, axilla., lumbar region, pelvis, and buttocks, this instrument can be highly recommended. As originally- proposed, this instrument was intended to be used in con- nection with radiographic work, whereby a permanent record should be made for the later setting of the compass, provided the identifying skin marks were not obliterated. On account of the very considerable time necessary- to pre- pare a negative for examination and measurement, it has been found desirable in many cases to operate the compass by data secured from fluoroscopic ex- amination, which is much more expeditious and, in many cases, will serve fully as well. The essential feature of the Hirtz compass is the possibility of adjustment of the movable legs that support the instrument, so that when resting on fixed marks on the body of the patient the foreign body will be at the center of a 238 SUHOKKY Fig. 130.—Hirtz compass guidance during a surgical operation sphere, a meridian arc of wThich is carried by the compass. This arc is capable of adjustment in any position about a central axis. An indicating rod passes through a slider attached to the movable arc in such a way as to coincide in all positions with a radius of the sphere, and whether it actually reaches the center or not it is always di- rected toward that point. If its movement to the center of the sphere is obstructed by the body- of the patient, the amount it lacks of reach- ing: the center will be the depth of the projectile in the direction indicated by the pointer. The value of the compass lies in its wide possibility as a surgical guide, in that it does not confine the attention of the surgeon to a single point marked on the skin, with a possible uncertainty as to the direction in which he should proceed in order to reach the projectile, but gives him a wide latitude of approach and explicit information as to depth in a direction of his own selection. The compass is shown in Fig- ure 131 and schematically- in Figure 132. Three metal arms respec- tively labeled 1, 2, and 3 in clock- wise rotation are so mounted as to turn freely upon a central pivot and have their upper surfaces all in a single plane. Each of these arms carries a slider, which may be adjusted to any- position along the length of the arm. Each slider has an adjustable leg at right angles to the plane of the arms, that may be held in any position by a small thumbscrew. These legs are grad- uated and the zero point is not at either end of the legs, but a few centimeters below the upper por- tion, which terminates in a small knob. The center post about which the arms rotate has a hole at right angles to the plane of the arms and is also shaped to carry the curved metal arc, A. (fig. 132.) The hole in the slider on arc A, carrying the indicating rod, can be made to coincide with the opening through the center post. Fig. 131.—Hirtz compass GENERAL SURGERY 239 W hen the legs are set at zero, quite irrespective of the position of the slider on the arms or of their angular position, and the compass stands on a plane surface, the indicating rod, passed through the slider on arc, A, will touch the supportmg plane at the center of the sphere of which A is a meridian arc. A friction clip on the indicating rod may be adjusted in contact wath the slider on A, and the distance from the lower end of this clip to the pointed end of the indicator will be the radius of the sphere of which A is an arc. Figure 133 shows the compass with the legs shifted so that thev no longer stand on the base plane, and, in fact, are at quite different heights; but the arc, A, and the arms of the compass have not been displaced, so that the pointer still reaches the center point, P, in this plane. Figure 134 shows the compass actually set upon the body of a patient, its legs resting on three skin marks, M, N, and O, and with tlie indicating rod pointing toward the projectile, but failing to reach it because of contact with the skin of the patient at S. The depth of the projectile in this particular direction Fig. 132.—Schematic drawing of Hirtz com- pass with legs adjusted at zero points and resting on a plane Fig. 133.—Arms and indicator of Hirtz com- pass. Same position as in Figure 132, but with legs elevated on blocks whose tops might correspond to skin markers is indicated in Figure 134 by- d. If, now-, the indicating rod is placed in the slider carried by the arc, A, the rod touches the skin at a different point, S', and the distance between the friction clamp on the rod and the upper surface of the slider on the arc, A, will be the depth of the foreign body- along the direction indicated by- the dotted line. It is evident from the construction that the surgeon may place the arc, A, in any position throughout 360°, and the slider at any position from the center to the extreme end of the arc, and still have the indicating rod point to the foreign body and show its depth from the point of contact with the skin. Figure 130 shows the compass in position on the patient at operation. The exact amount which each leg of the compass must be shifted from its zero point in order to stand on the marker to which it belongs and yet have the indicating rod in the proper position is easiest seen in Figure 135, in which only a single leg of the compass is showm; but the same will apply- to each of the legs in turn. Imagine a plane, parallel to the plane of the three arms of the compass, to be drawn through the projectile. The leg attached at arm number one 40997—27- -1S 240 SURGERY standing on the marker, M, would, if it could pass dowm to this plane, intersect the plane at the point, E, and under these circumstances, the indicator passing through the central post of the instrument would touch the skin at S, vertically above P. If the distance from the plane, from which measurements are made, to the lower plane, containing the projectile, is measured and, likewise, the distance MM', it is seen that the amount by which this particular leg is raised from its zero point, wdiere it would be set if it reached the point, E, will be tIn- difference between the depth of the foreign body and the depth of the marker from any plane of measurement, for example, that of the fluoroscopic screen or a photographic plate. The fluoroscopic screen may be placed in any position parallel to the base plane, EP, and the difference, ME, would be quite inde- pendent of the height of the plane from which all measurements are made. This may be summarized by saying that each rod is to be shifted from its zero point an amount equal to the difference between the depth of the pro- jectile below the fluoroscopic screen, or other plane of reference, and the depth Fig. 134.—Schematic drawing of Hirtz compass set up on skin of patient Fig. 135.—Reason for shift of leg of compass from zero point by the amount stated of the skin mark upon which this particular leg would stand, measured from the same plane. It is absolutely essential in the use of the compass to adopt a systematic procedure, so that the arm to carry the leg is identified with the depth of measurement of its own skin point. The data necessary to properly adjust the compass may now be stated by reference to Figures 132 and 135. The indicating rod in the central position and the three legs of the compass mark out, in any plane parallel to the base plane of Figure 132, four points of definite position in the plane. Any vertical shift of the legs will still allow them to retain their position in lines passing through the points, E, F, G, and P. The point G, Figure 132, is then in a vertical line passing through the marker, M, and the data necessary to set the compass must give the position in a plane of these four points, and in addition to this must give the depth from a fixed plane, parallel to the base plane EFG of the three markers on the skin of the patient and of the projectile within the patients body. Whether this data is to be found by a photographic or a fluoroscopic process is immaterial, as the steps in its use will be identical GENERAL SURGERY 241 When a fluoroscopic method is to be used, an auxiliary device may be found of considerable aid in rapidly and accurately securing the requisite data. Such a device is shown at A, Figure 136, and consists of three arms, each with a slider very similar to the original compass. In fact the latter may be used with rather less convenience by removing arc, A, and allowing the indicating rod to project a short distance below the center, with the legs temporarily removed. The auxiliary compass has its arms numbered in the same way as the original Hirtz compass and has a projecting pin which fits the perforation in the screen. One of the arms is rigidly attached to a ring concentric with the axis of rotation about the pin, while the other two are movable, but may" be clamped by thumb nuts to the ring. It is evident that placing the perforation in the screen in the vertical ray passing through the projectile definitely fixes the position of the center post. If, then, each marker in turn is brought into Fig. 136.—Accessory apparatus for fluoroscopic work with Hirtz compass. A, Auxiliary compass, pedestal support, and three markers with friction clips; B, Hirtz compass mounted with the three legs at different levels, so that a pointer reaches white spot on the base plane at the center of the sphere of which the curved arc is a part the vertical ray and the arm and slider adjusted so that the hole in the slider matches such a projection of each marker, the three openings in the sliders and the central pin fix the four points which it is necessary to obtain. It then remains to determine the depth of the projectile, for which one of the methods, A, B, or C, should be employed and also to determine the distance from the screen to the opaque markers. When using the fluoroscopic method, the latter depth can be very readilv determined by simply passing a suitable measuring rod through the perforated screen, which has been brought into the vertical ray passin- through the marker. This depth is to be recorded and accurately identified with the arm carrying the slider corresponding to that particular skin marker In order to facilitate this measurement a set of three measuring rods with friction clips, differing slightly in shape, are provided. As soon as these four depths and the four marks in the plane of the screen have been 242 SURGERY determined, the wrork of the roentgenologist is completed, provided he has made sure that the skin marks are plainly visible. The adjustment of the com- pass may then be carried out by an assistant to either the roentgenologist or the surgeon^ after, w-hich the instrument can be sterilized and is ready for the surgeon's use. FLUOROSCOPIC METHOD, WITH AUXILIARY COMPASS Find the shadow of the projectile, P0, on the screen, and reduce the size of the diaphragm, keeping the shadow in the center of the illuminated area. Adjust the screen so that the opening at the center of the screen coincides with the center of the shad- ow, lock screen carriage in this position for all except vertical travel. Mark the skin through the opening by use of the special marker pro- vided. Determine the depth of the projectile by either method A. or C. Raise the screen and attach three me- tallic markers (preferably three small washers) to the skin at suitable points, and mark the skin at each noint selected. Choose skin points with care to ensure: No in- terference with probable inci- sion; proper stability of the compass; as firm foot points as possible. Lower the screen near to or touching the skin, with the central hole still in the vertical ray through the projectile, and insert the pin of the auxiliary compass in the hole. Be sure that the screen is locked in position. Bring arm marked 1 to point toward the oper- ator's right and loosen thumb nuts on arms 2 and 3. Shift the tube to bring the right-hand marker in the vertical ray (leaving screen locked), and adjust the slider on arm No. 1 so that its opening coincides with the projection of the marker, Figure 137. If washers are used the round opening is easily identified. Do the same with each of the other two markers, insuring that No. 1 does not move when adjusting the others (a small clamp will aid in this) and lock each arm. The central pin and the three sliders then give the positions for the arms and sliders of the compass. Remove the auxiliary compass and determine the depth of M, N, and O below the upper surface of Fig. 137.—Method of showing fluoroscopic adapter with Hirtz compass GENERAL SURGERY 243 the glass on the screen. For the depths of M, N, and O use the small rods provided with friction sliders and make the measurement by passing the rod through the perforation in the screen, which, for this purpose, is to be brought vertically over each marker in turn. If the lriction clips are then pushed dowm until they touch the glass and are properly adjusted as to friction, the distance from the clips to the end of the rod will indicate the depth desired. These sliding clips are shaped to correspond to the projecting blocks on the sliders of the auxiliary compass, and care must be taken to use them in their proper places, so that there is a complete identification of the compass slider and the depth of the marker corresponding. Form the habit of using these in a definite order, during these depth measurements, to minimize chances of error. If no further fluoroscopic work is to be done these depths may be determined in daylight. Otherwise use the vertical ray from the tube. Setting the Hirtz Compass By use of the auxiliary compass.—(1) Remove the arc and the indicator rod; lower the three legs until the upper (rounded) ends project 1 to 2 cm. (2) Lay the auxiliary compass on a flat surface w-ith the center pin upward. Invert the Hirtz compass and place the central hole on the pin of the auxiliary-. Unlock wing nut at center of compass, thus releasing the arms; bring arm Xo. 1 and its slider to such a position that on loosening leg No. 1, it will drop into hole of the No. 1 slider of the auxiliary. Tighten set screws of slider and of leg No. 1 (fig. 138). Proceed in the same manner with arms, sliders, and legs Nos. 2 and 3. Tighten wing nut at center of Hirtz compass, thus locking compass arms. (3) If pedestal support is provid- ed, set the lock sleeve on the vertical rod so that w-hen the pedestal stands on a flat surface, and the Hirtz compass is placed thereon, with the pedestal rod through the central hole of the compass, it will be supported in such a position that the legs will drop to their zero points when loosened, leaving the compass supported on the pedestal. (4) Shift each le* an amount equal to the difference between the depth of the projectile and the depth of the skin marker on which each individual leg is to stand (Lee \0 1 stands on skin marker No. 1, etc.) Tighten each leg, Fig. 13S— Setting arms and legs of Hirtz compass directly from the auxiliary compass 244 SURGERY replace compass arc and indicating rod, the latter with lock sleeve properly set. and the compass is ready for sterilization and use by the surgeon." It is recommended that even if the compass is to be immediately set direct from the auxiliary a record of the data necessary for setting be made and retained until after the operation. From the diagram of data.—{I) The auxiliary, having been set to mark shadows on the screen, is placed on a plain sheet of paper with center pin down. Indicate with a pen the spot on the paper where the pin touches and mark it P0 (being directly over the projectile)—a small drawing board with a hole in the center, in which the pin mav be inserted through the record paper, may be helpful. Indicate the locations of the holes in sliders 1, 2, and 3, thus giving their relations to P0; identify each by number and write opposite each the depth in centimeters to the skin below the fluoroscopic screen. The depth of P„ below screen must be similarly indicated. (2) Take the Hirtz compass with indicating rod inserted in central hole, and set point of indicating rod on P„ of diagram. Loosen wing nut at compass center, thus releasing arms; bring leg No. 1 to stand on A D q mark No. 1 of diagram. r^^^^^ ....../ Proceed identically with legs Nos. 2 and 3; then, mmssss\smss^te^^^mss^m^smsssssmMC^~ f JL ^j. incbcating rod and £^ ^9 the three legs accurately Fig. 139—Detail of holder for direct setting of Hirtz compass On the proper points Ol diagram, tighten wing nut to lock compass. Tighten all set screws. (3) Place the compass on ped- estal support and proceed as indicated in paragraph 4 above. The instrument is now ready for sterilization and use by the surgeon. Care must be taken to avoid handling the compass in any manner that would displace any of the settings. In case of deferred operation, the four skin marks should be tattooed, or they must be renewed with sufficient frequency to insure their identification at time of operation. If metal washers are used, they may be sterilized and attached at the time of the operation; they serve very well to hold the compass legs on their proper skin points. Direct setting of the Hirtz compass.—Several devices for holding the Hirtz compass in order to make a direct adjustment of the foot points and leg heights on the patient have been proposed. This method possesses two distinct advantages: It may be done quite expeditiously; it indicates clearly to the operator how the compass is going to stand on the patient when in use. Its disadvantages are: The necessity of considerable illumination in the fluoro- scopic room when placing the compass; danger of movement of the patient between localization and final adjustment; need for the compass both in the fluoroscopic rooms and in the operating room. In order to adapt this method to the standard table, the design shown in Figure 139 has been developed. This consists of a tube fitting into the socket of the screen carrier, holding a square sliding rod with an end socket taking the hub of the compass. » This subtraction can conveniently be made by laying off on paper the distance from the top of the lead glass on the screen to P, then, placing auxiliary rod No. 1 with its sleeve indicating the skin depth for marker No. 1, mark this distance on the line previously made, and reset the sleeve to the length remaining on the projectile depth line. GENERAL SURGERY 245 The collar, A, on the tube has a V-shaped projection intended to fit a notch in the carrier socket so as to prevent rotation from a definitely determined position. The fundamental principles in this method are the alignment of the central axis of the compass with the vertical ray through the projectile, and the bringing of the compass to the proper height so that the top of the slider on the arc, when in its central position, is at a distance from the projectile equal to the radius of the arc. In order to secure the former, the holder should enable us to readily make the plane of the arms level. Then the compass should be allowed to move up or down in a vertical direc- tion without rotation. When the indicator is placed in the central position and the com- pass is properly placed on the patient, the radius mark on the pointer wfll be as far above the arc slider, through which the pointer is inserted, as the measured depth of the projectile along the vertical ray. While rigidly held in this position the arms and legs may be adjusted at will to support the compass in this position. (Fig. 140.) Care must be taken to insure that the patient does not move between the locali- zation and the completion of the adjustment; that the pointer is raised from its zero the correct distance; that all parts of the compass are locked before removal from the body. The holder must be adjusted before it is used the first time as follows: Remove screen-holding rod from the horizontal socket and insert holder. Remove arc from the compass, insert hub in the holder, and place two of the arms close together so that the line of the holder bisects the angle between them. Then lock the center arm clamp. Place a small level on the two arms perpendicular to the holder rod, and rotate rod until this shows level, then clamp by socket set-screws. Make a scratch mark where the V on the ring comes in contact with the socket. Remove the holder and file a small notch with a triangular file to take the V on the collar. Test out as to level, when the holder is replaced in the socket with the V engaging the notch. If not quite correct, loosen the set-screws at the end wdiere the square rod enters, rotate to level, and fasten firmly. Fig. 140.—Direct setting of Hirtz compass. position Compass and holder in 24(i SURGERY The above steps need to be done only once and the following procedure for use is then quite simple: Remove arc from the compass and insert in the holder, fastening with the thumb nut, B. Set the sliding clamp on the indi- cator rod at the ring mark; i. e., so that the distance from the lower end of the slider to the pointed end of the indicator is the radius of the arc. Insert indicator in the compass holder and raise until the distance from the top of the brass holder to the lower end of the sliding clamp is the projectile depth below the skin mark. Fasten by nut C. Raise the legs of the compass and adjust the holder until the lower end of the pointer rests on the skin mark. Lock carrier in position. Place arms and feet as desired so that the latter rest on as firm skin points as possible, and clamp all parts of the compass. Raise compass slightly by the vertical move- ment of the carrier, mark skin points for the feet, and identify them clearly. This method is much more con- venient than to mark the skin first and then adjust the compass to fit the marks. Remove compass, read and record height settings of legs, then record position of foot points, and center for resting the compass later if it should be necessary. For use in the operating room the compass may be sterilized by a flame. Use of the Hirtz Compass with Plates When it is desired to Fig. 141.-Centeringoftube above plate holder on cassette with small „_ + Q-uiicL fu0 Aaia nonoocarv cross wires, photographic method, Hirtz compass estaDiisn me aata necessary for the use of the compass with photographic plates or films, it is necessary that two exposures be made from two different target positions, either upon a single plate, or upon two separate plates or films, without movement of the patient or skin markers. The latter method is usually preferred. There is furnished for this work a small, flat square of celluloid into which are inserted two small steel wires forming a right-angled cross. The celluloid has two holes punched in diagonally opposite corners, through which a tape may be passed, and this is to be tied around the tunnel plate changer so as to fix the desired centering mark, when two plates or two films are to be used. GENERAL SURGERY 247 Figure 141 shows how- the tube is centered, using a plumb line to secure exact position. This must be done before the patient is placed in position, and care must be taken not to disturb the adjustment. Figure 142 shows the tube, patient, and markers in position for one of these ex- posures. One should not for- get to attach to the plate tunnel the marking device or to use the three metallic markers in contact with the patient's skin at points prop- erly chosen and marked for identification. The principle of the method is shown in Figure 143. A small marker, X, is placed approximately at the center of the plate, if one plate is to be used, or on top of the plate changing tunnel, if two plates are to be ex- posed. Let CX be a perpen- dicular erected to the plane of the plate at the point X and extending upward a distance of 60 cm. Let FtF2 be positions of the focus in a line Fig. 142.—Skin markers, plate holder, and tube holder in position for photographic method, Hirtz compass <^T- F, 3 CM." 3CM. M &-------------------■« PLATE, parallel to the plane of the plate at the level C. and assume that CFt and CF2 are each three centimeters in length. Suppose that M is one of the markers on the patient's body. When an ex- posure is made with the target at F^ the shadow of M will fall on the plate at M- and, when an exposure is made from the position F2, the corresponding shadow will be M,. Had the exposure been continuous during the motion of the target from Ft to F2, there would have been found on the plate a straight line of shadows connecting M. and M2. If we drop perpendiculars from the two focal positions to the plane of the plate, intersecting it at the points F'-F2, we see that F'.FJVI- is a plane perpendicu- lar to the plate and passes through Mv and the trace of this plane upon the plate is FjMj. Fig. 143—Schematic representation of plate, cross-wire marker, and tube focus positions for radiographic use of Hirtz compass 248 SURGERY In the same way a plane passed through F2F'2M2 will be perpendicular to the plate and its trace will be F'2M2. It follows from geometry that the inter- secting line of these two planes, _VlM0, will be a line passing through the point M and perpendicular to the plate. Consequently M0 is the foot point of this marker on the plate to be used in the compass adjustment. Also the lines M-M2, F'-F'- and F.F2 are parallel. Figure 144 shows part of a developed negative upon wliich there appears a shadow at M1; a shadow at M, and a single image of the marker on the plate - a single image, since its motion is zero or nearly so, the marker being most in contact with the plate itself. If one joins Mx and M2 by a straight line and then draws through the center of the cross a line parallel to M^2 and measures a three centimeter length on/this line through X in each direction from the center of the cross, the points so determined will be Fx and F2 of Figure 143. Cross connection between the ends of these lines, that is F'2M2 and F^M- then definitely locates the point M which will be the foot point sought. , 3 CM. m 3CM. . Fi««t—•*•—-*7»F< NEGATIVE 'gCMo M, M2 Fig. 144.—Construction for finding one of the foot points M from the shadows of a corresponding marker as shown at Mi and M2, and the shadow of the cross marker X Fig. 145. -Complete chart for setting feet of Hirtz compass The length of the line MXM2 will clearly decrease as M is placed nearer the plate, and increases as it is raised. For the definite 60-cm. target-plate dis- tance and 6-cm. tube shift there corresponds one height MM0 for one image shift M^L. These relative values are shown in Table 26 in which all measure- ments are given in centimeters or tenths of centimeters. Figure 145 shows a full construction and necessary record derived from the photographic plate used in setting the compass. This data is used exactly as was that derived from fluoroscopic examination. It will require a considerable amount of skill and judgment to so place the markers on the patient's skin as to give reliable readings and at the same time furnish proper support for the compass. These data are used exactly as were those derived from fluoroscopic exancunation. It will require a considerable amount of skill and judgment to so place the markers on the patient's skin as to give reliable readings and at the same time furnish proper support for the compass when used at operation. Especially one must insure that the shadows of all the markers fall on the photographic plate. It is also clearly undesirable to have the lines whose crossings are to indicate foot points for the compass setting too nearly parallel, as in that case a slight error in their location may bring a decidedly large shift in the position GENERAL SURGERY 249 of foot points. Transparent celluloid scales are sometimes furnished, w-hich assist somewhat in determining whether the shadow of the markers will fall on the plate. Knowing approximately, by previous fluoroscopic or other examination, the position of the projectile whose localization is sought, select a plate changer of proper size, attach the cross, and place on the table in the position to which it is to be used. By means of a plumb bob, adjust the tube stand so that the central posi- tion of the target shall be vertically over the metallic cross, and be sure that the distance CX, Figure 143, is 60 cm. Adjust stops to allow the tube to move 3 cm. in each direction from the central point. Place the patient on the tunnel plate changer, taking care that the cross, plate changer, and tube are not displaced in the process. Or, if the tube holder is rotated, fix stop for its exact return. Make sure that the tube is three centimeters from its center point and insert a plate. Place the three skin markers in the desired posi- tion. The balls as furnished with the apparatus may be used, or small metallic mark- ers, preferably V-shaped, may be attached to the patient's skin with small pieces of ad- hesive. Make the exposure needed. Remove the first plate, shift the tube, and make the second exposure. Do not attempt to get the data from the plate or film until it is dry. If it is once scratched or smeared, it will be impossible later to get good measurement. If the exposures are to be made on a single plate, be sure not to overexpose. When using two plates, the image of the cross is used to superimpose the plates and to transfer the data to the record sheet. Make the record described above, locating the foot points and the center points. Read MXM2, N,N2, 0,02, and P.P,, in centimeters and fractions enter these on the record under column marked spread, and enter under height the corresponding number in Table 26. Thus: Fig. 146.—Equipment supplied for use with Hirtz compass Spread Cm. 1.5 2.1 3.6 2.7 Height * MiMi X1X2 O1O2 P,P2 1 Cm. 12 15.5 22.5 18.6 Shift Cm. 6.6 3.1 3.9 P1P2— M1M2 P1P2—N1N2 P1P2—O1O2 The equipment supplied for use in method E is shown in Figure 146. 250 SURGERY Table 20.—Measurements for use in connection with Hirtz compass [Focus plate distance, 60 cm.; tube shift, 6] Spread-ing Height Spread-ing Height cm. cm. cm. cm. 0.1 1.0 .95 s. 2 .15 1.45 1.0 8. 55 .2 1.95 1.05 S. 95 .25 2.4 1.1 9.3 .3 2.85 1.15 9.65 .35 3.3 1.2 10.0 .4 3.75 1.25 10.35 .45 4.2 1.3 10.7 .5 4.6 1.35 11.0 .55 5.05 1.4 11.35 .6 5.45 1.45 11.7 .65 5.85 1.5 12.0 . 7 6.25 1.55 12.3 . 10 6.65 1.6 12.65 .8 7.05 1.65 12.95 .85 7.45 1.7 13.25 .9 7.85 1.75 13.55 Spread- ing cm. 1.8 1.85 1.9 1.95 2.0 2.05 2.1 2.15 2.2 2.25 2.3 2.35 2.4 2.45 2.5 2.55 2.6 Height cm. 13.85 14.15 14.45 14.7 15.0 15.3 15.5 15.85 16.1 16.35 16.65 16.9 17.15 17.4 17.65 17.il IS. 15 Spread-ing Height Spread-ing cm. cm. cm. 2.65 18.4 3.5 2.7 18.6 3.55 2.75 18.85 3.6 2.8 19.1 3.65 2.85 19.3 3.7 2.9 19.55 3.75 2.95 19.8 3.8 3.0 20.0 3.85 3.05 20.2 3.9 3.1 20.45 3.95 3.15 20.65 4.0 3.2 20.85 4.05 3.25 21.1 4 1 3.3 21.3 4.15 3.35 21.5 4.2 3.4 21.7 4.25 3.45 21.9 4.3 Height cm. 22.1 22.3 22.5 22.7 22.9 23.05 23.25 23.45 23.65 23.8 24.0 24.2 24.35 24.55 24.7 24.9 25.05 [Head-ing Height cm. cm. 4. 35 25.2 4.4 25.4 4.45 25.55 4.5 25.7 4. 55 25.85 4.6 26.05 4. 65 26.2 4.7 26. 35 4.75 26.5 4.8 26.65 4.85 26.8 4.9 26. 95 4.95 27.1 5.0 27. 25 The advantages of the Hirtz compass in selected cases are numerous. After the sterilized compass has been placed in position, the penetration needle, when brought in contact with the skin, indicates the point where the incision should be made, and the depth and the direction in which the foreign body lies. By means of the rotating device through which the penetration needle is passed, the surgeon can select the point of entry without in any way embarrassing the usefulness of the instrument. The instrument, being sterile, can be re-applied as often as needed during the operation. In using the compass, it is important that the skin marks selected for the compass legs should constitute a large triangle and that these marks should not be covered by drapes or towels during the operation. When the compass is being set, the patient should lie in either the prone or the supine position rather than on the side, and at operation exactly the same attitude should be assumed. It is important that the muscles be relaxed as far as possible; other- wise muscular contraction maintained during the X-ray examination is likely to disappear during anesthesia and thus possibly alter the position of the projectile to a considerable degree. Duval25 cites a case in which a bullet located in the adductors of the thigh shifted eight centimeters when the contracted muscles were relaxed. DEPTH OF ANATOMICAL LANDMARKS BENEATH THE SKIN The table given below is of value in determining the exact position of a foreign body in relation to points on the skeleton. In their article published in connection with this table, the authors state that the surgeon often experi- ences many difficulties when operating for the removal of a foreign body even after the roentgenologist has made an accurate localization.26 Previous to the war, the surgeon studied the ultimate depth of his operation only with regard to certain surrounding anatomical landmarks, and not in terms of centimeters or inches beneath a point on the skin. If the roentgenologist reports a pro- jectile as being 4.5 cm. from a point on the skin of the back overlying the trans- verse process of the 12th dorsal vertebra, the surgeon has little knowledge as GENERAL SURGERY 251 to where this depth will lead him. If, however, the surgeon knows that the average depth of this structure is less than 4 cm. from the skin, he appreciates the fact that the projectile must lie in or just anterior to the transverse process. The objection is, of course, that individuals vary greatly in thickness of various parts, but the authors call attention to the fact that the soldier is selected after rigid examination and, as a result, the extremely thin and extremely obese are not present. Table 27.—Depth of anatomical landmarks Incision Head, laterally: Just above zygoma.....____________________________......... Just below zygoma________......._______________............. To coronoid process or condyle of mandible__________________ Neck: Anteroposterior^— Through center of larynx____________......._______....... 3 cm. to side of center of larynx......_____________......... 3 cm. to side of center of larynx________________.....____ Through middle line of trachea just below caricoid_________ 3 cm. to side of center of trachea........._________________ From center of suprasternal notch.........._______________ Laterally— From center of middle of neck.....______________________ From center of middle of neck.....______________________ From just below tip of mastoid process.........____________ Chest: Superiorly— From a point midway between root of neck and tip of acromion. From a point midway between internal and external extremi- ties and just behind posterior border of the clavicle. Anteriorly— From center of lower border of clavicle backwards to sub- scapular fossa just clear of ribs. From a point just over tip of coracoid to subscapular fossa backwards. From a point 2.5 cm. external to sterno-clavicular joint just below clavicle. From a point 2.5 cm. external to sterno-clavicular joint just below clavicle. From a point 5 cm. external to sterno-clavicular joint just below clavicle backwards. From a point 5 cm. external to sterno-clavicular joint just below clavicle backwards. From a point 5 cm. below center of clavicle--------------- Posteriorly— To supraspinous fossa.....----------------------------- To intraspinous fossa____________________________...... To transverse process of seventh cervical vertebra---------- To pleura level of seventh cervical vertebra......---------- To anterior level of body of seventh cervical-------------- To transverse process of twelfth dorsal vertebra----------- To pleura level of twelfth dorsal vertebra----------------- To anterior level of body of twelfth dorsal vertebra......---- Abdomen: Thickness of wall from front— . 1 cm. to either side of middle line just above umbilicus....... 1 cm. to either side of middle line just below umbilicus----- Just internal to anterior superior spine to iliac fossa-------- Midway between anterior superior spine and pubic crest to front of acetabulum. Thickness of wall from side— On level of tip of twelfth rib in line upwards from anterior superior spine. Thickness of wall from back- To transverse process third lumbar--------------------- To anterior level of body of third lumbar----------------- To anterior level of psoas muscle.........-......----------- Hip and thigh from front: 8 cm. below anterior superior spine to head of femur------------- 8 cm. below anterior superior spine to neck of femur. ------------ - ■ 15 cm. below anterior superior spine (level of lesser trochanter) to front of femur. To greater trochanter-------------------.............------- To lesser trochanter---------------------V'jl™-.------- Brimofpelvis2.5cm.in front of sacroiliac synchondrosis.......... To anterior inferior spine------------.....----------------- Depth of ana- tomical position Cm. 2. 5 To sphenosquamosal suture. 4.0 I To sphenoidal bone. 2.5 5.0 4.0 7.5 4.0 4.0 3.0 4.0 6.0 6.0 5.0 5.0 7.5 7.5 3.5 2.0 3.0 4.5 5.0 2.5 2.0 4.0 5.0 7.5 3.5 5.0 J. o 3.0 4.5 11.0 13.0 6.0 5-7.0 4.0 11.0 9.0 9.5 3.0 To body of vertebra. To transverse process of cervical vertebra. Total depth of neck. To body of vertebra. To transverse process of vertebra. To posterior border of manubrium. To tranverse process of vertebra. To body of vertebra. To body of first cervical. To apex of pleura, downwards. Do. To first rib. To pleura. To first rib To pleura. Do. 252 SURGERY Table 27.—Depth of anatomical landmarks—Continued Incision Depth of ana- tomical position Hip and thigh from front—Continued Cm. To spine of ischium_______________________________________ 12. 5 To anterior surface of line of junction of ascending ramus of 7. 0 ischium and descending of pubis. To ischial tuberosity______________________________________ 13. 0 Hip and thigh from back: To ischial tuberosity______________________________________ 6. 0 To spine of sacrum on level of posterior superior spines of ilia_____ 3. 0 To sacral groove_________________________________________ 5. 0 To head of femur_________________________________________ 5. 0 To greater trochanter___________________________________ . 9. 0 To lesser trochanter_______________________________________ 7. 5 To brim of pelvis 25 cm. in front of sacroiliac synchondrosis_______ 10. 0 To anterior inferior spine___________________________..... .. 15. 0 To spine of ischium_______________________________________ 5. 0 To posterior surface of junction of ascending ramus of ischium and i 11.0 descending ramus of pubis. EYE LOCALIZATION In the case of foreign bodies in the eye, very accurate localization is neces- sary, as knowledge of the exact position of the foreign body mayT mean the saving of an eye or the pres- ervation of vision. The simple wSweet-Bow-cn apparatus consists of two gen- eral parts—the base or head- rest, as illustrated in Figure 147 and the localizer, as shown in outline drawing, Figure 14S. The headrest base is com- posed of the following parts: A plate-slide tunnel, so con- structed as to protect one- half of a 5 by 7 photographic plate while the other half is being exposed, and to protect the exposed half while the sec- ond exposure is being made. Four rubber-tipped legs to raise the tunnel so that it will act as a pillow to hold the patient's head level when lying on his side. A plate holder having a slide that will protect the plate from the ordinary light, but offer no resistance to the X ray. An arm or handle attached to the plate-holding slide to enable the operator to shift the plate the correct distance for each exposure, and to withdraw the same when both exposures have been made. A pneumatic cushion for the comfort of the patient. A double clamp to hold the patient's head and to prevent any horizontal movement. A single vertical clamp to press the head downward upon the pneumatic cushion. The localizer consists of a heavy metal base, Figure 148; an upright standard, B, to support the localizer and permit the Fig. 147.—Headrest for use with the eye localizer GENERAL SURGERY 253 same to be adjusted and held firmly at any desired height. The indicator ball D, with its needle-supporting item D2, which, when properly adjusted to the center of an eye, will cast its shadow on the photographic plate and serve as a landmark to indicate the center of the cornea. The metal tip E, of stem E2 is made cone shaped, so as to more easily differentiate its shadow from that of ball D. These indicators are permanently- adjusted a known distance apart (15 mm.), and the base of the localizer is provided with two holes exactly 15 mm. from center to center, which should be employed to verify this adjustmentjin case of doubt. When an X-ray plate is made of them obliquely, adjusted to an eye as above stated and as indicated in "front view" on the chart, we are enabled by their shadows to definitely locate the source and course of the rayTs~of tlight (in relation to the chart) that caused the shadows. Also, the position of any foreign body- that may- show on the same plate can very easily be determined by the position of its shadow in relation to that of the ball and cone, because the exact position of the latter with refer- ence to the chart is known and indicated (front view). Tube C12 and notch F18 are sights similar to those used on a rifle, with which the operator can accurately align the center of the cornea of the afflicted eye w-ith ball D and its supporting step D.2 Fu is a spring trigger which presses upwards against pin F.13 F5 is the end of the rod to which the indicator-ball and cones D and E are attached by bracket F, the whole being supported by passing tnrougn tube U.J spring j." Deing attached to stationary tube C5 by means of bracket C,7 rod F5 with bracket Fc can be pressed forward until pin F13 is engaged by notch F.15 By loosening set screw C4 the bracket C can be raised or lowered until ball D, with its supporting stem D,2 is in exact alignment with the center of the cornea of the affected eye, and the screw is then tightened. The patient is instructed to close his eyes, and the entire instrument, with its base, is slid forward until indicator ball D presses into the eyelid approx- imately its thickness. The trigger F17 is then depressed to disengage notch F15 from pin F13, w-hen spring F16 will cause the rod F5 and indicator-ball D and cone E to rebound exactly 10 mm., being restricted by knob F7 in slot C.fi The subject and localizer are now^ in correct position for making the two necessary exposures. First Exposure Place patient's head, affected eye downward, on the plate-holder base, with inflated cushion in position, as shown in illustration, being careful that the Fig. 148.—Sweet eye localizer 254 SURGERY inflated cushion does not extend over the marked lines on the cover—otherwise it will cast a shadow on the photographic plate. If the subject shows a tendency to move about, the horizontal clamp, as shown in Figure 147, must be adjusted to the base of the head and forehead, otherwise the vertical clamp, as shown in illustrations herewith, will be sufficient. The double horizontal clamp can be adjusted for either eye by means of its two off-center holes and clamp screws. Place the diaphragmed tube in position so that its central rays will exactly parallel the front vertical plane of the patient's eye, as shown in Figure 149. A plate, having previ- ously- been placed in the plate holder, is now placed in the tunnel with the outer flange protruding, as shown in il- lustration. This will expose one-half of the plate to the action of the rays, while the other half will be protected for the second exposure. The localizer (fig. 148) is now placed on the stand in front of the affected eye; its trigger is "set" as al- ready described and, after the indicator ball has been adjusted to the plane of the cornea, the entire instrument is pushed forward on its base until the ball presses into the patient's closed eyelid ap- Fig. 149.—Position for first exposure in localization of projectiles in the proximately its tniC__neSS| eye. Be certain that the tube is centered accurately over the cone so the tri___Ter SDrin__ is then that both ball and cone will be superimposed ~& * . released and the indicator ball and cone recede exactly 10 mm., thereby permitting the patient to open his eyes and wink them in a natural manner. By- referring to localizer chart you will observe that due allowance of 10 mm. has been made by placing the indicator ball and cone just that far from the front plane of the cornea. It should also be borne in mind that the front of the cornea is 10 mm. in front of the shadow of the indicator ball, as shown in your negatives. The tube is now centered over the localizing ball and cone so that the shadows of the two will coincide (fig. 149). Some object, such as a candle or a piece of white paper, that can readily be seen by the patient, should be placed in alignment with the sights of tin? indicator, but several feet removed therefrom, and the patient should be in- structed to look constantly at this object while the two exposures are being made. GENERAL SURGERY 255 Fig. 150.—Specimen plate of projectile in the eye, illustrating the method of measurement Second Exposure The first exposure having been made with the rays perpendicular to the plane of the plate and parallel to the patient's eye, thereby superimposing the shadows of the indicator ball and cone and their support- ing stems, as shown in the right-hand half of illustration (fig. 150) the X-rayT tube is then shifted toward the pa- tient's feet four or five inches and tilted so that the indi- cator rod points to the ball of the localizer, thereby- caus- ing the central rays to pass obliquely through the center of the cornea of the patient's affected eye, as shown in Fig- ure 151. The photographic plate must now be shifted by pushing the plate holder inward, by- its handle, as far as it will go, thereby pro- tecting that portion that was acted upon by the rays in the first exposure and bring its unexposed half in proper position to receive the rays from the second exposure. In this position the second exposure is made with the rays falling obliquely upon the indicators, thereby- sepa- rating their shadows, as showm in left half of illustration. It should be remembered that it is not essential that the exposures be made w-ith the tube at any specific dis- tance from the plate, or even that it be the same distance from the two exposures. Neither is it important that the tube be shifted an exact or known distance for the second exposure, as by the use of the charts and Sweet's method the course of the ray is automatically established. This is shown by the line A-D through P1 41)997—27----19 Fig. 151—Second exposure for localization of projectiles in the eye. Notice shift of tube in order to separate the shadows of ball and cone. Be careful not to produce any lateral shift. The tips of ball and cone must be kept in alignment and P2 of outline drawing, Figure 152. 256 SURGERY Charting the Plates In charting the plates the following method is pursued: Upon the negative (right-hand half of the illustration) which represents the first exposure, a line is drawn through the horizontal axis of the indicator ball and cone w-hich are here superimposed, thereby projecting their supporting stems and establishing the visual axis of the eye (fig. 150). A second line is drawn at right angles to the first through the center of the foreign body's shadow-. With a small pair of dividers step the distance from the edge of the indi- cator ball to the intersection of the horizontal and vertical lines that you have just drawn. Then step this distance off on the diagram chart, making a dot with a pen, or a very sharp, hard pencil, to represent the exact distance (distance R. fig. 152). HORIZONTAL SECTION FIRST EXPOSURE R, DISTANCE FROM BALL B TO PROJECTILE 5HAP0W F1, ZZTz MM. V, DISTANCE OF PROJECTILE SHADOW F1 ABOVE HORIZONTAL PLANE, 9 MM. M, DISTANCE OF BALL B FROM ANTERIOR SURFACE OF CORNEA, 10 MM. N, DISTANCE OF PROJECTILE POSTERIOR TO ANTERIOR SURFACE Qf CORNEA, \Z% MM. 5EC0ND EXP05URE X, DISTANCE FROM BALL B TO PROJECTILE SHADOW ?*, 10^ MM. Y, DISTANCE FROM CONE C TO PROJECTILE SHADOW Pl, \b%. MM. O, DISTANCE FROM CENTER OF BALL B TO CENTER OF CONE C, 15 MM. A-D, LINE OF CENTRAL RAY PASSING THROUGH TRUE POSITION OF PROJ AND ITS PROJECTED SHADOW5 P1 P2. INTERSECTION OF PLANE F1 F2 WITH PLANE P* Pl IS THE POSITION OF PROJ IN FRONT VIEW AT F2. F1, P05ITION OF PROJECTILE IN SIDE VIEW. F, POSITION OF PROJECTILE IN HORIZONTAL SECTION. AVERAGE DIAMETER OF EYE, 24 MM. FRONT VIEW TEMPORAL SIDE Fig. 152.—Schematic drawing of localizing chart, illustrating the method of obtaining measurements On the vertical line that has been drawn through the shadow of the foreign body (right-hand half of fig. 150) measure the distance of the foreign body above or below the horizontal line and indicate the same on the chart above or below the axis, distance V locating dot F1. Place another dot on the same horizontal plane and draw a line through these two dots, parallel to the axis, projecting into the front view as shown. Since the position of localizer ball B, as shown on the chart, side view, is the same as when the first plate was made, the location of the foreign body must be at point F1. We have yet to establish its location to the nasal or temporal side. Project a line vertically through point F1 to the 45° angle (see fig. 153), thence horizontally through the horizontal section. GENERAL SURGERY 257 Upon the negative (left-hand of illustration) which represents the second or oblique exposure, a line is drawn through the horizontal axis of both the ball and the cone, thereby projecting their supporting stems and establishing the relation of their horizontal planes to that of the foreign body. A third line is drawn at right angles to the first two through the center of the foreign-body- shadow. With dividers the distance of the shadow of the foreign body above or below the horizontal plane of the shadow of the ball is measured, and the same is marked by a dot on the front view of the chart just above or below the center B, as indicated by distance X, because that was the relative position of the indicator ball when it cast the shadow. The distance of the shadow of the Fig. 153.—Chart used in eye localization foreign body- above or below the horizontal plane of the shadow- of the cone is measured, and the same marked on the chart at the point above or below C indicated by distance Y, because that was the relative position of the indicator cone when it cast the shadow-. A line drawn through dots P1 and P2 will represent the true course of the rays in the second exposure, and its intersection with the projected line from the side view through the point F1 will be the position of the foreign body when viewed from the front, while a vertical projection through the horizontal section shows the position of the foreign body to the nasal or temporal side at point F. In these eye localizations a source of error is the fact that this is a schematic eye, constructed to correspond to the average eye which is about 24 mm. in diameter, but this may vary 3 mm. from the average. 258 SURGERY Sometimes the variation can be measured with an opthalmoscope and cor- rections made, but ordinarily the eye is so injured that this is impossible, and we must assume that the eye corresponds to the schematic eye. This error, of course, w-ould interfere only in cases where the foreign body is located 1 or 2 mm. inside or outside the sclera. In that event one would not be certain whether the foreign body was within or without the globe of the eye. This point may often be determined in the following manner: Place the patient on his side with the afflicted side next to the plate and center the tube over the eye. Fix the vision of the good eye on a spot in a plane parallel to the plate, so placed that the eye is rotated toward the top of the head. Make an exposure of one-half the correct amount, then shift the vision to a point well toward the feet, still keeping the head fastened securely in place, and expose the remainder of the necessary time. If there are two images of the foreign body, it is certain that the foreign body moved with the eye and therefore must be in the globe. It is barely possible for the foreign body to be in an ocular muscle and move, thereby giving two images, but its position near the exterior and anterior portion of the globe would help differentiate this. In an acute case where a localizing apparatus is not available, this method may be all that is necessary. EXTRACTION X-rav guidance during surgical operations is indispensable for the expedi- tious removal of a certain proportion of foreign bodies. It is applicable not only to the extraction of projectiles and other foreign metallic substances, but also for the removal of pathological foreign bodies, such as renal calculi, en- countered in civil life. In fact, if there is any question as to the location of an elusive stone or doubt as to whether or not all stones have been removed, it is possible, by means of the fluoroscopic bonnet and portable X-ray equipment, to make an X-ray- examination of a kidney which has been lifted out of the wound at operation. This method of screen control is also useful during the injection of opaque fluids into the urinary tract, during the aspiration of intra- thoracic accumulations of fluid, and in the control of injection of air, oxygen, and other gas into the pleural or peritoneal cavity, or into the ventricles of the brain. The method of intermittent fluoroscopic control is more satisfactory- for general use in the extraction of metallic foreign bodies than are electro vibrators, telephone probes, or other similar devices, for the reason that a considerable percentage (approximately one-fifth) of the foreign bodies of war are not magnetizable. Fluoroscopic control methods save time, lessen trauma, and conserve the temper of the surgeon. The requirements for the malleable band, harpoon, and Hirtz compass methods have already been sufficiently referred to in the preceding section. Two other methods of fluoroscopic control will be described in detail: The method of the open screen in the darkened room, and the bonnet method in the usual light of the operating room. FIG. 154.—EXTRACTION OF A FOREIGN BODY UNDER FLUOROSCOPIC CONTROL. THE OPEN SCREEN METHOD IN DARKENED ROOM. THE RED LIGHT ABOVE THE TABLE SERVES TO ILLUMINATE THE SURGICAL FIELD IN THE PRELIMI- NARY STEPS BEFORE THE DIRECT SEARCH FOR THE FOREIGN BODY BEGINS. BY MEANS OF THE FOOT SWITCH THE RED LIGHT IS TURNED OUT AND CUR- RENT IS TURNED INTO THE X-RAY TUBE BENEATH THE TABLE, AS ILLUS- TRATED IN FIGURE 155 FIG. 155.—THIS ILLUSTRATION REPRESENTS THE RADIOLOGICAL STEP OF THE PROCEDURE OF LOCALIZING FOREIGN BODIES UNDER FLUOROSCOPIC CON- TROL. THE ROOM IS IN DARKNESS EXCEPT FOR THE FLUORESCENCE FROM THE SCREEN DURING THE ACTUAL X-RAY LOCALIZATION GENERAL SURGERY 259 OPEX SCREEN IX DARKENED ROOM The requirements for this method are the usual fluoroscopic horizontal table; a fluoroscopic screen; a proper overhead red or green light, sufficiently bright, preferably under control of the same foot switch that controls the X-ray- current; surgical equipment, including sterile sheets, gloves, gowns, and instruments. No instruments of special design are needed except a pair of narrow-jawred forceps. A special bullet-seizing forceps or a forceps of the type used for exploration of the gall bladder or common duct is usually- satisfactory for grasp- ing the foreign body. The forceps of Wullyamoz are bent at a right angle in such fashion that the prehensible portion of the instrument is held in the line of the vertical ray without exposing the hand of the operator. If it is not convenient to use the ordinary horizontal fluoroscopic table, any wooden or aluminum topped table w-ill suffice if so constructed that an X-ray- tube can be placed be- neath it without danger of short-circuiting the current. The modern bedside equip- ment (fig. 156) is very satisfac- tory for this purpose. The small Coolidge tube at the tube-holding arm can be turned downward and placed iinder the table at a point vertically beneath the foreign body when the patient lies in the position for operation. Blankets of black or green cloth draped around the table to the floor w-ill prevent the escape of light into the room, or a smaller piece of black cloth can be placed directly around the tube for the few moments necessary for the examination. The ordinary horizontal fluoroscope is, of course, already equipped. In military hospitals in the forward area there is seldom need for the use of the open screen in the darkened room. When this method is required the patient can be carried into the X-ray room and the surgery done there. This method interrupts, of course, the routine work of the X-ray department and hence for forward hospitals the bonnet method, described below, is preferable, as it can be carried out in the operating room. In stationary hospitals, where there is likely to be more time for deliberate work, the writer considers it desir- able to provide a special room for extraction of foreign bodies under X-ray con- trol, employing the method of the open screen in the darkened room for a certain percentage of difficult extraction cases. One may use the ordinary lead-glass covered, fluoroscopic screen: or an old intensifying screen, no longer useful for radiographic work, may be fastened Fig.156 uent of the tube and table for the bonnet method 260 SURGERY to a piece of lead glass by means of adhesive tape and held by an assistant whose hands are properly protected by leaded rubber gloves. Special tables were constructed during the war supplied with a hinged arm for holding the fluoro- scopic screen, so that when the screen was not in use it could be tilted back out of the way of the operator. For the overhead light one may employ an ordinary incandescent bulb, stained red. This red light may be as brilliant as the surgeon desires. The writer prefers a bluish bulb mounted in a yellow globe, which gives a very agree- able light, much like moonlight. On the other hand, the overhead light in daily use in the fluoroscopic room may be utilized in place of a red light for most of the manipulations; if at any stage of the operation more illumination is required, a headlight may be supplied to the surgeon. Where extractions under X-ray- control are frequent, it will be advantageous to provide a special source of overhead light, 5 or 6 feet above the fluorscopic table, so arranged with glass filters that a powerful red light is throwm upon the operative field. If this light is equipped with a rheostat for dimming or intensifying the illumination, it will be all the more serviceable. In the absence of more elaborate equipment, a hand lamp equipped with a red bulb will serve. Before the operation it is important that both the surgeon and the radiolo- gist spend ten or more minutes in an abscurely lighted room, or with the eyes protected by smoked glasses. After the patient has been made ready upon the table, and the sterile linen has been arranged as for any aseptic operation, an additional sterile sheet, known in France as the velum, is thrown over the operative field and fastened down by towel clips on the side next to the radiologist, opposite the surgeon. On the side next to the surgeon, the sheet is held at its two corners by sterile forceps in the hands of assistants. These assistants may or may not be dressed for sterile wrork as the circumstances warrant. The assistants holding the front ends of the velum drop it over the operative field, protecting it from the radiologist and his unsterile screen. Figure 154 shows the operating scene at this moment. The red light is then extinguished and the X ray is turned on (fig. 155). The radiologist adjusts the tube under the table so that only a small spot on the screen, not more than 3 cm. square, will be illuminated, and the foreign body is brought to the center of this spot. The tube is then fixed in position and the radiologist makes pressure against the skin with a sterile pointer at a spot directly over the foreign body. The surgeon notes the point on the skin thus indicated and, if it is a satis- factory path of approach to the projectile, makes his incision there. The radiologist then steps back, the velum is raised, care being taken not to con- taminate its underside, and the surgeon proceeds with the incision and dissec- tion toward the foreign body. During the dissection, at such times as he wants help, the surgeon holds the end of a forceps directly over the point where he believes the foreign body to lie, and the protecting velum, its underside still sterile, is turned down over the wound, the red light is again extinguished, and the radiologist corrects the position of the surgeon's forceps by directing him to move it to the right or the GENERAL SURGERY 261 left, until the correct spot is found. The surgeon has only to work directly- downward to come upon the object of his search. It will be unnecessary in many cases to expose the foreign body completely by dissection; often it is only necessary to determine its approximate ana- tomical position, especially when it lies in the depth of a muscle. Frequently it will be possible, after making a small skin incision, to extinguish the red light, turn on the X-ray current, and under fluoroscopic guidance insinuate the end of a closed, narrow-jawed, blunt forceps into the tissues until it touches and moves the foreign body. With the X-ray current still on, the jaws of the forceps are separated, the foreign body grasped and extracted. The red light or the ordinary brilliant white light of the room is then turned on, and the remainder of the operation conducted in the usual manner. In some situations it will be possible to turn a jagged projectile so that the extraction forceps will seize it by its sharp or jagged edge or point. A needle may be grasped near one end. One who has not gained experience in this method of extraction can not appreciate the ease with wdiich a foreign body may be secured and removed in this manner. In a series of several hundred extractions performed in this w-ay, the wTiter has never been longer than 20 minutes, usually much less, from skin puncture to extraction of foreign body, and only twice has he failed to remove the foreign body. Both failures were in cases in which hypodermic needles were broken off deep in tissues too thick to be easily studied with the fluoroscope. Protection of both the patient and the operator from an over-exposure of X rayTs is of first importance. It goes without saying that the usual lead lining of the X-ray tube holder protects the patient and the operator from all rays except those illuminating the spot upon the fluoroscopic screen. This field of radiation should be kept as small as possible and nothing but the forceps of the operator should ever enter it while the current is on; sufficiently long forceps should be employed to keep the hands out of the direct rays. Protection of the patient and additional security for the operator is afforded by placing over the tube a filter of at least 2 mm. of aluminum, and by reducing to a minimum the time required for the X-ray observations. Onlookers not directly interested should not prolong the operation by participating in the screen work. The method is entirely safe if reasonable care is taken to minimize the time of X-ray observations. If the eyes have been properly prepared by a preliminary stay- in obscurity, 1 or 2 milliamperes of current will suffice. A foot switch is essential. The X-ray current should be off every second the observer's eyes are not intent studying the screen. During early experiences, the X-ray current may be turned on and off twenty or thirty times during the operation; but after the first few cases the extraction will be accomplished during a very few moments. BONNET METHOD The bonnet procedure has the advantage over the foregoing method that it can be carried out in the operating room in the usual light by which the surgeon operates. The requirements are an ordinary fluoroscopic horizontal table, or a makeshift; a fluoroscopic bonnet; and a sighting needle or pointer sufficiently- 262 SURGERY long to permit the hand holding it to remain outside of the zone of active X rays. The United States Army bedside unit, which is now being adapted to general practice, affords a very convenient instrument for taking the X-ray- apparatus to the operating room, providing the surgeon does not wish to take his patient to the X-ray room. An ordinary massage or nonmetallic table or a stretcher will serve the purpose. The tube-holding arm and tube of the bedside unit is placed under the table, approximately under the foreign body- when the patient is in the position for operation. No effort need be made to hide the glow of the X-ray tube, as this type of X-ray operation can be carried on in the most brilliant light needed for operating purposes. A fluoroscopic bonnet, or, in its absence, a hand fluoroscope of the ordinary- type, will be needed. In the latter instance, it will be necessary to provide the radiologist with a pair of smoked spectacles. The bonnet fluoroscope, especially Dessane's, is much simpler and more convenient. As soon as the radiologist finishes his observation, the lower part of the bonnet is turned up and held in this position by springs, w-hile a shutter of smoked glass comes down auto- matically in front of his eyes (fig. 156). The position of the hood thus lifted eases the weight and materially lessens the inconvenience of its use. The screen in this form of fluoroscope measures 13 by- 18 cm., an area much larger than the illuminated field should ever be. For a pointer or sighting device, an ordinary urethral sound or a long forceps may be used, if a special localizing pointer is not provided. The radiologist must put on the bonnet or a pair of smoked glasses 12 or 15 minutes before he will be needed, unless he is already engaged in fluoroscopic work, so that w-hen called he has only to don the bonnet and step to the operat- ing room. For anesthesia in these cases, when a local anesthetic is not suitable, nitrous oxide gas is preferable since it is nonexplosive. The danger of an explosion of ether vapor, however, has, in the writer's opinion, been considerably- overesti- mated. He has seen only one case and in this no harm at all was done as the flame was instantly smothered. The danger, of course, is greater with the open drop method than with some form of rebreathing anesthetic device. The Ombredanne anesthetic mask is very satisfactory for this purpose. Alter the patient has been made ready- for operation in the position in which the localization was done, the protective sterile velum is placed over him in the manner already- described. When the surgeon is ready, the radiologist indicates through the sterile velum, by means of a pointer, the exact spot on the skin which lies vertically above the foreign body. While he holds the pointer in place the velum is lifted on the side next the surgeon, who places the end of a sterile forceps on the skin in the position shown by the radiologists pointer. The bonnet and velum are lifted out of the way, the surgeon notes carefully the point indicated on the skin and cuts down vertically upon it to find the foreign body. If he does not find it at the depth he supposes to be correct, he ties the bleeding points in order to clear the field of haemostats, and asks to be shown again the spot where the vertical ray corresponding to the projectile passes through the wound. This takes but a moment on the part of GENERAL SURGERY 263 the radiologist and is done as often as required. The surgeon places his sterile pointer in the wound as nearly as possible above the exact center of the image of the foreign body. Correction of the position of the surgeon's forceps is made by telling him to move to the left, right, front, or back, until the correct loca- tion has been found. After the extraction procedure has been completed it will be advisable to make still another observation to insure that the whole of the foreign body has been removed. This method will rarely fail except in badly planned operations where an insurmountable difficulty of an anatomical or physiological nature has been overlooked, or where through some accident it will be necessary to terminate the operation suddenly. In the case of recent wounds, the surgeon will often prefer to conduct his search through the already- existing wound rather than to cut down vertically upon the foreign body. Here again the bonnet will afford valuable control, especially if the tube beneath the table is susceptible of movement. The bonnet method is particularly helpful in cases of old encapsulated pro- jectiles or foreign bodies. By using a very small diaphragm aperture the radiologist employ-s the bundle of rays perpendicular to the plane of the table. When the foreign body is brought into the line of this ray and the point marked upon the skin perpendicularly over the ray, the surgeon knows if he dissects vertically downward he can not fail to find the foreign body. Ledoux-Lebard and Ombredanne have demonstrated the special value of this method in cases of intra-osseous projectiles. REFERENCES (1) Buguet, Abel and Gascar: Determination a l'aide des rayons X de la profondeur ou la siege d'un corps etranger dans les tissus. Comptes rendus hebdomadaires des stances de I'academie des sciences, Paris, March 30, 1896, cii, 786. (2) Thompson, Elihu: Electrical Review, May, 1896. (3) Imbert, A., and Ber tin-Sans, H.: Photographies stereoscopiques obtenues avec les rayons X. Comptes rendus hebdomadaires des seances de I'academie des sciences, Paris March 30, 1896, cii, 786. (4) White, J. William, Goodspeed, Arthur W., and Leonard, Charles L.: Cases Illustrative of the Practical Application of the Roentgen Rays in Surgery. American Journal of the Medical Sciences, Philadelphia, 1896, n. s. cxii, No. 2, 125. (5) Davidson, James Mackenzie, and Hedley, W. S.: A Method of Precise Localization and Measurement by Means of Roentgen Rays. Lancet, London, October 16, 1897, i, 1001. (6) Gerard (Method described by Vilain and Maffei): Procede Geometrique de determina- tion des corps etrangers inclus dans les tissus. Clinique, Bruxelles, May 13, 1897, xi, 297. (7) Levy-Dorn, Max: Ueber Methoden die Lage innerer Theile mittelst Roentgenstrahlen zu bestimmen Verhandlungen der duelschen Gesellschaft fur Chirurgie, 36th Congress, Berlin, April 22, 1897, 50. (8) Stechow: Ueber die Verwendung der Roentgenstrahlen bei der Armee im Frieden und im Kriege. Comptes rendus du xii Congres International de medecine, Moscou, August 19-26, 1897, v, sect. 10, Military Medicine, 128. (9) Exner, S.: Eine Vorrichtung zur Bestimmung von Lage und Grosse eines Fremdkorpers mittelst der Roentgenstrahlen. Wiener klinische Wochenschrift, Vienna, January 7, 1897, x, 1. (10) Remy, Ch., and Contremoulins: Nouveau perfectionnement des applications chirurgi- cales des rayons X. Bulletin de I'academie de midecine, Paris, March 30, 1897, xxxvii, 354. 264 SURGERY (11) Morize: Sur un nouveau procede de determination de la position des corps etrangers par la radiographie. Presse mtdicale, Paris, February 12, 1898, vi, 66. (12) Galeazzi, R.: Ueber die Lagebestimmung von Fremdkorpen vermittelst Roentgen- strahlen.. Zentralblatt fur Chirurgie, Leipzig, 1899, xxvi, No. 18, 529. (13) Sechehaye: Etude sur la localisation des corps etrangers au moyen des rayons Roentgen. Bale et Geneve, Georg et Compagnie, 1899. (14) Case, James T.: History of Foreign Body Localization. American Journal of Roent- genology, New York, 1918, v, No. 3, 113. (15) Hirtz, E.: Methode radiographique et appareil simple pour la localisation precise et la recherche des corps Strangers. Bulletins et memories de la societe de chirurgie de Paris, March 25, 1914, xl, 373. (16) Henrard, Etienne: L'etat actuel du radiodiagnostic des corps etrangers. Bulletins et memoires de la societe de radiologic mHicale de France, Paris, 1914, vi, No. 53, 82. (17) Ombredanne et Ledoux-Lebard: Localisation et extraction des projectiles. Paris, Masson et cie, 1917. (18) Delherm, Louis, and Rousset, J.: Le reperage des projectiles. Paris, A. Maloine et fils, 1918. (19) Nogier, T.: Localisation et extraction des projectiles de guerre. Lyon, 1918. (20) United States Army X-Ray Manual. New York, Paul B. Hoeber, 1918, 209-291. (21) Symington, Johnson: Cross Section Anatomy. (22) Stein, Arthur, and Stewart, Wm. H.: Roentgen Examination of the Abdominal Organs Following Oxygen Inflation of the Peritoneal Cavity. Annals of Surgery, Philadel- phia, 1919, lxx, No. 1, 95. (23) Viallet and Tanton, J.: Plaie p6netrante de la fesse gauche avec perforation de la vessie par eclat de grenade. Retention intravesicale du projectile. Ablation. Bulle- tins et memoires de la Societe de chirurgie de Paris, 1916, xlii, 2836. (24) Strohl, A.: Procede simple pour localiser rapidement les projectiles par la radioscopie. Journal de radiologic et d'electrologie, Paris, 1916, ii, No. 3, 173. (25) Duval, Pierre: Technique operatoire de l'extraction des projectiles sous la direction du compas de Hirtz. Revue de Chirurgie, Paris, 1916, ii, No. 1, 1. (26) Metcalfe, James, and Keys-Wells, Ernest M.: The Anatomical Position of Localized Foreign Bodies. Lancet, London, May 27, 1916, i, 1978. CHAPTER IX GAS GANGRENE Since the comparatively recent discovery and isolation of the germs w-hich cause gas bacillus infection, this lesion, which had been grouped among the more virulent varieties of sphacelus or mortification, has become a recognized and distinct surgical entity. Always of great rarity in times of peace, the wide variation in its clinical manifestations resulted in a correspondingly diverse interpretation of this species of infection. With the advent of the World War, however, it became much more frequent, especially on the Western Front, and afforded abundant opportunity for a thorough investigation. It was then expected that the entire subject would be quickly and satisfactorily standardized and an adequate classification of its more or less complex features formulated. Although considerable progress has been made, the problem has not as yet been satisfactorily solved. Unexpected difficulties have been encountered. Thus, the usual association of several varieties of specific organ- isms in the same focus of infection, to w-hich, not infrequently, are added one or more varieties of pathogenic organisms, has greatly increased the complexity of the clinical manifestations. Furthermore, it is difficult to account for the fact that infection by a single species of the specific organism may cause widely different results. It is also quite possible that the list of specific organisms that cause this infection is not yet complete and that certain unexplained features of the infection may be due to an imperfect knowledge of its cause. On the whole, while a certain uniformity has been reached in its classification, the general result of laboratory and clinical investigation during the war led to the conclusion that the subject is one of great complexity and that many of its problems have not yet been satisfactorily solved. ETIOLOGY Diversity- in language and in methods of investigation led to considerable confusion in the classification of the specific organisms which cause gas bacillus infection. Certain varieties which, from their description by- observers in widely- separated countries, seemed to be different species, were ultimately- found to be identical. Other varieties described in pre-war literature were not identified by- any- observer during the war period. The confusion was still further increased by- the frequent association with the specific organisms of some of the more common pathogenic germs, resulting in a considerable modification of the clinical features of the original infection. Notwithstanding the confusion arising from these various causes, it has been demonstrated bey-ond doubt that the majority of cases of gas infection are due to one or more varieties of anaerobic bacilli and that the extent and severity of the infection depends directly upon the capacity of these organisms to secrete toxin. Their growth and development is favored by dead muscle tissue and the liquefaction of this tissue by certain proteolytic ferments, which 265 266 SURGERY many of these organisms possess in variable amounts, provides a medium in which, unquestionably, the secretion of the toxin is promoted. A majority of these same organisms possess also saccliarolytic ferments which are largely, if not entirely, responsible for more or less gas production, a clinical feature that long since stamped this infection with its classic title. Less important, as well as less constant, is the occasional possession of certain fat-splitting ferments which cause disintegration of the fatty connective tissue in the invaded area. In close association with these anaerobic organisms, aerobic varieties are almost always found. These play an entirely secondary- role and are never dangerous w-hen alone. Certain varieties, however, possess proteolytic ferments and by liquefying tissue provide a medium that stimulates the growth and development of the anaerobic varieties. Douglas, Fleming, and Colebrook x point eel out that further development of the anaerobes is favored by the capacity of the aerobes to absorb oxygen and thereby to diminish the quantity of this element in the area of infection. Closely associated with the specific organisms of gas gangrene and yet nonpathogenic in character, is a third group of bacilli wliich produce putrid abscesses in animals and to which the foul odor of the discharge in these infected wounds is due. While tabulations of these various specific and more or less closely affiliated organisms rarely agree, the writer selected the tabulation published in 1919, by Jablons,2 in connection with a paper on the subject of gaseous gangrene, omitting, however, a list of aerobic and anaerobic bacteria which, isolated in cases of gaseous gangrene before the war, were not confirmed subsequently by any other observer: (1) Toxicogenic organisms, anaerobic: (a) Those capable of reproducing the disease in animals— (1) B. welchii, Gas bacillus, Bacillus aerogenes capsulatus, Bacillus per- fringens. (2) Vibrion septique, bacillus of malignant edema. (3) B. oedematiens, B. gasoedem, B. bellonensis. (4) B.fallax. (5) B. hystolyticus. (6) B. sporogenes. (7) B. aerofetidus. (8) Streptococcus anaerobicus. (b) Those which do not reproduce the lesions in animals— (9) B. bifermentans. (10) B. putrificus. (11) B. tertius. (12) Bacillus V of Ghon and Sachs. (2) Aerobes capable of reproducing analagous lesions in animals— (13) B. mesentericus. (14) B. anthracoides. (3) Those which are found in association and produce in animals putrid abscesses or are nonpathogenic are— (15) B. proteus. (16) B. coli. (17) B. subtilis. (18) B. pyocyaneous. (19) B. friedlander. (20) B. mycoides. GENERAL SURGERY 267 Of the various anaerobic organisms, Nos. 1, 2, 3, 4, 6, and 7 possess an active saccharolytic ferment, the Bacillus hystolyticus possessing none. No. 1 has a slightly active proteolytic ferment which is more actively present in 5, 6, 7, 9, and 10. Weinberg and Seguin,3 in an analysis of 91 cases, found No. 1 present in 77 per cent, No. 2 in 13 per cent, No. 3 in 34 per cent, No. 4 in 16^ per cent, Xo. 5 in 9 per cent, No. 6 in 27 per cent, No. 7 in 5y2 per cent, No. 9 in 2 per cent, No. 10 in 2 per cent, and No. 11 and No. 12 each in 1 per cent. Of the (.)1 cases, 10 were caused by a single variety of anaerobic bacillus, 14 by- several varieties and 67 by both aerobes and anaerobes. There was no instance of an infection caused by- an aerobe alone. The frequent association of one or more varieties of these specific organisms, as demonstrated in the above table, is interesting also because of the possibility- of consequent inhibition or in- tensification of the virulence of the infection. Thus the toxins of B. oedema- tiens and of V. septique are practically- destroy-ed by B. sporogenes. On the other hand, B. welclvii and B. oedematiens mutually stimulate activity. A similar stimulation occurs when B. welch ii and V. septique are associated, while B. welchii alone is stimulated by B. sporogenes. Pathogenic organisms frequently- coexisting in wounds infected by- one or more varieties of gas bacilli include streptococci, diplococci, staphylococci, tetanus bacilli, diptheroid bacilli, and others. Thus Ivens 4 reports 4G4 cases in 59 of which a virulent streptococcus was isolated and in 15, the bacillus of tetanus. Weinberg and Seguin,3 in their analy-sis of 91 cases state that strepto- coccus was found in 40 per cent, diplococcus in 33 per cent, staphylococcus being slightly less frequent. Douglas, Fleming and Colebrook 1 discuss certain interesting features of symbiosis, stating that streptococcus, staphylococcus and diptheroids stimulate the growth of B. welchii and that with both staphylococcus and streptococcus the stimulation is mutual. Furthermore that streptococcus stimulates the growth of other anaerobic bacilli. The predisposing and local conditions wliich favor the development of this infection may be grouped as follows: Predisposing—(1) Systemic, as in the more common types of infection; causes that diminish the pow-ers of resistance, such as fatigue, loss of sleep, lack of nourishment, (2) Loss of blood with consequent loss of antigen bodies, as well as of other elements that ordi- narily inhibit infection. (3) Shock, which causes a suspension of nervous activity and regulation. Local conditions—(1) Atmospheric conditions of heat and continued moisture or humidity. (2) The character of the soil. Thus, soil that has been repeatedly fertilized contains large numbers of the specific organisms of gas gangrene. Fragments of clothing and of other material so contaminated and driven into the wound, together with similarly infected shell fragments, frequently cause gas gangrene. (3) Wounds involving the large intestine. Such wounds provide a means of exit for the specific organisms w-hich are indigenous in this part of the intestinal canal. (4) Length of exposure. It is quite obvious that this infection is more common in neglected wounds than in those in which debridement is promptly done. 268 SURGERY As to the character of the wound, lacerated and contused wounds caused by irregular high-explosive fragments of low velocity-, with a relatively" small wound of entrance into which muscle substance may prolapse, create favorable conditions for the development of this infection. The more extensively muscle tissue is damaged the greater the likelihood of infection. Contusion, without laceration of muscle tissue, as, for example, from the pressure of broken bony fragments, predisposes to its death by directly compressing its blood supply. A similar though more destructive condition arises from a cutting off of the main arterial supply or from interference with the venous return. The importance of an intact circulation in preventing the development of this infection is seen in those cases in which the infection appears in wounds of several weeks' duration, subsequent to the ligation of a nutrient artery for aneurysm or for secondary hemorrhage. Conditions relieved by prompt debridement well illustrate competent predisposing causes for gas gangrene. Thus, irregular pockets from which proper drainage is impossible, hematomas from uncontrolled bleeding, foreign bodies, fragments of clothing, loose bone fragments, damaged and lacerated tissues, all favor, if neglected, the development of this infection. The need of providing free and unrestricted drainage of all discharge from every- part of the wound can not be too strongly emphasized. While gas bacillus infection is unquestionably due to one or more varieties of specific organisms, of which a list has been given, the presence alone of the specific organism in the wound would not necessarily result in infection, for wounds from the discharge of which the specific organism of gas gangrene has unquestionably been cultured have been observed repeatedly to heal by primary or secondary union without the slightest evidence of infection. It is only in wounds in which muscle is so traumatized that it undergoes necrosis and where the damaged tissue is so deeply placed that access of oxygen is difficult or impossible that this justly dreaded infection is likely to develop. PATHOLOGY Lesions caused by gas bacillus infection vary according to the virulency of the specific organisms; the presence or absence of associated germs, such as streptococci, staphylococci, the bacillus of tetanus, and the bacilli producing putrid changes; and especially the extent of the death of muscle tissue due to the violence of the trauma or to the destruction of the main or collateral cir- culation of the part involved. It is therefore impossible to define any single pathological picture that is typical of the infection as a whole. Reference has been made above to the toxicogenic qualities of anaerobic bacilli and to the proteolytic and saccharolytic ferments which they possess in variable amounts. To their capacity to secrete toxin the greatest importance is attached, for not only do these toxins cause tissue changes leading ultimately to gangrene at the point of infection, but, with their rapid entry into the general circulation, patients quickly succumb to the intensity of the virus. On the other hand, in the absence of toxin secretion, no serious local or constitutional changes are observed. PLATE I MULTIPLE HIGH EXPLOSIVE WOUND. MARKED COMMINUTION OF CORTICAL SECTION OF TIBIA SHOWING MIXED AND PURE GAS INFECTION GENERAL SURGERY 269 TOXICOGENIC CHANGES For anaerobic bacilli to secrete toxins, dead muscle is necessary. Such a suitable medium is usually provided by the force of the trauma, either directly through the impact of a displaced bony fragment or through the crushing of the intima of nutrient vessels, with resulting thrombosis. Where death is due to circulatory interference the color of the muscle becomes purple and on microscopical examination the striae are intact. On the other hand, when death is directly the result of the action of gas bacilli the color is either brick- red or mahogany, depending upon the degree of hemolysis, and the striation is lost. This change in the color of muscle tissue as well as its loss of contractility and the fact that muscle so invaded remains dry without sign of blood when divided are positive indications of the presence of gas gangrene. Microscopical examination of the affected muscle shows at first a dilata- tion of the capillaries and small blood vessels, followed either by" a rupture of their wralls with small ecchymotic extravasations or, because of the paralysis of the muscular part of the media by the local action of the toxin, multiple aneurysmal dilatations appear. In both, the lumina of the vessels are throm- bosed, a condition that still further contributes to the spread of the gangrene. In necrosis due to ordinary- pyogenic infection, nature usually endeavors to restrict the infection by phagocytic concentration and other defensive means. In gas bacillus infection, however, mobilization of nature's protective forces does not take place. On the contrary, extension along the course of the muscle or muscles originally involved is veiy rapid, and, in the event of the shutting off of the main blood supply, the entire extremity becomes quickly- necrotic. The bacilli are found in the early stages of infection betw-een individual muscle fibers. These become swollen, surrounded with an edematous exudate, and finally, losing their structure, are invaded directly by the infecting organism. Edema develops early and causes the initial swelling. At first a serous exudate, it soon becomes discolored at the point of infection. Remaining clear at the outskirts of the infection, it extends along the areolar planes and in the subcutaneous tissues, preceding the extension of the infectious process in the muscle planes. Occasionally it spreads with such speed as to deserve the title of "malignant" and under these circumstances it completely outstrips and over- shadows the phase of tissue necrosis. All anaerobic bacilli, with the exception of hystoliticus, though in different degree, possess saccharolytic ferments. Upon this content seems to depend the production of gas. At first deeply seated, it infiltrates individual muscle fibers betw-een which the bacilli have penetrated and, as it increases in amount, extends along the course of the wound to the subcutaneous tissue and so at times over the entire body. Animal experimentation has shown that this gas has no toxic properties. By the pressure it exerts in the deeper planes it proba- bly facilitates the extension of the infection, and by compressing the blood supply increases the degree of necrosis. It can not be too strongly emphasized that it does not usually develop in sufficient amount to be detected in the early stage of the infection"and that when it can be recognized the infection has reached a stage in wdiich radical treatment is demanded. 270 SURGERY Proteolytic changes include the conversion of necrotic tissue into a mushy shapeless mass of extremely- foul odor which, in localized processes, give rise to the formation of putrid abscesses, and in the rapidly extending varieties in- crease the intensity- of the general toxemia. Some of the bacilli of gas infection secrete fat-splitting ferments, with the result that fatty connective tissue is attacked and partially digested. It is both interesting and important to consider the pathological changes that mark the line of demarcation between healthy tissue and the invaded area, Such a line may- be either regular or extremely- irregular, due to the unequal involvement of the different planes. In the muscle tissue an area of congestion with small hemorrhages generally- is observed, on the proximal side of which muscle fiber still retains its normal contractility, color, and blood supply. If a single muscle only is involved, the infectious process may be limited to that structure extending up and down along its longitudinal axis, for adjacent muscles are well protected by intermuscular aponeurosis acting as a barrier unless there is a shutting off of the main arterial supply, in which event massive gangrene of the entire extremity rapidly develops. The associated serous exudate in the zone of muscle necrosis is usually irritating and infectious, while beyond the line of demarcation it is probably innocuous as long as it remains clear and straw colored and is free from any suspicion of odor. Lesions found in distant organs are chiefly due to toxemia. The occasional development of metastasis, however, and the recovery of the specific organism from the circulation during life, clearly demonstrate that under certain con- ditions the infection may become generalized. This is borne out by- the obser- vations of Weinberg and Seguin3 who, in their study of 91 cases, recovered the Bacillus welchii in 4 cases before death and in 11 of 13 after death. The Vibrion septique was recovered in 3 out of 4 cases and the B. oedematiens in two only before death and in 5 afterwards. Further proof of generalization is furnished by the observation of Mullally and McNee5 in which the bacillus of malignant edema was recovered at the site of three needle punctures four days after the patient was wounded; an amputation of the arm was performed six days sub- sequent to the receipt of the injury. This patient recovered from the infection only to succumb to an attack of pneumonia one month later. In metastatic gas gangrene the organism is frequently recovered from the secondary focus. These metastases usually occur in the buttock or shoulder, regions ordinarily subjected to pressure in the recumbent posture, with consequent diminution in the local blood supply-. To the region attacked by- metastasis the infecting organism travels through either the blood or lymph. While lymphatic transmission is probably the rule, the development of metastasis when the evident path of infection is directly opposed to the course of the lymphatic stream demonstrates the fact that the bacillus must be occasionally transmitted by the blood current. The occurrence of metastasis in an extremity from a primary focus on the trunk may be mentioned in illustration of infection by this route. On the other hand, in the much more frequent metastasis in the buttock or shoulder from a primary focus in the corresponding extremity, the specific organism is probably con- veyed through lymphatic channels. While anaerobic bacilli unquestionably GENERAL SURGERY 271 crease rapidly in the occluding thrombi at the point of infection and easily lss into the adjacent blood stream, their further development must be greatly ipeded by the oxygen content of the red cell. This probably accounts for e difficulty in recovering these bacilli from blood smears. To be sure, in the ter stages of the infection when the patient becomes moribund, resistance to Le entrance into the general circulation greatly- diminishes and at that stage i well as immediately after death, they are more frequently recovered from le blood, as Weinberg has demonstrated, than during the active course of the .feetion. On the contrary-, the absence of oxygen carriers in the lymphatic ream facilitates the transmission of the bacilli by this route, although the mphatie ganglia may more or less effectively- retard their progress. The riter knows of no attempt to determine the presence or absence of the specific ^ganism in the glands which directly- drain the primary focus of infection. ivestigation of this part of the subject might lead to very interesting results. LESIONS IN DISTANT ORGANS Changes in the abdominal organs vary according to the type of infection. Hien associated with pyogenic organisms, the liver, spleen, and kidney-s show cute degeneration such as is ordinarhy seen in septic processes. In gas gan- rene alone, these changes are not so marked. In their place these same organs ppear swollen and spongy and on section show- a frothy- or foamlike infiltration ue to the presence of gas. Although similar changes can be produced in iboratorv animal experimentation, it is not at all certain that in man they are ot post-mortem in character. At all events, there is no record of any such bservation during the life of the patient. Adrenal capsule.—The yellow cortical substance becomes grayish white, ue to the disappearance of the lipoid tissue. The fasciculated cells show egenerative and inflammatory changes similar to those observed in peritonitis ut more rapid in development. In the presence of these advanced changes 1 the cortex, the interior or pulpy portion of the glands remains normal. liese changes are of interest on account of their possible relation to the changes bserved in the blood pressure of patients suffering from gas bacdlus infection. Brain.__This organ is usually pale and somewhat edematous. The fluid i both the subarachnoid space and ventricular cavity may be increased. In elayed death, the basal vessels show gaseous infiltration. ' Heart .—The muscle fiber is pale and shows cloudy swelling. There may e subendocardial ecchymotic extravasations. Lungs.—There are often patches of bronchopneumonia, in which ocea- onally the anaerobic bacillus may be found. There may be small subpleural emorrhages. Stomach and intestines.—These organs usually are distended, although teeptionally they may be empty. CLINICAL MANIFESTATIONS Variations in the type and number of the specific organisms, as well as leir frequent association with one or more varieties of common pyogenic rganisms. mentioned above in the consideration of the pathology of this 401W7—27---20 272 SURGERY subject, make it necessary to observe a rather wide latitude in any description of the clinical manifestations of gas gangrene. The subject perhaps is prefer- ably approached by a detailed description of individual symptoms followed by their collection into groups according to the severity of the infection. PERIOD OF INCUBATION This is usually- from one to four days, according to the malignancy of the specific organism and to the extent of the necrosis of muscle tissue. It is noteworthy, however, that this period may- be prolonged for weeks or even months. In fact the specific organism may- remain quiescent during the entire reparative process and continue harmless for months in the cicatrix, only to be released in the course of an operation then undertaken to remove a piece of shell fragment or other foreign body or to correct a bony deformity- resulting from the original trauma, or it may- even follow the removal of the cicatrix for plastic purposes. A similar outbreak of the infection occasionally develops in cases of appendicitis in which a secondary abscess may occur months or years after the original operation. In gas infection, however, such tardy activity is not, as in colon infection, necessarily mild but may prove most serious and even may terminate fatally-. INVASION The invasion is usually insidious. If the infection is not associated with pyogenic organisms, pain, referred to or below the point of infection, is not infrequent. It is rather a more or less sudden intensification of the pain previously existing due to the trauma of the penetrating wound from which it must be carefully distinguished Under similar conditions (absence of pyogenic organisms) swelling is quickly added to the pain, due to the incipient edema of the subcutaneous tissue. This edema gives to the skin above and below the wound a whitened appearance followed by a creamy tint, and makes the surface veins more distinct and dilated. Also it imparts a slightly- tense feeling of elasticity, though there is no pitting on pressure, to the subcutaneous tissue. Of the four cardinal symptoms of inflammation these two only are present, redness and heat being conspicuously absent. The frequency- with w-hich the streptococcus or staphylococcus is associated with the specific organism, however, accounts for numerous exceptions to this general rule. In that event all four symptoms of inflammation may be elicited. In addition to the pain and swelling, local symptoms include the appear- ance of the wound and its immediate environment, the type and character of the edema, the formation, location, and behavior of the gas. LOCAL SIGNS AND SYMPTOMS CHARACTER OF THE WOUND At first, as in a healthy wound, the immediate discharge is serosanguinolent. However, the serous element quickly diminishes in amount, becomes pinkish and discolored, and shortly afterward assumes a dirty brown color. The discharge is irritating to the surrounding parts. The wound rapidly becomes GENERAL SURGERY 273 unhealthy and its sloughy- surface is apt to be covered with a gelatinous dis- charge which, as gas is produced, may contain air bubbles. These same bubbles can frequently be expressed from the w^ound. The discharge, more- over, usually- develops a more or less typically foul odor in the early stages of the infection due to rapidly increasing putrid bacteria in tissues already swarming with the specific organisms. The edges of the wound become necrotic and ragged. With the approach of the gas toward the surface, the skin adjacent to the wound assumes a brown, bronzed, or orange color; in Fig. 157—Gas gangrene of arm before operation. (Courtesy of Maj. Benjamin Jablons, M. C.) the more malignant types the color is blue or violet, In this discolored area, coalescing vesicles appear. These vesicles are numerous in the vicinity of the wound, and occasionally they show a tendency to encircle irregularly the circumference of the extremity. In other cases they seem to follow the course of the superficial veins. If their contents are light in color these vesicles are believed to be due to lymphatic occlusion; if dark in color, to thrombosis of the smaller superficial blood vessels. Later, as the condition progresses, the fluid contents mav contain air. The segment of discolored skin containing 274 SURGERY these vesicles gradually becomes leatherlike and may eventually be discharged as a slough. Such necrosis is rapid and certain in the more malignant type where the discoloration is blue or violet and is the forerunner of death of the entire extremity- below the level of the infection. EDEMA This is due to serous exudate both in the involved muscle planes and, afterwards, in the subcutaneous tissue. In the zone of infection it is tinged with blood and swarms with anaerobic germs and, later, with those responsible for the foul odor of the discharge. Receding from the point of primary infec- tion the specific organisms decrease in number until, at the line of demarcation, the serum, although still possessing toxigenic qualities, is entirely- free from organisms of any kind. In this area it is considered by some to be relatively harmless, if not actually beneficial. It is thus said to be analogous to the straw-colored exudate in the early stages of infectious peritonitis, which, at Fig. l/vs.—Gas gangrene of arm, colored man, after amputation. (Courtesy of Maj. Benjamin Jablons, M. C.) first free from contaminating organisms, speedily becomes invaded by the spreading infection. The edema extends more or less rapidly along the lymphatic spaces in the neurovascular sheaths and in the subcutaneous tissue, and while at times it indicates the level of muscle necrosis, it occasionally outstrips this particular phase of the lesion and spreads with frightful rapidity over the entire body and neck. The edema is at times much less compressible than is ordinarily the case, and the line of demarcation is sharply delineated by a distinctly- raised wall which permits an accurate estimate of its progress. Such a type of edema seems to be associated with the more malignant forms of gas bacillus infection, especially with those due to the bacillus edematiens. GAS FORMATION The presence of gas causes a distinct crepitation which can be detected by gently stroking the overlying skin with a smooth, flat instrument, and, as it becomes more abundant, by pressure with the palmar surface of the fingers. It indicates by its location the muscle or muscles involved and extends in all PLATE II HIGH EXPLOSIVE SHELL WOUND; GAS GANGRENE. LEFT KNEE, WITH JOINT RESECTION SHOWING MARKED GASEOUS EMPHYSEMA OF CENTRAL AREAS, AND PUTREFACTIVE INFECTION OF SUPERFICIAL MUSCLES WHICH HAS PRODUCED BRONZING PLATE III GUNSHOT WOUND; GAS GANGRENE. RIGHT KNEE, SHOWING DELAYED GANGRENE OF THIGH MUSCLES FOLLOWING FRACTURE AND OSTEOMYELITIS OF FEMUR GENERAL SURGERY 275 directions until the affected muscles are completely necrotic. Intermuscular septa ordinarily check its advance until the entire extremity becomes gangren- ous, when gas infiltration is rapidly generalized. It can be detected in the early- stages by auscultatory percussion and shortly afterwards by ordinary percus- sion. X-ray exposures show at first longitudinal streaks which, extending, become gradually more distinct and then quickly develop into air bubbles— an extension which can be readily noted in successive X-ray plates. As gas production increases, bubbles appear in the discharge or may be expressed from the wound. The length of time elapsing before gas can be recognized is approximately longer when the affected muscle is deeply seated than when it is superficial. When deeply seated, the infection may have gained great headway before this symptom appears. In general, it must be emphasized that the presence of gas is not manifest in the early stages of the infection. The subcutaneous tissue becomes infiltrated with the gas when it passes along the interstices of the wound towrard the surface of the body. It is at this stage that it either appears in the discharge or may be expressed from the wound. The possibility of the primary involvement of the sub- cutaneous tissue has been much discussed. That gas infection develops origi- nally in necrotic muscle is now generally conceded, and where the gas is entirely superficial to the deep fascia, involvement of a small portion of the under- lying muscle has been assumed. The strongest argument that has been advanced in favor of the development of this infection without damage to muscle substance rests upon those cases in which gas bacillus infection has followed the subcutaneous injection of some medicinal agent, such as camphor or digitalis, or where it has developed after the infiltration of subcutaneous tissue with saline solution in hy-podermoclvsis. As a matter of fact, however, it is in patients already suffering from gas gangrene at some distant point that this unusual condition has been noted, and it is quite possible that it may- he accounted for as a metastatic manifestation due to the presence of the specific organism in the general circulation. INCREASING SWELLING The initial whitening of the skin due to the incipient edema has been noted. With the formation of gas and the continued edema, the swelling increases, involving the extremity more rapidly below- the point of infection than nearer the trunk. The gradual extension of the swelling may be demon- strated by successive measurements of corresponding portions of the two extremities, the line of demarcation being at that point where no increase in the circumference of the affected extremity can be detected. It can not be too strongly emphasized that treatment should not be delayed until the characteristic symptoms of crepitation and odor appear. In the early part of the war radical and thorough debridement of the wound had not been developed, and treatment frequently was delayed untd symptoms of infection had appeared, with most unfortunate results. Even in the latter part of the war, because of unavoidable delay in the succor and transportation of the wounded, or because of the virulency of the infection, patients not 276 SURGERY infrequently were admitted to hospitals at the front in such a condition that no radical measure could be of benefit. These unfortunate patients afforded abundant opportunity for the observation and study of the later clinical mani- festations of the infection. CONSTITUTIONAL SYMPTOMS Constitutional symptoms are due to the toxemia as well as to the absorp- tion of chemical products resulting from the destruction and decomposition of the invaded tissues in the infected area. Circulation.— Acceleration of the pulse is one of the earliest symptoms. In a few hours after the invasion the pulse reaches 130 or higher and is small in quality. At first a temporary rise of pressure is noted, possibly due to suprarenal changes; a rapid fall quickly ensues and, in fatal cases, continues to the end. Temperature.—The temperature is almost always relatively low, usually not exceeding 101° to 103° F.; it is entirely out of proportion to the quality and rapidity of the pulse. This peculiar combination, namely, a low temperature with an unusually rapid pulse, should immediately excite suspicion of the presence of this serious infection. Respiration.—Respiration is decidedly7 increased in frequency due to the rapid decrease in red cells, and other changes that greatly diminish the oxygen content of the blood. In the more malignant cases dyspnea appears, although usually the skin remains pale, without sign of cyanosis, to the end. Surface of the body.—With the development of the circulatory disturbance and the progressive anemia marked pallor appears. This continues to the end. Jaundice is not infrequent, giving, together with the pallor, a dusky hue to the skin. The surface of the body is usually- moist and may be bathed in perspiration. Bowels.—There is usually constipation; occasionally diarrhea. Central nervous system.—-Patients are usually apathetic and fail to appre- ciate the seriousness of their condition. Restlessness is not uncommon; delirium rarely appears; consciousness is preserved to the end. Death results from paraly-sis of the important basal nerve centers. GROUPED SYMPTOMS Since gas infection varies widely in virulency, and consequently in the extent and character of both local and constitutional symptoms, it is customary to somewhat arbitrarily assign all cases to one of three groups: (a) Those of mild character; (_») those of a malignant type; (c) those intermediate in severity. It is quite obvious that the line of demarcation between these different groups is not always sharply- defined. Thus, an infection w-hich appears at first mild and localized, may suddenly become virulent and spreading, wTiile infections of moderate severity may rapidly develop malignant manifestations. Unfortu- natelyr infections, originally serious, rarely if ever become less virulent. In these malignant cases only prompt treatment can save the patient's life. GENERAL SURGERY 277 Mild Cases In view of the fact that one or more varieties of anaerobic organisms frequently can be cultured from the discharge of wounds which heal without complication, it is not at all surprising that gas gangrene may remain localized. This fortunate result is most likely to ensue when the damage to muscle is superficial, or slight in extent, and the muscle exposed to air; or when the associated anaerobic bacilli are mutually restrictive. Similarly, when a single muscle only is invaded, the infection, although spreading in both directions along its longitudinal axis, may yet be confined by the intermuscular barrier to the muscle originally- involved. In these cases of localized gangrene the infection not infrequently appears after transportation of the patient to a base hospital. The relatively- long period of incubation is followed by a mild grade of infection, with the result that the mortality is very much less than in a field or evacuation hospital. In this group of cases the local symptoms differ from those previously enumer- ated in their extent and frequently resemble the local symptoms of an abscess due to one or more pathogenic gas-producing bacteria. In fact, the symptoms of crepitation common to both types of infection has probably- led to erroneous diagnoses. By the inspection of the abscess cavity in the course of treatment the two conditions are readily differentiated. In infection due to pathogenic organisms leucocytic infiltration is extensive, and muscular necrosis, limited to the immediate abscess wall, is manifested by irregularly- sloughing strings. The red-brick color, so characteristic of gas gangrene, is absent. The consti- tutional symptoms in the two conditions present a sharp contrast. In abscess due to pathogenic gas-producing organisms the temperature is relatively high, the pulse bounding and of good tension, the face decidedly red, and, w-hen excep- tionally the infection becomes diffuse, delirium with metastatic multiple abscesses mav occur, a condition never developing in uncomplicated gas bacillus infection. Severe or Malignant Cases In the severe or malignant types of gas gangrene, the intensity of the in- fection is measured chiefly by the rapidity of extension of the local symptoms and the quickness with which patients become acutely toxic, the latter being indicated especially by extreme circulatory weakness and a condition of col- lapse. While the evidence of grave constitutional disturbance shows no essential variation, the local symptoms, especially the crepitation, the edema, and the character of the discharge, may vary very considerably. Thus, theoretically, the invasion of dead muscle by anaerobic bacilli alone results in a condition of intense toxemia w-ith little edema and, if the bacilli do not possess the saccharo- lytic ferment, in little or no gas production. In infection due to Vibrion septique edema may be the predominant symptom. As has previously been noted the type and rapidity of extension of the edema may also vary. Thus in infection due to the Bacillus edem.aticns the edema is much less compressible than is the case in infection due to the Vibrion septique and. advancing with a sharp line of demarcation in the formation of a raised wall, it may extend much more rapidly- over the main part of the entire body. Again the foul odor of the discharge 278 SURGERY develops only when one or more putrid bacteria are added to the specific organ- isms. As a matter of fact, however, such association is rarely, if ever, absent. Considerable variation in the character and arrangement of the bulla, and in the color of the skin near the point of infection is not uncommon, a darker color indicating more extensive vascular changes. Finally the fre- quent association of the specific organism with pathogenic bacteria may greatly modify the character of the local symptoms. In a general way, gas produc- tion, edema, and the development of a foul discharge may be considered fairly- constant local symptoms while, according to the nature of the specific bacillus, either gas production or edema may predominate. CLINICAL PATHOLOGY LEUCOCYTOSIS Observers differ materially in regard to the behavior of the white cell in gas gangrene infection. The larger number state that they are diminished. All agree that, in the tissue invaded by the specific organism, the barrier caused by the massing of leucocy-tes is either defective or absent. This discrepancy in the effect of the infection upon the general and polymorphonuclear count is perhaps to be ascribed to the fact that, in the early stages of infection, as well as in cases of mixed infection in which pathogenic organisms are present, the leucocyte count, although ultimately diminished, may at first be increased. It is also quite possible that the increased leucoeytosis, reported by some observ- ers is essentially a relative increase made possible hj the rapid and progressive decrease in the number of red cells. More striking is the condition of the red cell itself. There is a marked anemia, even in the early stages, the number of red cells diminishing to perhaps less than one million per cubic centimeter. In an interesting and exhaustive essay on this subject, Jablons 2 has called atten- tion to anisocytosis, stating that the macrocytes predominate at the beginning, while the microcytes predominate toward the end of the infection. He further states that poikilocytosis is constant. In 10 cases there was a noticeable poly- chromatophilia, nucleated red cells being present in 4 cases. The blood serum in fatal cases shows a definite hemolysis. Examination of the urine, especially in cases of mixed infection, reveals the presence of albumin and casts. TREATMENT PROPHYLAXIS Debridement of all contaminated wounds, especially of those due to ex- plosive fragments at short range, at the earliest possible moment, is unques- tionably the most efficient means of forestalling the development of gas gan- grene. Wounds so treated should be left in such condition as to permit free exit of all discharge and should be allowed to heal by granulation, secondary- closure being done, if at all, after the danger of infection has passed. This pro- cedure, adopted generally in the latter part of the war, greatly diminished tbe incidence of gas gangrene and lessened its virulence. GENERAL SURGERY 279 Serum Therapy As the knowledge of the bacteriology of gas gangrene increased it was generally expected that serum administered both as a prophylactic and also after the infection had appeared, would prove as successful as serum therapy- had proved in tetanus and diphtheria. It was found, however, that while some animals could be rendered immune for various lengths of time in the labora- tory, the results achieved in man were somewhat disappointing. This w-as probably due to several factors. In the first place the spread of the infection was frequently so rapid that the patient became either moribund or died before the specific organism could be isolated. In the second place the infection, usually due to more than one variety of the bacillus, was associated with some form of pathogenic organism, such as the streptococcus or staphylococcus, in either of which conditions a serum prepared from a single species w-ould naturally prove of little or no value. This complex nature of the infection led Weinberg and Seguin6 to replace serum derived from a single organism with one composed of a mixture of the sera of several of the most frequent organisms of gas gangrene. A similar polyvalent serum was introduced by Leclainche and Vallee.7 The use of this "hit or miss" method w-as more encouraging. Thus Frances Ivens4 reported 10 cases treated by the mixture of Weinberg and Seguin with a successful result in 5. The fatal cases were septicemic when the serum was given. M. Weinberg 8 stated that the polyvalent serum of Leclainche and Vallee seemed to have given particularly good results as a prophydactic, es- pecially- in wounds in w-hich the specific organism was associated with strepto- coccus. He further emphasized the fact that the best autovaccine is one pre- pared from all the organisms both anaerobic and aerobic, found in the wound. Several injections are made daily or every two days and "in certain cases the effect is indisputable." Weinberg and Seguin referred to 6 eases of infection due to Bacillus oedematiens which recovered after treatment by anti-oedematiens serum ''after the infection had reached an alarming stage." Frances Ivens 9 describes the results of the prophylactic treatment of wounds with anti-gan- grenous serum. This writer reports 433 cases, many- of which presented clinical signs of gas gangrene and divided them into three groups, as follows: (1) 222 cases (126 fractures) treated by 10 c. c. each of anti-Welch, anti-Vibrion septique and anti-oedematiens serum of Weinberg. (2) 151 cases (110 fractures) treated by 30 c. c. of Leclainche and Vallee polyvalent serum. (3) 57 cases (34 fractures) treated by 30 c. c. Weinberg and 10 c. c. of Leclainche. In each case the serum was given subcutaneously in one pint of saline at the time of operation. RESULTS Group (1): Mortality, (a) where the serum w-as given at or before the first operation, no case died of gas gangrene; (b) amputation, of 14, 2 died after a fortnight from streptococcal septicemia; (c) conservative treatment, serum therapy has permitted " conservative treatment instead of amputation in a large number of cases." The result in 10 cases was not ascertained owing to early evacuation of the patients. Group (2): (a) Mortality, 19 fatal cases, of which 3 were due to gas gangrene and 3 to gas gangrene with concurrent septicemia; (b) amputation, 4 of 15 w-ere fatal, 2 with concurrent septicemia. 280 SURGERY In the majority of cases no severe streptococcal infection occurred during the period of preventive administration with the Leclainche polyvalent serum. Group (3): (a) Mortality, 2 cases, one of massive gangrene; (b) ampu- tation, 3 cases, 1 for streptococcal infection, 2 for secondary hemorrhage. Gangrene was present at the beginning of treatment in 10 cases. Of these, massive gangrene developed only in 1, 15 days after the preventive dose of serum had been given. Frances Ivens9 concludes that a powerful antigan- grenous serum is of real value in preventing gas gangrene; used in sufficient quantities it is of great value as a disintoxicating agent in cases of advanced infection; that the Leclainche and Vallee polyvalent serum has a marked effect in cases with concurrent streptococcic infection; that anaphylactic phenomena were frequently averted through the dilution of the serum with normal saline solution. Before secondary operation, a further fractional dose of the serums should be administered. While these interesting results seem to indicate that serum administration is a valuable method of treatment, it is perhaps unfortunate that no attempt was made to compare them with those of a fourth group in which surgical measures only were employed. Unquestionably the virulence of gas gangrene, irrespective of the special etiological organism, varied according to the location of the battle line, the question of easy or difficult succor and transportation, the presence of heat or moisture, and other well-known conditions. While the 433 cases reported by Ivens occurred betw-een March 21 and September 6, 1918, in patients " recently wounded, arriving at the hospital for primary operation," it is quite possible that conditions favored a relatively mild grade of infection. It is believed, without belittling in any way the results obtained in these 433 cases, that in other parts of the battle line the mortality might have proved much greater in an equal number of cases treated by similar methods. At least during the Meuse-Argonne operation, patients were admitted for primary treatment to an evacuation hospital not infrequently with the infection so far advanced that no form of serum therapy could possibly have been of any avail. In this connection it is interesting to compare the results obtained by serum therapy within the German lines with those of Frances Ivens.9 Herman Coenen10 reported 1,180 wounded injected immedi- ately- with polyvalent serum. Of these only 8, of whom 4 died, developed gas gangrene. Of 75 wrounded not injected, 8, of whom also 4 died, developed gas gangrene, a very much higher percentage. The serum w-as given in doses of from 20 to 40 c. c. and later in larger doses intraveneously. Anaphylactic com- plications were rare and were manifested by dyspnea, heart weakness, and coma, resulting rarely in death. In 1917, Aschoffn reported 2,356 wounded, of whom 223 were injected with polyvalent serum, of whom 98 died (43 per cent), while of those not injected 68 per cent died. SURGICAL TREATMENT Gas gangrene, irrespective of the efficiency of prophylactic serum therapy, demands prompt surgical attention. The shorter the period of incubation, the more prompt should be the treatment. Especially where the infection shows a malignant tendency the greatest precaution should be exercised to detect it in GENERAL SURGERY 281 its incipiency. Treatment consists either in the excision of the infected area, together with all dead tissue, or of amputation. On the trunk and buttocks, obviously excision only is available. In the extremities the question of ampu- tation must receive due consideration. Excision is justified where the period of incubation has been relatively- long, where the infection is near the tip of an extremity-, where the infection is localized or very slowly spreading, where the main circulatory- channels are intact, where no fracture exists, where no large joint has been opened, and, irrespective of its virulence, where the infection involves the trunk. On the other hand, amputation is indicated in extensive laceration of the soft parts, where several groups of muscles are invaded byT the infection, w^here there is an extensive comminuted fracture with or without opening into a large joint, where gangrene is self-evident, where the main vascular channels are divided, and where the symptoms of general toxemia develop early. To advise delay in the presence of one or more of these condi- tions until the question of the rapidity of extension can be determined, is to waste valuable time and to jeopardize the chances of recovery-. A third group comprises infection on the border line. While prompt operation is as essential in these as in the more serious types of infection, the question of excision or of amputation depends upon the individual judgment of the surgeon. Many- lives have undoubtedly been sacrificed by conservatism which might have been saved at the expense of the loss of a limb. In cases of doubt, amputation is the operation of choice. In either excision or amputation, the narcosis, for obvious reasons, should be as short as possible, and all constriction during and after the operation, should be avoided, for the pressure so exerted still further decreases a local blood supply already severely impaired, and mechanically forces poisonous infectious products through lymphatic and vascular channels into the general circulation. The object of excision should be to remove foreign bodies, includ- ing shell fragments, clothing, and all dead tissue, especially- necrotic muscle, stopping only w-hen the divided muscle tissue both bleeds and contracts; to remove all hematoma; to check all bleeding; and to leave the operative field free from pockets so that all discharge shall pass without possibility of retention into the enveloping dressing. Large joints, if involved, may require excision, although in these cases, amputation, as already stated, is usually preferable. All fractures should be so treated as to avoid constriction by any form of reten- tive apparatus. . When amputation is indicated, no delay is justifiable. He who hesitates will frequently lose his patient. Only the plane, not the time, of amputation is to be determined. It should be at a level sufficiently high to permit of the division of healthy contractile muscle and, if possible, on the proximal side of the area of edema. As in the case of excision, no closure of the operative wound should be attempted. Circular or lateral flaps of skin and subcutaneous tissue are advocated. These mav be easily and quickly fashioned and event- ually brought over the end of the stump when all danger of infection has passed. In this way secondary amputation, involving further sacrifice in the length of the extremity, mav frequently be avoided. Such a procedure is far preferable to the alternative measure, the so-called guillotine amputation, in which the 282 SURGERY skin, muscle, and bone are all divided at the same level. The dressing after either excision or amputation should be loosely- applied and arranged so as to avoid pressure or constriction. Antiseptic wet dressings have been advocated to prevent the reappearance of the infection in the wound, such as Dakin's solution, hypertonic salt solution, peroxide of hydrogen, and weak solutions of sulphate of quinine. Some prefer to leave the wound freely exposed to the air. This, at least, has the advantage of facilitating dressings without the excessive pain of which patients almost invariably- suffer when the compresses, partially- dry and closely adherent to denuded tissues, are removed. Of all local appli- cations, dichloramine-T is preferred, as it combines a certain antiseptic value with the possibility of removal of compresses previously moistened by it, with the minimum discomfort to the patient. The "open air" method also is of value, especially if combined with some form of cage protection arranged so as to avoid pressure or constriction of the stump. While metastasis in pyogenic infection is usually the precursor of a fatal termination, it must not be so regarded in gas gangrene. This rare complica- tion, occurring usually in parts subjected to pressure, such as the buttocks or shoulders, must be attacked in the same way as the original focus of infection, namely, through the excision of the necrotic tissue, the wound being left open. A considerable number of recoveries after operation for metastasis have been reported, probably to be explained by the difficulty the specific organism encounters in its effort to flourish in the general circulation. While radical surgical treatment is invariably indicated in all cases of gas gangrene in which the patient is not moribund, the mention of other measures less frequently- practised, should not be omitted. Chief of these is treatment designed to increase the blood supply in the infected area. This may- be ac- complished either by cataplasm or by enveloping the limb with continued hot applications, always taking care to avoid constriction. By increasing the blood supply and therefore the oxygen content, the activity of anaerobic organisms is correspondingly curtailed. The Bier method of constriction, well on the prox- imal side of the infection, has also had a limited trial, chiefly by its author and a few others in German hospitals, w-ith a certain amount of success. In still other cases, through special apparatus, devised in German hospitals, intermit- tent or rhythmic constriction is applied to the affected extremity with more satisfactory results than when the constriction is stationary. The writer has failed to find any mention of the application of constriction to the treatment of gas gangrene by any member of the Allies. For this reason the actual value of this method is more difficult to estimate than the value of other methods of treatment which were in general use bv friend and foe alike. Theoretically the insufflation or injection of oyxgen into the infected field ought to inhibit, if not actually paralyze, anaerobic activity. Because of the impossibility, how-ever, of oxygen so injected coming into direct contact with all specific organisms, this method proved of little value. Furthermore patients so treated are exposed to the danger of the entrance of gas directly into venous channels with, at times, a fatal result. During the war, transfusion w-as occasionally given and while its value was not generally admitted, favorable reports were cited in a limited number of cases. GENERAL SURGERY 283 PROGNOSIS The prognosis of gas gangrene depends upon the nature of the specific organisms, their association with pyogenic organisms, and the stimulating or inhibitive effect of each upon the others' activities. Local conditions and the type of a warfare also influence the prognosis. In the discussion of the pathol- ogy- and symptoms of gas gangrene, these factors received due consideration. The question of the location of the infection, irrespective of its tvpe, modifies the prognosis. Cases in which the trunk or buttocks are primarily involved, having a mortality of about 50 per cent, are more serious than infections of the extremities in which the prognosis becomes more favorable as the tip of the extremity is approached. REFERENCES (1) Douglas, S. R., Fleming, A., and Colebrook, L.: Studies in Wound Infections; on the question of Bacterial Symbiosis in Wound Infections. Lancet, London, April 21 1917, i, 604. ; (2)TJablons, Benjamin: Gas Gangrene. Xew York Medical Journal, 1919, c\, December 20, 1914. (3) Weinberg, M. and Seguin, P.: Etude sur la gangrene gazeuse. Annates de I'Institut Pasteur, Paris, 1917, xxxi, No. 9, 442. (4) Ivens, Frances: A Clinical Study of Anaerobic Wound Infection with an Analysis of 107 Cases of Gas Gangrene. British Medical Journal, London, December 23, 1916, ii, 872. (5) Mullally, G. T. and McNee, J. \\\: A Case of Gas Gangrene Exhibiting Unusual Proofs of Blood Infection. British Medical Journal, London, April 1, 1916, i, 478. (6)_Weinberg, M. and Seguin, P.: Essais de serotherapie de la gangrene gazeuse chez l'homme. Comptes rendus des seances de I'academie des sciences, Paris, 1917, clxv, No. 5, 199. (7) Leclainche, E. and Yalec, H.: The Specific Serum Treatment of Wounds. Journal of Comparative Pathology and Therapeutics, Edinburgh and London, 1916, xxix, No. 4, 283. (8) Weinberg, M.: Bacteriological and Experimental Researches on Gas Gangrene. Pro- ceedings of the Royal Society of Medicine, London, 1915-16, ix, Occasional Lecture, March 10, 1916, 119. (9) Ivens, Frances: The Preventive and Curative Treatment of Gas Gangrene by Mixed Serums. British Medical Journal, London, October 19, 1918, ii, 425. (10) Coenen, H.: Ein Rtickblock auf 20 Monate feldarztlicher Tatigkeit, mit besonderer beriicksichtigung der gasplegmane. Beitrdge zur klinischen Chirurgie, Tubingen, 1916, ciii, 397, 463. (11) Aschoff, L.: Ueber bakteriologische Befunde bei den Gasoedemen. Deutsche medi- zinische Wochenschrift, Leipzig and Berlin, February 14, 1918, xliv, 172. CHAPTER X TETANUS The incidence of tetanus in the American Expeditionary Forces was de- cidedly low; so low, indeed, as to warrant the statement that, as a disease;, we had no real clinical experience with it: only 36 cases were reported as being associated with 176,132 battle injuries, or a rate of 0.014 per thousand.1 This fact in itself is worthy- of more than passing notice and is but a further exem- plification of our good fortune in being able to profit by the experiences of our Allies. The relationship of soiled gunshot wounds and the occurrence of tetanus was well understood prior to the beginning of the war in 1914, and such injuries occurring on the highly fertilized ground of the battle fields of France were inevitably followed by a high incidence of tetanus. However, the Allies did not anticipate any such number of cases of tetanus as occurred in the first few months following the beginning of the war. Even had it been otherwise, there was neither organization nor adequate material for proper administration of antitoxin. Within a very few months, however, the British ordered that a preventive dose of antitetanic serum be given to every wounded man.2 The results of this order were reported to be excellent; in the latter half of the y-ear 1915 only 36 cases of tetanus developed among those who received a preventive dose of antitetanic serum within 24 hours of receipt of injury.2 This measurable, though not entirely complete, control is graphically shown in Chart VI, which is a compilation of Maj. Gen. Sir David Bruce, chairman of the British war committee for the study of tetanus, to show the ratio per thousand among the cases of tetanus.3 The case incidence shown in Chart VI refers to cases of tetanus arising in hospitals in England among the wounded arriving there from the battle fields, and it does not have to do with the cases occurring in France; however, another study by Cummins4 which combined the incidence figures for the Brit- ish Expeditionary Forces and those used by Bruce, shows a very similar curve. The elevations in the incidence curve as shown in Chart VI may be ex- plained as being partly due to periodic, increased battle activities, and partly to the occurrence of trench foot. More especially is this true, in so far as trench foot is concerned, in 1916, to which further reference is made below. What is of greater interest, as regards the American Expeditionary- Forces, is the almost uniform flattening of the curve during 1918, at a time w-hen we were actively engaged with the enemy. VARIETIES OF TETANUS BACILLUS Tulloch,5 by means of serological tests, identified four classes of tetanus bacilli. Twenty-three strains of the tetanus bacillus were obtained from war wounds of men not suffering from tetanus. Seventeen of these strains belonged 284 GENERAL SURGERY 285 Chart VI.—Incidence of cases of tetanus. Ratio of cases per thou- sand wounded, by months PREVENTION SERUM PROPHYLAXIS Once the necessity for the administration of antitetanic serum to all injured men was fully- appreciated, the belligerent nations so organized their medical forces as to insure the administration of the serum at the earliest possible moment following the injury. This meant the serum must be as readily- avail- able, and practically as far forward, as was the first-aid packet; some means of rapidly determining, by a mark—usually- an iodine-painted cross on the fore- 286 SURGERY hand—or bv ticketing, whether or not an acutely injured man had received an adequate dose of the serum; and finally a checking up at the operating hospitals to insure protection in cases in which, through inadvertence, the administra- tion of the serum had been omitted. The British adopted 500 units as the preventive dose, to be given sub- cutaneously at a distance from the wound; the French, 10 c. c. (equivalent to about 600 units).2 It was expected that this routine injection of serum would bring about the lowest possible incidence rate of tetanus; however, when, with the occurrence of large numbers of trench foot, it was observed that with such a condition tetanus frequently was associated, it was realized that the portal of entry into the body by the tetanus bacillus need not necessarily be an open wound.6 Therefore all cases of trench foot were included with battle injuries for which the serum w-as to be administered as a matter of routine, with the result that in trench foot the occurrence of tetanus wras prevented. It was appreciated by the British that 500 units of antitoxin was in many instances too small a dose, and on July 4, 1917, modified instructions required the use of 1,000 to 1,500 units "in all deep wounds in those which are contami- nated w-ith dirt, and in those in which there is fracture of bone." 3 The size of the dose, however, w-as not fully determined as late as December, 191S. Bruce at that time announced his preference for multiple and smaller doses,3 an attitude that was based upon the fact that the antitoxin disappears within the body within a relatively few days. Duration of Passive Immunity With the view of determining the duration of immunity conferred by- anti- tetanic serum, MacConkey and Homer 7 carried out a series of experiments on guinea pigs. In these experiments it was found that immunity from the mini- mum dose was considerably diminished at the end of 10 days, and at the end of 2 weeks it had about disappeared; immunity could not materially be prolonged without increasing the dosage of serum to a degree impractical in man. They concluded, therefore, that it is necessary, in order to maintain immunity-, to repeat the usual protective doses about once a week during the danger period. As stated above, the British, in 1917, required an increase of the initial dose in certain classes of wounds, from 500 units to 1,000-1,500 units. The British tetanus committee, in the same year, recommended that, additional thereto four doses, each of 500 units, should be given at intervals of seven days. This latter recommendation was responded to variously, from 40 to 90 per cent.3 consequently, it is impossible to say definitely what influence multiple doses of serum had upon the lowering of the incidence of tetanus. During the fall of 1918 the strength of the primary dose to be given at the front was increased to 1,500 units, with the hope that a higher degree of immunity might be obtained. Second, third, and fourth doses were to be given at weekly intervals, the strength of each to be 500 units.3 Since the war ended soon after this last change in the administration of the serum inadequate time remained to determine whether or not any improvement resulted from it. What is of particular interest, how- ever, is the fact that, with the increase of the number of multiple injections, the GENERAL SURGERY 287 mortality rate progressively decreases in those contracting tetanus. There is a relationship betw-een prophylactic injections of antitetanic serum and the pro- longation of the incubation period of tetanus, w-hich must be taken into con- sideration in the present connection, for it is possible the decreased mortality mentioned above might to a certain extent be attributable to cases with lengthened incubation periods; a long incubation period goes hand in hand with low mortality. According to Bruce,3 the average incubation in davs in 1914-15 w-as 13.4; 1915-16, 31.2; 1917-18, 46.19. SURGICAL PROCEDURES The tetanus bacillus being an anaerobe, thriving best on putrescent tissue, it follows that the early and absolute excision of such tissue, as well as foreign bodies, ranks first as a prophylactic. This w-as one of the great surgical lessons which the war taught and w-as not appreciated thoroughly until 1917, and after other and much less satisfactory methods had been tried out. It is true that tetanus was only one of the several kinds of w-ound infection for w-hich w-ound excision was devised, nevertheless the agreement is general that thorough wound excision had a material influence on the incidence of tetanus following its general adoption in the spring of 1917. On the other hand, nothing occurred during the w-ar to change the opinion obtaining prior thereto that operation should be avoided in cases of tetanus, for by the time tetanus symptoms appear there is already a general toxic condition. Because it was recognized so frequently- during the war that tetanus bacilli could lie dormant for surprisingly long periods, only to light up on surgical interference, the administration of a prophylactic dose of antitetanic serum was generally practiced prior to secondary operation on war wounds and upon manipulations incident to the reduction of compound fractures. MODIFIED TETANUS With the widespread use of antitetanic serum for the prophy-laxis of tetanus, classical forms of the disease occurred less commonly than the modified (local tetanus). Burrows 8 states that this localized tetanus may be splanchnic, cephalic, or seated in the limbs, and explains its occurrence on the basis of laboratory experiments with animals. These experiments showed that the teta- nus toxin gains access to the nervous system either by the general blood stream or by the motor nerves. The injection of antitoxin in cutting off approach by the blood stream permits the toxin to find access only along the motor nerves. Hence it can cause only local spasticity. MEMORANDUM ON TETANUS, AMERICAN EXPEDITIONARY FORCES Based upon the facts outlined above, the following information was pro- mulgated to the medical officers of the American Expeditionary Forces for their guidance in the prevention and treatment of tetanus:9 Spores of the tetanus bacillus are universally distributed in soil that has been cultivated and manured. In consequence they are virtually constant throughout the battle fields of France. And since the soil inevitably gets upon the clothes and bodies of soldiers, all wounds must a priori be regarded as probably contaminated with tetanus. Tetanus spores 46997—27---21 288 SURGERY in such wounds may at any time develop into tetanus bacilli and produce tetanus toxin, with consequent development of symptoms of the disease. The tetanus bacillus thrives particularly on injured tissue. Wounds with tissue de- struction, especially if there are pyogenic infection and blood clots, are particularly dangerous. Wounds may appear clean and heal by primary intention and nevertheless harbor tetanus bacilli; or tetanus spores may remain latent in such wounds, and when secondary operation produces tissue death or small blood clots they may develop and cause tetanus. Tetanus antitoxin.—Tetanus antitoxin neutralizes, multiple for multiple, the toxin of the tetanus bacillus. However, it must be remembered that the toxin produced by the bacil- lus becomes very rapidly attached to the nerve cells which it injures, and toxin which has become fixed in this manner is amenable to the neutralizing action of the antitoxin to a very slight extent only or not at all. For this reason, the prophylactic value of tetanus antitoxin has been established beyond doubt, but the success of its therapeutic use depends largely upon an early diagnosis and proper administration. Prophylactic use of tetanus antitoxin.—A prohylactic of 1,000 units of tetanus antitoxin will be given to all wounded, whatever the nature or severity of the wound. This should be , done as soon as possible after infliction of the wound, preferably at the battalion aid station. Some of the antitoxin will be furnished in syringes, but it is impossible to provide all of it in ' this form. Care will be taken, therefore, that battalion aid stations and other advanced ] dressing stations be provided with a supply of sterilizable 10 c. c. syringes and suitable needles I for serum provided in bottles. Since tetanus antitoxin is eliminated by the body within 10 to 14 days and since the | incubation time of the disease varies greatly, depending upon fortuitous circumstances, such as the extent of tissue death and secondary infection, at least one subsequent dose of 1,000 units will be given after an interval of 7 days. It is recommended that officers giving these repeated doses take cognizance of the memorandum on anaphylaxis and be guided in their serum administration thereby. Tetanus antitoxin will also be administered as a routine measure in the following | conditions: 1. Upon the recognition of "trench foot" with or without skin abrasion. 2. In j case of frost bite. 3. During operations performed under conditions of unsatisfactory asepsis, e. g., emergency operations, operations for hemorrhoids, fistulse, or any conditions where fecal contamination is a possibility. 4. During secondary operations necessary in the course of treatment of wounds received 7 or more days previously. 5. Following the manipul- ations incident to the reduction of compound fractures or dislocations, after the removal of adherent drains or any other procedure resulting in disturbance of the healing process in a wound 7 or more days old. The antitoxin will be administered subcutaneously, preferably over the lower abdomen by or under the immediate supervision of a medical officer. All injections, with amounts and dates, signed by the officer administering them, will be entered on patient's field medical card. j In addition to the above regulations for the routine administration of tetanus antitoxin, medical officers are advised that two injections may not be sufficient in all cases. In severe injuries where prolonged suppurative processes persist, especially when fecal contamination of the wound per rectum or through intestinal fistulse is present, and when much tissue necrosis occurs, three or even four doses may be indicated. The attending medical officer must bear this in mind and exercise judgment accordingly in the individual case. Early diagnosis.—As stated above, the success of specific treatment in tetanus depends primarily upon early diagnosis. For this reason surgeons should be constantly on the alert for local manifestations which often precede the development of generalized tetanus. Since the toxin is conveyed to the central nervous system by way of the nerve trunks, there may be early rigidity, spasticity, or even twitching of the muscles surrounding the wound—which occasionally may be accompanied by pain and a local increase of reflexes. These symptoms, , as well as "sore throat," "stiff neck, "early trismus, and in head wounds, facial paralysis should be constantly watched for and nurses should be instructed to keep this in mind when- ever dressing a wound or doing other services for patient. GENERAL SURGERY 289 By conscientious attention to early manifestations of this nature life may be saved. Immediate treatment should be instituted in all doubtful cases. Treatment with antitoxin.—When the early symptoms of tetanus have been recognized or when the disease has distinctly manifested itself, energetic treatment with antitoxin should immediately be instituted. There are many different ways of administering the anti- toxin, and it is by no means plain as yet whether the subcutaneous, intravenous, or intrathecal method will eventually prove to be the most efficacious. However, it would seem that in cases recognized early a combination of immediate intrathecal and intramuscular injections is advisable. In every case strongly suspected of being tetanus at least 5,000 units of tetanus antitoxin should be given intrathecally as soon as possible. This is done by lumbar puncture, prefer- ably under an anesthetic. The serum should be injected slowly and in volume should about replace the amount of spinal fluid withdrawn. When little or no spinal fluid flows, as occa- sionally happens, a relatively small volume of serum should be injected (about 5 c. c), and this very slowly. In all cases intrathecal injections should be done slowly, either by gravity or directly with a syringe, and repeated within 12 hours if the first volume injected does not contain 5,000 units. After such injections it is a good plan to raise the foot of the bed and remove the pillows. At the same time 8,000 to 16,000 units of antitoxin should be adminis- tered intramuscularly, with observance of all precautions spoken of in the circular dealing with dangers of anaphylaxis. The intrathecal injection will often give rise to meningeal irritation and turbid spinal fluid, which, however, need cause no alarm. Both the intrathecal and intramuscular injections may be repeated daily for two or three days. It is rarely necessary to inject subsequent to this, because any effect the antitoxin will produce results from the first injection, since antitoxin is not completely absorbed for se\ _ral days and is not eliminated completely for 10 or 12 days. Supplementary treatment.—Morphine and other sedatives should be given with the idea of resting the patient, and they should be administered in doses sufficient to give the most adequate physiological effect compatible with safety. As soon as the diagnosis of tetanus is made the case will be reported by telegram to the chief surgeon, A. E. F. REFERENCES (1) Sick and Wounded Reports to the Surgeon General. On file, Historical Division, S. G. O. (2) McConkcy, A. T.: The Prophylaxis of Tetanus. British Medical Journal, London, December 11, 1915, ii, 849. (3) Bruce, xMajor General Sir David: Tetanus. War Medicine, Paris, 1918-19, ii, No. 5, 724. (4) Cummins, S. L., and Gibson, H. Graeme: An Analysis of Cases of Tetanus Occurring in the British Armies in France between November 1st, 1916, and December 31st, 1917. Lancet, London, March 1, 1919, i, 325. (5) Tulloch, W. J.: Report of Bacteriological Investigation of Tetanus Carried out on Behalf of the War Office Committee for the Study of Tetanus. Journal of Hygiene, Cam- bridge, 1919, xviii, No. 2, 103. Hi) Bruce, Major General Sir David: Importance of Early Prophylactic Injection of Anti- tetanic Serum in Trench Foot. British Medical Journal, London, January 13, 1917, i, 48. (7) McConkcy, A. T., and Homer, Annie: On the Passive Immunity Conferred by a Pro- phylactic Dose of Antitetanic Serum. Lancet, London, February 17, 1917, i. 259. IS) Burrows H.: Modified Tetanus. Lancet, London, January 27. 1917, i, 139. L<» Bulletins on Transmissible Diseases and the use of Therapeutic Sera, American Expedi- tionary Forces, May, 191S. CHAPTER XI TRENCH FOOT ETIOLOGY Trench foot is the name given to the combination of vasomotor, nervous, and trophic conditions arising in the feet of soldiers immobilized in the trenches during the war 1914-18. Since the American Expeditionary Forces had rela- tively little experience in trench warfare, it obviously follows there could be no great number of such foot conditions in these forces attributable to the peculiar conditions of trench warfare; however, 2,064 admissions to hospital were due to trench foot in our Army.1 The major portion of these admissions arose from conditions other than those connected with trench warfare, and in all probability would have been called byT another name, such as chilblain or frostbite, were it not for our knowledge of the subject acquired from the French and the British. As a matter of fact, the British spoke of it as frostbite during the earlier years of the war,2 as did the French,3 the change in name being due to the fact that, though frostbite may have been justified as a name by the appearance of the affected parts, it was not so by the climatic conditions, for trench foot occurred more especially during damp weather when the ther- J mometer did not reach as low as the freezing point. The causative agencies are almost invariable.4 They are cold, prolonged j immersion in water or mud, accompanied by motionlessness, all of which thus j tend to affect the circulation in the lower extremities. Such agencies obtained I to a greater extent during the earlier years of trench warfare when many of the trenches were of relatively poor construction, without dugouts, and in many places illy drained. And because of the exigencies of service, relief from trench j duty was deterred for a longer time than later. For protection against enemy fire, men hugged the bottoms of the trenches, knee deep in water or mud, j unable to change their footwear for days at a time. Little or no early j attention was paid to the constricting influence of wearing apparel on the legs and feet—a very large contributing factor in the production of trench foot. PATHOLOGY The essential pathological feature of trench foot is an ischemia due to j damp cold, with or without a contributory external constriction.4 This inter- | ruption in the circulation through the capillaries alters the capillary walls, thus leading to greater permeability and causing edema and stagnation,5 [ either or both of which set up the evolutional stages referred to below under symptoms. Raymond and Parisot,3 searching for an infectious agent in cases of trench i foot, found both the blood and cerebrospinal fluid negative. In studying the | lesions, however, they reached the conclusion that certain fungi, which they 290 GENERAL SURGERY 291 isolated from smears of the liquid of blisters on trench feet, became parasitic and pathogenic under the influence of more or less continuous immersion in cold water, and readily invaded the body through the macerated epidermis. These findings have not been confirmed by other investigators among whom there was a unanimity of opinion that trench foot is not an infectious disease. SYMPTOMS Because of the evolutional changes observable in trench foot, unless checked either by removal of cause or by treatment, the clinical picture of the condition as a whole may readily be divided into stages. First stage.—Primarily the man affected begins to feel a painful cold and numbing sensation, followed by a prickling and burning sensation extending to the legs, frequently ot sufficient intensity as to interfere with walking.4 Usually the pain is severe enough to require morphine. It is a painful anesthe- sia and one feels as though one is walking on cotton.3 Second stage.—In addition to the painful anesthesia there is now edema. Usually the skin is red; it may be blanched. The blush and its accompanying swelling may extend from the foot to, the middle of the thigh. Third stage.—In this stage bleb formation is superimposed on the swelling. The discoloration—sometimes mottled due to hemorrhage—and painful anesthesia remain. The blebs are irregular in shape and vary in size; they may contain serum or blood, and their floors are of a gelatinous material. Fourth stage.—Infrequently a case is so severe as to result in more or less deep mortification of the tissues of the foot, with or without a preceding blister formation. When the blebs are present their gelatinous floors become dark, dry, and of a boardy consistency. PROPHYLAXIS The occurrence of trench foot among the American Expeditionary Forces was regarded as an indication of a lack of good sanitary discipline,6 because experience had shown that the prevalence of this disease could be precluded by providing proper facilities to units for the care and treatment of the feet and by a strict daily routine within organizations. Organization commanders were made directly responsible for the provision and availability of suitable facilities, and further, for seeing that the men of their commands made full use of them. The following instructions, published in general orders, General Head- quarters, A. E. F.,6 comprise all the essential features of foot hygiene to be observed in the prevention of trench foot: ******* 3. The chief predisposing and exciting causes of "trench foot" are as follows: 1. Hygienic: (a) The existence of systematic disease. (6) Insufficient nourishment, particularly hot foods', and lack of sleep and comfort, (c) Too infrequent changes of shoes and socks, allowing of accumulation of bacteria-laden secretions, with a consequent maceration of the skin of the feet. 2. Circulatory interference: (a) As the result of the wearing of tight shoes, socks, leggings, puttees, or breeches, (b) As the result of long continued standing or sitting without exercise and with the feet and legs in constrained positions, (c) As the result of prolonged exposures of the feet to the effects of wet and cold. 292 SURGERY 4. The commanding officers of all units will be held personally responsible that the following instructions are carried out under the personal supervision of a commissioned officer: (a) That there is available a sufficient supply of dry, clean, well-fitting, woolen socks. All men will be instructed to habitually wear socks without garters. The tendency of the sock to creep down is prevented by fastening to the breeches by means of safety pins, (b) That there is available for each man present not less than one change of shoes or boots, and that all boots and shoes are in serviceable condition, well fitted, thoroughly greased, and of sufficient size to permit of wearing woolen socks, (c) That the wearing of rubber boots for periods longer than a few hours be discouraged. Troops should be warned of the disad- vantages of this form of footgear. Rubber boots always ventilate badly and remain moist after removal. In drying, they should be wiped out upon the inside after removal of the inner sole, and then hung by the inside straps suspended with the feet down. Neither puttees nor leggings will be worn under boots, (d) That there are available at all times suitable rooms set aside for use as drying chambers and that this space be of such arrangement and size as to adequately provide for the drying of all footwear or other clothing, (e) That the feet of all are vigorously rubbed at least once each day, and preferably with some animal fat, such as tallow or whale oil. (/) That active foot exercises be indulged in at frequent inter- vals, and from time to time that this be supplemented by removal of shoes and socks, with subsequent drying and massaging of the feet, (g) That special efforts be made to discover men who are suffering from corns, ingrown nails, blistered, or inflamed feet. Any one of these conditions alters the gait and thereby decreases efficiency and increases the tendency i to "trench foot." All such cases should be placed under the surgeon's care without delay. | (h) That every effort be made to reduce to the lowest possible minimum the necessity of the j men performing duty with their feet in mud and water; this is frequently' only a question of trench drainage and the elevation of "duck boards." I 5. Since an ample supply of woolen socks is a primary need, arrangements will be made for the delivery of dry socks to the men at the front and for the return of wet ones to the dry- ing rooms, thereby insuring to each man at least one change a day. 6. Before marching into a forward area, company commanders will make the necessary- inspections of their command to see that all shoes are well fitting, in good repair, and properly j "dubbined," and that each man has at least three pairs of serviceable woolen socks upon his | person. At this time all members of the command will be warned against too tightly applied puttees. This danger is particularly prominent during wet weather, since dry puttees prop- erly applied, which subsequently become wet, shrink 3 per cent of their length. 7. Since the lack of nourishment in general, and hot foods in particular, strongly pre- disposes to "trench foot," the responsible commanders will make suitable arrangements for the supply of hot food to the men. Food containers for bringing up hot food will be provided, and cookers and kitchens will be placed in localities suitable for supplying food and drinks. There will be served each day to all men in the forward areas not less than two hot meals, preferably one at midday and one between midnight and 5 a. m. 8. Plans for improvising and constructing field cookers, kitchens, clothes driers, or other j special arrangements found necessary to properly carry this order into effect will be furnished upon application to these headquarters. 9. Foot powders and the various oils, greases, or ointments to be used in the prevention and treatment of "trench foot" and other diseases of the foot will be furnished by the Medical Department. The necessary supplies for application to boots, shoes, etc., will be supplied by the Quartermaster Corps. 10. The proper requisitions to meet the needs of this situation will be prepared and i forwarded without delay to the various supply department depots for filing. Subsequent to the promulgation of this order w-hale oil and grease in general came to be looked upon with disfavor; they made a coating which prevented the moisture from getting away- from the skin.7 It was thought that oil should be used onlyT w-hen gum boots are not available or when it is impossible to remove the gum boots for long periods at a time. GENERAL SURGERY 293 TREATMENT The treatment of trench foot as practiced in the American Expeditionary- Forces was based largely upon the work of Raymond and Parisot, of the French Army. The methods to be followed were published in Memorandum Xo. 4, Army Sanitary School, A. E. F., in the fall of 1917, the essentials of which were as follows:7 Edematous stage.—-Foot baths with green soap and water. Large hot fomentations consisting of camphor 1 part, sodium borate 15 parts, boiled water 1,000 parts. The gauze compresses should be covered with an imper- meable material (oiled silk or oiled paper) and should extend well above the upper limits of the edema. The most strikingly early effect of this treatment is the relief from pain, permitting men who have been unable to rest because of the pain to drop promptly off to sleep. Blister stage.—Blisters larger than one-half inch in diameter should be excised and their gelatinous floors wiped away with a pledget of sterile cotton. On the bare surface thus produced place aseptic compresses of camphor 30 parts and ether 1,000 parts. Over these compresses the fomentations used for the edematous stage are placed and continued in use until after the disappear- ance of the edema, when the camphorated ether will suffice. Slough stage.—-The treatment outlined above will be adequate usually to prevent the formation of sloughs. When sloughs are present, however, loosen them by the camphor-ether compresses and alkaline camphor fomentations for the purpose of gaining access to the affected tissues beneath. Surgery is to be avoided except wrhen the sloughs are hard, whereupon incise through them down to the grumous layer beneath, avoiding blood letting, then apply the compresses. The cautery should not be used. The use of potassium iodide gave surprisingly good results in the elimina- tion of pain in trench feet,7 its action being almost specific. Trench foot strongly predisposes to tetanus; consequently- each patient suffering from trench foot should receive a dose of antitoxic serum that should be repeated at weekly intervals until the lesions become healthy in appearance. REFERENCES (1) Sick and Wounded Reports. Historical Division S. G. O. (2) Munroe, H. E.: The Character and Treatment of Frostbite. British Medical Journal, London, December 25, 1915, ii, 926. (3) Raymond, Victor and Parisot, Jacques: Etiologie, prophylaxie et therapeutique de l'affection dite gelure des pieds. Comptes rendus des seances de I'academie des sciences, Paris, May 1, 1910, clxii, 694. (4) Cottet, J.: Trench Foot; Etiology—Pathology—Symptomatology. War Medicine, Paris, 1918, ii, No. 5, 707-11. (5) Cannon, W. B.: In discussion of Ashford's article on Trench Foot. War Medicine, Paris, 1918, ii. No. 5, 723. (,6) General Orders No. 11, G. H. Q., A. E. F., January 17, 1918. (7) Ashford, Bailey K.: Trench Foot; Its Treatment. War Medicine, Paris, 1918, ii, No. 5, 717. CHAPTER XII WOUNDS OF SOFT PARTS a Following the disastrous practice in the early months of the war of absten- tion from surgical intervention, it w-as for a time considered sufficient to remove projectiles and superficially clean the wound channel. Experience soon showed the inefficiency of these procedures. This tentative period lasted nearly two years, 1914 and 1915. In 1915 the method of "debridement" was initiated; in 1916 it was practiced, and in 1917 and 1918 it was elaborated and improved. This advance was dependent upon careful observation of the pathological factors involved in wounds produced by projectiles. In wounds of the soft parts the muscles offer little resistance to the impact of a projectile and are extensivley lacerated even in many cases where the external wound is insignificant. Pathogenic organisms find an excellent culture medium in the devitalized tissues. A large variety of organisms flourish in war wounds and both anaerobic and aerobic bacteria grow at an active rate after a latent period of a few hours after the infliction of the wound. The habitat of these microorganisms is chiefly in the lacerated muscular masses. According to Borst,1 there are three zones in gunshot injuries of soft parts. The first, or innermost zone is represented by the wound channel or wound cavity, which is filled with necrotic tissue, extravasated blood, foreign bodies, and shreds of torn muscles. Next comes the zone of direct traumatic destruc- tion, with cauterization of tissue. This is of variable width, according to the physical and morphological peculiarities of individual tissues and projectiles. Bacteria find the best possible culture-medium in the necrotic or seminecrotic tissue. In the third, or outer zone, the tissue is not necrotic, although greatly reduced in vitality. The fact has come to be definitely appreciated that all accidental wounds must be considered as contaminated, and this is especially true of gunshot wounds. With this knowledge of wound pathology it became evident that physical measures would best insure disinfection and that chemical measures should be regarded as accessory; also that the prospects for success from the use of these measures lie in employing them early, when the organisms which have been introduced into the wound are still superficially situated along the wound tract and have not extensively multiplied. Physical disinfection consists in ablation of necrotic tissue and removal of foreign bodies. This method, known as debridement, constitutes the greatest advance from a surgical standpoint that was developed in the recent war. It not only saved many lives but enabled many wounded soldiers to return to the front after a rela- tively short period of disability. ° The statements made in this and the following chapter concerning the treatment of wounds of the soft parts and joints are based upon articles by the writer in: Surgery, Gynecology and Obstetrics, Chicago, 1918, xxvii, 289-311 (with B. J. Lee and P. A. Dineen); Journal of the American Medical Association, Chicago, 1919, lxiii, 383-388; Annals of Surgery, Philadelphia, 1919, lxx, 266-286; Oxford Surgery, 1921, V, 715-775; Keen's Surgery, 1921, VII, 557-589. 294 GENERAL SURGERY 295 Notwithstanding the superior results derived from debridement, objections were raised that valuable tissues might be needlessly sacrificed, and especially that suppuration often occurred in spite of excision. Such failures following wound excision led to the utilization of other agents in the fight against infection, especially fluids for irrigation, having in mind both mechanical, solvent, and bactericidal properties. All the customary antiseptics were utilized early in the war. Morestin2 recommended equal parts of commercial formol, glycerin, and alcohol. Gaudier3 utilized methylene blue in alcoholic or watery solution, 1: 1000. It is noteworthy that many antispetic agents which are highly efficient in the test tube, for example bichloride of mercury, show less efficiency in the w-ound. Moreover, most antiseptic agents damage not only the bacteria but also the tissues, especially when used in strong concentrations, so that the sur- viving organisms find an excellent culture medium for their growth in the changed or necrotic tissues. The many antiseptics which were recommended showed striking limitations in their efficacy, and great expectations were raised by the introduction of Dakin's solution, about the middle of 1915,4 approximately the same time as extensive debridement began to be used. Carrel recommended that the new antispetic be injected into the wound channel.5 The results were not highly successful, and thereafter Carrel regarded Dakin's fluid merely as the supple- ment to the operative procedures for the purification of contaminated wounds. The success of the Carrel method 5 depends largely upon aseptic details, espe- cially thoroughness, gentleness, and cleanliness in dressings, and repeated flushings of the wound surfaces. In many cases a prompt and careful operation is sufficient and need not be supplemented bv instillation of Dakin's fluid. Yet in infected wrounds most surgeons consider that Dakin's fluid in continuous irrigations or interrupted instillations constitutes by far the best method of wound treatment. But some have not observed superior results from Dakin's fluid as compared with the ordinary antiseptics, and consider the bactericidal action of this antiseptic as exaggerated, the results being due to the irrigation and the solvent properties rather than to its bactericidal properties. The ideal treatment of war wounds, as based on experience gained in the World War, consists in complete excision of all devitalized tissue, followed by the application of immediate suture or secondary suture, according to condi- tions existing in a given case. When there is good reason to believe that little or no cause for infection is left, as when the whole tract has been excised and the wound appears healthy throughout, suture may be applied. This primary suture is performed either layer by layer or in bulk, the important point being to leave no dead spaces. Drainage is injurious rather than useful. Some operators, before closing the wound, irrigate it with ether, weak tincture of iodine, or salt solution. When there is doubt as to the condition of the wound, primary suture must be omitted. The excision having been made as completely as possible, dressings are applied and suture performed subsequently if no infection fob 296 SURGERY lows. The indications for such delayed suture are to a large extent dependent upon the quantitative and qualitative estimation of bacterial flora in the wound. This is determined by smear and culture. It has been shown that in the absence of streptococci and with few other organisms a wound can usually be sutured safely. According to the time when delayed suture is done, a distinction is usually made between "delayed primary suture," if it is done within five days after the initial operation, and "secondary- suture,' if it is performed a longer time afterwards. But the real distinction between delayed primary suture and secondary suture is one of wound repair rather than of time. Delayed primary suture is one in which the edges can la- approximated and will unite without excision of tissue. Secondary suture h one in wliich the epidermis has grown inward and must be excised for proper union. In late secondary suture dense granulation tissue must also be excised. A very important point for the successful outcome of primary- sutures is the interval between the infliction of the wound and the performance of the operation; this interval should be reduced to the shortest possible time. In the beginning, wounds were sutured primarily only when the wrounded were operated upon within the first 12 hours, but later primary sutures were success- fully applied at the end of 36 up to 48 hours after the infliction of the injury. At first only wounds of the soft parts were sutured, then articular wounds, and finally selected compound fractures. Immobilization of the damaged region is indispensable to a successful outcome of the operation. It is generally^ conceded that the first primary sutures were performed in July of 1915, by Rene Lemaitre.6 From July, 1915, to July, 1917, in 1,046 primary sutures, he had 944 complete cures, 39 partial cures, and 13 failures. Gaudier,7 in November, 1916, also advocated this method. The procedure began to find more general adoption but not without giving rise to much con- troversy. In November, 1916, Tuffier8 stated that, on the basis of official statistics, primary suture fails in 34 per cent of the cases. Dupont,9 in March, 1917, published 49 cases of primary suture, including 4 sutures of articular wounds, with only 5 failures, only 1 of which was serious. Pierre Duval,10 in October, 1917, sutured 1,058 of 1,230 wounds, with 86 per cent of complete cures in six weeks. For wounds which are not primarily sutured he recom- mended suture in three to five days. By Gross, Tissier, Houdard, Di Chiara, and Grimault,11 759 sutures were applied from July 23 to September 10, 1917, w-ith 675 primary unions, 47 partial and 37 total failures;6 i. e., 88 per cent success. Marquis, Descazals, Luquet, and Morlot12 published results of their work during a period of attack; in the four days of this attack they sutured 500 wounds, including 133 bony and 34 articular wounds. The total mortality was 6.5 per cent, and 36 per cent of the w-ounded were discharged as con- valescents 50 days after the infliction of the wounds. From July, 1917, to February, 1918, Lemaitre6 performed 1,618 primary sutures, with 1,555 com- plete cures, 44 partial cures, and 19 failures. The chief methods and agents which w-ere employed for combating infec- tion in w-ar wounds are mentioned, although it is not feasible to discuss all of b By complete failure is meant necessity for removing all stitches; by partial failure, superficial infection necessitating the removal of a few stitches. GENERAL SURGERY 297 them in this chapter: Debridement;" the Carrel-Dakm method;5 dichlora- min-T;1* hypochlorous acid preparations, Eusol and Eupad;15 hypertonic solutions or lymphagogic agents (Sir Almroth E. Wright);16 salt pack (Col. H. MAY. Gray);17 magnesium chloride (Delbet);18 collargol:19 Bipp (Rutherford Monson):20 mdated starch;21 flavme;22 brilliant green;22 methyl violet (pyoktanm);23 magnesium sulphate;2* sunlight25 and ozone;26 acetozone;27 vaccine and serum treatment of infected wounds:2* Delbet's pvoculture;29 introduction of living anaerobes (Donaldson's method);30 vuzin (Morgenroth and Tugenreich);31 Vincent's powder.32 OPERATIVE TREATMENT During the World War the wounded usually w-ere received at the evacua- tion hospitals in from 4 hours to 24 hours after the receipt of injury, but during periods of battle activity the delay was sometimes much greater. They pre- sented various degrees of shock, hemorrhage, laceration of the soft parts, and associated lesions. Frequently the wounds were multiple. They contained pathogenic microorganisms and in most cases foreign bodies. When admit- ted few- of the wounds showed evidence of gas bacillus infection.33 Operative treatment is indicated for the majority- of the wounded as soon as possible after the receipt of the injury. Each hour increases materially the danger from infection. Cases that could be saved within 14 hours are often lost after 24; wounds that could be closed successfully w-ithin 8 hours often become the site of infection and gas gangrene, resulting in amputation or death if left untreated for 18 hours. After the arrival of the patient at the hospital, expedition in the surgical treatment must be effected by the help of a well-organized routine. The first essential is the careful sorting of cases at the admission tent. Patients pre- senting a considerable degree of shock should be left undisturbed on their stretchers and sent to the shock ward. They- must first be treated for the shock, and operation deferred until reaction is evidenced by a rise of blood pressure. The chief exceptions to this rule are cases with cranial w-ounds, abdominal wounds, and sucking thoracic wounds. Walking cases and slightly wounded eases are referred to the dressing w-ard or to the service for slightly wounded. Of the remainder the majority demand N-ray- examination and early operation. The dressings are removed and the wounds carefully examined. Those whose condition does not contraindicate it are bathed. Cases with active bleeding, with sucking thoracic wounds, with penetrating abdominal wrounds, with frac- tures of the femur, with penetrating wounds of the knee, and with multiple wounds, receive the first attention. Cases which have reacted from shock may- be taken at any time. Cases with uncomplicated wounds of the soft parts are, in general, cared for after the more urgent cases. The success of operation depends largely upon the thoroughness of the roentgenologist's examination and the accuracy of his findings. Experience proved that his report should be made on the patient's card according to a definite system. It should include the anatomical site, the size of each foreign body in millimeters, the depth in millimeters, and the position of the part at the time of observation. For example: 1. Right thigh: F. B. 10 by 15 mm.; 298 SURGERY SO mm. under point marked on skin; limb in extreme outward rotation. 2. Left leg: no F. B.; fracture both bones, middle third; much comminution. The operator thus visualizes the condition more accurately than if the report w-ere made in fractions of an inch, or if some relative term were employed. "Millimeter" is employed to avoid error and confusion. In times of great activity some cases must be operated upon without X-ray examination. They should be selected carefully and should comprise those in which apparently a foreign body is not present or in which the foreign body is superficial. The patient should always be examined by the surgeon before anesthesia is begun. In wounds of the extremities the surgeon should determine whether there is a nerve lesion and an arterial pulse. Apparently innocent wounds of the trunk may in reality be very serious. The possibility of intrathoracic or intraabdominal involvement should always be borne in mind. Cases in which the genitourinary tract may have been injured demand examination of the urine. The preparation of the patient usually is done in the operating room on an extra table while the preceding operation is being completed. The wound is protected with gauze, the part shaved thoroughly, and scrubbed with soap and water over a wide area. Application of chemicals may follow. A common procedure is to cleanse with ether and then apply tincture of iodine. It is important to prepare a wide field and, in wounds of the extremities, to encircle the limb. The part is draped economically with towels and sheets. A general anesthetic should be employed except in rare cases. Nitrous oxide-oxygen, administered by an expert anesthetist, is the least harmful. It should be the anesthetic of choice for patients in a condition of shock, gassed cases, and thoracic cases. Ether, however, is employed in routine cases. Minor operations may often be performed under primary anesthesia. Local anes- thesia is rarely used. For convenience of discussion wounds of the soft parts may be subdivided as follows: 1. Wounds by fragments of shells, grenades, or bombs, a. Frag- ment retained; penetrating wounds, b. Fragment not retained; perforating, plaie en seton, through-and-through wounds, or gutter wounds. 2. Wounds by bullets—rifle, pistol, or machine gun. a. Bullet retained; penetrating wounds, b. Bullet not retained; perforating, plaie en seton, through-and- through wounds, or gutter wounds. A fragment of shell or grenade is of high velocity, irregular in shape, and with sharp edges. In contrast to a bullet it carries with it pieces of clothing and skin into the tissues. Because of its irregular shape it exerts a destruc- tive effect upon the tissues which thus form an excellent medium for the devel- opment of the microorganisms carried in from the clothing and skin. After a latent interval of six hours or more both aerobes and anaerobes proliferate rapidly and penetrate more deeply into the tissues. The local changes and the later systemic effects depend upon the character of the microorganisms and the tissue resistance. A bullet at close range exerts a marked explosive effect; during the major part of its flight, approximately from 500 to 1,500 yards, it penetrates the GENERAL SURGERY 299 soft parts with little destruction of the tissues; at long range it loses its steadv spinning movement and causes mutilation and laceration. In the majority of cases of perforating bullet wounds the missile passes like a stiletto through the clothing and tissues. Infection may not result because the projectile carries no clothing into the wound and penetrates with little laceration and traumatism of the tissues. When such is the case operation is usually not required, since the few organisms which are present have not the proper environment for growth. Under certain conditions, however, when the appear- ance and feeling of the part suggest considerable hemorrhage or destruction of tissue, perforating wounds by bullets must be treated in the same manner as those made by fragments of shell. The rule is not to operate upon perforating bullet wounds with punctate wounds of entrance and exit and with little or no ecchymosis, swelling, or tension of the soft parts. DEBRIDEMENT The general plan or aim of surgical treatment is the prevention or limita- tion of infection, the early- closure of the wound, and the preservation or reestablishment of function. The first indication is to obtain a clean wound. This is accomplished, primarily, by debridement c of tissues—that is, by free incision and excision of injured and contaminated tissues and by the removal of the foreign material carried by the missile into the wound. The principle of this procedure may be visualized by considering a typical case of a wound of the soft parts with a tract from the skin to the interior of the muscles, containing a fragment of shell and pieces of clothing along its course, and having for its walls lacerated muscle. Pathogenic organisms are present throughout this tract. The devitalized, pulpified walls of the tract furnish an ideal medium for the growth of bacteria. One can readily imagine that immediate wide excision of such a tract as a whole, including removal of the devitalized skin, subcutaneous tissues, aponeurosis and muscle, together with the shell fragment, clothing, and microorganisms contained within the tract, will leave a healthy aseptic wound, provided the skin adjacent to the wound has been properly prepared and the operator has employed a technique comparable to that used in clean operations. To obtain an aseptic wound is the ideal desired, though it is doubtful whether this is actually achieved in any case. But, however skeptical one may be as to the total eradication of micro- organisms under the conditions which prevail in these wounds, many wounds after operation undergo repair as if aseptic, and cultures and smears made from them are often sterile. Even during times of greatest activity debridement should be properly carried out and the best possible technique observed. The temptation to relax in these respects during periods of stress should be resisted. The time saved by careless work is not sufficient to warrant the additional risk incurred; only rarely is it justifiable to substitute incision and drainage for debridement in recent w-ounds. The closure of the wound may be carried out by immediate or primary- suture, delayed primary suture, or secondary suture. is used to signify both the incision and excision of devitalized tissues, and removal of foreign body. 300 surgery- Technique The skin incision, wiren possible, should be made parallel to the long axis of the limb. This permits wide exposure of the underlying tissues and renders subsequent suture less difficult. A transverse incision should rarely- be employed. In the case of a deep transverse perforating wound it is better to make two longitudinal incisions and work inward from each rather than make a transverse incision with division or excision of considerable muscle tissue. In the former case suture is usually readily done at an early- date, whereas in the latter primary- suture is often impossible because of the difficulty of uniting the severed muscle. Even when this is accomplished the sutures frequently tear out and allow retraction of the muscle with resulting dead space and break- ing down of the wround. When the transverse wound has not been closed primarily, or has reopened, secondary suture is delayed and is more difficult. The functional result is also less favorable on account of the transverse section of the muscle. Transverse incisions should be employed in the extremities only in super- ficial wounds involving the subcutaneous tissues or with very superficial involv- ment of muscle. In the gluteal region and on the trunk the incisions, in general, should be in the direction of the fibers of the underlying muscle. Occasionally, as in deep, transverse, through-and-through wounds of the calf, a long median incision may be employed advantageously; the tract is exposed in the middle of its course and debridement is carried out from this region in both directions. The skin wounds of entrance and exit are excised by small elliptical excisions and the wound edges approximated. The operation itself consists in the free excision of all tissues with which the foreign body has come into contact and all devitalized tissue, except struc- tures such as nerves, large vessels, and bones, whose removal would interfere with the function of the part and cause permanent disability. Free excision, however, does not mean ruthless, blind butchery of the parts, but rather, careful, intelligent dissection, with liberal removal of such parts as should be removed, and with equally scrupulous preservation of such parts as may be left with safety-. The wound itself, with all contused skin, is excised by removing an elongated ellipse of skin. No healthy skin should be sacrificed on the sides of the ellipse, as it is important to conserve as much skin as possible in the transverse plane of the limb to facilitate suture. This is especially important in the forearm. There is no advantage in attempting a debridement through a short incision. A deep debridement demands a long incision. The skin incision must always be vertical to the skin surface; the tendency to bevel the incision should be avoided, as this interferes materially with satisfactory suture. Lemaitre6 prefers to begin with a short incision, say of 5 or 6 cm., and to increase it as the need arises. He does not hesitate to extend the ends inward or outward or to transform the incision into a flap. When there are two wounds one or two incisions may be employed as already described. Similarly when the foreign body has taken a transverse or oblique course, penetrated a considerable distance, and lodged in the tissues, GENERAL SURGERY 301 two incisions may at times be used to advantage, one over the foreign body and one to excise the wound of entrance, both being used for excision of the tract. After excision of the skin wound the instruments should be discarded or washed in alcohol. The skin edges are widely retracted and the subcutaneous tissues removed as far as there is evidence of laceration or contamination. It is not necessary, however, to remove all blood-infiltrated subcutaneous tissue. in general, the fingers are kept out of the wound and the dissection made with instruments. Good exposure of every plane by retraction is essential, the edges being rolled outward with toothed retractors or some form of clamp, such as the All is forceps. Fig. 159.—Debridement. Excision of the external wound Fig. 160.—Debridement. Excision of the aponeurotic layer The aponeurosis is treated in the same manner as the skin that is, by a long straight incision with removal of the wound by a relatively- narrow ellipse. (Fig. 160.) The aponeurosis is of great value in secondary sutures in the lower extremity and shoulder, and, therefore, should not be ruthlessly sacri- ficed. It must be emphasized that liberal excision of aponeurosis or skin is not necessary because it is not in these tissues that infection ordinarily origi- nates or develops. The aponeurosis should be widely retracted and muscle planes exposed. It is this tissue that favors infection. All traumatized and devitalized muscle must be removed. This demands excision for a distance of 0.5-1 cm. on all sides of the tract. The dissection is made parallel to the fibers of the muscle; a long, relatively narrow- ellipse is removed so that the sides tend to fall together after the excision. The dissection should be made by planes, muscles should be identified, and the situation of nerves and large vessels should always be borne in mind. The tract should be follow-ed by- sight, not by probing; for this purpose a reflecting headlight is indispensable. 302 SURGERY If the tract is lost between muscle planes, often slight flexion or extension of the limb will bring it into view. Careful hemostasis is necessary at all stages. Sponging of blood should be done by pressure and not by rubbing, because the latter method may carry organisms from an infected to a clean part of the wound and may cause a small tract to be lost to view.6 The foreign body- should not be extracted until reached in the dissection, otherwise the parts fall together and the tissues immediately beyond the body, which often con- tain clothing, may not be adequately excised. When the excision is complete all exposed muscle must look healthy, contract when pinched with forceps, and ooze when snipped with scissors; otherwise its vitality has been diminished to such a degree as to favor gas bacillus infection. At times the finger must Fig. 161.—Debridement. Excision of injured mucles be introduced to search for the foreign body, but, as a rule, in cases where the track is lost or w-here for other reasons difficulty arises in locating the foreign body, fluroscopy should be employed/* If this fails, the tissues should not be blindly torn up, but after a careful search one should desist, leaving the wound open and removing the foreign body subsequently, after more careful X-ray- localization or under the screen. When the deep tissues are so markedly infiltrated with blood as to suggest the possibility of constriction of the muscles under the overlying fascia, this fascia must be incised so as to free the muscles from internal pressure. When the fragment or tract is in proximity to a large vessel, as, for instance, the brachial vein, the vessel should be inspected and, if traumatized, should be treated by ligation and excision of the contused portion; otherwise The Bergonie vibreur was used to advantage at La Panne and elsewhere. GENERAL SURGERY 303 secondary hemorrhage is likely to occur. If there is danger of gangrene result- ing from ligation a primary suture should be performed and the case watched with particular care. In the case of a small lateral wound Lemaitre6 advises repair of the vessel wall by suture if the neighboring tissues are healthy. Ordi- narily, however, it is best to ligate the vessel about 1 cm. above and below the vascular wound and to excise the intervening portion. Though sudden and unexpected hemorrhage will occasionally confront the surgeon, the absence of an arterial pulse below the lesion and the widespread infiltration of the soft tissues about the wound usually warn the operator in advance of the presence of a vascular lesion. The importance of having a tourniquet at hand at all times is obvious. Care should be taken to avoid injury to nerves by careless dissection. A severed nerve should be united, and if possible the nerve should be buried within muscle tissue. When preliminary examination shows that a nerve Fig. 162.—Change of position of wound tract from changed position of limb has been injured, it should be exposed above or below the tract early in the operation to avoid traumatization during debridement. When the excision has been completed all hemorrhage should be controlled. Vs little catgut as possible should be buried. The wound should be irrigated with saline ot Dakin's solution. Ether has been extensively employed for irrigation of wounds after debridement, but it probably has not sufficient merit to warrant its use. Lemaitre 6 employs 5 per cent tincture of iodine, after drying the wound, to fix the superficial microorganisms. One of its disad- vantages is the slight secretion of turbid serum due to its action upon the super- ficial cells of the wound. We have not been able to note any advantages from T'the wound is left open vaselined gauze is placed over the exposed skin edae and subcutaneous tissues in order to prevent the dressing from adhering and to lessen oozing and pain when the dressing is removed. Gauze soaked m Dakin's solution is placed loosely in the wound m such a way as not to cause retention of secretions. Dry gauze is applied over this and the dressing kept in place with a bandage. This is the routine treatment for cases which are to be 40907—:J7—22 304 SURGERY evacuated early. Cases w-hich are to be retained may be dressed similarly, or Carrel-Dakin treatment, if indicated, may be begun at once. The indications for Carrel-Dakin treatment may be summarized as follows: If the operator feels that debridement is satisfactory and that the wound is likely to be susceptible of suture in a few days chemical disinfection is unneces- sary'and Carrel-Dakin treatment is not used. If, for any reason, such as in- complete excision of tissues or the large size of the wound, it seems probable that the w-ound must be left open for a week or more, Carrel-Dakin treatment is advisable. Even clean wounds that are left open for a considerable time always become infected, but the use of Carrel-Dakin treatment will prevent or limit the infection. When infection has occurred the use of Dakin's solution will do much to control and terminate it. liider these conditions the treatment is Fig. 103.—Wound by shell fragment two weeks after debridement and primary suture PRIMARY AND SECONDARY SUTURE There are two conditions under which war surgery is performed at the front: First, relatively quiet periods; second, times when military activities are acute. In quiet times a thin but fairly continuous stream of wounded are passed back to the forward hospitals, but only occasionally, as after a raid, does congestion occur. The wounded usually can be operated on almost as soon as they are received; there need be no hurry, and the patients may be carefully wTatched after operation. The aggregate of such cases along a wide sector in quiet periods reaches formidable figures. The ultimate aim of treatment is to restore the soldier to full activity, with complete restoration of function, in as short a time as possible. Obviously, one of the conditions of such restoration is the repair of the wound. During quiet times early closure of the wound may be undertaken successfully in a large proportion of cases. Great benefit thereby accrues both to the patient GENERAL SURGERY 305 and to tin' service. But the long relatively tranquil periods also are of use in affording an opportunity for study and demonstration as to what may be done and wiiat should be done under the varying conditions of w-ar surgery-. As a result of such study of technical methods and tissue repair, rules may be formu- lated and safely enforced for the treatment of the wounded during periods of greater activity. It must be recognized, therefore, that local conditions such as the degree of battle activity, alter materially- the indications for suture, particularly- for primary- suture, in the advanced area. The following is an outline of the general principles and technic of the three varieties of suture of war wounds, namely, primary suture, delayed primary- suture, and secondary suture in wounds of the soft parts: Fig 164 -Perforating shell wound, left thigh, the same missile penetrating right thigh and fracturing right femur. All wounds closed by primary suture. (Heuer, Keen's Surgery) PRIMARY SUTURE Debridement having been completed, the choice of treatment lies between primary suture and leaving the wound open. If ideal conditions, that is, early and thorough debridement, have been approximated and the ease can be llS^ days, primary suture may be made Otherwise, the wound is left open and sutured subsequently. Obviously, the decisiori m a^ gn n ease as o whether primary suture may be made, must be attended with much n er intv a mistake may be costly to the patient. In active periods, as in roffen vV when there are many wounded, the exigencies of a service demand hLte in t primary operation, and the patient must be evacuated, passing from the opera orlTontrol'soon after the operation. Under these conditions, pri- IlTutni^e should not be considered. It may be ^^^^^n qui* periods and in hospitals where patients may be letamed for obsenation 306 SURGERY Fig. 165.—Multiple, penetrating wounds of back, soft parts, closed by primary suture. Lower left wound "failure." (Heuer) Fig. 166.—Long perforating wound of thigh, with opening of knee joint, closed by primary suture. (Heuer) GENERAL SURGERY 307 The advantages of primary suture are obvious; the disadvantages consist chiefly in the danger of closing within a wound, especially within a wound imperfectly debrided, noxious microorganisms, particularly anaerobes of the types which produce gas gangrene. A resulting gas bacillus infection or a Fig. 167.—This and Figure 168 show perforating wounds of forearm with fracture (see fig. 169), two weeks after debridement and primary suture pyogenic infection in a few cases will counterbalance many successful closures. The only means of rendering primary suture safe is by extreme operative care Fig. liiS and thoroughness, thoughtfulness and judgment in the selection of cases, and, finally, scrupulous watchfulness for some days after the operation. When the circumstances are such as to warrant primary suture the follow- ing considerations must be weighed in each case in deciding whether or not 3().s SURGERY suture is indicated: (1) The interval between the receipt of the wound and tlie operation; the type of tissue and situation of the wound. Thus, wounds involving the muscles of the calf, thigh, or gluteal regions should not be closed as a rule after a longer interval than eight hours. In these muscular parts gas bacillus infection is prone to occur and to result disastrously. In other muscu- lar parts the time often may be extended to about 12 hours. In wounds not involving muscles the time mayr be further extended. It must be understood, however, that such rules based on the time between the injury and the opera- tion are not absolute and have been advanced only as a suggestive working basis. Wounds of the face and scalp are regularly sutured. Wounds of the hands should, as a rule, be sutured. Extensive wounds of the feet should, as a rule, be left open, treated by the Carrel method, and closed subsequently. Fig. 169.—Outline of X-ray, Figure 107 (2) Extensive laceration of the soft parts or the presence of a large shell frag- ment or of considerable clothing in the tissues shortens the time within w-hich primary suture may safely be made. (3) Conditions which demand haste in the operation, and therefore militate against thorough and painstaking debridement, preclude primary suture; for instance, multiple wounds, condition of shock, or period of a rush. (4) Diminution of the vitality of the parts, especially as a result of vascular lesions, precludes closure; for instance, wounds of the calf with the posterior tibial artery sectioned, or marked infiltration of the tissues with blood. (5) As has been emphasized, primary suture must not be made unless the patient can be watched carefully for days thereafter. Accordingly, it w-as a general rule in the American Expeditionary Forces that during active periods no primary suture of wounds of the soft parts should be made except in w-ounds of the scalp, face, or hands, as enumerated above. Technique Thorough debridement is essential, and aseptic technique must be observed throughout the operation. Hemostasis must be complete. The wounds GENERAL SURGERY 309 should be washed sufficiently to remove blood clots and loose fragments of t issue. Many operators, after drying the wound apply ether to the w-ound sur- faces; this, however, is empiric. Lemaitre6 applies tincture of iodine to fix residual microorganisms. It is questionable, however, w-hether the ether or the iodine are factors of importance. The muscles and aponeurosis are approxi- mated with interrupted catgut. As little and as fine catgut should be intro- duced as will approximate the tissues and obliterate dead spaces. The skin and subcutaneous tissues are closed with interrupted silkworm gut. Drainage should be avoided. If employed, the drain should be removed as soon as possible, in general, within 24 hours. In some cases, especially in deep wounds of muscular parts, a few strands of silkworm are advantageous as a means of obtaining subsequently a culture from the interior of the w-ound. At the first dressing the silkworm should be removed and cultures taken, and if hemolytic cocci are found the wound should be reopened. After the dressing has been applied the part should be immobilized. Partial primary^ suture of wounds of the soft parts has nothing to recom- mend it; it is often harmful; it should therefore rarely be employed. A wound w-hich has been closed by primary suture should be examined within 24 hours; moreover, the general condition of the patient should be care- fully watched. These precautions can not be too strongly urged. If they are observed, there is not much danger of fatal infection; if they are neglected, avoidable fatalities will occur. It is, in general, the failure to recognize the development of gas bacillus infection or pyogenic infection as early as one should, and the unwillingness to admit failure of the primary suture and the necessity for complete reopening of the wound and free excision of gangrenous muscle, that cause the fatalities. When gas bacillus infection develops after primary suture its onset is suggested usually by local tenderness or spontaneous pain in the wround after 12 hours, or by changes in the general condition of the patient which should be watched for and immediately recognized. These changes can be noted, as a rule, in about IS to 24 hours after the operation. Thev are rapid pulse, peculiar gray appearance of the face, and moderate rise of temperature, for instance, to 101°. The condition, if left, rapidly becomes worse, and six hours later the systemic symptoms are often greatly accentuated. The patient becomes pro- foundly toxic, with high temperature, delirium, and dyspnea. Locally, in t epical cases, the part is swollen, tender, tense, and often bronzed in patches; the face, however, may look and feel normal. A tympanitic note on finger percussion, as emphasized by Lemaitre,6 can often be demonstrated. Crepita- tion is frequently present, On opening the wound, or perhaps not until the aponeurosis has been opened, bubbles of gas and thin, brownish fluid exude; the typical rotten meat smell is noted, and the involved muscle shows the char- acteristic appearance and lack of vitality, notably, an unhealthy salmon color, friability, and failure to contract on pinching. Cultures in these cases show- various anaerobes, especially B. welchii (perfringens), often associated with pyogenic organisms. 310 SURGERY DELAYED PRIMARY' SUTURE The distinction between delayed primary suture and secondary suture is one of tissue repair rather than of time. Delayed primary suture is one in which the edges can be approximated and will unite without excision of tissue. Secondary suture is one in w-hich the epidermis has grown inward and must be excised for proper union. This is, in general, about one week. In late sec- ondary sutures dense granulation tissue must also be excised. The determi- nation as to when a wound may be sutured depends on bacteriologic findings and clinical observation. It must be emphasized that the cooperation of a bacteriologist is indispensable in making a decision as to the indications for delayed primary and secondary sutures. The practical function and indis- putable importance of the bacteriologist in war surgery lies in this. In the Fig. 170.—Large penetrating shell wound, internal aspect of leg, closed by retarded primary suture. (Heuer) consideration as to whether a wound is suturable or not reliance must be placed chiefly on cultures, the important feature being the determination of the presence or absence of hemolytic cocci. For this a routine blood-agar examination is essential. Bacterial counts are far from exact, yet they give an indication as to the degree of bacterial contamination of a wound, especially the progress from day- to day, and are of value especially- for one untrained in estimating clinically the indications and contraindications for suture. From 18 to 24 hours after the original operation of debridement or excision of tissues the wound is dressed and a culture and a smear are made. A report is returned as soon as possible. If no organisms are found, suture is indicated. If hemolytic cocci are present, suture is not considered. In the absence of hemolytic cocci, if the wound is clinically suturable, the presence of a few GENERAL SURGERY 311 anaerobes or other organisms (approximately one in two fields) does not contra- indicate suture. A considerable number of organisms of any- kind indicates the necessity for caution. Suture, in that event, should be delayed and a culture and a smear repeated at the following dressing. Delayed primary suture is usually made within six days after the primary operation. The advantages of this method are the practical elimination of the danger of gas bacillus infection and the marked lessening of the danger of pyogenic infection. The disadvantages are the possibility of postoperative contamination of the open wound and the subjection of the patient to a second operation, with the attending discomfort and danger of postoperative com- plications, such as pneumonia. These disadvantages, however, do not equalize the risk incurred by primary suture in doubtful cases. Fig. 171.—Large perforating wound of thigh, closed by primary suture. (Heuer) Technique All dressings of wounds after the primary operation should be made according to the Carrel-Dakin technique. The anteoperative preparation of the wound for delayed primary- suture consists in painting the skin with tincture of iodine, after thorough cleansing as in the routine dressing. Some operators also paint the wound surfaces. The details of suture are the same as for primary suture. SECONDARY SUTURE The following routine is generally followed: After 48 hours, at the daily dressing, a culture and a smear are made. The first report, therefore, contains the approximate number of organisms per field and the varieties of organisms. Thereafter, a smear is made every two days. It is also advisable to make a culture occasionally. Care must be taken not to touch the skin surface in making the smear, since skin contamination vitiates the value of the report. From the smear a bacterial curve may be plotted according to Carrel's plan. When the organisms in two successive counts are few, that is, approximately one per two fields, and a culture shows an absence of hemolytic cocci, the wound is considered susceptible of secondary- suture, except when the wound has contained hemolytic cocci at any time. In that case careful cultures are made 312 SURGERY from granulation tissue and from the discharge from all parts of the woi and absence of hemolytic cocci should be established by two successive nega cultures before suture is made. It has been observed that streptococci prone to lie dormant in small numbers but to flare up and cause vim infection after closure of the wound. Fig. 172.—Wound, posterior aspect, right thigh; compound comminuted fracture of femur. Two weeks after debridement. Treated by Carrel method Technique The preparation is the same as for delayed primary- suture. Lemaitre c distinguishes two varieties of secondary suture: (1) Secondary suture of the skin. The incision surrounds the new epidermis along the wound edges. A healthy normal skin edge must be present for successful suture. The skin is freed by undermining in all directions as far as necessary in order to approxi- mate the edges with the minimum tension. This separation is made in the plane immediately superficial to the deep fascia. Only dense scar tissue or GENERAL SURGERY 313 projections of granulation tissue are removed from the wound. The deep fascia is then approximated with interrupted catgut when possible; usually this may be done in the thigh and shoulder, but rarely in the leg, arm, and forearm. The skin and subcutaneous tissues are closed with silkworm gut. Considerable tension may be allowed, far more than we are in the habit of permitting in civil practice. If little skin was removed at the original operation Fig. 173—Same wound as that shown in Figure 172, two weeks after secondary suture the skin stretches in a short time, tension is relieved, and good union results. The result of suture is directly proportionate to the degree of tension. If there is extreme tension infection may be expected. It is surprising, however, how well most of these wounds do, even after some infection. After the suture is completed a drv dressing is applied with considerable pressure and left undisturbed, if conditions warrant, for about eight days, after which sutures are removed7. (2) Secondary suture reconstruction. The granulation tissue 314 SURGERY and scar tissue are removed from the entire w-ound and all layers are recon- structed bv suture. When two longitudinal wounds are on the same transverse plane, with considerable loss of tissue in each, one wound can usually- be closed completely and the other closed in part. A dry dressing is applied and the wTounds are left for about eight days, after which the sutures are removed. The unclosed portion then presents a flat, clean, granulating surface. WOUNDS OF THE FACE Wounds of the face must be considered independently. However severe, extensive, and dirty the wound, virulent pyogenic infection and gas gangrene are not prone to develop. This feature makes it possible by timely operative intervention to avoid in most cases the gruesome mutilations which were so often allowed to occur in the early days of the war. The rule which may- be safely followed is to repair wounds of the face as soon as possible after the receipt of the injury without general excision of tissues. The wound is cleaned thoroughly, and only such tissue is removed as is definitely devitalized. The mucous membrane is then closed and the skin wound sutured. Such wounds unite quite regularly. Secondary plastic operations are made in order to improve unsightly scars, to reconstruct the angle of the mouth, etc. The fre- quently associated fractures of the maxillae should be treated by- a surgeon- dentist. In his absence the original operator should conserve as far as possible all fragments of bone. WOUNDS OF THE HAND In general, the soft parts should be studiously conserved; when conditions warrant, primary- suture should be made and early active motion enforced Wounds by shell fragments with retained foreign bodies should be operated upon. Wounds caused by very small fragments may be left unopened, espe- cially if bone, tendons, or joints are uninvolved. In extensive wounds of the hand slow, painstaking cleansing by- conservative debridement is necessary. Tendons are cleaned carefully; unopened tendon sheaths should not be entered. If practicable, divided tendons are sutured. If suture is not possible, severed tendons should be united with others so as to obtain the best functional result. Even extensive wounds of the hand should be closed if they have been carefully and thoroughly treated. If a dead space is present a drain should be introduced. Plastic operations with sacrifice of a finger and excision of a metacarpal are advisable if the danger of infection can thus be diminished. WOUNDS OF THE FOOT Ample longitudinal incisions are necessary except for perforating wounds near the margin of the foot, in which case a transverse incision is employed, laying open the whole track. In the anterior part of the foot it is best to expose the whole track by incision through the web between the toes. Con- servation of the digits is not necessary- to the same extent as in the hand. Usually primary suture may be made in slight wounds. Extensive wounds of the foot should be left open and treated with Dakin's solution. GENERAL SURGERY 315 REFERENCES (1) Borst, Max: Pathologisch- anatomische Erfahrungen uber Kriegsverletzungen. Sammlung klinischer Yortrdge begriindet von Richard von Volkmann, Leipzig, 1917, n. s. no. 735, Chirurgie No. 201, 299. (2) Morestin, H.: De l'emploi de formol dans le traitement des plaies tres septiques et des gangrenes gazeuses. Bulletins et memoires de la societe de chirurgie de Paris, March 24, 1915, xli, 740. (3) Gaudier: Cited by Delbet in Discussion of article by Le Grand: De l'emploi d'un fixateur colorant avant la desinfection mecanique. Bulletins et memoires de la societe de chirurgie de Paris, June 2, 1917, xliii, 1347. (4) Dakin, Henry M.: Au sujet de l'emploi de certaines substances antiseptiques dans le traitement des plaies infectees. Presse medicate, Paris, September 30, 1915, xxiii, 377. (5) Carrel, A., Dakin, H. M., Daufresne, Dehelly and Dumas: Traitement abortif de l'infection des plaies. Presse medicate, Paris, October 11, 1915, xxiii, 397. (6) Lemaitre, Rene: Suture of War Wounds. Medical Bulletin, Paris, 1918, i, Supple- ment, March, 292. (7) Gaudier, H.: A propos du traitement des plaies de guerre recentes. Bulletins et memoires de la societe de chirurgie de Paris, November 8, 1916, xlii, 2463. (8) Tuffier: Traitement des plaies de guerre. Bulletins et memoires de la societe de chirurgie de Paris, November 8, 1916, xlii, 2452. (9) Dupont, Robert: Les enseignements de la guerre. Evolution des idees sur le traite- ment des blesses. Progres medical, Paris, June 28, 1919, xxxiv, 249. (10) Duval: Note sur le traitement des plaies de guerre des parties molles a la * * * armee. Bulletins et memoires de la societe de chirurgie de Paris, October 3, 1917, lxiii, 1739. (11) Gross, Georges, Tissier, H., Houdard, L., di Chiari, F., and Grimault, L.: Primary Suture of War Wounds (Translated and abstracted from the Bulletins et memoires de la societe de chirurgie de Paris, October 10, 1917, xliii, pt. 2, 1086). Medical Bulletin, A Review of War Medicine, Surgery, and Hygiene, Paris, 1918, i, No. 5, 383. (12) Morquis, Descazals, Luquet and Morlot: Suture of War Wounds in Time of Attack (Translated and abstracted from the Bulletins et memoires de la societe de chirurgie de Paris, December 19, 1917, xliii, pt. 2, 2281). Medical Bulletin, Paris, 1918, i, No. 5, 388. (13) Riche, P.: A propos des blessures de guerre. Bulletins et memoires de la societe de chirurgie de Paris, October 14, 1914, xl, 1110. (14) Skillern, Penn G.: A Series of War Wounds Treated with Dichloramine-T. Annals of Surgery, Philadelphia, 1919, lxix, No. 5, 498. (15; Fraser, John, and Bates, H. J.: The Surgical and Antiseptic Values of Hypochlorous Acid (Eusol). Edinburgh Medical Journal, 1916, n. s. xvi, No. 3, 172. (16) Wright, Sir Almroth E.: Memorandum on the Treatment of Infected Wounds by Physiological Methods. British Medical Journal, London, June 3, 1916, i, 793. (17> Gray, H. M. W.: Remarks on the General Treatment of Infected Gunshot Wounds. British Medical Journal, January 1, 1916, i, 1. (18) Walther and Delbet: Sur Taction de la solution de magnesium. Bulletins et memoires de la societe de chirurgie de Paris, February 13, 1918, xliv, 283. (19) Boese, Karl: Ueber Collargol, seine Anwendung und seine Erfolge in der Chirurgie und Gynakologie. Deutsche Zeitschrift fur Chirurgie, Leipzig, 1921, clxiii, Nos. 1-2, 62. (20) Morison, Rutherford: The Treatment of Infected Suppurating War Wounds. Lancet, London, August 12, 1916, 26s. (21) Berczeller, L.: Ueber Iodstarke. Biochemische Zeitschrift, Berlin, 1922, exxxiii, 502. (22) Browning, C. C, Gulbransen, R., Kennaway, E. L., and Thornton, L. H. D.: Flavine and Brilliant Green Powerful Antiseptics with Low Toxicity to the Tissues; their Use in the Treatment of Infected Wounds. A Report to the Medical Research Committee. British Medical Journal, London, January 20, 1917, i, 73. 316 SURGERY (23) Gaudier: A propos de l'emploi d'un fixateur colorant avant la disinfection niecanique. Bulletins et memoires de la societe de chirurgie de Paris, July 11, 1917, xlm, 1528. (24) Alston, James: The Treatment of Inflammatory and Suppurating Lesions by Magne- sium Sulphate. Medical Press, London, April 2, cvii, 258. (25) Leriche: De la sterilisation par le soleil des plaies infectees. Bulletins et memoires de la societe de chirurgie de Paris, May 16, 1917, xliii, 1063-1072. (26) Stoker, George: The Surgical Uses of Ozone. Lancet, London, October 21, 1916, ii, 712. (27) Gore-Gillon, G., and Hewlett, R. T.: Acetozone as a General Surgical Antiseptic. British Medical Journal, London, August 18, 1917, ii, 209. (28) Duval, Pierre, and Vaucher, E.: Premiers resultats des essais systematiques de scro- therapie preventive antigangreneuses. Bulletins et memoires de la societe de chirurgie de Paris, October 16, 1918, xliv, 1535. Also Tuffier et Sacquepee: Analyse et resultats des methodes de traitement (primitif, secondaire et tardif) des plaies de guerre. Archives de medecine et de pharmacie militaires, Paris, March 14, 1918, lxx, 517. (20) Delbet, P.: Pyoculture et index opsonique. Bulletins et memoires de la societe de chirurgie de Paris, July 28, 1915, xli, 1601. (30) Donaldson, Robert, and Joyce, J. Leonard: A Method of Wound Treatment by the Introduction of Living Cultures of a Spore-Bearing Anaerobe of the Proteolytic Group. Lancet, London, September 22, 1917, 445. (31) Morgenroth, J.: Ueber chemotherapeutische Antisepsis. I. Zur experimentelleni Begriindung der Vuzin Tiefenantisepsis. Deutsche medizinische WochcnscJirift, Berlin, May S, 1919, xlv, 505. (32) Bazin: Recherches experimentales sur le pouvoir antiseptique du melange boro-hypo- chlorite de Vincent. Comptes rendus des seances de la societe de biologie, Paris, Fet- ruary 9, 1918, lxxxi, 122. (33) Crile, G. W.: Lectures of Army Sanitary School, A. E. F., No. 109. On file, Historical Division, S. G. (). CHAPTER XIII WOUNDS OF JOINTS The experience gained in the World War resulted in striking changes in the treatment of wounds of joints caused by projectiles. During the early years of the war poor results usually followed these lesions by reason of an undervaluation, on the part of surgeons, of the resistance to infection which the synovial membrane of a joint offers, a failure to comprehend the proper operative procedures, and the universal employment of prolonged immobiliza- tion. But in the last 18 months or 2 y-ears methods of treatment were adopted in the allied armies which gave results far superior to any that preceded. PREOPERATIVE MANAGEMENT Although attention must be focused upon the operative treatment as the most important factor, the preoperative management of the patient can not be disregarded. As soon as possible after the receipt of the wound a first-aid dressing should be applied. Active hemorrnage, as a rule, can be controlled by a light pressure bandage over the dressing. This failing, a tourniquet may be applied. It must be emphasized, however, that a tourniquet is a dangerous accessory. It should be applied close to the wound, and should be removed as soon as possible. It is essential in joint wounds that the part be immobilized before the patient is moved. In a large proportion of cases, especially- when associated with fracture, traction also should be applied. For transportation in the advanced area the following splints are advisable:0 For fractures involving the knee joint the Thomas leg splint and the hinged half-ring modification (Blake-Keller) are applicable. A litter bar attached to the stretcher supports the injured limb during transportation. For slight injuries of the knee joint without marked effusion, also for injuries to the ankle and tarsus, the Cabot posterior wire leg splint is advisable. This splint provides immobilization only. For injuries of the hip joint the Thomas traction leg splint or the long Liston splint should be used. For injuries involving the shoulder and elbow- the hinged modification of the Thomas arm splint is useful when fixation and traction are desirable. The advantage of this splint is that the injured limb may be brought to the side of the body- for recumbent trans- portation, which can not be done with the ordinary Thomas arm splint. For the smaller joints, wiiich need only immobilization, the ladder splint or the wooden coaptation splint may be used. The wounded arc received at a front hospital, for instance, a mobile hospital or an evacuation hospital, from about 4 hours to 24 hours or more after the receipt of injury. Their previous treatment, besides a first-aid dressing for the w-ound and a temporary splint for immobilization, has consisted in the administration of antitetanic serum and appropriate treatment for those pre- " Manna! of Splints and Appliances for the Medical Department of the United States Army, 1917. 317 318 SURGERY senting a condition of shock. The patients on arrival at the hospital present various degrees of shock, hemorrhage, laceration of soft parts, and associated lesions. The wound or wounds contain pathogenic microorganisms and, in . most cases, foreign bodies. The devitalized tissues provide an admirable medium for the growih of microorganisms which, however, lie dormant for a time, roughly- from 6 to 8 hours, after wliich they become active and infection progresses with variable rapidity and intensity. INDICATIONS FOR OPERATION All w-ounds of joints by projectiles, except certain perforating (through- and-through) wounds by bullets, should be operated upon. Perforating bullet wounds are not operated upon if the wounds of entrance and exit are punctate and there is no evidence of displacement of fragments or of hemorrhage. Punc- tate wounds are made by a bullet of high velocity with no explosive effect and no deflection during its course through the limb. In such cases the bullet cuts through clothing and tissues, carrying few organisms into the wound and pro- ducing little destruction of soft tissues or comminution of bone. Experience proved that under these conditions infection rarely occurs even when a fracture is present. Therefore these cases do not demand immediate operation. They should, however, be carefully watched, and distention of the joint should be treated in the manner described in the after-care of operated cases. In all other eases operation should be performed as soon as possible after the receipt of the injury-. Delay increases the danger of and from infection by- reason of the bacterial types which are usually present and the characteristics of their growth and penetration in the tissues. But before operation certain preliminary precautions are essential. Thus: A careful examination by- the surgeon of the patient and his lesions is essential. The general examination should be sufficiently thorough to preclude the possibility of overlooking a serious associated lesion. The degree of bone involvement and the presence and position of retained foreign bodies should be established by the X ray. The surgeon should satisfy himself as to whether there is or is not a nerve lesion; this is especially- important in the upper extremity-. He must also examine for arterial lesions, especially- in wounds of the lower extremity-; the presence or absence of the anterior and posterior tibial pulse should be noted. Moreover, the time elapsed since the wound was received, the situation of the wound, the extent of injury to the soft parts, and the general condition of the patient are factors w-hich must be weighed before a plan of action can be decided upon. ROENTGENOLOGIC EXAMINATION The success of the operation depends largely upon the thoroughness of the roentgenologist's examination and the accuracy of his findings. His report should be made according to a definite sy-stem. The following routine has been found the most satisfactory: Anatomic site and size of each foreign body in millimeters, depth in mil- limeters, position of the part, if it is not in the anatomic position; bone lesions. For example: " Right knee, F. B 10 by 15 mm., 50 mm. in depth, under the point marked on the skin, the limb being in 45 degrees outward rotation; comminuted fracture of internal condyle; no displacement." GENERAL SURGERY 319 PREPARATION OF PATIENT The local preparation is usually done in the operating room on an extra table while the preceding operation is being completed. The wound being protected with gauze, the surrounding skin is shaved and scrubbed with soap and water. Application of chemicals may follow-. The usual procedure is to cleanse with ether, following this with the application of tincture of iodine. It is important to prepare a wide field; even to encircle the limb. The part is draped with towels and sheets. A general anesthetic should be employed save in exceptional cases. Nitrous oxide-oxygen, administered by an expert anesthetist, is the least harmful. It should be the anesthetic of choice for patients in a condition of shock. Ether, however, is employed in routine cases. After careful consideration of the factors enumerated above the surgeon should proceed as far as possible in accordance with a definite plan. The choice between amputation and conservation of the limb should be made, if possible, before the operation is begun, so that the patient may be spared futile efforts to save the limb. Irreparable mutilation of the soft parts, excessive comminution of bone, wounds of the main vessels of the limb, especially in the lower extremity, irremediable injury- to essential nerves, or advanced gas bacillus infection, are the main features which call for the consideration of amputation. The condition of the patient is often the deciding factor. But the results of conservative treatment are sufficiently good to weigh in its favor in cases of doubt. Amputation is indicated in a relatively small percentage of cases. Conservative operative treatment of recent wounds of joints has for its object, first, the prevention of infection; second, the preservation of function. The important features are thorough debridement, complete closure of the joint, and early movements. The adoption of these principles by our Allies in the war of 1914-18 followed three w-ell-defined stages: 1. Debridement; drainage; irrigation with antiseptic solutions; immobilizations. 2. Debridement; Carrel-Dakin treatment of the joint; immobilization. 3. Debridement; lavage of the joint with Dakin's solution or ether; joint suture, with drainage of the joint for about 24 hours; immobilization; passive movements and massage in 8 to 10 dayTs. During the development of these methods the results improved progres- sively, but were not satisfactory, as was demonstrated by Depage * at La Panne, Belgium, where these procedures were conscientiously carried out and the results analyzed. It was recognized early in the war that the main features which are of importance in the treatment of battle casualties of other types, particularly early operation and thorough debridement, are likewise indicated in the treatment of wounds of the large joints. But, whereas in other ty-pes of wounds it is often advisable to leave the w-ound unsutured and to supplement the operative treatment by chemical sterilization before proceeding to a final closure, it was found that an unsutured joint in general did not progress satisfactorily. In such cases postoperative chemical sterilization could not be depended upon, and the introduction into the joint of drains, such as rubber 4 0907—27---23 320 SURGERY tubes, was found to result disastrously, in that they often introduced infection and caused pressure necrosis, thus diminishing the resistance of the synovial membrane and articular cartilage to infection. Moreover, they failed to accomplish their purpose, that is, to drain the joint. Immediate closure of the joint by suture was found to be essential to success. Therefore the surgeon must rely upon the primary- operation for the prevention of intra-articular infection, which is the immediate aim of conserva- tive treatment. The important factor being the debridement of tissues, the principles of this, as applied to wounds of the soft parts, bones, and cartilage, must be fully understood. TECHNIQUE The details of a conservative operation may be summarized as follows: Complete debridement of the tract of the projectile through the soft parts and bone; removal of foreign bodies; thor- ough irrigation of the joint; absolute closure of the joint by- suture; primary or delayed closure of the superficial parts according to the rules laid down for primary- suture of the soft parts alone; finally, early active motion. The incision or incisions must be placed so as to permit not only thorough debridement of the soft parts but also free access to the foreign body and involved bone. Though no rules can be formulated, longitudinal incisions are to be preferred when practicable; however, the position of the wound or wounds and that of the foreign body- are, in general, the determining factors. The primary incision includes the wound of entrance and is often supplemented by a second incision. In a perforating wound the second incision usually-includes the wound of exit; in a penetrating wound it is placed in such position as to expose a retained foreign body- which otherwise would be inaccessible. The incisions must be of sufficient length to give adequate exposure. (Fig. 174.) Fig. 171.—Gunshot wound of knee. A, Incision for debridement of wound of entrance; B, incision to expose retained foreign body. (See fig. 175.) (Keen's Surgery) GENERAL SURGERY 321 .iiiuwty Through these incisions debridement of the soft parts (fig. 175) proceeds as in operations elsewhere. The technique is practically the same as for wounds of the soft parts alone, but the refinements of technique in respect to asepsis and adequate exposure must be fully observed, and traumatization of the synovial membrane should be reduced to a minimum. It is sometimes difficult to identify the opening in the capsule or even to determine wiiether the joint has been penetrated. This difficulty is met most often in the case of small perforating and pene- trating wounds with little or no bone involvement in which a fragment of shell has either perforated the limb, travers- ing [the joint in its course, or has penetrated the joint and lodged in it or in adjacent tissues. But, after the cap- sule has been exposed in the debridement, the orifice into the joint must be demon- strated before the joint is opened. Great care should be exercised to avoid open- ing a joint that is unin- volved, and, similarly, not to neglect proper operative measures in a joint that is involved. The capsule and synovial membrane should be opened by a liberal incision with thorough elliptic excision of contused or contaminated tis- sue, conserving, however, all tissues that can be left safely. Foreign bodies must be re- moved. The subsequent steps depend upon the presence or absence of a bone lesion. If none exist, the joint is irrigated and closed; if a bone lesion is present, it must be appropriately treated before closure of the joint. In all cases contaminated bone surfaces must be cleaned as thoroughly as possible; that is, treated on the principle of removal of contaminated tissue. Fig. 175.—Gunshot wound of knee. Outer side: After debridement of wound and opening of capsule. Dotted lines indicate extent to which capsule has been opened. Inner side: Arthrotomy to reach foreign body in internal condyle. F, Femur, internal and external condyles, with gutter wound debrided; C, capsule; VE, vastus externus; 1TB, iliotibial band; VI, vastus internus; B, biceps femoris. (Keen's Surgery) 322 SURGERY This is done with gouge, chisel, or curette, with the sacrifice of as little bone as possible. An intra-articular w-ound of the bone or cartilage, such as a gutter, depres- sion, or canal without complete fracture, constitutes the simplest type, of lesion. The bone wound should be cleansed as above described. When there is an injury to an articular surface consisting in a limited and incomplete separation of a" layer of cartilage with a thin layer of underlying bone, it is advisable to remove the partly separated and poorly nourished cartilage, and with chisel, gouge, or curette to cleanse the surface from which it has been detached. Where a fracture line has resulted in partial detachment of a large fragment of bone with its articular surface, but the fragment retains good contact with the soft parts, it is left after the tract has been followed and contaminated surfaces have been cleansed as thoroughly as possible. But under such condi- tions it is important that the fractured surfaces be left in close contact. An intervening space interferes materially with union, as Cotton emphasized years ago.2 If an attached fragment is to be removed, this should be done if possible by the subperiosteal method of Oilier, using the Leriche modification of the sharp Oilier elevator. By this method a re-formation of the bone is more probable. In extensive involvement of the articular surfaces an effort should be made to save the joint, provided the conservable articular surfaces and soft parts are sufficient to warrant a reasonable hope of securing a useful joint. In this connection it must be borne in mind that stability is essential in the knee and ankle; that is, in the weight-bearing joints. When there is such loss of the articular surfaces as to preclude obtaining a useful joint, resection should be elected. A classical resection should be done when stability and rigidity- are desired, as in the knee; otherwise an atypical resection may be made. The final steps of the operation in all cases are as follows: Complete hemostasis should be secured. The joint is then thoroughly washed with salt solution to remove blood clots, bone fragments, and debris. Some operators recommend that this be followed by lavage with ether under sufficient pressure to distend the joint. However, this use of ether is empiric; it is questionable whether it exerts any beneficial influence. The synovial membrane and capsule are closed with fine chromic gut which should be, as far as possible, extra-articular. When feasible, these two layers should be sutured independ- ently. Complete closure of the joint without drainage is the invariable rule. When there is such destruction of the soft parts that the edges of the capsule can not be approximated, if an attempt is to be made to save the joint, the defect in the capsule should be completely closed with muscle or fascia, using a pedunculated flap, if necessary. In a few cases in w-hich this was impossible the w-riter has seen a partial closure made and the wound treated by the Carrel method, the aim being to close the joint subsequently by- a plastic- operation. He has not, however, seen this method successfully carried out without infection. GENERAL, SURGERY 323 The soft parts overlying the capsule may be closed or left open for subse- quent suture. If the ideal conditions—that is, early and thorough debride- ment—have been approximated and the case can be watched for some day-s. primary suture may be made; otherwise, the wound is left open and sutured subsequently. In active periods, as during offensive military operations, with a consequent large number of wounded, the exigencies of the service demand haste in the primary operation, and the case must be evacuated and pass from the operator's control soon after the operation. Under such condi- tions primary suture of the superficial tissues should not be considered; it may- be employed only in quiet periods and in hospitals where patients can be watched. In this connection it must be urged that cases of wounds of the large joints, e. g., knee, should be included in the nontransportable class after opera- tion, when conditions warrant their retention. The advantages of primary suture are obvious; the disadvantages consist chiefly in the danger of closing within a wound, especially within a wound imperfectly debrided, pathogenic microorganisms. A resulting gas bacillus infection or virulent pyogenic infection in a few cases will counterbalance many successful closures; moreover, primary suture increases the danger of joint infection by inward extension of a superficial infection. The danger, however, is lessened if interrupted silkworm sutures, placed at rather long intervals, are employed for the approximation of skin and subcutaneous tissues. If the soft parts are left open, vaseline-saturated gauze or other bland nonadhering gauze is placed along the edges of the wound so as to cover the skin edges and subcutaneous tissues. This prevents the dressing from adher- ing and lessens hemorrhage and pain on its removal. Gauze soaked in Dakin's solution is placed very loosely- in the wound. It should be so adjusted as not to cause retention of secretions. In cases in which there is an extra-articular lesion of bone in conjunction with a joint lesion, the joint is treated and closed as described; the extra- articular bone lesion is appropriately- treated and the wound of the soft parts is left open. Every effort should be made to close such a wTound by delayed primary suture, because prolonged exposure will often result in infection, and infection will secondarily involve the joint. POSTOPERATIVE CARE The ultimate aim of treatment is to restore the individual to full activity, with complete restoration of function, in as short a time as possible. EARLY ACTIVE xMOBILIZATION It must be emphasized that early reestablishment of the function of the part is dependent upon early active mobilization. Before the war immobili- zation for a considerable period after operations upon joints was the usual practice. Complete loss of function, limitation of function, or delay in return of function frequently resulted. Ha vino- in view- the early and complete reestablishment of functions, Willems3 of Hoojstade, Belgium, urged that postoperative immobilization should not be employed, and demonstrated the correctness of his claims by 324 SURGERY a series of brilliant results. Other surgeons were slow to accept his method to the extent of adopting immediate mobilization with the elimination of all splinting. But various operators practiced short periods of immobilization, and subsequently inaugurated movements at an earlier date than was their former practice. Moreover, as the beneficial results and relative freedom from complications became evident, they gradually- approached and even followed Willems' plan. An example of the conservatism which prevailed may be illuminating. Thus, in 1917, Cook4 advised "that when the object of treat- ment is mobility, and the asepticity of a ease has been provisionally estab- lished—i. o.. after the temperature has been normal for about a week—light Fig. 176.—A convenient method of recording the range of motion. (Keen's Surgery) movements are applied. Further treatment in this direction is regulated by absence of reaction and comparative freedom from pain." The writer was taught the Willems method at La Panne in the winter of 1917-18. The method, however, was not at that time generally accepted, so in the early- w-ork with the American Expeditionary Forces at Evacuation Hospital No. 1 he was somewhat conservative in its application. In general, he employed a splint for a brief period, but enforced early movements when- ever practicable. As a means of recording the range of motion he found it convenient to use a diagram (figs. 176, 177). The date is entered on the arc opposite the degree of motion. Dowden 5 states without reserve that, owing to the practice of immo- bilizing joint lesions, thousands of British soldiers have been rendered cripple- for life. In this respect views as to the treatment of joint injuries have under- GENERAL SURGERY 325 gone a radical change as the result of the experiences on an unprecedented scale in the recent w-ar. It may properly be urged that after operations for recent joint wounds immediate mobilization should be employed in all cases in which a fracture does not contraindicate, or the character of the wound of the soft parts is not such as to interfere with repair of the wound. The patient should be encouraged and directed to move the joint as soon as the operator feels that this can be done without interfering with tissue repair. For instance, following a trans- verse wound with removal or suture of the patella or after suture of an exten- sive wound of the thigh, a period of immobilization must be enforced. In the treatment of wounds associated with fracture, mobilization of the joint is not indicated if it is likely to interfere with alignment or union or promote excessive callus formation. But Willems3 claims that constant mobility prevents the development of intra-articular callus and, therefore, is advan- Fig. 177.—The same method as that shown in Figure 176 of recording motion in the elbow. (Keen's Surgery) tageous rather than harmful. On the other hand, in the type of wound with little involvement of bone and soft parts, a splint should not be applied. The patient should flex and extend the knee as soon as he has recovered from the anesthesia. The movements must be active, not passive; they should be as extensive and frequent as feasible. Little pain is experienced if the move- ments are begun early. Supervision by a nurse for the direction and encour- agement of the patient is -essential. Willems 6 recommends that patients with little or no bone injury- should be out of bed soon after the operation, even as early as the second day. In w-ounds of the lower extremity they are en- couraged to walk, gradually increasing the amount from dayT to day-. Crutches and cane are used at first, but are soon discarded. In the case of joints of the upper extremity patients are directed to scrub and sweep, gradualty increasino- the period of work. In cases with a bone lesion the patient is kept in bed for a longer period, the time being roughly proportionate to to the de°ree of bone injury. In cases associated with fracture they- are 326 SURGKRY encouraged to get out of bed and use the limb as soon as this can be done without endangering alignment and union. Early use of the joint is essential for early restoration of function. TREATMENT OF THE WOUND A wound which has been closed by primary suture should be examined within 24 hours; moreover, the general condition of the patient should be care- fully watched. These precautions can not be too strongly urged. If they are followed there is not much danger of fatal infection; if they are neglected, avoidable fatalities will occur. Obviously, one of the conditions of early restoration of function is the repair of the wound; therefore, when the soft parts have been left open, the wound should be closed as soon as possible by delayed, primary, or secondary suture. The distinction between delayed primary suture (Duval) and second- ary suture is one of tissue repair rather than of time. Delayed primary suture is one in which the edges can be approximated and will unite without excision of tissue; this is, in general, about one week. Secondary suture is one in w-hich the epidermis has grown inward and must be excised to permit proper union. In late secondary sutures dense granulation tissue must also be excised from the surface of the wound and the skin must be mobilized. The determination as to when a wound may be sutured depends upon bacteriologic findings and clinical observation. The cooperation of a bacteriologist is indispensable in making a decision as to the indications for delayed primary and secondary sutures. In the consideration as to whether or not a wound is suturable reli- ance must be placed chiefly- upon cultures, the important feature being the de- termination of the presence or absence of hemolytic cocci. For this a routine blood-agar examination is essential. Bacterial counts are far from exact, yet they give an indication as to the degree of bacterial contamination of a wound, especially the progress from day to day. Eighteen to 24 hours after the original debridement the w-ound is dressed and a culture and a smear are made. If no organisms are found, suture is in- dicated; if hemolytic cocci are present, suture is not considered. In the ab- sence of hemolytic cocci, if the wound is clinically- suturable, the presence of a few anaerobes or other organisms (approximately one in two fields) does not contraindicate suture. A considerable number of organisms of any kind indi- cates the necessity of caution. Suture in that event should be delayed and a culture and a smear repeated at the following dressing. When a wound is left open for a considerable time cultures and smears are made at regular intervals. The reports contain the approximate number of organisms per field and the varieties of organisms. When the organisms in tw-o successive counts are few, that is, approximately7 one in two fields, and a culture shows an absence of hemolytic cocci, the wound is considered suscep- tible of secondary- suture, except w-hen the wound has contained hemolytic cocci at any time. In that case careful cultures are made from granulation tissue and from the discharge from all parts of the wound; and absence of hemolytic cocci should be established by tw-o successive negative cultures before GENERAL SURGERY 327 suture is made. It has been observed that streptococci are prone to lie dor- mant in small numbers and to flare up and cause virulent infection after closure of the wound. Delayed primary suture is usually made in from two to six days after the primary operation. The advantages are the practical elimination of gas bacillus infection and marked lessening of the danger of pyogenic infection. The dis- advantages are the possibility of postoperative contamination of the open wound, the subjection of the patient to a second operation, and some interfe- ence with the institution of early movements. However, these disadvantages do not equalize the risk incurred by primary suture in cases w-hich can not be carefully- watched. All dressings of wounds after the primary operation should be made ac- cording to the Carrel-Dakin technique. The introduction of tubes to permit frequent chemical disinfection with Dakin's solution is indicated only in eases which are infected or which are evidently destined to be left open for a considerable time—that is, a week or more. The preoperative preparation of the wound for delayed primary or sec- ondary suture consists in painting the skin with tincture of iodine after thorough cleansing, as in the routine dressing. Some operators also paint the w7ound surfaces. POSTOPERATIVE INFECTION Superficial infection may require the removal of only- a few- stitches; more extensive infection of the superficial tissues requires reopening of the entire wound to the capsule. The wound should then be treated by the Carrel method and may be suturable subsequently. If the joint becomes distended, and infection is suspected, it should be aspirated immediately and a culture made. The wuiter has seen turbid fluid containing diplococci aspirated from a distended joint on the third day after operation, and uneventful recovery follow; also much turbid fluid evacuated from between the sutures in the capsule on the second and again on the fourth day by pressure on the subcrural bursa. In the latter case the joint was markedly- distended until the fourth day-. Possibly, as a result of the distention, there was no limitation of motion at any time. This patient quickly regained full motion and in six weeks was back at the front, with perfect function. If the patient's condition, the local examination, and the character or cul- ture of the aspirated fluid indicate pyogenic infection, one or more incisions should be made at once. But if the original incision is so placed as to allow satisfactory drainage it should be reopened and the treatment for suppurative arthritis begun. Willems' method of drainage by active movements is here recommended. The important feature is to begin treatment early; no drains should be used; splints arc dispensed with or arranged for support without joint fixation. Free mobility every two hours should be enforced by- active movements so as to evacuate the joint. Early- nonvirulent infections with little or no bone involvement usually do well. In severe or long-standing infections, especially with bone involvement, the treatment has not proved as satisfactory. The method will be described in detail in a later paragraph. 328 SURGERY In two cases under the waiter's care, where purulent intra-artieular infection occurred and the joint was reopened, Carrel treatment was carried out for a few days and secondary suture of the joint w-as made successfully in eight days. The Carrel treatment is most appropriate in wide open joints for a short period and where the joint is opened soon after the infection has begun. Hughes and Banks7 have obtained admirable results by its use, especially in the elbow and shoulder, and have been able to sterilize the wounds and perform secondary suture in a large proportion of cases. KNEE-JOINT Certain details which bear upon individual joints, especially the knee, must be emphasized. For the initial operation, lateral incisions are to be preferred; but, as stated above, the situation of the wound or wounds, and the position of the foreign body must, as a rule, be the determining fac- tors. Occasionally the incision may be curved or even transverse, but division of the patellar tendon should rarely be made and then only when full exposure of the joint is essential, as when a foreign body lies in the region of the crucial ligaments. When the wound of entrance is above the patella the joint may be explored to a consid- erable extent through the wound of debridement. In one of the writer's cases a foreign body em- bedded low in the articular surface of the femur was brought into view above the patella by acute flexion of the knee. Removal of the for- eign body and treatment of the bone injury were effected through this incision (figs. 178, 179). The following are the usual procedures followed for the various types of bone injuries: (1) A small partially detached piece of articular cartilage should be removed; (2) articular cartilage with considerable bone, the whole attached to soft parts, should be left; (3) extensive comminution of a condyle which necessitates its removal demands resection. Removal of one condyle will Fig. 178.—Gunshot wound of the knee. A, wound of entrance, incision for debridement; B, situation of foreign body. (Keen's Surgery) GENERAL SURGERY 329 result in so much lateral mobility as to necessitate later resection. In the decision between primary- resection and conservation of an imperfect joint it must be borne in mind that stability is essential in the knee; (4) where great disorganization of the articular surfaces exists immediate resection is indicated. Tuffier8 affirms that this method of treatment forms one of the greatest advances made in the surgery of the joints, and has caused a large diminution in the number of amputations of the thigh. Leriche 9 ad- vises that the tibia be nailed to the femur to prevent dislocation after resection. For this pur- pose Blake recommends two spikes, converging from each side of the tibia upward and inward into the femur. They- are removed wiien union has taken place. When the bone lesion is so extensive that resec- tion would be necessary through the narrow shaft above the condyles, am- putation is in general preferable. Compound fractures of the patella should be treated by removal of completely' separated fragments and preserva- tion of large attached fragments which should be approximated if possi- ble by suture. Complete removal of the patella should be avoided, since the functional result is poor. However, when the patella must be removed a flap from the quadriceps tendon should be attached to the patellar tendon, as advised by Murphy.10 Much difficulty may be experienced when excision of a portion ol the head of the tibia has been necessary. The defect in the capsule is difficult to close. When the loss of articular surface is slight it may be possible to supplement Fig. 179.—Gunshot wound of the knee, same as that shown in Figure 178. Incision in capsule after debridement. Foreign body exposed by acute flexion of knee. A: RF, Rectus femoris; F, femur articular surface; C, cap- sule. B: F, Femur articular surface; T, tibia; P, patella. (Keen's Surgery) 330 SURGERY the deficiency in the capsule by turning a flap of fascia from an adjoining part and suturing it in place so as to complete the closure. If the loss of articular surface is considerable, resection is usually necessary. In compound fractures of the tibia" in which the joint is not directly involved, but with one or more lines of fracture extending into the joint, intra- articular infection frequently develops. If hemarthrosis is marked, arthrotomy, irrigation, and closure are indicated in general, in addition to the operative treatment of the w-ound and the fracture. Every effort should be made to convert the compound into a simple fracture at an early date by suture under bacteriologic control. In the cases which the writer observed in w-hich an open knee joint was associated with a wound of the popliteal or femoral artery, amputation ulti- mately became necessary except in two instances. One of these was an open knee joint without bone involvement complicated by a wound of the popliteal artery. Arthrotomy and ligation of the popliteal artery (Jopson) were fol- lowed by a good functional result. The other was a case operated upon by Delrez. * It was a penetrating bullet wound of the popliteal space, with division of popliteal artery and vein. The bullet was extracted under the method of Hirtz by trepanization of the condyle. Both vessels were doubly ligated. Mobilization was begun four days later. There was almost complete restora- tion of function in six weeks. An analysis of a series of cases of wounds of the knee joint which were operated upon and followed by Jopson and Pool" affords approximately the average figures for this type of wound: Total number of cases___________________________________________________ 34 Average time between receipt of wound and the operation (excluding one case of three days' duration)____________________________________________hours__ 11 Shortest interval_________________________________________________do--- 3^ Longest interval__________________________________________________do--- 26 Type of missile: High explosive shell fragments________________________________________ 25 Pistol_____________________________________________________________ o Rifle or machine gun________________________________________________ 4 Penetrating wounds: High explosive_____________________________________________________ 23 Pistol or rifle_______________________________________________________2-25 Perforating wounds: High explosive_____________________________________________________ 2 Pistol or rifle_______________________________________________________ 7-9 Wounds with bone involvement: Femur____________________________________________________________ 12 Femur and tibia____________________________________________________ 3 Femur and patella__________________________________________________ 6 Tibia_____________________________________________________________ 3 Patella___________________________________________________________ 4-28 Wounds without bone involvement________________________________________ 6 Complications: Multiple wounds___________________________________________________ 10 Wound of main blood vessels_________________________________________ 3 Femoral artery_________________________________________________ 1 Popliteal artery_________________________________________________ 1 Popliteal artery and vein_________________________________________ 1 Contusion of peroneal nerve__________________________________________ 2 Shock or hemorrhage, or both_________________________________________ 4 Gas gangrene (preoperative)__________________________________________ 2 GENERAL SURGERY 331 Primary Operation In all except two cases the joint was sutured primarily. In one case primary amputation was necessary-, and in another an attempt was made to save a badly shattered limb, in wiiich the wound of the knee joint was of second- ary importance. This case came to amputation, but not for joint infection. Primary amputation___________________________________________________________ 1 Primary suture of joint________________________________________________________ 32 Primary closure of superficial wound____________________________________________ 21 Delayed primary closure of superficial wound____________________________________ 4 Secondary suture of superficial wound___________________________________________ 4 Evacuated before suture of superficial wound____________________________________ 2 Amputation for vascular gangrene before skin wound was sutured__________________ 1 Amputation for gangrene of foot in case in which joint and soft parts were not closed. Gangrene resulted from gaiter with traction for two days prior to admission (French soldier)--------------------------------------------------------------------- 1 Total number of infections during stay in hospital_______________________________ 8 Infection of joint and soft parts________________________________________________ 3 Infection of soft parts alone, severe, requiring reopening, Carrel treatment and secondary suture------------------------------------------------------------ 1 Infection limited and superficial, requiring the removal of only one or two sutures, not interfering with primary wound healing--------------------------------------- 4 Evacuated within 24 hours (this case was amputated at the base, details are lacking) — 1 While joint infection occurred in three cases, in only one did this result in ankylosis. In the others the infection was controlled by prompt reopening and Carrel treatment for several days. In both of these the joint and soft parts were sutured successfully after sterilization. Secondary Amputations In two cases amputation was required before evacuation. In neither was it done for infection; in one it was for gangrene following an associated wound of the popliteal artery and vein, and in the second for gangrene of the foot, the result of prolonged pressure by the anklet used in connection with the Thomas splint, which had been in place for two days before admission. In another case, evacuated 24 hours after operation, the record shows the limb was amputated later at a base hospital. End Results The average length of stay in the hospital w-as 26 clays. o Deaths. Total number-------------------------------------------------------- Cause: 1. Multiple wounds, gas gangrene, retroperitoneal infection. 2. Multiple wounds, shock, gas gangrene. Amputations, primary----------------------------------------------- llUOIIIlttblUl-. ^.ui-ui.- ~. --- _. . FairTeTul^ SeVGral months; g°°d weight"bearing ^ Pot^Vit f^ complete ank~vlosis the result of infcction; one secondary resection for weak joint)---------------------------------------- Result as t o f unct ion undetermined------------- - - - - . , ...nu:- o/i Knnr« nmnutation at base-------------------------- l-o4 332 SURGERY A review of the above results convinced us that a conservative policy in dealing with wounds of the knee joint caused by projectiles is strongly indicated. It was shown that infection can be avoided in the great majority of cases; that even when intra-articular infection develops, function can sometimes be pre- served, or, if lost, that amputation is not inevitable; finally, that early and complete restoration of the joint offers the best chance for an early and com- plete restoration of function. Mouchet and Pamart u reported the late results one year after early operations on 54 soldiers who had sustained wounds of the knee by projectiles, 49 being high-explosive shell fragments. There were 39 per cent good results; 25 percent fair results; 35 per cent bad results. They found that the greatest functional deficiency occurred in cases of arthrotomy for wounds with bony lesions. The worst results followed U-shaped arthrotomy-. SHOULDER When resection is necessary for extensive comminution of the head of the humerus the subperiosteal method is strongly recommended by Leriche,9 who urges that great care be taken to preserve the continuity of the capsule and periosteum. He advises that the end of the humerus be immobilized for a time in the glenoid cavity- and that movements be undertaken very- gradually in order to avoid a flail joint. Conservation of bone is important. The extensive resections wilich were done during the second year of the w-ar resulted in almost useless flail limbs. ELBOW In the elbow the conservation of bone is an object to be especially aimed at; therefore classical resections are less often advisable than in the knee. The head of the radius and the capitellum can be sacrificed without material loss of function, especially- if active motion is begun early. When the internal con- dyle must be removed function is less perfect and lateral mobility is to be expected, yet the result may be fairly- satisfactory. In more extensive lesions. especially when there is such extensive comminution of the articular surfaces that resection is necessary, the choice must often be made between a movable flail joint and ankylosis in a useful position. If resection is performed byT the subperiosteal method, which permits regeneration of bone, even extensive resection of the lower extremity of the humerus may be followed by favorable results. Le Fur 13 believes that the bad results following this method are referable more to the destruction of the muscles and periarticular tendons than to the loss of bone. Leriche 9 urges subperiosteal resection when the mechanism of the joint is seriously- disturbed; that is, when the trochlea or the articular surface of the ulna are badly involved. J3e states that callus forms rapidly, that anatomic and functional restitution are gradually brought about, and that in many cases within a year after com- plete resection there is perfect pronation, supination, and flexion, with marked solidity. He closes the wound by delayed primary- suture under bacteriologic check and does not employ the Carrel treatment; the arm is put up in acute flexion and full supination; very limited and infrequent active movements are GENERAL SURGERY 333 begun in 8 to 10 days. He urges rigidity, and states that it is a flail joint and not ankylosis that is to be feared. Unfortunately, under the conditions which prevailed in the hospitals of the forward area, subperiosteal resections could rarely be performed, nor could the intensive care which is necessary in the after-treatment be given the individual case. ANKLE In wounds of the ankle, with considerable involvement of bone, astra- galectoniy is usually indicated, followed by complete closure of the joint. As Chutro 14 has emphasized, it is important to displace the foot backward after astragalectoniy in order to provide a fulcrum of sufficient length, and to give proper weight-bearing fines. The ankle is one of the most troublesome joints to treat in the presence of infection. Suppuration often extends not only- to the tarsal joints but also along the tendons of the foot, and amputation not infrequently- results. Therefore a successful initial operation is especially- important. WOUNDS PRODUCED BY SHARP INSTRUMENTS These should be treated on the principles outlined for wounds caused by- projectiles. The soft parts should be thoroughly debrided; the joint widely- opened, a wound of the bone or cartilage cleansed with chisel or curette, the joint irrigated, and the synovial membrane and capsule closed. The soft parts may be sutured or left open, according to the rules already laid down. LATE COMPLICATIONS OF WOUNDS CAUSED BY PROJECTILES In general, wounds of joints wliich have been properly treated progress satisfactorily if infection does not occur, and a large proportion of the patients regain full function in a relatively short time. On the other hand, the occur- rence of infection seriously affects the outcome; not only is the mortality greatly increased, but even in the more favorable cases reestablishment of function is often prevented by partial or complete ankylosis. These two com- plications, infection and ankyiosis, must be discussed in some detail. SUPPURATIVE ARTHRITIS Suppurative arthritis constitutes the most serious sequel to wounds of joints. As an early complication it has been considered under the postoperative treatment of recent wounds. Attention must now be directed mainly to the treatment of the later and persistent phases of joint suppuration which con- stitute one of the most difficult and discouraging problems of military surgery. A large number of these cases were treated in every base hospital of the American Expeditionary Forces. The most important factors w-hich led to the development of chronic suppuration were ill-advised conservative measures rather than early operative treatment of the wound, failure of the initial operation to prevent infection, or ineffective early treatment of the infection itself It should be stated, however, that in most cases failure of the initial operation was due to uncontrollable conditions, such as a long interval between 334 SURGERY the receipt of the wound and the admission to the hospital, excessive and pro- longed contamination, especially in association with bone lesions, or early- evacuation with imperfect supervision of the patient and wound. Every effort should be made to recognize the infection early in its develop- ment. If, after the initial operation or in cases in which no operation has been performed, the local examination or the general condition of the patient sug- gests infection, the joint should be aspirated. If the character or culture of the aspirated fluid indicates pyogenic infection, arthrotomy should be per- formed. In the case of staphylococci or streptococci there should be no delay- but where there is distention of a joint with turbid fluid, not containing pyo- genic organisms, delay is w-arranted and aspiration may even be repeated. The injection of antiseptic solutions after evacuation of the effusion has met with some success. Xo attempt will be made here to describe the appropriate incisions for the various joints and the details of dissection; such description may be found in standard works on surgery. One or more incisions should be made, unless an existing incision is so situated as to allow satisfactory drainage; in that event it should be reopened. Continuous drainage is best provided by Willems' method of active movements, especially in the knee joint (see infra). But if for any reason this method can not be carried out, for instance, by reason of extreme suffering, or considerable bone involvement, the Carrel-Dakin method of chemical disinfection is the best substitute. Moreover, in early cases of nonvirulent infection, especially with little bone involvement, success may rapidly- follow the inauguration of this treatment. It is evident, however, that the construction of most joints renders it extremely uncertain whether irrigation of the entire joint cavity can be accomplished. Drainage by rubber tubes is objectionable in that the tubes produce pressure necrosis and do not drain adequately. They should never be used in superficial joints, as the elbow or knee. At times they must be employed in deep joints, such as the shoulder and hip. But it must be emphasized that any kind of drain within a joint is harmful and should be avoided if possible. When cases have not been treated sufficiently early by arthrotomy and active movements or by the Carrel-Dakin method, or have failed to respond satis- factorily to these procedures, a chronic virulent infection may be expected. The articular cartilages and adjacent bone become involved and this renders joint suppuration long and serious. In general, a well-established suppurative process continues until the involved cartilage has been entirely eroded. More- over, extension of the infection to the cancellous bone of the epiphyses, which quickly occurs if there are fissures or lines of fracture, leads to osteomyelitis, wilich is peculiarly resistant to treatment. In many cases the infection also extends to the soft parts, causing periarticular abscesses. RESECTION In cases which are not progressing satisfactorily under conservative methods resection offers a means of establishing satisfactory drainage, and is, in general, the best method of treatment. After resection the w-ound is treated GENERAL SURGERY 335 by the Carrel method. It may be allowed to close by granulation or, when sterile, may be closed by secondary suture. Unfortunately, there is no single indication for resection in suppurative arthritis. It is this which makes decision so difficult and often too long deferred. Various factors must be weighed, such as the degree of local infection, tne extent of bone involvement, the severity of septic symptoms, and the general resistance of the patient. The same factors must be considered in the decision as to whether resection or amputation should be done. Amputation must be practised in a certain proportion of cases of prolonged joint infection, especially when there is such a degree of sepsis and diminished resistance that the less radical procedure of resection with the necessarily long after-treatment apparently can not be supported. Amputation is a life-saving measure where resection has failed or has been too long delayed, but nice judg- ment is necessary to determine when it is indicated. One is always averse to advise the sacrifice of a limb, and consequently many cases have been lost by- persisting too long in more conservative measures. The general treatment of septic joints having been outlined, certain specific details which bear upon individual joints must be considered. The knee is the joint in which the most serious infections are encountered and is one of the joints most resistant to treatment. As Tuffier emphasizes, its anatomic structure alone will explain the frequent failure of irrigation and drainage. "Infection spreads backward sooner or later, and no amount of irrigation of the anterior cavity will affect suppuration in the posterior pouches." Frequently pus finds its way through the back of the joint into the deep portion of the popliteal space and then passes upward or dowmvard along the great vessels and burrows among the muscles of the thigh and calf. Abscesses also mav extend from the subcrural bursa anteriorly between the bundles of the quadriceps, especially between the rectus and vastus externus (Guenard).15 Among 40 cases of suppuration of the knee joint seen by Guenard in the course of a vear, such migratory abscesses were observed 14 times. Drainage of such abscesses by appropriate incisions is necessary-; the occurrence of the abscess in itself does not, as a rule, demand more radical procedures. Of the various methods for drainage of the popliteal space, that advocated by Abbott is said to be very satisfactory. Through an incision on the inner aspec t of the leg below the condyie the popliteus muscle is exposed and separated from the tibia. The space is thus drained with the muscle between the vessels and the drainage tract. The knee is the ideal joint for the employment of Willems' method. Blake16 states that functional results are obtained by this method which would be unattainable by any other treatment, and believes that this is due largely to the conservation of the cartilage and synovial membrane by the maintenance of function. By reason of the gravity of wounds of the knee when complicated by infection radical measures are often indicated at a relatively early stage, the effort bein^ made to control infection, though at the sacrifice of joint function. Therefore when cases have failed to respond satisfactorily^ to conservative 4C1KI7—27----24 336 SURGERY treatment and the local and general conditions are bad and are becoming progressively worse, adequate drainage should be provided. For this, various methods have been practised, among which are: Transverse incision through the ligamentum patellae; the patella is turned upw-ard, the semilunar cartilages removed, and lateral and crucial ligaments divided, the knee is sharply flexed and held in this position until infection is controlled, when the joint is resected or, if possible, extended. Rankin 17 advocates a similar procedure, but opens the joint by means of a flattened inverted U-shaped incision through the quad- riceps tendon w-hich allows the patella to be turned dowm and gives free access to the subcrureus pouch. Chaput18 and Guenard15 advocate patellectomy Fullerton 19 recommends resection with temporary- wide separation of the ends of the bones. Ballance not only resects but removes the posterior margin of the sawn condyles in order that drainage of the posterior portion of the joint may be better ensured. In all of these methods the Carrel-Dakin treatment has been employed advantageously after adequate exposure has been obtained. Drainage by resection has led to the best results. Not only is drainage thus established, but, in addition, the removal of the articular cartilages and much of the infected bone favors repair, since these tissues are largely respon- sible for the persistence of the infection. As Fullerton 19 describes the operation, a U-shaped incision is employed, the patella is removed, and the articular ends sawn across, removing in all about two inches. A few- stitches may be introduced in the middle of the flap, the remainder of the wound being left open. Wide separation of the ends of the bones is obtained by traction through a Thomas splint. The wound is treated by the Carrel-Dakin method. The ends of the bones are not allowed to approximate until infection is completely controlled, and then only gradually, the limb being immobilized in slight flexion. If union has not taken place when the wounds have healed, the case may be operated upon again and the freshened ends brought into apposition as in a clean case. Resecting is indicated when the general condition permits, but in cases of long standing infection, with fever and poor general condition, amputation is sometimes advisable. In the lower limb its consequences are less serious than in the upper, and the results of delay are frequently- disastrous. For persistent suppuration of the shoulder, elbow, hip, and wrist, resection is also often indicated in cases which are doing badly-. Details of resection, including subperiosteal resection, as well as the proper positions for ankylosis in these joints, are outlined elsewhere. For persistent infection of the ankle, especially if there is an infected fracture of the astragalus, astragalectoniy gives the best result. Mobility Versus Stability After Resection When adequate drainage has been secured by resection of a septic joint the choice between mobility and stability must be made. If stability is elected, the functional usefulness of the ankylosed joint depends almost entirely upon the angle of ankylosis. With special reference to the relative advantages of ankylosis in a favorable position or a certain amount of motion imperfectly controlled, Osgood20 states "that with certain exceptions after septic com- GENERAL SURGERY 337 pound joint fractures, ankylosis in a position favorable for function is a result vastly superior to small degrees of fairly stable motion or large degrees of a more or less flail-like movement, alway-s imperfectly- controlled by muscle action. This is, without exception, true with respect to the shoulder joint, the hip joint, the knee joint, and the ankle joint, for people wrho must earn their livelihood. One exception is the elbow, which may in a few trades be better even flail than stiff, though it usually involves the wearing of apparatus. One other exception is the wrist, which, with a few^ degrees of motion, but never flail, may be more serviceable than a stiff joint. It will be noted that both elbow and wrist are nonweight-bearing joints, over which run certain tendons, all of whose attachments need not be disturbed by the excision. The muscular control of the joints may- be to some extent thus conserved. Even these exceptions are debatable." These arguments seem sound and are sus- tained by such reports as Tavernier and Jalifier,21 who describe numerous cases of flail joints upon which they operated to improve the function of the elbow, shoulder, and wrist. But most surgeons are not as definitely- in favor of rigidity- after resection of these joints. Their views are to some extent supported by the analysis of large series of cases, such as that of Tuffier. Osgood's recom- mendations as to the best angle of fixation for the different joints is given in a later paragraph. Functional Results op Resection Tuffier8 has summarized the late results of joint resections. Based upon the examination of 1,810 cases, comprising: 630 elbows, 330 shoulders, 282 knees, 231 astragali, 152 wrists, 122 hips, 29 posterior tarsal joints, 14 anterior tarsal joints, he finds: Elbow, 49 per cent solid and with variable degree of mobility, 30 per cent flail, 20 per cent ankylosed. Shoulder, 45 per cent solid and with variable degree of mobility, 38 per cent flail, 16 per cent ankylosed. Wrist, 64 per cent solid and mobile to some extent, 36 per cent ankylosed. Hip, 30 per cent solid with restricted mobility; ankylosed, 48 per cent. Ankle (astragalectoniy), 20 per cent solid with some mobility; ankylosed 70 per cent, In the knee the operation does not aim at mobility, but rigidity. Ankyloses occurred in 85 per cent of the cases. Resection of a joint may be indicated at the primary operation w-hen there is such destruction of the articular surfaces as to preclude saving the joint, or secondarily for severe suppuration to obtain adequate drainage, or remotely, in order to give greater mobility- or greater strength to the limb. The cases analyzed by Tuffier were all of the first and second of these three groups. VOTIVE MOBILIZATION IX PURULENT ARTHRITIS—WILLEMS' METHOD In applying mobilization in the treatment of purulent arthritis Willems'8 original purpose was to secure efficient drainage after arthrotomy. He found that there w-as no system of irrigation w-hich could be depended upon to limit the extension of the infection, not even the Carrel procedure, and that resection solely to ensure drainage appeared too radical. He therefore endeavored to drain the joint by squeezing out the pus through active movements. His early attempts were convincing. He states that when an infected joint has 33S SURGERY been opened by unilateral or bilateral arthrotomy the patient can move the joint without difficulty. With each movement of flexion and extension pus is expelled. This expulsion is the more complete the more extensive the move- ments and the more vigorous the muscular contractions. When these move- ments are repeated a sufficient number of times all the secretions are expelled. The suppuration usually lasts for w-eeks, first profusely, then diminishes to a few- drops daily, and finally ceases. For a long time a fistula persists which closes periodically- and must be reopened in order to drain the small quantity of retained secretion. The swelling of the periarticular tissues persists to some extent until after complete cicatrization. Periarticular abscesses are practi- cally unknown. The general condition improves very rapidly. Active mobilization thus accomplishes ideal drainage without the assistance of any other measures. The movements become easier and less painful the oftener they are repeated. The muscles are very slightly affected by the arthritis. The quadriceps and the brachial biceps, which usually undergo rapid atrophy in purulent arthritis of the knee and elbow, remain surprisingly strong. The end of the treatment is usually reached with an almost negligible degree of atrophy. As soon as the articulation becomesdry, a tendency to stiffening is occasion- ally noted. In order to avoid this danger, Willems partially closes the arth- rotomy- wounds w-hen the suppuration has become markedly diminished, only a small opening being left corresponding to that portion of the wound where the secretion still persists. By this method the mobility can almost invariably be preserved, at least to a great extent; not infrequently it is perfect. Willems attributes the satisfactory results to limitation of the infection to the synovia as the result of perfect drainage, which militates against its extension to the cartilage and bone. He admits that all articulations are not equally well adapted to drainage by arthrotomy and active mobilization. The thoroughness of the drainage is proportionate to the more or less extensive range of movements of the joint. From this viewpoint the elbow and the knee, which can perform wide excur- sions, are the most favorable. The wrist and ankle, where extension and flexion are more limited, expel the secretions less thoroughly, and in these joints the method has yielded less rapid and less complete results. Willems reports 20 cases of suppuration of the knee, with no deaths, no amputation, 1 resection, 3 cases of ankylosis. The functional results were, in general, good and in many cases perfect. Willems' technique is as follows:6 In the cases of serous staphylococcus synovitis it is sufficient to reopen the original incision. In the presence of streptococcus infection classical bilateral arthrotomy is indispensable. The joint must be opened very widely on both sides. The wounds are covered with aseptic dressings loosely applied. Xo immobilizing appliance is employed. Hot dressings are applied for the first 48 to 72 hours, changed every 2 to 3 hours if considerable joint swelling and local reaction follow the operation. As soon as the patient wakes he is instructed to begin active move- ments. His confidence must first be won by having him carry out with the healthy limb the movements which he is to do with the w-ounded limb. In GENERAL SURGERY 339 the cases of the knee the procedure is as follows: First the patient raises the entire limb from the bed; he flexes the thigh on the pelvis, then alternately flexes and extends the leg on the thigh. Delrez considers it a noteworthy fact that although passive movements are extremely painful, active movements cause no inconvenience, the patient complaining of heaviness of the limb, but not of pain. The first sessions are fatiguing, later ones becoming progressively easier. The active mobilization must be repeated at least every hour during the day and two or three times in the course of the night. The patient is gotten out of bed as soon as possible, using his injured arm or leg if the temperature is low and bone lesions do not contraindicate. Cases in Delrez's service were seen walking about with pus escaping from the knee joint at every step. It was observed that some patients had to be urged and almost driven to use the limb. If this was done early, little pain resulted; if delayed or used only after a long interval, motion was painful and restricted. Cessation of movements was usually followed by accumulation within the joint, associated with increased pain and temperature reactions. The method undoubtedly affords a valuable weapon of defense against suppurative arthritis. ANKYLOSIS The treatment of deformities with impairment of function resulting from partial or complete ankylosis has been outlined by Osgood 23 in an admirable article which is here summarized: If the joint has been the seat of a serious infection, it is usually unsafe to undertake considerable operative procedures for from six months to a year after the subsidence of the sepsis. Judgment as to when these surgical attempts are safe is alw-ays difficult. Massage more or less violent may serve as a guide. If, after such massage, a definite recrudescence of the cardinal signs of inflammation occur, it is usually unsafe. The absence of this reaction is suggestive of sufficient quiescence to make operation possible. The first determination is whether mobility or ankylosis in a favorable posi- tion for function is to be sought. It must be recognized, however, that restora- tion of perfect mobile function is rarely possible in these cases. Only the hip and the elbow should be attempted, the hip more rarely than the elbow. The great majority of the cases in which decision between attempts at mobility or ankylosis in a favorable position must be made occur in war surgery among workingmen whose wage-earning capacity must be the controlling factor in this decision. It is a matter of constant surprise to find how little disturb- ance of wage-earning capacity is caused by a completely stiff joint in a favorable position for his trade. Generally speaking, the shoulder should be fixed in 50° to 80° abduction, in a plane about midway between the anteroposterior and lateral planes of the trunk; that is, the elbow should come somewhat forward. A single elbow should be fixed in such position that the angle which the forearm and upper arm inclose is about 100°; that is, a little more obtuse than a right angle. Where both elbows are ankylosed, one should be a little more than a right angle (100° to 110°), the other a little less than a right angle (70° to 80°). In both these positions the hand should be midway between pronation and supination. The wrist should bo in dorsal flexion. The hip should be fixed in 5° to 10° abduction, 5° to 10° outward rotation, and 10° to 20° of flexion. The 340 SITROERY knee should be fixed with varying degrees of flexion up to 45°, depending on tlie occupation. The ankle gives best function in right-angle dorsal flexion, with perhaps a little equinus to allow- for the heel of the shoe. We are inclined to believe that in the vast majority of cases, except possibly the elbow joint, ankylosis in a favorable position should be the operation of choice in war surgery in case of terminal joint deformity-. Partially Ankylosed Joints With or Without Deformity The problem with partialbv ankylosed joints, according to Osgood,23 is the restoration of as large a range of mobility as possible. "In joints which have been the seat of an infection," he says, "gentleness of manipulation is the rule to be followed almost without exception. Brisement force under an anesthetic is rarely- successful in gaining greater range of motion and is often provocative of a lighting up of the old infection. It is to be thoroughly discouraged. Light massage, mechanotherapy, and hydrotherapy are the first procedures, ac- companied by gentle passive movements and the stimulation of the patient to carry out active movements. These latter are by far the most important. Between these treatments, apparatus is often of great advantage, both that which retains motion gained in the direction desired and that which by elastic pull constantly exerts gentle traction in the appropriate lines. Recovery is gradual and often seems to the patient slow and tedious. If his endeavor to gain motion is coupled with the stimulation of a definite occupation, which accom- plishes a purpose of some sort, time passes more quickly, motion increases automatically and almost unconsciously. Tailoring, carpentry, leather work- ing, brace making, printing, basket making, and farming are all easily adapted occupations." REFERENCES (1) Depage: Contribution a l'etude des plaies articulaires. Bulletins et memoires de la societe de chirurgie de Paris, November 29, 1916, xlii, 2722. (2) Cotton, Frederic J.: Dislocations and Joint Fractures. W. B. Saunders & Co., Phila- delphia and London, 1910, 34. (3) Willems, Charles: Immediate Active Mobilization in the Treatment of Gunshot Wounds of Joints. Medical Record, New York, June 7, 1919, xcv, 953. (4) Cook, Franklin: Gunshot Wounds of Joints; their Pathology and Treatment. Lancet, London, May 12, 1917, i, 711. (5) Dowden, J. W.: The Curse of Immobilization. British Medical Journal, London, November 23, 1918, ii, 570. (6) Willems, Charles: Treatment of Purulent Arthritis by Wide Arthrotomy Followed by Immediate Active Mobilization. Surgery, Gynecology, and Obstetrics, Chicago, 1919, xxviii, No. 6, 546. (7) Hughes, Basil, and Banks, H. S.: War Surgery from Firing Line to Base. Balliere, Tindall and Cox, London, 391; 401. (8) Tuffier and Nove-Josserand: De la valeur des membres qui ont subi des resections articulaires pour plaies de guerre. Presse medicate, Paris, May 18, 1916, xxiv, 224. (9) Leriche, R.: Traitement des fractures. Masson et Cie., Paris, 1916-18. (10) Murphy, John B.: Tuberculosis of the Patella. Surgery, Gynecology, and Obstetrics, Chicago, 1908, vi, No. 3, 262. (11) Pool, Eugene H., and Jopson, John H.: Treatment of Recent Wounds of the Knee- Joint. Annals of Surgery, Philadelphia, 1919, lxx, No. 3, 266. (12) Mouchet, Albert and Pamart: Resultats eJoignes des arthrotomies du genou. Bulletins et memoires de la societe de chirurgie de Paris, April 24, 1918, xliv, 768. GENERAL SURGERY 341 (13) Le Fur, ReneZ Resultats e'loignes des resections du coude. Paris chirurgical, March 30, 1916, viii, 233. (14) Chutro, Pedro: Infected Wounds of the Ankle. Journal of Orthopedic Surgery, Boston, 1919, xvii, No. 9, 521. (15) Guenard: Arthrites purulentes du genou. Les absccs migrateurs d'origine articulaire et leur traitement. Journal des praticiens, Paris, 1917, xxxi, No. 12, 179. (16) Blake, Joseph A.: Gunshot Fractures of the Extremities. Masson et Cie., Paris, 1918. (17) Rankin, W.: On the Treatment of Certain Selected Cases of Septic Arthritis of the Knee. British Medical Journal, London, September 1, 1917, ii, 287. (18) Chaput, H.: Nouveau mode de drainage des plaies articulaires de guerre et des arthrites purulentes communes du membre superieur. Paris medical, 1916, xxi, No. 33, 143. (19) Fullerton, Andrew: Excision of the Knee-Joint as a Method of Treatment for Severe Infections. British Medical Journal, London, November 25, 1916, ii, 709. (20) Osgood, R. B.: Notes on Excision of Septic Joints. American Journal of Orthopedic Surgery, Boston, 1918, xvi, No. 10, 323. (2D Tavernier, L. and Jalifier: Traitement des laxites articulaires consecutives aux resec- tions. Lyon chirurgical, 1918, xv, No. 4, 399. (22) Willems, Charles: Traitement de l'arthrite purulente par l'arthrotomie simple suivie de mobilisation active immediate. Bulletins et memoires de la societe de chirurgie de Paris, June 10, 191S, xliv, 1098. (23) Osgood, R. B.: Bone and Joint Casualties and the Transport Splints. Pennsylvania Medical Journal, Athens, Pa., 1919, xxii, No. 4, 205. CHAPTER XIV WOUNDS OF THE CHEST At the time the United States declared war on Germany, effective methods for treating various types of wounds, with some few exceptions, had been established by surgeons of the Allied armies. Among these exceptions were wounds of the chest. There were wide and some irreconcilable differences of opinion as to the care of intrathoracic injuries. These differences were caused by failure to understand the interdependence of the functions of the circulatory and respiratory- apparatuses and to appreciate the contribution of their func- tions to the powers of resistance, defense, and repair, powers which must be conserved and developed in order to facilitate immediate recovery and to minimize the extent and duration of subsequent disability. The possibilities for rendering service to the wounded in this direction, as well as in others, through investigations of inherent problems were recog- nized early in the history of the American Expeditionary Forces by the then chief of the research division of the American Red Cross in France. He secured early opportunities to begin these studies, and, in so far as he was permitted, continued to give assistance; special apparatus was provided for experi- ments; also supplies of oxygen and nitrous oxide gases, and transportation, which were essential and otherwise unobtainable, were provided.1 Work was begun by the writer in 1917 at the Ambulance de l'Ocean, at La Panne, Belgium, under Col. A. Depage of the Belgian Medical Department, and included clinical, post-mortem, and experimental observations. This w-ork sufficed to disclose the more significant problems and to indicate means for their solution. Late in 1917, the chief consultant, surgical services, of the American Expeditionary Forces, recommended continuation of the work, and in 1918, the chief surgeon, A. E. F., detailed for this purpose medical officers, nurses and enlisted men for duty at the Central Medical Department Laboratory at Dijon.2 Experimental studies, carried on in the section provided for surgical re- search, with the help and advice of the director and of the chief of the division of surgical research, w-ere continued until the Chateau-Thierry operation began. After this time, and until the beginning of the armistice, a unit a composed of medical officers, nurses and enlisted men appointed by the chief surgeon, A. E. F., w-as detailed to sundry field hospitals for the care of nontransportable wounded and to mobile hospitals in zones where there w-as active fighting. The directions of the chief consultant of the surgical services were (1) to discover the physiologic interrelationships between the circulatory and respira- tory mechanisms in order to determine the functions w-hich need the protection ° The members of the unit detailed to the study and treatment of thoracic injuries were: Col. J. L. Yates, M. C, in charge; Maj. W. F. Verdi, M. C, surgeon; Capt. W. S. Middleton, M. C, and Capt. M. A. Blankenhorn, M. C, phy- sicians; Capt. Robert Drane, M. C, and Capt. J. M. Steiner, M. C, radiologists; Capt. J. T. Gwathmey, M. C, and Anna Fitzgerald, A. N. C, anesthetists; Anne Bernard, A. N. C, surgical nurse. 342 GENERAL SURGERY 343 to assure the largest opportunities for immediate and remote recoveries; (2) to develop the simplest effective surgical methods compatible with physiologic requirements; (3) to apply these methods to the w-ounded whenever there was any possibility of saving life and without regard to the high mortality rate that would inevitably accompany acceptance of the gravest risks; (4) to follow each fatality with necropsy to determine what should not be done, to trace the results in those who recovered and thereby discover the dependence of degrees of functional rehabilitation upon methods employed in order to get better methods; and (5) to make eventually a report indicating how soldiers suffering from intrathoracic injuries could be the more certainly protected against death and disability. What follows in this chapter is in consequence of compliance with these directions. No attempt has been made to preserve chronologic sequence in observations; facts as thev now appear important are presented. Statistics are avoided as far as possible since, because of the many- inevitable sources of error, they can not fail to be even more than usually- unreliable. PHYSIOLOGIC INTERDEPENDENCE OF RESPIRATION AND CIRCULATION Two factors, peculiar to thoracic injuries, are of sufficient importance to be kept constantly in mind: First, mere existence, as well as additional activi- ties, including the capability- of withstanding the extraordinary stresses im- posed by wounds and by surgical treatment, depends fundamentally upon ability to provide oxygen for tissue metabolism. Second, chest injuries im- pose not only the burdens incidental to other tissue insults but also definite restrictions to the supply and delivery of oxygen. Suitable methods of treatment will protect the means wiicreby oxygen is supplied to the body and delivered throughout the body- and will be determined byr knowledge of the activities upon wliich the functions of supply- and delivery of oxy-gen depend. A summation of all relevant observations made by the writer during and since the World War was presented before The American Association for Thoracic Surgery in 1924.3 It is given here in full, with a few minor changes, as it indicates the essential activities and functions, and how they may- be conserved and rehabilitated. THE SIGNIFICANCE OF VITAL CAPACITY IN INTRATHORACIC THERAPY A biologic aphorism, no life without breathing, indicates in a general way the importance of respiration. Activities sufficient merely to support life or to realize the utmost physical and mental powers, including defense and repair, are produced by metabolic processes which are dependent primarily on oxida- tion. This explains why man, although he may survive for weeks without food and for days without water, can exist for only a few minutes deprived of air. It also explains why any reduction in supplies of oxygen to the body, in deliveries of oxygen throughout the body and in utilization of oxygen by the body, im- poses a corresponding degree of disability. The many diseases affecting the thorax and its contents, the enormous totals of transient and permanent disabilities and the large number of deaths 344 SURGERY they cause constitute a serious problem. More effective therapy is needed to provide greater limitations of disability- and to reduce mortality. There is a direct road to this accomplishment. Reduction in vital capacity is so constant a result of thoracic diseases that the extent of this reduction is an accurate measure of the disabilities attributable to them.6 In order to obtain better methods of treatment, it is essential to know the structures and the functions of the structures that determine vital capacity, how vital capacity- is affected by various lesions and consequent malfunctions of these structures, and how therapeutic methods can protect vital capacity against reduction during aggressive phases of diseases and facilitate its rehabilitation during regressive phases. Four distinct phases are notable in completed respiration: (1) Ventilation of intrapulmonary air effected by breathing; (2) external respiration, the inter- change of gases between the intrapulmonary air and intravascular blood through alveolar and capillary walls; (3) transportation of aerated blood to somatic cells and of blood needing aeration to lungs by a coordination of the pulmonary and systemic circulations, and (4) interchange of gases between blood and tis- sues through capillary walls and cell surfaces, or internal respiration. Although most essential, internal respiration is germane to this subject only as it is in- fluenced by the other steps in complete respiration. Clinical interest centers in the finer workings of the mechanisms of breath- ing, of circulation, and particularly of external respiration, because of its direct relationships to vital capacity and to life itself. External respiration not only accomplishes aeration of blood throughout life, no matter how great or how little are the demands for oxygen, but this accomplishment has to be relatively- complete at any or all intervals. In order to simplify the immediate presenta- tion, let it be supposed that the walls of all of the alveoli are fused into one sheet of epithelium against which is applied a similar sheet composed of the pulmonary- capillary endothelium. Suppose further that the intrapulmonary air is in an even layer on the epithelial surface and the intrapulmonary blood is flowing in another even layer on the endothelial surface. Conditions being normal, the oxygen in the layer of air suffices to aerate homogeneously and completely the layer of blood as it passes over the endo- thelial surface. Should the amount of blood be increased, either the area of the sheet of endothelium must be enlarged or the layer of blood must become thicker. If the layer of blood becomes too thick, it will be aerated neither homogeneously nor completely. On the other side, if the intrapulmonary- air be in too thick a layer, because the area of epithelium is too limited, aeration is likewise defective. The states of defective aeration, anoxemia and cyanosis, are abnormal. Therefore, it is presumable that there is a natural control which correlates the volume of ventilated air and the area of alveolar epithelium & Estimations of vital capacity are not always the only or even the most dependable sources of information. Fre- quently, it is impracticable to make them. Occasionally, they can lead to erroneous interpretations. As will be made clear later, vital capacity is influenced by the circulation. An individual may have an apparently competent circulation while at rest and show at such times an approximately normal vital capacity; yet that same individual.if the reserve cardiac energy were limited, would show a material reduction in vital capacity after exercise which would be less of a tax on the myocardium than many types of diseases or operations. Other examples need not be cited. This suffices to emphasize the fact that vital capacity readings, like other single sources of clinical information, are reliable when intelligently inter- preted in conjunction with all other evidence. GENERAL SURGERY 345 (degree of infiation) with the expanse of endothelium (cross section and length of capillaries) and the amount of blood (unit volume). Moreover, since the de- mand for oxygen comes from the tissues and is manifested by increments of carbon dioxide in the blood, it is likely that the unit volume of blood in the pulmonary capillaries exerts a telling influence on the three other variables. A further step in presenting the problem is a supposition that the sheet of alveolar epithelium has been turned into a single sac communicating with a bronchus, and the layer of blood is confined in loops of contiguous capillaries connected with the pulmonary artery and vein. Conditions affecting each of the many alveoli which constitute the portion of the breathing unit directly concerned in external respiration would then be illustrated by a single large alveolus. Obviously, the first and great commandment is to discover the means whereby the amount of blood requiring aeration establishes conditions suited to this accomplishment. Knowledge of the structures constituting the apparatuses of breathing and of circulation can alone determine therapeutic priciples. It is necessary to know- how they operate during periods of rest; what adjustments occur when activities are gradually or abruptly^ increased and diminished; what adapta- tions are employed to meet handicaps imposed by disease; what are nature's methods to increase resistance and to hasten repair; wiiat forms of treatment cooperating with natural methods of adjustment, compensation, and adaptation will augment defense most effectively and facilitate functional recovery. Breathing, external respiration, and the deliveries of blood to and from the lungs are effected by extrathoracic and intrathoracic structures w-hich are so intimately associated physically or physiologically-, or both, that they- must be considered together. The extrathoracic portions need not be described in detail. It is only- necessary to recognize that the chief control of the distribution of blood in the systemic circulation and the rate of flow in both systemic and pulmonary- circuits, as well as the rate and depth of breathing efforts, is in the central nervous sy-stem. The intrathoracic portions not only provide external respiration but they also are the structures affected by the diseases here considered, and give diag- nostic, prognostic, and therapeutic indications. An accurate measure of tlie efficacy of external respiration is vital capacity, which is usually defined as the amount of air expelled by the most complete expiration after fullest inspiration. This means that when the air cells are distended to physiologic limits, inflation, and therefore the total area of alveolar walls, are greatest for normal conditions and are thus disposed to aerate equiva- lent amounts of blood. Aeration is an exchange of oxygen and carbon dioxide through alveolar and capillary walls. Xatural economy has apparently established a means of con- trol whereby the total expanse of alveolar wall as determined by the extent of pulmonary inflation compels corresponding variations in the total expanse of capillary wall and the amounts of mtracapillary blood. Grades of pulmonary 340 SURGERY inflation are actively determined by variations in rate, depth, and force of breath- ing movements, and, as will appear later, are influenced passively by the unit volumes of blood in the pulmonary capillaries. Length, diameter, and, therefore, the contents of pulmonary capillaries can be attributed to three forces, since there is no effective vasomotor control of the pulmonary circulation. These forces are the blood pressures in the pulmonary circulation, fluctuations in intrapleural negative pressures, and alternating intravascular aspiration and expression caused by elongation and shortening of blood vessels with the inspiration and expiration of each breathing cycle. In addition to central control by the nervous system, there is a peripheral intrathoracic governor which so coordinates the activities of the breathing and circulatory units as to keep volumes of ventilated air present in the alveoli which will aerate at any and all times those amounts of blood being driven through the capillaries. The governor simultaneously correlates the other two factors, namely, the total area of alveolar epithelium and the entire expanse of capillary endothelium. Knowledge of the structure and function of the governor or gear which coordinates the two sets of variables, volumes of ventilated air and area of alveolar epithelium, with expanse of capillary endothelium and amounts of blood to be aerated, is of basic importance, since it determines how external respiration is affected by disease and can be benefited by treatment. Moreover, such knowledge answers two other significant questions: Why are reductions in vital capacity so accurate a measure of disabilities? What are the structures and what are their activities that influence vital capacity. Investigation of the various actions and reactions exhibited by the units concerned in respiration during health and the changes imposed by diseases should answer the question. It is necessary to observe the changes in those units under various conditions. Normal respiration is possible so long as movements of thoracic parietes, particularly of the diaphragm, are unrestricted; intrapleural negative pressures are undisturbed, and pulmonary elasticity is not impaired, provided the right heart delivers adequate amounts of good blood in the absence of obstruction due to incompetence of the left heart. NORMAL RESPIRATION DURING REST During periods of rest, expenditures of energy and hence demands for oxvgen are least. In consequence, the volume of tidal air, that exchanged with each complete breathing cycle, is lowest, as is the tidal blood, the amount driven through the pulmonary capillaries during the same breathing cyrcle. Aeration of tidal blood of rest is accomplished by the tidal air of rest which produces the lowest level of pulmonary inflation with minimal exrenditures of energy. This is the period of greatest phy-siologic economy- in which the storage of energies exceeds expenditures by the largest margin. The reserve supply of air stored in lungs during periods of rest is five or six times larger than the tidal air. Approximately three-fifths of the reserve air is available for sudden physiologic requirements, leaving two-fifths to meet GENERAL SURGERY 347 urgent pathologic demands. A comparable amount of reserve blood available for similar emergencies is stored, less actively circulating, in larger pulmonary vessels. Tidal air, approximately three-eighteenths of all the air concerned in breathing, serves to ventilate the intrapulmonary air more than enough to keep its oxygen content effectively high. Although one-third of the tidal air is required to fill the trachea and bronchi, the remaining two-thirds causes a change estimated at three-twentieths in the sizes of the air cells. Thus there is an established relationship between the volume of tidal air (three-eighteenths) and variation in sizes of air cells (three-twentieths). Pre- sumably the same relationship obtains between the amount of tidal blood and the length and cross section of capillaries. All combine to afford the means to aeration of the blood circulating through the pulmonary capillaries. NORMAL RESPIRATION—ACTIVITIES GRADUALLY VARIED As activities gradually^ are increased after a period of rest, the slowly progressing demands for oxygen are met by proportionately higher levels of inflation produced by- larger volumes of tidal air and by increased amounts of tidal blood driven by higher pressures. Relationships between tidal air and alveolar size and between tidal blood and capillary dimensions occurring during rest are but little distorted though produced less and less economically as activities increase. A level is reached which may be termed optimum, whereat the tidal air equals the vital capacity. This is the upper limit of economic expenditures of energy at which extraordinary activities can be prolonged without causing early exhaustion. When this level is unusually high, it gives the remarkable endurance exhibited by exceptional athletes, by superior race horses, and by certain individuals in meeting the stresses of disease. Activities raised above the optimum level initiate compensatory responses and mark uneconomic expenditures of energies which assure exhaustion. In order to supply the oxygen demanded for internal respiration, breathing is more rapid and the heart beats faster to develop higher pressures. Finally a still higher level is reached which may be called maximum, because at this level the utmost powers are realized for the brief period before exhaustion forces reduction in activity". When the sequence is reversed, the processes are orderly reductions in breathing and cardiac rates and diminutions in volume of tidal air, pulmonary inflation, the amounts of tidal blood and capillary expanse. The relationships between'the total areas of alveolar walls and capillary- walls are adapted to the blood that requires aeration and the intrapulmonary air, properly ventilated, which supplies the oxygen. Gradually increased activities provide opportunities for orderly adjust- ments in the actions of respiratory- units and develop the largest total power of which an individual may be possessed. Hence the desirability of a suit- able warming-up process'before severe contests. 34N SURGERY NORMAL RESPIRATION—ACTIVITIES VARIED ABRUPTLY If a resting individual should suddenly engage in a critical physical contest, the demands for oxygen w-ould jump in a few seconds from lowest to highest limits. The reserves of air and of blood stored in the lungs w-ould be utdized until compensation could be accomplished. It has been estimated that the amount of blood delivered by the pulmonary- circulation can be increased abruptly more than tenfold. Or should the individual while driving at the maximum level of action suddenly change to complete rest, the rate of external respiration measured by deliveries of aerated blood would decrease with almost the same rapidity. The relationships between volume of air and total area of air-cell wall and amount of blood and expanse of capillary wall must be preserved with a fair degree of accuracy- not merely to effect proper aeration of blood but to continue life. A very few seconds suffice to cause dilatation of the right heart or to pro- duce edema of the lungs. These complications are seen infrequently because of a peripheral means of control that maintains the air-cell-capillary balance. Abrupt changes are not alone less economic than are gradual but also are more dangerous, as they permit less opportunity for orderly adjustments and are operated almost entirely by expenditures of reserve energies or margins of safety. This also applies to the handicaps imposed by disease. The more gradually- induced are the less immediately dangerous, and this principle should be recognized in methods of treatment. Changes affecting the relationships involved in aeration of blood should be minimized in extent and in the rapidity with which thev are produced. ADAPTATIONS TO PATHOLOGIC STATES Vital capacity- is a suitable term. It does not occur post mortem. When it is less than the tidal air of rest, life can not continue. If it is equal to the tidal air of rest, existence is possible until the relationships effecting external respiration are disturbed by increased demands for oxygen. The excess of vital capacity- over the tidal air of rest measures ability to work and the margin of safety. Observations of natural adaptations to the handicaps of diseased states are as valuable as they disclose the compensatory changes that assure the nearest approach to normal external respiration of which the measure is vital capacity. Normally, a volume of ventilated air on one side of a sheet of alveolar epithelium of exactly proportionate dimensions is separated by the interposi- tion of another w-all of vascular endothelium just as exactly proportionate in area to an equivalent amount of blood needing aeration. Normally, these variables fluctuate synchronously and almost equally. The upper limits are set by the total areas of epithelium and endothelium which can be presented, since the volume of air and blood can be further increased by raising the respiratory and cardiac rates for brief periods. Limitations in any of the four factors—volume of ventilated air, total expanse of alveolar epithelium, total area of vascular endothelium or unit GENERAL SURGERY 349 volume of good blood—reduce the essential function, external respiration, which is manifested byT corresponding reductions in vital capacity. Adaptations strive to maintain the broadest margin of safety or the largest vital capacity. When a part of the alveolar epithelium is incapacitated, the remaining portions are expanded so that the total area available for external respiration may remain as nearly normal as possible. This is compensatory or physiologic emphysema. Likewise, the unit volume of blood is correspond- ingly increased in the capillaries in contact with hyperfunctioning alveoli. This is compensatory or physiologic hyperemia. Moreover, the unit volume of blood is reduced in the capillaries adjacent to the incapacitated alveoli. Similarly, increase or decrease in the unit volume of blood delivered through capillaries is associated with equivalent inflation or deflation of corresponding alveoli. Passive congestion is quite different. The capillaries are engorged, but the unit volume of blood passing through them is reduced. Pulmonary- elasticity is restricted, and the total area of alveolar epithelial surface is dimin- ished. Reduced vital capacity here also indicates the limitations in external respiration. The important connection in maintaining the relationships which determine external respiration lies between the air cells and the capillaries. The inter- dependence of alveolar inflation and volume of air on one side and of capillary- size and amount of blood on the other side is obvious. Air cells and capillaries are not only intimately associated functionally but closely related physically. Capillary loops, arranged in a mesh work, sur- round, separate, and yet connect alveoli. When inflation increases, capillaries are straightened and elongated; w-hen it decreases, they are shorter and more tortuous; hence, the aspiration and expulsion of blood with inspiration and ex- piration. Contrariwise, if tortuous capillaries are straightened and elongated by increased unit volumes of blood, the walls of corresponding air cells are carried with them and inflation results. Also, if this action, which corresponds to a positive phase in erectile tissue, is reversed, capillary walls are less tense, ves- sels shorten, and their lumens are decreased, air cells contract, and some defla- tion occurs. This is the peripheral control, the intrapulmonary governor, and may be called the air cell-capillary gear. The existence and functions of an air cell-capillary gear are not generally- recognized and are disputed by clinicians as well as by physiologists.c The « Haldane remarked the need of a governor: "We have no guaranty that even during quite normal breathing the distribution of air in the individual lung alveoli corresponds exactly with the distribution of blood to them. Unless this correspondence is exact some alveoli will receive more air in proportion to their blood supply than others, and, as a conse- quence the mixed arterial blood will be a mixture of more or less fully arterialized (aerated) blood with some of the conse- quences first discovered (anoxemia). It is probable indeed that in some way or other the air supply is proportioned to the blood supply whether bv regulation through the muscular coats of the bronchioles or regulation of the blood distribu- tion; but it is also certain that this proportioning is only an approximation" (Haldane J. S.: Respiration, Yale University Press, New Haven, Conn., 1922, 137). ,._..,.•■_., • k »- , , v. .v Certain it is that all the alveoli are unequally supplied with air. Fluoroscopic observations of normal breathing prove this in the increased inflation of the zone of lung adjacent to the diaphragm during each inspiration. The cont.ol of air and blood as suggested by Haldane, would scarcely afford an approximation in the proportioning. On the other hand, the air cell-capillary gear provides exact proportioning for each alveolus though not the same proportioning for all alveoli, else there could be no compensation in health nor adaption in disease. Inequalities in alveolar inflation and in the venti- lation of intra-alveolar air would occur even in health, and could explain the mixtures of more or lessperfectly aerated blood noted by Haldane. 350 SURGERY latter demand properly controlled crucial animal experiments for proof that would be acceptable to'them. They are unaware that one animal, even though denied the distinction of being included among laboratory species, has been giving conclusive although spontaneous demonstrations for centuries. Clini- cians have recognized, in those demonstrations, the signs and symptoms of natural adaptations to intrathoracic diseases which occur in man. Animals are divisible, as Miller4 showed, into those having thin pleura- and those having thick pleura?. Animals with thick plcurre have mediastina which are impervious to air and to water. The blood supplied to lung paren- chyma and visceral pleura comes chiefly from the bronchial artery. Animals with thin pleura, have mediastina which are pervious to air and to water. Their lung parenchyma and visceral pleura obtain blood supply more largely from the pulmonary artery. Man is of the thick pleura type. Observations made on the usual laboratory animals (cat, dog, and rabbit), w-hich are of the thin pleura type, are not directly applicable to man. Attempts to use such experimental observations directly in explanation of human physiologic and pathologic manifestations have led to confusions w-hich are the bases of most misconceptions. The evidence for an air cell-capillary gear is direct and indirect. If the pulmonary artery is ligated or obstructed in man or in other animals with a thick pleura, the portion of the lung supplied is deprived of function. It atrophies, contracts and becomes airless. There is no infarction. If a bronchus is ligated or obstructed and pneumonia is not occasioned, the portion of lung supplied is deprived of function. It atrophies, contracts and becomes airless. There is no infarction. In man, no portion of lung which has had either its air or pulmonary- arterial supply destroyed can be functionally rehabilitated. Obviously, if either part of the air cell-capillary gear is incapacitated, the other part is simultaneously disabled. If the rate and depth of respiration be increased above normal, the carbon dioxide content of the blood is reduced and apnea results. The unit volumes of blood in the pulmonary capillaries are increased because inflation is increased. Extraordinary aeration results, not because of tissue demands expressed through central nervous system control, but because of the coordinating action in breathing and circulatory units effected through the peripheral governor. If the rate of cardiac contractions is suddenly increased by emotions, there is a correspondingly increased inflation; respirations are deeper and more rapid. There is a transient sense of air hunger. This is a common experience. Inspira- tions are involuntarily deeper because a larger unit volume of blood is delivered through pulmonary capillaries at higher pressures and inflation of alveoli is inevitable. Animal experiments are thus far unsatisfactory. Negative-pressure cabinets are required to eliminate complicating factors incidental to disturbed intrapleural negative pressures and to the intratracheal positive pressure usually employed. Pneumothorax or hydrothorax induced in an animal with a thick pleura causes a contralateral compensatory emphysema proportionate to the amount of air or water introduced. The animal will tolerate increasing GENERAL SURGERY 351 positive pressures so long as it is able to develop and to maintain the higher pulmonary arterial pressures required to develop the degree of contralateral compensatory emphy-sema required for external respiration. If the animal be fatigued previous to the experiment, the limit of tolerance is lowered because cardiac energies are less. If the same experiments are made on animals with a thin pleura, pneumothorax and hy-drothorax are soon bilateral; compensation is less possible because intrapleural pressures of both chest cavities vary together and toleration is limited. Further confirmation lies in the fact that as animals with a thick pleura are progressively- exhausted, the tolerance of intrapleural positive pressures falls until it equals the intolerance of animals with a thin pleura. Observations have been made often enough during operations on human beings to furnish sufficiently- reliable controls to satisfy all requirements for accuracy. The following examples are pertinent. When chronic pleuritic adhesions are divided before pulmonary elasticity has been permanently de- stroyed, the underlying lung, relieved of restraint, bulges outward if the patient is in fairly good shape even when no differential pressures are employed. If, during an open thoracotomy- performed on a strong patient under positive pressure anesthesia, the positive pressures are reduced or stopped, the mediasti- num bulges toward the open side. A focal parenchymatous hemorrhage is surrounded by a halo of emphysema. The focal pressure of a finger on visceral pleura will produce emphy-sema in the adjacent lung. Other observations, after lobectomies, are notable. Each lobectomy causes greater compensatory- emphysema in the remaining lung. The limit of lung capable of supporting life is that which will provide a vital capacitv slightly- in excess of the tidal air of rest. Attempts to observe actions of the air cell-capillary- gear in excised lungs are quite futile. Post-mortem changes occur rapidly. Blood pressures in the bronchial artery are absent. It is impossible to wash out all the blood from the capillaries. The effects of negative pressures are lost. The amount of force which must be applied to drive water through the pulmonary arteries exceeds the strength of the capillary endothelium and alveolar epithelium. Leakage through the air passage results. Inflation of lung by forcing air into bronchi will not cause the pulmonary artery to aspirate fluid because the capillaries are plugged or collapsed. Injecting water into the pulmonary veins causes no inflation just as might be expected because passive congestion is known to reduce vital capacity. On the other hand, sufficient air pressure in the pulmonary artery w ill cause inflation of the lung and aspiration of fluid by the bronchus before the capillary walls are ruptured. The simplest experimental demonstration is to ligate with suitable pre- cautions in a strong living animal the pulmonary artery of one lung and to observe bv Rontgen-ray examination the increased compensatory emphysema produced in the contralateral lung. All the manifestations noted can be explained by the interactions of pul- monary inflation and deflation and of the amounts and pressures of blood in 4t;!i!)T—27-----2u 352 SURGERY pulmonary capillaries effected through the air cell-capillary gear. They are supplemented by the forces of blood in the bronchial arteries which fluctuate with physiologic activities of the lung, since they are under control of the systemic vasomotor mechanism. Dunham had recognized the air cell-capillary governor and constructed a model to illustrate its actions as shown in Figure 180. The jar represents a pleural cavity. It contains a rubber bag, an air cell instead of a lung, con- nected with the middle glass tube instead of a bronchus. The glass tube at the left is connected with a coil of guinea pig's intestine glued to the air cell to imitate a pulmonary- capillary. The tube at the right makes it possible to establish nega- tive or positive (intrapleural) pres- sures. Suitable variations of air pressures exerted through the three tubes demonstrate the effects of breathing, fluctuations in unit vol- umes of blood delivered to the pul- monary capillaries, and changes in intrapleural pressures. The model has been criticized because the pul- monary capillaries have been repre- sented as end vessels. A moment's consideration will explain how diffi- cult or impossible it wTould have been to reproduce a complete circulation and how unnecessary. Whether or not some blood passes through the capillaries, a sufficient unit volume of blood would cause them to straighten and to elongate. The adaptations are few in num- ber. Their effectiveness varies di- rectly with grades of competence or Hence, there are many variations in Fig. 180.—Dunham's original model of the air cell-capillary incompetence of the circulatory unit extent though none in character of responses. Collapse Collapse results w-hen intrapleural negative pressures are neutralized by an open thorax or intrapleural exudates of appropriate amounts. One or both lungs may be affected. The extent of collapse is determined by elastic recoil of the lung opposed by- the expansive forces exerted through the pulmonary and bronchial arteries. The lower the blood pressures, the greater the collapse. The greater the collapse, the less reserve air and blood in the lung, the less the residual air is ventilated, the less blood is in circulation and the more urgent the GENERAL SURGERY 353 need for contralateral compensation to protect external respiration. Unfortu- nately, the greater the need, the less the capacity to develop compensation. Another important influence is the rapidity of reductions in negative pressures. As already noted, adjustments are most effective when they are induced gradually and thus occasion less unfavorable expenditures of energies. Observations on the effect of w-ar injuries and surgical wounds of the thorax have proved that a competent individual can survive a wide parietal opening even when suddenly produced, whereas a comparable individual, made incompetent by exhaustion, exposure, starvation, hemorrhage, dehydration, and infection can barely- tolerate a small opening. Likewise, it has long been known that a gradually increasing pleuritic exudate is of far less moment Fig. 181.—Sheep's lung five weeks after ligation of the artery supplying the left upper lobe than one produced rapidly, and that life is possible when the former exceeds in bulk amounts which are fatal in the latter. The extraordinary dangers of abrupt production of bilateral pneumothorax or the rapid formations of bilateral pleural effusions are well known, even to laymen. Graham and Bell,5 working with animals of the thin pleura type, in which, unlike man, a unilateral pneu- mothorax can not be maintained, found that the evil effects of the rapid bilateral reductions in intrapleural negative pressures could be measured by the size of parietal defects. Other experimental evidence has been presented to indicate that if negative pressures are reduced sufficiently- gradually, almost normal inflation of the lung can be maintained when parietal defects are created subsequently. 354 sum.ERY All of these manifestations can be explained physiologically. Nature attempts to maintain suitable areas of alveolar air and blood requiring aeration in order to protect external respiration on which life depends. Should nitraple- ural negative pressures be reduced sufficiently gradually in a competent in- dividual, there is reason to believe that redistributions of blood in both circuits and increased blood pressures can by action through the air cell-capillary gear maintain full normal inflation after the negative pressures are neutralized. When negative pressures are so rapidly reduced in the competent that com- pensatory adjustment can not be made, or gradually reduced in the incom- petent, who are unable to make adjustments, corresponding grades of deflation are caused. Fig. 182.—Sheep's lung five months after ligation of the artery supplying the inferior margin of the left lower lobe, showing adhesions produced by simple thoracotomy Pulmonary- deflation inevitably measures an equivalent reduction in the corresponding pulmonary blood supply. It should be recalled that the pul- monary circulation is not provided with an effective vasomotor control. The blood normally destined to reach an area of deflated lung is delivered to the nearest area in which the intracapillary pressures will permit circulation to occur. Wherever an increased amount of blood is driven through pulmonary- capillaries there is produced a corresponding degree of inflation, a compensatory emphysema. Thus, if the area of deflation is small, the compensatory em- physema will appear in the same lobe; if larger, in the same lung; if larger still, in the opposite lung. Compensation is produced by the amounts and pres- sures of blood delivered and is, therefore, most effective in the virile. Limita- tions of compensatory pressures can be estimated in the weak by determining reductions in circulatory competence as well as by measuring the deficit in vital capacity. GENERAL SURGERY 355 These are nature's methods of maintaining the air alveolar capillary- blood relationships that underlie external respiration. The effectiveness of the relationships is measured by vital capacity-. If it is less than the tidal air of rest, life is impossible; if equal, bare existence is possible; and as it exceeds the tidal air of rest, it measures the margin of safety, the limits of possible physical and mental activities, including defense and repair. External Compbessiox Collapse is the deflation caused by the elastic recoil of lung when intra- pleural negative pressures are neutralized. The amount of deflation is con- trolled by the opposing forces, the blood pressures in the pulmonary and bronchial arteries. External compression is produced wiien a force exceeding the pressure of an atmosphere acts on a lung from without and produces a grade of deflation corresponding to the preponderance of compressive force from without the lung over the expansive resistance of the blood pressures within the lung. On the release of external compression the lung reexpands to the grade of deflation due to collapse. This is often noted w-hen chronic pleural exudates are divided or removed or wiien pleural effusions are removed. Deformity of chest walls, intrathoracic tumors, aneurysms, intrapleural transudates, exudates, spontaneous and artificial pneumothorax, thoracoplasty and intrathoracic operations are causes of compression. An outline of changes produced by- the common cause, pleuritic exudates, suffices for all. Exudates formed in a pleural cavity free from adhesions eventually- gravi- tate. Should they- increase, the lung is floated upward so far as its hilum attachments permit. As the level of the fluid rises out of the costophrenic sinuses, the lung is elevated and negative pressures are reduced to zero after which external compression begins. It is exerted first on the supra-adjacent lung. This is exactly- contrary to the effects of diaphragmatic contractions, which diminish pressures on supra-adjacent lung, and are readily seen fluoro- seopically in the zone of increased inflation just above a contracting diaphragm. Pulmonary vessels carrying low pressures are easily compressed; air cells are smaller; and this zone of lung becomes proportionately inactive physio- logically so that the bronchial arterial blood supply is also correspondingly reduced by the usual vasomotor responses. The same series of changes, becoming more and more accentuated, develop as the exudate increases. With increasing exudation, the significant adaptive changes become more noticeable. At first, compression of the pulmonary circulation diverts blood to the nearest margin of lung under less compression and creates there a zone of physiologic emphysema in the same lobe. Gradually, this extends to higher lobes and finally to the contralateral lung. Thus are produced zones of skodaic resonance and the contralateral emphysema, long noted with pleuritic effusions. Should the exudate form rapidly, as it often does in streptococcus infections, patients mav succumb hi a few hours because of their inability to deliver the requisite blood pressures to continue the adaptive emphysema. Physiologic emphysema, be it recalled, is merely a natural method of developing a sufficiently- large area of functioning alveolar epithelium in one part of a lung to compensate 356 SURGERY for reductions elsewhere, and thus to provide enough external respiration to support life. Again, the exudate may be produced more gradually, and, though it cause complete external compression of the entire lung on the affected side, the patient is able to survive. Moreover, the more gradual productions of exudates are favorable to the formation of adhesions between visceral and parietal pleurae and thus to localization of the process. Another point is noteworthy. Intense irritation of visceral pleura tends to produce a subserositis or cortical pneumonitis that may be effective in reducing pulmonary elasticity, which interferes with vital capacity. There is a parallelism between the adaptive processes in the cerebral and pulmonary circulations neither of winch is under direct vasomotor control. Both can compensate for gradually increasing antagonistic pressures remark- ably well. Both are lcthally incapacitated if the counter pressures rise more rapidly than the patient can develop compensatory rises in blood pressures to offset their effects which are respectively cerebral anemia and impaired external respiration. Internal Compression Internal compression differs from external in that the force is exerted within the lung instead of on it. The common causes are chronic passive congestion, pneumonias, tumors, foreign bodies and parenchymatous hemor- rhages. The effects of internal compression are the same as those arising from external compression. They differ in extent and in distribution. Compen- satory emphysema develops about a focus of internal compression by the same air cell-capillary gear. The blood being diverted from a focus of greater to surrounding zones of lesser pressures produces an enveloping layer of hyperemia and consequent emphysema. If the foci of internal compression are sufficiently large and numerous, they can produce a manner of skodaic resonance and even lead to contralateral emphysema. Should the force exerted by foci of internal compression be sufficient, large branches of pulmonary arteries, bronchial arteries or bronchi can be occluded. The effects of such occlusions will be noted later. Pulmonary Circulation Abnormalities in the arterial circulation are gradual occlusions of pul- monary arteries producing equally gradual increments in peripheral resistance, sudden occlusions of larger branches by injuries, ligations and emboli causing abrupt increments in peripheral resistance. Gradual occlusions or obstructions to arterial circulation occur in chrome external and internal compressions of the lung in pleural effusions, tubercu- losis, bronchiectasis and pathologic emphysema. High peripheral resistance leads to hypertension in the pulmonary circulation by extraordinary exertion of the right heart which results in hypertrophy and diminished reserve power. This explains why individuals so affected are especially sensitive to sudden changes in intrathoracic pressures and why all grades of pulmonary compression should be minimized. GENERAL SURGERY 357 Sudden occlusions or obstructions to main branches of the pulmonary- artery are produced by ligation and by emboli. They- cause a sudden shunt- ing of considerable volumes of blood into other vessels and an abrupt rise in peripheral resistance. A strong individual tolerates such a change without notable variations in pulse rate or systemic blood pressures. A weakened heart may be incapacitated almost immediately. Permanent occlusion of a pulmonary artery causes atrophy-, shrinkage and atelectasis in the lung affected. Ligation has been practiced and is still advocated in treating tuberculosis and bronchiectasis. It is in effect a physiologic lobectomy- wiien the principal artery to a lobe is tied. But it does not cause gangrene or infarction because the parenchyma and visceral pleura are supplied by the bronchial arterial circulation. Experiments indicate that life is possible after four-fifths of the pulmonary- arterial circulation has been destroyed in successive stages, as in repeated lobectomies. Sudden occlusions of much more than three-fifths are incom- patible with life. Two erroneous notions about the effects of pulmonary embolism are prevalent. One is that embolism is the cause of gangrene and infarction of the lung; the other, that deaths from emboli can always be attributed to their size. Embolism can be an indirect cause of gangrene or infarction if it pro- duces secondarily^ enough internal compression to occlude a bronchial artery. Usually, gangrene and infarction are occasioned by thrombosis in pneumonia or occur in lungs with circulatory impairments incidental to cardiac lesions or consequent on pleural effusions. The victims of pulmonary embolism expire or they recover, perhaps to die later of pneumonia. Survivors suffer only from such ill effects as may- be attributed to a physiologic lobectomy. Deaths from pulmonary embolism in debditated patients are often due to emboli sufficiently large to raise periph- eral resistance abruptly above the limits of their restricted powers of cardiac compensation. There are, however, many deaths of relatively healthy in- dividuals, as, for example, a few weeks after a simple herniotomy, which fail to be thus explained. Barcroft6 has suggested that an embolus can be caught close to one of the nerve endings present in the pulmonary arterial wall and may, by irritation, interfere reflexly with normal cardiac impulses. Operative removal of pulmonary emboli has been recommended and, in one instance, has been accomplished without killing the patient. Removal of emboli could not be sufficiently prompt to obviate the sudden deaths. It could therefore only be employed to rehabilitate a fraction of the pulmonary circulation or prevent embolic pneumonia. The very patients needing to have a portion of their pulmonary circulation restored are those so debilitated that thoracotomy would be a fatal burden. None could say that any given embolus was o-oino- to cause metastatic pneumonia, or that its removal would prevent the pneumonia or would help to reduce the dangers of septicemia. Hence the removal or attempted removal of a pulmonary embolus is almost without exception a highly dramatic example of surgical malpractice. 35S SURGERY Interference with the circulation in the pulmonary veins is due to obstruc- tions caused bv incompetence of the left heart or resulting from pulmonary- compression. Both add to peripheral resistance in the pulmonary circulation. If the obstruction develops abruptly, and the use of positive pressure with too great anesthesia is a nice example, acute cardiac dilatation is constant and often fatal. Acute venous obstruction can become so critical that systematic venesection is indicated. Gradually increased obstruction leads to chronic passive congestion with its series of handicaps. Abrupt increments in chronic obstruction can cause edema of the lungs. Bronchial Arterial Circulation Bronchial arteries carry six times the pressure of the pulmonary artery, and, as stated, supply the major part of nutrition to lung parenchyma and visceral pleura. Hemorrhage from rupture of the bronchial artery into a bronchus causes exceptional deaths with hemoptysis; into a lung, the diffuse parenchymatous hemorrhagic infiltration called splenization. Obstruction of this blood supply can produce infarction and gangrene. The principal sig- nificance is surgical. Splenization is commonly a positive indication to excise the portion of lung affected. Incisions and resections of lung require accurate ligation of severed branches of the bronchial artery which are easily recognized by the spurting of red blood. Usually, it is safest to remove all lung bereft of its bronchial arterial blood supply. Broxchial Air Circulation Obstruction of bronchi deprives the corresponding lung of its supply of air and assures atelectasis because the air present at the time obstruction occurs is rapidly absorbed. Commonly, an obstruction of larger bronchi leads to pneumonia through infection added to the pressure exerted by- retained secretions. The surgical significance is clear. Bronchial defects must be repaired accurately, and, when such repair is impossible, the corresponding lung should be removed. Pneumonias The more acute and diffuse the inflammation, the greater and more abrupt is the internal compression and increase in peripheral resistance in the pul- monary circulation. Processes of this type are more apt to be accompanied by restricted movements of the diaphragm on the affected side, which are almost certainly inhibited if pleurisy develops. The danger lies chiefly in the extra load thrown on the right heart in addition to the burdens of myocardial injuries from toxemia. It is particularly desirable to reduce the expenditures of energy- by the heart. Benefits of early and repeated aspirations of pleural exudates introduced years ago by Bow-ditch 7 are too important to be neglected. Occasionally, the diaphragm is but little affected. Paralysis obtained by inject- ing the phrenic nerve can be helpful. The main obligation is to reduce cardiac- labor in order to aid compensation and to increase pulmonary blood supply. Chronic pneumonia reduces pulmonary elasticity and increases peripheral resistance in the pulmonary circuit. GENERAL SURGERY 359 Emphysema Pathologic emphysema means reduced pulmonary elasticity-, increased peripheral resistance in the pulmonary circulation and a limited capacity for compensation. It commonly indicates a narrower margin of safety than would be suspected. The right heart has been working for a considerable period against abnormally high peripheral resistance, and its store of reserve energy is subnormal. The bronchial arterial supply is reduced, and the powers of resistance and repair in both parenchyma and visceral pleura are accordingly restricted. Intrathoracic operations on patients suffering from emphysema are extraor- dinarily hazardous. Such patients are likewise less able to tolerate pleural effusions and should be protected by early and repeated aspirations, preferably by- continuous one-way drainage. Atelectasis Lung becomes atelectatic w-hen its supplies of air or of blood from the pul- monary artery are stopped. It is physiologically inactive and receives the least blood through the bronchial arteries. Such lung atrophies and is cicatrized. both leading to contraction. Contraction is powerful enough to carry with it adjacent lung so that an area of atrophy, which is but a part of a lobe, may- reduce the whole lobe to a small mass puckered about the hilum. In the performance of intrathoracic operations, this must be considered. Lung that has become permanently atelectatic or is likely to become so is more safely excised as a rule. Observations of the actions and reactions in the breathing and circulatory7 units occurring under physiologic and pathologic conditions show that nature attempts to maintain such interrelationships as will assure preservation of the basic function of external respiration with the largest margin of safety- therein. Control of the basic relationships, namely volume of ventilated air, area of alveolar epithelium, expanse of capillary endothelium and unit volume of blood, is in part in the central nervous system, but to a larger extent is vested periph- erally7 in the air cell-capillary gear. Vital capacity measures the efficacy- of the relationships so that, in effect, nature strives to maintain a high normal vital capacity-, a lead that therapy- must follow. Vital capacity is determined in the last analysis by- the integrity- of the pulmonary circulation affected by and affecting the state of the breathing unit. Preservation and rehabilitation of the pulmonary circulation, the quality-, quantity and pressures of the blood delivered by- it, are the most important part of intrathoracic therapeutics. NATURAL DEFENSE REACTIONS Nature's methods of meeting irritations from injury or disease by- increas- ino- resistance and hastening repair through reduced but not inhibited function are more evident and perhaps more significant in the chest than elsewhere. Irritations affecting thoracic parietes or viscera almost constantly- restrict parietal movements. Costal excursions may be more affected than diaphrag- 360 SURGERY matic or vice versa. Both are influenced because there is a common control. This is well illustrated if one side of the diaphragm is paralyzed by blocking the cervical portion of the phrenic nerve when there is an immediate, if tran- sient, limitation in the costal excursions on that side. The effects of restricted motion are to encourage somatic rest, to conserve energy, to limit dissemination of irritants and to prevent atrophy and hy- phemia inevitable with nonuse. They may be noted in parietes, in lung and in pleurae. Restricted motion in extrapleural parietes subject to irritation is of no especial moment other than assuring the richest blood supply compatible with minimal expenditures of energy7. Restricted motion in the parietes has very definite influence on the lungs. When restricted motion is considerable, as in more intense types of irritations, the diaphragm is more or less relaxed and is prone to be forced by intra-abdomi- nal positive pressures into an unusually high position. Pulmonary excursions are thereby reduced, and more important still, the total volume of lung or the grade of inflation is less. It has been found experimentally that a lung in approximately a mean position between extremes of inflation and deflation produced by inspiration and expiration receives the largest unit volume of blood with the least cardiac effort. Under such conditions the vessels are neither elongated nor tortuous and peripheral resistance is lowest. It has also been found that under these most favorable conditions pleuropulmonary resistance to infection is highest, and the rate of repair and functional rehabilitation is well-nigh doubled. The effects of restricted parietal motion on the visceral and parietal pleurae are significant since pleurisy7 is commonly the cause and frequently the danger of treatment. The parietal pleura receives its blood from the same vessels that supply- the adjacent parietes so it is helped by restricted parietal motion. The visceral pleura is more effective in defense against pleural irri- tations than the parietal because it has a richer blood supply and a larger expanse. The gravity of serositis in general is determined by the excess rate of production of effusions over the rate of their absorption. Resistance of serous cavities is commensurate with their ability to maintain visceral and parietal reflections of serosa, in apposition by absorption of exudates. Absorption from the pleural cavity- is notoriously- slow7 and slower still if visceral pleura is incapaci- tated by compression of exudates. Lung in the mean position between inflation and deflation provides its pleural surface with its richest blood supply. Hence, through diminished parietal motion, Nature protects the welfare of parietes, viscera, and pleurae. Besides the foregoing adaptations in the breathing apparatus, there are responses in the circulatory unit. Satisfactory7 determinations of rates of flow and pressure of blood within the pulmonary- circulation are yet to be made. Blood is forced through the lesser circuit in one-fifth the time under one-sixth the pressure required to drive it through the sy-stemic. Fluctuations in blood pressure occur, perhaps synchronously" with variations in systemic pressure, but are less in extent. Presumably, the margin of safety in the right heart GENERAL SURGERY 361 is as wide as m the left. Howrever, nothing definite is knowm of the persistence and effects of pulmonary arterial hypertension. Shunting of blood from one part of a lung to another or to the contralateral lung is attributable in the main to hydrodynamic influences. Anatomists have found nerve cells indicating possible vasomotor controls, but physiologists have not demonstrated corresponding functions. However, tw-o peculiar reactions occur that may- be caused by- such influences. Massive collapse of an entire lung has followed injury to the opposite side of the chest. Such lung must be deflated, and deflation can result only from failure of air to enter the bronchi or from interference with delivery- of blood through the pulmonary- arteries. Massive collapse might be explained by a unilateral temporary occlusion near the bifurcation of the trachea were it not for the second reaction. Surgeons who have performed open thoracotomy7 without the protections from differential pressures have noted a sudden lateral shifting of the mediastinum which has been called fluttering or epilepsy of the mediastinum. This has been found experimentally to be associated with equally sudden variations in intrapleural negative pressures, and, in the absence of tracheal obstruction, was attributed to shunting of blood from one pulmonary- artery7 to the other. Conceivably, such shunting might be explained by alternating kinking and unkinking of the pulmonary arteries, but alternating vasometer spasms seem more plausible. TREATMENT The object of treatment is to protect and to restore the function of external respiration, which is estimated by the vital capacity. The means are to assure the integrity of both the circulatory and the breathing units. Available methods are few7. Circulatory Unit Abnormalities occur in the amount and distribution of blood in an organism. If the amount of blood has been reduced by hemorrhage or as the result of increased blood destruction or decreased hematopoiesis, prompt relief is attain- able with transfusions. If the amount of blood in circulation is reduced be- cause of exemia or the escape of plasma into the tissues, benefits follow intra- venous administration of hypertonic glucose which may be given with and without insulin or with and without gum acacia. Each has its indications. The importance of overcoming shock or states bordering on shock can be illustrated experimentally. If a robust dog is bled from a femoral artery until the heart stops, and an open thorax is then created promptly, the heart beats again for a considerable interval and more blood escapes from the artery. If, however, a dog in a state of prolonged and profound shock is simflarly treated, the heart is not reactivated. In other words, little or no reserve blood is stored in pulmonary vessels during shock. Immediate compensatory or adaptive responses are impossible. Additional demands for oxygen can not be met because an important cog in the mechanism of external respiration is not working; hence, the need for providing an ample blood supply before attempting an operation and avoiding pulmonary compression, so far as possible, if that operation is intrathoracic, 362 SUKGERY Breathing Unit Means to counteract lesions in the breathing apparatus are extrapleural and intrapleural. Extrapleural procedures can restrict parietal movements, increase pul- monary deflation or produce compression. Lesser degrees of restricted movements of the parietes can be obtained by bandages, swathes, and adhesive plaster, particularly if it is remembered that adhesive plaster splints are fully effective only when snugly applied, corsetlike, around the entire chest. Frequently, desirable benefits can be secured by further increasing the spontaneous restrictions to motion, par- ticularly if the lung is placed simultaneously in that stage of deflation wherein the blood supply is most favorable. Then, benefits may be provided readily by section of the cervical portion of the phrenic nerve, if permanence is re- quired, or by injecting it with cocain or with appropriate dilutions of alcohol should subsequent regeneration be desirable. Extrapleural thoracoplasties operations are effective in producing permanent compression to aid in obliteration of cavities, particularly in tuberculosis and some forms of bronchiectasis. Failures of these operations, if patients are properly selected, can be attributed to insufficient costal resections or to having attempted too much at one stage. The operations are dangerous because the patients are usually weakened by a losing struggle against an affection that is mainly7 unilateral, and during operation they- must lie on the sounder side. A more serious handicap is cardiac incompetence. Increased peripheral resistance in the pulmonary circuit has resulted from the internal compression caused by the lesions. It is usually of long duration and has sufficed to reduce the margin of safety especially in the right heart. Fever, intoxication and anemia add burdens by causing myocardial degeneration. It is obvious why excisions of parts of only a few ribs can so alter distribution of blood in the pulmonary7 circulation that the greater labor required to effect compensation can lead through progressively" increasing tachycardia to lethal myocardial exhaustion. Rest, digitalis, transfusions and intravenous administrations of glucose can be extremely7 valuable in surgical preparation. The greatest assurance of safety- lies in performing these operations in stages with sufficient intervals to permit orderly- readjustments in the circulatory apparatus. One stage too many is preferable to one stage too few-. An incompleted operation can pro- vide the dangers and distresses of a finished procedure w-ithout affording the benefits. Intrapleural procedures are called closed when free pleural surfaces are not exposed to the air and open when they are so exposed. Closed methods are drainage afforded by single or repeated aspirations or by the continuous removal of exudates accomplished by air-tight, inter- costal tube drains, artificial pneumothorax and thoracotomies performed through preformed adhesions. The same sources of danger are present in all. One is the sudden entrance of air into free pleural space. The other is caused by- rapid and forceful operating. Both have the same effect, abrupt changes in GENERAL SURGERY 363 intrathoracic pressures which require immediate readjustments in the pulmonary circulation. Likewise, the same precautions are to be observed. Aspirations and drainage through tubes should be gradual. Artificial pneumothorax should be induced slowly and at repeated sittings so/that intrapleural pressures are progressively reduced before positive pressures are created. Accurate hemostasis and gentleness are essential in closed thoracotomies. Empyema will continue to be an important part of intrathoracic therapy. The best treatment is prevention, w-hich means early diagnosis and immediate aspiration as first advised by Bowditch.7 Fluoroscopy, essential to both, has been insufficiently practiced and is more generally available since bedside roentgen-ray units have been made easily portable. Early aspiration, perhaps closed drainage, even if it fail to abort empyema, can minimize its severity, extent and the necessity for rib resection. More important still, it reduces the persistence of diaphragmatic paralysis, which Prvor8 showed to be so common and Middleton9 found to be commensurate with reduced vital capacity- and degrees of disability. Moreover, pulmonary deflation with its added burdens on the pulmonary circulation are minimized during aggressive phases of pneumonias when a slight shift in the patient's favor can obviate a fatality. Rib resections impair parietal mobility and are to be avoided whenever possible. On the other hand, it is usually unwise to delay7 performing this operation after the application of ordinary- surgical principles indicates open drainage. Much may be accomplished by the use of surgical solution of chlori- nated soda (Dakin's solution) to dissolve fibrin and by employing gentian violet as advocated by Keller,10 to disintegrate fibrous tissue. After-care has been too often neglected. As soon as the acute process per- mits, breathing exercises are needed to stretch adhesions, to reactivate the diaphragm and to develop compensatory- physiologic emphysema in order to maintain a high vital capacity. Discussion of open methods for treating intrathoracic lesions is limited to consideration of way-s of performing thoracotomy in the absence of pleural adhesions. Incisions should be designed to assure permanent air-tight healing, else open pyothorax is inevitable. It is the principal cause of postoperative disabilities and deaths. Differential pressure is required for safety-. Analgesia suffices. Both can be obtained by the proper use of gas-oxy-gen as developed bv Gwathmey.11 It is wise to inject the phrenic nerve with 1 per cent cocaine. The immediate paralysis of the diaphragm makes operation easier and hastens recovery. There is less postoperative discomfort as the effects of cocaine last for four or more days. Effusions are more rapidly- absorbed because the pulmonary- blood supply is richest under these conditions and healing of lung tissue is favored. Operators differ in respect to drainage. Postoperative pleuritic effusions are constant, commonly- of considerable volume, are slowly- absorbed and offer a favorable medium for bacterial growth. They- cause pulmonary compression and its train of evil influences. Air-tight drainage is possible, is effective, and is seldom to be regretted. Omission of drainage can be disastrous. While suturing the wound at the end of a thoracotomy, 364 SURGERY it is important to obtain air-tight closure with lungs in full inflation and to obtain it in such a manner that the stitches may not cause tension necroses. After-care, if otherwise it can be called such, includes breathing and body exercises to restore parietal movements, pulmonary elasticity, and intrapleural negative pressures as steps in the rehabilitation of external respiration which can be measured by frequent estimations of vital capacity. SUMMARY Life and activities are made possible by external respiration which is provided through coordinated actions of the breathing and circulatory units. Coordinated actions of breathing and circulatory units maintain sufficient volumes of ventilated air in contact with a suitable area of alveolar epithelium to assure such interchange of gases through a similar expanse of capillary endothelium as will aerate equivalent amounts of blood. The interrelation- ships between the volumes of ventilated air, the area of alveolar epithelium, the expanse of capillary endothelium and the amounts of blood needing aera- tion must remain constant although they are constantly fluctuating with each breathing cycle and with variations in activities of the individual. This constancy- is assured under normal conditions by an arrangement of an air cell-capillary structure and function whereby fluctuations in degrees of inflation produce equivalent fluctuations in amounts of blood, and vice versa. Under abnormal conditions, the relationship is modified through the air cell-capillary7 gear, so that additional areas of alveolar epithelium and of capillarv endothelium are provided to compensate for such as may- be temporarily- or permanently7 inactivated. External respiration in a normal individual is undisturbed whether he is at rest or exercising full mental and physical powers. Disability is nil, and the limits of activities, including defense and repair, are measured by normal vital capacity-. External respiration in persons affected with incompetent breathing or cir- culatory units is impaired. This impairment restricts the development of mental and physical powers to the level at which the relationships between ventilated air, areas of alveolar epithelium, expanse of capillary endothelium and amounts of blood can no longer be kept constant. There is disability- corresponding to the level. Activities including defense and repair are pro- portionately7 restricted, and the restriction is measured by the reduction in vital capacity. Preservation of vital capacity during the acute phases of diseases affecting the thorax and its contents and restoration of vital capacity- thereafter are the therapeutic objectives. Vital capacity measures external respiration which is largely- under control of the air cell-capillary gear. Treatment seeks to renew- parietal mobility, to reestablish normal intrapleural negative pressures and to restore pulmonary- elasticity, at the same time providing for deliveries of suitable amounts of good blood by- the right heart and preventing obstruction to the pulmonary circu- lation through incompetence of the left heart. The specific aim is to rehabili- tate the air cell-capillary gear in order to secure the largest measure of external respiration. Achievement is measured by vital capacity. GENERAL SURGERY 365 CONCLUSION The principal effects of intrathoracic diseases are the malfunctions due to lesions of heart and lungs. Both heart and lungs are possessed of remarkable powers of compensation and repair but, when seriously affected, cause enormous totals of distress, disability and death. Many lesions of heart and lungs from which spontaneous recovery- is impossible can be remedied surgically by- pro- cedures already devised. A wider application of known methods and the introduction of new7 pro- cedures can be hastened by more exact knowledge of intrathoracic structures and functions. At present, vital capacity is significant in estimating latent powers including defense and repair, in determining therapeutic procedures and in measuring results of treatment. Vital capacity7 is regulated by the air cell-capillary gear, the weaker part of which is the circulatory segment. Progress in intrathoracic surgery depends largely on the realization of more effective measures to promote and to con- serve the integrity- of the pulmonary circulation. APPLICATION OF BIOLOGIC PRINCIPLES TO THORACIC INJURIES The actions, reactions, and adaptation of the breathing and circulatory units above described will be discussed in reference to thoracic injuries in particular. Repetition, even though fatiguing, will emphasize the biologic principles underlying treatment, which, if correct, will be permanent however much methods may be improved. Thoracic injuries affect the parietes alone, the viscera alone, or, most frequently, both parietal and visceral lesions are produced. Hemorrhage and the exposure of lacerated tissue to air and to infection, which occurs with all wounds, are of special significance because of the untoward effects of hemopneumopvothorax. Chest injuries, severe enough to need treatment and not causing prompt death, produce an immediate defense reaction, restricted motion, particularly of the injured side or the side of greater injury. The virtues of restricted motion in respect to defense and repair are two- fold. The blood supply exceeds deliveries made wiien there is immobilization. Continued limited motion, an incomplete interference with function, assures opportunities for the earliest and most complete restitution of function. Thoracic parietes are benefited by a narrowing of intercostal spaces. Tension upon soft tissues is reduced, a richer blood supply is favored and the size of tissue defects is minimized. Simultaneously, diaphragmatic excursions are curtailed, first, through spasm; later, through relaxation due to fatigue, which, in the presence of intra-abdominal pressure, carries the affected side to an un- usually high position. Some motion, even when there is paralysis of one side of the diaphragm, is provided by a contralateral tug with each inspiration so that here, too, conditions favorable to healing are provided. Diminished motion of the parietes, and particularly of the relaxed dia- phragm, not only decreases pulmonary excursions but also lowers the mean 366 SUROKRY pulmonary inflation. Hence there is a diminished volume of lung subjected to less motion. Observations made by Steiner12 upon patients suffering from irritations to lung and to the visceral or parietal pleuno, even before pneu- monitis or pleuritis is demonstrable and though they may never develop, prove this reduction in size and motion of lung to be a natural defense reaction. Experimental evidence (Cloetta) 13 shows that these conditions provide for delivery of the richest blood supply to a unit volume of lung, and, quite as important, with the least expenditure of cardiac energy. Pleural defense and repair is obviously- affected by the same conditions since the blood supply to the parietal reflection is derived from the vessels supplying the chest wall and the diaphragm and the visceral layer is nourished (in man) chiefly7 by the bronchial arteries. Pulmonary inflation is also affected through injuries to the circulatory mechanism by hemothorax, by intrapulmonary hemorrhage and by variations in the volume and force of the blood delivered to the lung. Hemothorax, usually accompanied by some pneumothorax, is the com- monest complication. Blood, escaping from either visceral or parietal lacera- tions into a pleural cavity free from adhesions, tends to settle in the costo- phrenic angles so that intrapleural negative pressures are reduced and progres- sive degrees of collapse occur before the lung volume is affected by direct pressure. As the level of the extravasated fluids rises, pressure is exerted chiefly upon the contiguous lung which is also elevated. When the extrapulmonary pressure exceeds the tension within the pulmonary arteries, that portion of the lung is deflated. At the same time the blood w-hich should have been delivered to the zone of lung under compression is shunted to the superadjacent lung, wherein, because of the air cell-capillary gear, a margin of compensatory- emphysema is produced. This emphysema produces the Skodaic resonance constantly recognizable above the level of pleural effusions. Should the hemor- rhagic extravasation continue to increase, the same compensatory changes are augmented so long as the circulation remains competent. However, a point will be reached at which the excess blood diverted from the compressed lung can no longer be distributed only to homolateral lung, but will in part be shunted to the lung in the opposite side of the chest. Here will be produced by the same air cell-capillary action the contralateral emphysema so commonly noted with large pleural effusions and massive pulmonary consolidations. When unilateral negative intrapleural pressures are nullified—i. e., equal to the atmospheric pres sure—the lung is in a position of collapse or as it would be with an open thorax. Intrapleural pressures in excess of the atmospheric produce degrees of pulmonary- compression which vary directly with the amount of positive pressure exerted upon the lung and indirectly with intrapulmonary intravascular tensions. The final state, complete, rapidly produced unilateral compression, is seldom compatible with life and therefore rarely encountered. From a practical standpoint it is wise to examine these adaptations more closely. However they may be produced, by variable proportions of hemo- thorax, pneumothorax and pleuritic effusions, as unilateral intrapleural pressures grow progressively more positive, they are met, as has been shown experiment- ally-,3 by increments in systemic blood pressures within the lesser circulation. GENERAL SURGERY 367 So long as intravascular tension within a lung exceeds the extrapulmonary pressure the unit volumes of blood delivered will remain approximately- normal, but such deliveries are secured by a greater expenditure of cardiac energy. When the extrapulmonary pressure exceeds the intrapulmonary vascular tension, there occurs the inevitable shunting of blood from zones of greater to the nearest zones of lesser compression. The compensatory emphysema inevitable with increased blood deliveries assures proper aeration of excess blood, but it is obtained at the cost of increased cardiac labor which is proportionate to the adaptations demanded and is effective so long as circulatory competence persists. Possibilities for compensation vary within wide limits. Our observations have shown that a competent circulation in man will adjust itself to an abrupt interruption to the blood supply of an entire lung without recognized embarrass- ment, A healthy monkey- will tolerate an increase in unilateral intrathoracic pressure exceeding twice the atmospheric pressure without giving indications of immediate distress. On the other hand, dogs, in wilich neither unilateral pneumothorax nor unilateral hydrothorax can be maintained, have not such powers of adjustment. They can barely tolerate atmospheric intrapleural pressure and then the better when slowly induced so as to provide opportunity and time for a compensatory rise in blood pressures. When their heart muscle isjfatigued by meeting repeated demands for compensation, dogs can tolerate progressively less reduction in negative pressure. Similarly-, a fatigued monkev or a man handicapped by myocardial deficiency, hemorrhage or shock, may be unable to withstand even atmospheric pressure, although gradually induced. Another complication due to lesions in the circulatory apparatus is intra- pulmonary hemorrhage, which may arise from lacerated pulmonary- arteries or veins or from severed bronchial arteries. Resultant interstitial extravasa- tions reduce pulmonary elasticity- and affect pulmonary inflation. The results vary- from localized hematomas to a diffuse brawny- infiltration or splenization that may involve an entire lobe and is in effect an infarction. Intrapulmonary- hemorrhages cause intrapulmonary- compression, and, like extrapulmonary compression, compel a shunting of blood from foci wherein intravascular tension is exceeded to surrounding lung wherein it is not exceeded, so that the same factors are active in causing compensatory emphy-sema. Incompetence is the most significant of all injuries to the circulatory- unit whether produced by myocardial deficiency-, anemia or exemia alone or in combination, because of the limitations to compensations that make external respiration possible. So important is this phase of the problem that it is fair by wav of emphasis to anticipate therapeutic discussion and state that those procedures offering the greatest immediate protection to the lesser circulation and the largest possibilities for its rehabilitation, both measurable by vital capacity, are most effective in intrathoracic therapy. SURGICAL METHODS The aims of civil and of military surgery are identical, to provide the largest opportunities for functional recovery with the least danger, delay, and distress. Handicaps imposed by- warfare too frequently restrict what 4C).U»7—27-----2(1 368 SURGKKY should be done to what can be done. Makeshift methods need not be dis- cussed as they are born of unfavorable conditions and individual ingenuity. Interest centers in means to a satisfactory performance of thoracotomy under field conditions, for thereby- alone can many of the severely wounded be saved from death and a very large proportion of all the wounded be returned promptly to duty. Surgeons have been enabled to invade body cavities effectively by first learning to control subsequent inflammation of the lining membranes of those cavities. This is particularly true of the thorax. Appreciation of the need to control pleuritis by restricting pleural irritation and by conserving the defensive and reparative powers of the pleura is simultaneous with the realiza- tion that the great majority of deaths not immediately due to injury and much of the late disability are attributable to acute and chronic pleural in- flammation. The explanation is simple. Chest wounds provide all of the conditions favorable to the development of pleuritis, tissue laceration, unyielding costal parietes, hypertension due to hemothorax, exudation more rapid than absorp- tion, foreign bodies, and the presence of bacteria. Acute pyothorax added to burdens of recent wounds and exposure is an extremely- serious complica- tion, particularly7 when, as often occurs, circumstances prevent adequate personal attention to the sick. Chronic pyothorax, even though treated as superbly- as has been done by Keller,10 inevitably- causes material disability-. Methods for controlling pleural irritation should cooperate with natural defense reactions. Mesothelium lining serous cavities, compared to other tissues, is exceptionally resistant to irritants and possessed of correspondingly high powers of regeneration, provided its blood supply is adequate. The extent and character of serositis is determined by the intensity- of irritations, their dissemination through motion, capillarity-, and gravity, by the hypertension produced within the cavity and the subserous reactions which curtail the supply of blood. In other words, resistance of serous activities is commensurate with their ability to maintain their mesothelial surfaces in approximation. This depends upon a greater rate of absorption than of exuda- tion and upon flexible parietes. Pleural resistance is relatively lower than peritoneal because the rate of absorption of pleural effusions is less rapid than the rate of exudation and because parietal adaptability is virtually- limited to the various positions which may- be taken by the diaphragm. A major portion of pleural resistance is borne by the visceral reflection and this is subject to material reductions by the interferences with the circu- lations in the lung consequent upon injury. As already stated, the total volume of blood delivered to a normal lung is commensurate with activity of respira- tion and with circulatory competence. If, as the result of extrapulmonary pressures (air, blood, exudate) or intrapulmonary pressures (interstitial hem- orrhage), the pulmonary arterial pressure is surpassed, deflation occurs which amounts eventually- to atelectasis when blood flow is inhibited. By the same token, if a large branch of th« pulmonary- artery- is occluded, permanent atrophy of the lung supplied thereby is the result (figs. 181, 182). Presumably, in areas GENERAL SURGERY 369 of partial or complete deflation and in atrophy the bronchial arterial blood supply is proportionately- reduced. If the bronchial supply- is withheld, necrosis follows. Although Karsner and Ghoreyeb 14 have showm that w-hen the pressure in either the pulmonary or bronchial circulation is reduced to zero, blood may pass over from one to the other, it was not evident in w-ounded human lungs that this interchange was free enough to be effective. Tlierefore, in man, because the visceral pleura is supplied by- the broneial arteries, the basic need is to maintain a degree of pulmonary inflation compatible with function because the bronchial arterial blood supply varies directly with func- tional activity. Natural defense reactions indicate that the limited degree of inflation deter- mined by reduced costal excursions and the high position of a relaxed diaphragm is the most propitious. According to Cloetta,13 the pulmonary- vessels in a lung thus inflated are neither tortuous, as in greater deflation, nor elongated, as in great inflation. In consequence, lungs thus inflated contain the maximum unit volume of blood delivered with the least cardiac effort. Rapidity and extent of dissemination of intrapleural irritants are well illus- trated by a simple hemothorax. As first demonstrated experimentally by Denny and Minot,15 and confirmed by the observations of Elliott and Henry16 upon the wounded, intrathoracic movements are sufficiently active to defibrinate the blood in the pleural cavity which does not coagulate promptly and to spread the exudate over the entire pleura free from previous adhesions. Delrez17 and Middleton 18 show-ed that blood is so irritating to joint and chest serosa as to produce a serofibrinous serositis. Middleton 18 found the chief irritants to be fibrin and fibrinoplastic substances. Not all of the latter are removed wiien coagulation occurs so that serum remains an active irritant. These facts explain the diffused pleural reactions, varying from a sero- fibrinous to an organized exudate, noted when a thoracotomy is performed hours, days, or weeks after a hemothorax has resulted from injury. They also help to explain why pleuritis must be combat ted otherwise than peritonitis. Generalized pleuritis is the rule; generalized peritonitis, the exception. Thoracic parietal adaptability is restricted to the diaphragm; abdominal parietal adaptability is only restricted beneath the costal angles and in the pelvis. In both healing occurs by adhesions between irritated surfaces which must be in apposition. Hence routine drainage of the general pleural cavity, which is possible if prop- erly done, is indicated, and attempted drainage of the general peritoneal cavity, which is physically and physiologically- impossible, is contraindicated. Irritation of serosa provokes a very rapid serous effusion which occurs promptly with hemothorax and soon exceeds the amount of blood originally- present. High position of the diaphragm is a constant accompaniment of hemothorax (Bradford,19 Elliott,16 Soltau 20) and is due at first to inhibition of contractions and later to paresis. Steiner's 12 observations upon the early- effects and Prvors 8 studies of the late effects of pleuritis show that the early upward displacement of the diaphragm is almost constant and tends to persist rather than to recover unless specially treated. The effects of pleuritis above mentioned are intensified by the presence of bacteria and their toxins. When the pleuritis is intense it provokes a cortical 370 SURGERY subserous pneumonitis unless the lung be so devoid of circulation that reaction is impossible, and then, like a foreign body, it is an added burden to defense. Moreover, even when a lung is but partially- compressed its circulation is inade- quate for defense because it is only under such conditions, according to Karsner and Ash,21 that pulmonary embolism causes infarction. The effects of collapse and compression of the lung upon the circulation, particularly the burdens thereby added to the heart, have been described. It is only necessary to add here that heart muscle, recently compelled to over- exertion, is particularly susceptible to intoxication. Hearts, already fatigued and still compelled to" work disadvantageous^-, tolerate so poorly even the limited absorption from pleuritic effusion that the margin of safety is widened if their physical load is reduced by pulmonary reinflation which decreases peri- pheral resistance notwithstanding greater absorption of toxins from the pleura through the improved circulation. Moreover, the improved circulation also raises local resistance and favors repair. Basic Principles in the Treatment of Thoracic Injuries The capability of maintaining its lining membranes in apposition is a gauge of its powers of absorption and roughly measures resistance of a serous cavity. Accumulation of fluid or air means dead space, hypertension within the cavity-, diminished blood supply and decreased resistance, and in the chest, added cardiac labor. Methods of treatment, which prevent separation of serous surfaces, or, after separation has occurred, reestablish and maintain sur- face contact, provide the best opportunities for immediate recovery, of course assuming that circulatory incompetence is given proper attention. The degree of ultimate recovery is determined by the promptness and completeness of restoration of function. Since the identical factors controlling respiration affect the circulation, measures must be adapted to restore mobility of the parietes, especially the diaphragm, to reestablish normal intrapleural negative pressures and pulmonary- elasticity. The most important part of treatment is restriction of pleuritis; the next most important is overcoming the effects of pleuritis. If these demands are given due consideration, no essential detail will be omitted. The specific objectives are four: (1) Parietal healing.—Permanent air-tight parietal closure is imperative, because the worst complication is open py-othorax, particularly if it occurs early and before the formation of limiting adhesions. Smooth healing of parietal pleura is especially advantageous. It limits pleural effusions and offers the most effective barrier to the extension of inflammation, the usual antecedent to open pyothorax, either from within the chest to the parietes, or vice versa. Also it is the best protection against persistent or recurrent empy- ema. (2) Restriction of pleural effusions.—Pleuritic effusions interfere with all of the factors w-hich together make normal respiration possible and they likewise decrease pleural resistance. They can be restricted by reducing pleural irrita- tion but not enough to be absorbed as rapidly as they form. Their removal is GENERAL SURGERY 371 always desirable and often imperative and may- be accomplished without ill effects by closed (air-tight) drainage. (3) Puhnonary inflation.—Underinflated or overinflated lung adds to cardiac labor and narrow-s the margin of safety. Lung tissue that can not be inflated, or, if inflated, can not remain inflated, is without function and therefore without the blood supply- essential to defense and repair. In general, such tissue is a direct menace and should be removed. (4) Pleural adhesions.—Early- fibrinous adhesions are inevitable and desir- able. They- limit the progress and extensions of pleuritis. Experience in com- bating peritoneal adhesions and the work of Delrez17 and of Willems22 in over- coming adhesions following arthritis have proved that the principle of inducing active motion as early- as the infectious process permits and of continuing it to the limit of pain inhibition gives the best functional results. The same prin- ciple applied in the treatment of pleurisy is equally- efficacious. The anatomic explanation for the return of function is the persistence of some more or less isolated mesothelial cells of the serosa beneath exudates, even after organiza- tion has occurred. If motion disrupts adhesions gradually- and without causing hemorrhage, the mesothelial cells which have been exposed by- the disruption can, because of their extraordinary- regenerative pow-ers. overgrow the adjacent tissue defects. Thus is made possible restoration of a pleural cavity- after pleuritis which can be so perfect as to permit of normal function. If these four points are kept constantly- in mind, the details of treatment to be described will appear less petty. Attention to details secured the tissue repair upon which recovery- of function depends, and when neglected, as was at times imperative during periods of stress, the average of results obtained was less satisfactory. TYPES OF CHEST INJURIES Injuries to the thorax affect the parietes alone, both the parietes and viscera, or, more infreqcntly, the viscera alone. The last are due to indirect violence, or to sudden and considerable changes in atmospheric pressure result- ing from near-by explosions. Wounds, perforating, penetrating, or tangential, are similar to those involving other structures, but are distinguished by one peculiarity-—their liability to produce an open thorax. They are also com- plicated by wounds of the abdomen and spine more commonly than are wounds elsewhere. In general, shell fragments cause greater tissue injury than bullets, and more commonly carry other foreign bodies and bacteria with them into the tissues. The physical injuries of the thorax are of the same type as injuries elsewhere- they include a central zone of tissue destruction, an intermediate zone of tissue injury, and a surrounding zone of hemorrhagic infiltration, which merges into an outer margin of active hyperemia in the tissues still capable of defensive reaction. They are subject to the same bacterial contamination, the same implantation of foreign bodies, as are other wounds. Injuries of the Thoracic Parietes Alone These comprise about 10 per cent of chest wounds, and consist of con- tusions, lacerations, and punctures, with or without simple or compound frac- 372 suk<;i_kv tures of the ribs, scapula, clavicle, or sternum. They are caused by crushing injuries, by the direct impact of spent missiles, and most commonly by tan- gential injuries from various types of projectiles. In general such injuries require the same treatment as similar wounds elsewhere—thorough cleansing and a resection of the necrotic and dangerously devitalized tissues. The most important details arc to avoid opening the pleural cavity and to protect the parietal pleura from infection. Contused skin and subcutaneous fat do not heal w-ell, particularly- if suture is necessary. As a rule wide cutaneous resections are avoidable, but when indicated some plastic flap closure can be made. Except in the muscles of the erector spina, group and the muscles attached to the scapula, there is relatively little danger of gas gangrene, because chest muscles are not surrounded by unyielding structures, and are less liable to the pressure anemia caused by swelling after injury- or by the constriction of ban- dages. As a consequence less radical excisions of injured portions of the chest musculature are required than in similar injuries elsewhere. Fractures are treated upon general principles although in compound fractures of the ribs particular care is necessary to resect damaged tissues widely and to avoid additional injury to intercostal structures. Injuries to nerves and blood vessels about the clavicle are repaired as accurately as possible. Perforating wounds of the parietes occurring so low- in the lateral aspects of the chest as to affect only the costophrenic sinuses may occasion negligibly slight intrathoracic disturbances, and yet they may require thoracotomy to effect deep transpleural repair. Injuries of the spine without cord lesions require particularly careful excision because of the liability to infection due to muscle injury and the presence of bone fragments. Lesions of the cord may- demand laminectomy. When paralysis is complete, efforts to obtain primary healing are particularly desirable in order to reduce subsequent distress. Injuries Involving Both Parietes and Viscera In 10 per cent the visceral injuries are due to force transmitted from the parietal injury- without penetration of the parietal pleura. In the remaining 80 per cent the visceral lesion is caused by- projectiles or indriven rib fragments. In these it is important that an air-tight closure of the pleura be secured whether it has been opened by- the primary7 injury- or at operation. Variations in methods of operating upon wounds of the chest wall, from those outlined above, are determined by the extent of intrathoracic injury, the necessity- for performing thoracotomy, and the general condition of the patient. Whether the parietal pleura is opened by the primary injury or at subsequent operation, a permanent air-tight closure is essential. Ideal repair of defects in serous membranes is obtained by an accurate approximation of serous surfaces without undue tension, because anything foreign to serous surfaces, including other living tissues, is an irritant. When the defects in the parietal pleura can not be closed by approximation, as fre- quently occurs with multiple rib injuries, makeshifts must be provided. The best substitute for parietal pleura is visceral pleura. Distended luno- is easily y operation. At the close of the war there wras a growing sentiment in favor of open operation in the treatment of extensive hemothorax, particularly- if massive clotting had occurred. Aspiration remained the method of choice in treating limited hemothorax as it led to early recovery and return to duty. The arguments against operative treatment of hemothorax are that con- servative treatment, early- aspiration with air replacement as practiced by Ibistianelli,27 or aspiration after 7 to 10 days, with or without oxygen replace- ment, gives better results, particularly a lower immediate mortality rate, and reduces the pressure upon surgical facilities during periods of active fighting. The indications from the standpoint of morbid physiology are definitely for the earliest elimination of pleural irritation and pulmonary compression, the inevitable consequences of hemothorax and pneumothorax. Hemothorax is of itself seldom sufficient to cause death either through pressure or acute anemia. The large amount of bloody fluid which is present after a few- hours, its dilution as compared to normal blood, its liability- to increase after active hemorrhage has ceased, prove that a pure hemothorax has a transient existence, and that it is only a few- minutes before a secondary pleuritic effusion is added. In the presence of clots there is still more intense irritation, a fact which led Elliott,16 Davies28 and others to advocate open operation for their removal. Later results of hemothorax are equally serious. Bradford29 noted a decreased absorption rate of fluid and gas from the pleura attributable to the fibrinous exudate. Delayed absorption of hemothorax has been repeatedly- mentioned, and, according to Davics.2S it is far from being the exception. 378 SURGERY Absorption is not always promoted by aspiration, as evidenced by the example reported by Tuffier30 of a hemothorax which persisted for 15 months in spite of 27 aspirations. As the result of pulmonary compression, vicious adhesions, thickened pleura, and an immobile diaphragm, there is deficient expansion, shoulder drop, scoliosis, parenchymatous sclerosis (Tuffier),30 and incapacitating dyspnea. The dyspnea may last for months or even years, and, according to Leslie,31 is largely dependent upon the degree of permanent collapse of lung tissue. The possibility of secondary infection of a hemothorax adds another and more dangerous complication. 'Gask25 found that nearly all war wounds are contaminated. Soltau,32 in his bacteriologic studies of empyema, found gas- producing organisms in 44. Soon after operation pres- sures had fallen to 60/30. Transfused 500 c. c. citrated blood. Pressures raised to 100/60, temporarily. Death within a few hours. Necropsy: Kissing wound at apex of right lung. Splenization right upper lobe. Moderate hemothorax. Dilatation of right heart. This man could have recovered had it been possible to operate when he was in good condition. Removal of right upper lobe would have been neces- sary-. An illustration of the need to protect the pulmonary- circulation. S. N. E. L. September 12, 1918: Shell fragment, penetrating, right chest. Entrance wound at tip of right clavicle. Moderate hemothorax. Foreign body 1.8 cm. in diam- eter within lung. Cough and hemoptysis marked. Duration five hours. Condition good. Operation: Entrance wound and tract excised. No rib damage. Entrance into pleura not found. Superficial drainage. No aspiration. September 14, 1918: Healing smooth. Pleuritic effusion reducing. Heart no longer displaced to left. Evacuated in good condition. 1921. Records available. Disability less than 10 per cent. GENERAL SURGERY 405 Immediate aspiration should have been performed. 9. W. J. McC. September 12, 1918: Shell fragment, penetrating wound, right chest wall. Entrance in third interspace at right sternal margin to lodge beneath skin over fifth rib in anterior axillary line. Small hemothorax; heart not displaced. Some hemoptysis. Duration unknown. Condition good. Operation: Excision of wound of entrance; resec- tion of upper right margin of sternum and of fractured third rib. Pectoralis major muscle split for exposure. Foreign body 2 cm. in diameter removed. Pleura not opened. Xo suture closure. Gutta-percha drain. September 17, 191S: One aspiration removed straw- colored serofibrinous fluid. X ray shows some cloudiness at right base. Diaphragm and its excursions normal. December 24, 1918: Returned to active duty. August 3, 1921: Little disability. Xo cough. Rating 10 per cent. Heart normal. In lungs there is slight increase in peribronchial striae; otherwise normal, as is the diaphragm. Basal chronic pleuritis, right. Vital capacity, 90 per cent. Disability is due to pleuritis which could have been eliminated with aspiration at time of operation and subsequent breathing exercises. This is an example of pulmonary injury caused probably by indirect violence. In this instance thoracotomy w7as not indicated as it would have been had there been splenization of the lung. 10. F. K. September 12, 1918: Bullet, through-and-through wound, left chest wall. Entrance at anterior axillary line, level of fourth rib; exit at posterior axillary fold at level of sixth rib. Small hemothorax; dyspnea. Duration seven hours. Condition good. Operation: Wounds of entrance and exit excised; connecting tract laid open and excised. No rib injury nor pleural laceration. Superficial wound closed with drainage. September 18, 1918: Pleuritic effusion persists in small amount, but is decreasing. Evacuated in good condition. Xo further records. Estimated disability less than 10 per cent. Aspiration, perhaps repeated, should have been employed. 11. P. O. September 26, 1918: Bullet, through-and-through wound, right chest wall. Entrance just below right sternoclavicular joint; exit below and external to right nipple. Small hemothorax. Xo dense shadows. Duration five hours. Condition fair. Operation: Ten and a half hours later. Wounds of entrance and exit resected; connecting tract opened. No rib or pleural damage. Lacerated outer one-half of pectoral muscle removed. Partial closure. Superficial drain. September 30, 1918: Condition excellent. No increase in pleuritic effusion. Evacuated. No further records. Estimated thoracic disability zero. Aspiration, especially if performed under fluoroscopic control, would have been wiser. 12. E. L. October 1, 1918: Bullet, through-and-through wound, neck and right chest. Entrance above inner third clavicle; exit, right axilla, level of fifth rib. Cold. exhausted; pulse feeble and rapid. Extreme interstitial emphysema of face, neck, arms, and thorax. Grunting dyspnea. Exhaustion due to long, hard ride. Duration 12 hours plus (?) Operation: Excision of entrance wound. Air escaped from tissues in bubbles. Wound packed with gauze and a tube drain inserted. Condition prevented further inter- vention Death 14 hours later. Necropsy: Left pleural cavity, negative pressures persist. Right pleural cavity, positive pressure; lung compressed and diaphragm depressed by large hemopneumothorax. Through-and-through wounds of trachea in episternal notch and of left upper lobe. Peritracheal emphysema; trachea not obstructed. Death due to obstruc- tion of venous return from head. This man arrived too exhausted to stand operation. If he had been received earlier tracheal repair or tracheotomy would have been effective. 13 R M October 13, 1918: Shell fragment, through-and-through wound, left chest wall. Entrance beneath anterior axillary fold; exit below angle of scapula. Much bone 406 SURGERY damage. Small hemothorax. Condition good. Duration 22 hours. Operation: Entrance and exit wounds excised. No pleural injury. Wide resection of scapula. October 19, 1918: Evacuated in excellent condition. Xo further records. Estimated thoracic disabil- ity zero. Even this limited hemothorax should have been aspirated. 14. W. J. W. October 14, 1918: Shell fragment, penetrating, right chest wall. Entrance wound right axilla, level of fifth rib. Foreign body, 0.3 by 0.7 cm., beneath right nipple. Operation: Entire wound excised. Foreign body removed. No rib or pleural injury. Partial closure. October 16, 1918: Wound clean. No abnormal chest findings. Excellent condition. Evacuated. No further records. Estimated thoracic disability zero. 15. G. S. October 14, 1918: Shell fragment, penetrating wound, left chest. Entrance just below spine, left scapula. Moderate hemothorax. Foreign body 0.6 by 0.S cm. in lung. Intrapulmonary hemorrhage. Duration, nine hours. Condition, fair. Operation: Two and a half hours later. Wound of entrance excised. Fractured scapula resected. Pleural defect closed with muscle. Partial closure. October 15, 1918: Comfortable. Sta- tions changed. No further records. If this man's condition had permitted, a thoracotomy of election should have been performed, as it would have caused less risk than a splenized lung. 16. B. W. November 1, 1918: Shell fragments, 0.5 by 0.8 cm., and 0.5 by 0.12 cm., penetrating wounds of back and right chest. Sucking wound at entrance at ninth rib below angle of right scapula. Small hemopneumothorax. Heart displaced to left. Complete section of cord. Duration, 24 hours. Condition, poor. Operation: Wound of entrance excised. Contused muscle, broken ribs, and vertebra, resected. Closure with muscle flaps. Superficial drainage. Died within six hours. No necropsy. Lethal injury. Treatment with morphine would have been wiser. 17. H. G. H. November 2, 1918: Shell fragments, penetrating; seven wounds of back and right chest. Moderate hemothorax; hemoptysis. Duration, six hours. Con- dition, poor. Operation: One and a half hours after admission. Multiple wounds excised and superficial foreign bodies removed. Fractured spinous processes resected. Wound in pleura closed. November 18, 1918: Condition, fair. Fluid in chest despite previous aspiration. No pneumothorax. Febrile. Died some days after evacuation. No further notes. This man's life might have been saved by proper drainage, as he died presumably from emphysema. 18. H. C. H. November 12, 1918: Bullet through-and-through wound, right chest. Entrance over third rib, right parasternal line; exit, right posterior axillary line at level of fifth rib. No hemoptysis. Moderate hemopneumothorax and cardiac displacement. Some tissue emphysema. Duration, 34 hours. Condition, fair. Operation: Exit wound excised. Slight sucking. No rib injury. Closure with superficial gutta percha drain. Entrance wound excised. No rib injury. Closed. Chest aspirated. November 16, 1918: Temperature normal. -No cardiac displacement. Small pleuritic effusion. Condition, excel- lent. Evacuated. February 5, 1919: Discharged from service. No further treatment. August 12, 1921: Dyspnea on slight exertion. No cough. No limitation in respiratory excursions. Slight fibrosis at right apex. Diaphragm free. Heart: Rapid action; other- wise normal. Vital capacity, 110 per cent. Disability rating, 25 per cent. Disability granted is due to cardiac excitability and not to previous injury. This man's treatment, in view of the duration of injury before operation, has been justified by the results. An intercostal catheter drain might have done harm and accomplished no more good. GENERAL SURGERY 407 SUMMARY OF GROUP I The number (18) treated by extrapleural excision is 20 per cent of the entire series. It would have been much larger had not so many- of the less seriously wounded been sent to hospitals farther away. Fatalities.—There were four deaths (22 per cent). Tw-o (7, 12), lethally affected at time of operation, could have recovered if operated upon earlier. One (16) was fatally injured because of a cord lesion; one (17), despite multiple injuries, might have recovered had the principles of primary drainage been under- stood and suitable apparatus been available. One (17) was operated six hours after injury; the others after 24 hours. No death can be attributed to the operation itself. One is chargeable to surgical error, the failure to provide drainage. This gives a surgical mortality of 5 per cent. Disabilities.—The ultimate disabilities of 13 of the 14 w-ho recovered are quoted from allowances made by the War Risk Insurance board or by estimates made in comparison therewith. Three (11, 13, 14) recovered without disabdity from thoracic lesions. Five (1, 2, 3, 4, 10) had disabilities of less than 10 per cent. Two (5, 9) had ratings of 10 per cent, One (6) was rated at 20 per cent and one (18) at 25 per cent. The ratings of two (5, 6) are low and the rating of one (18) is high. The result in one (15) can not be surmised. A generous estimate of the average disabilities for this group is 10 per cent. The average interval before return to duty was about 90 days. Pleuritis, arising from hemothorax, caused the disabflities in all but one (18, disordered action of the heart). In four, hemothorax w-as caused by transmitted violence as the parietal pleura had not been punctured. Three of these (11, 13, 14) recov- ered without disability, and in the fourth (10) it was less than 10 per cent. On the average 24 hours had elapsed between receipt of injury and operation. Had it been possible to have hospitals close to the zones of conflict or to have had effective sifting of the wounded and expeditious transportation, the mortality rate would have been less. Had the proper use of intercostal catheter drains been understood or had the members of this unit been permitted to give patients individual postoperative attention, particularly- in earlier and perhaps repeated aspirations, the disability rate (10 per cent) would have been reduced. Also had continued after-care, especially breathing exercises, been a routine, the average duration of disabdities (90 days) would have been less. DEDUCTIONS Virtually all wounds of the chest should be treated by prompt excisions of injured extrapleural tissues, which without adding to immediate dangers give protection against inflammation in parietal tissues that can cause pyothorax and frequently reveal unsuspected deeper lesions demanding more radical operation. Parietal excisions should be performed under positive pressure gas analgesia, because these minor operations can thus be more rapidly and safely conducted. Discomforts are less than w-hen local anesthesia is employed; there is less likeli- hood of spreading infections and the exposure of a sucking wound is not accom- panied by pulmonary- collapse. Administration of ether by open methods is unwarranted. 40S SURGERY Aspirations or suitable drainage of hemothorax should be almost routinely- employed with parietal excisions to reduce pleuritis and be followed by system- atic exercises to minimize the effects of pleuritis. This combination assure* the most complete, undelayed recoveries. CONCLUSIONS The chief objections to routine parietal excision have been : (a) It increases immediate dangers; (6) it is too time-consuming, especially during periods of active fighting when simple aspiration with or without air replacement suffices; (c) it overburdens the forward hospitals and nurses. (a) Immediate dangers are not increased and ultimate dangers are reduced. (6) Less time and attention are required to obtain healing if wounds receive prompt attention. Reasons have been given to show why simple aspiration is inadequate and ofttimes dangerous in spite of the many excellent recoveries that may be secured. Air replacement is unsound therapy. Its one excuse is to stop hemorrhage from lacerated lung and can only be effective by producing pulmonary- compression. Not only is pulmonary compression undesirable from every standpoint, but also it must be controlled by- manometric determina- tions which are time-consuming, (c) Virtually all wounds must be given some attention and all but those receiving trivial injuries must be hospitalized. Hos- pital facilities of an army have physical limitations which can be increased only by reducing the durations of disabilities. When the numbers of severely wounded overtax forward hospitals, those suffering from less severe chest wounds can be sent as far back as they can be delivered within 24 hours while still in good condition. This plan in the long run would be more effective than the giving of makeshift early treatment that assures more prolonged and less com- plete recoveries. Parietal excisions, with and without immediate aspiration or primary- drainage, are applicable to the least severe chest wounds or to those in such critical condition that no further intervention may be attempted. GROUP II. LIMITED THORACOTOMY 1. E. B. July 20, 1918: Bullet, through-and-through wound, both sides of chest. Entrance at left nipple; exit above right nipple. No physical signs of intrapleural involve- ment. No X-ray examination. Duration nine hours. Condition (?). Operation: En- trance and exit wounds excised and connected. Fractured ribs and sternum resected. Wounds in lung sutured and in pleura closed with muscle. No aspiration. July 23, 1918: Hemothorax with increased pleuritic exudate, right side. Dyspnea. July 24, 1918: Aspira- tion unsuccessful. Condition poor. Hospital moved forward. Patient left in poor condi- tion August 2, 1918. Died. No further notes. Notwithstanding severe injuries affecting both pleural cavities and anterior mediastinum, this man had the power to recover had proper primary- drainage been employed. 2. A. R. July 20, 1918: Shell fragment, penetrating wound, sucking, right chest. Entrance over scapula. Large hemothorax. Foreign body present. Duration (unknown). Condition (?). Operation: Lacerated tissue excised; fractured scapula and rib resected. Muscles closed over sucking wound in pleura. Foreign body not removed. Severed supra- scapular nerve sutured. July 24, 1918: Uncomfortable convalescence. Pleuritic exudate disappearing. Evacuated in good condition. 1921. Records available. Disability below 10 per cent. GENERAL SURGERY 409 This man's recovery was due to good luck rather than to good management. Hole in lung should have been repaired; chest aspirated, possibly drained if the wound was of long duration because of the sucking type. 3. A. F. G. July 21, 1918: Bullet, through-and-through, sucking wound, left chest. Entrance over sixth rib, anterior axillary line; exit, paraspinal line, level of twelfth rib. Hemopneumothorax moderate. Duration (unknown). Condition (?). Operation: Excision of wounds of entrance and exit. Resection of fractured ninth, tenth, and eleventh ribs. No lung injury recognized at operation. Closure of parietal defect. July 24, 1918: Rapid convalescence. Still some hemopneumothorax though disappearing. Evacuated in excellent condition. No further records. Disability (?). Immediate aspiration was probably7 employed but not recorded. Sub- sequent aspiration was indicated, possibly- primary drainage if the sucking wound was of more than a few hours' duration. 4. C. J. D. July 22, 191S: Shell fragments, multiple wounds, right jaw, neck, shoulder, and right chest, sucking, perforating. Wound of entrance in second interspace anteriorly. Moderate hemopneumothorax. Heart displaced to left. Duration (unknown). Condition good. Operation: Extrathoracic wounds excised and packed. AVound of entrance excised. Foreign body, thought to be in lung, not sought. Hemothorax aspirated. Parietal wound closed. July 24, 1918: Condition good although pleuritic exudate is not receding. Evacu- ated in good condition. August—, 1918: Phlebitis right leg. August 30, 1918: Returned to United States. February 0, 1919: Discharged from service. August 5, 1921: Disability attributable to leg alone. Vital capacity 87 per cent. Slight pleural thickening at right base. Heart competent. Foreign body in posterior chest wall. Another recovery attributable to good fortune. An undrained sucking wound causing no pyothorax. Quite probably this man's condition after excision of multiple wounds prohibited more radical intervention. 5. W. D. S. July 22, 1918: Bullet, perforating wound, left chest. Entrance fifth interspace, midclavicular line; lodgment in ninth interspace, close to vertebra. Moderate hemopneumothorax. Duration (unknown). Condition (?). Operation: Excision of wound of entrance. No rib injury. Opening into pleura closed. Incision over foreign body pos- teriorly. Foreign body removed. No rib injury. Hemothorax aspirated through defect in parietal pleura which was then closed. July 24, 1918: Easy convalescence. Evacuated in good condition. November 20, 1918: Returned to organization (Infantry). December 20, 1918: Readmitted to hospital because of trouble in knee, supposed to be synovitis. May 10, 1919: Discharged from service. Given a disability of but 10 per cent because of chronic synovitis; none because of chest injury. August 5, 1921: Synovitis proved to be due to sclerosis of pyramidal tract due to injury to spine. Heart and lungs quite normal. Vital capacity, 98 per cent. Without knowledge of man's condition at time of operation, or duration of wound, it is unwise to say that more radical treatment would have assured better repair. It could have secured none as a zero disability attests. 6. J. H. T. July 23, 1918: Shell fragment, penetrating, sucking wound, right chest. Entrance over scapula; compound fracture of scapula and three subjacent ribs. Small hemothorax. Duration (unknown). Condition fair. Operation: Excision of entrance wound; resection major portion of fractured scapula and ribs. Very large foreign body removed from pleural cavity. Hemothorax aspirated. No lung injury required repair. Closure of pleural defect with muscle flaps and subcutaneous fat. July 24, 1918: Superficial healing good Some pneumothorax persists. Uncomfortable but otherwise in excellent condition. Evacuated later much improved. 1921: Official record show disability less than 10 per cent. 410 SURGERY This recovery is another to be attributed to good fortune as the pleural cavity was much soiled because of a large sucking wound. Suitable drainage would have hastened recovery and made it the more certain. 7. M. D. July 27, 1918: Shell fragments; wounds of left neck and arm with pene- trating wound of left chest. Entrance over eighth rib near angle of scapula. Moderate-sized hemothorax. Duration (unknown). Condition (?). Operation: Excision of entrance wound. Fractured eighth rib resected. Inner table of rib found extending into pleural cavity. Hemothorax evacuated. No note on foreign body. Lung distended normally. Muscle closure of pleural defect. Layer closure of superficial structure; drained with gutta- percha. July 31, 1918: Excellent recovery. Pleuritic exudate slight and diminishing. Hemothorax here due to bleeding from rib. Left chest slightly hazy. Foreign body 0.5 by 0.5 cm. in lung. Diaphragm motion present; restricted on left. Evacuated in good condi- tion. Later returned to duty and then lost. Disability (estimated) 10 per cent. Removal of so small a foreign body from the lung is contraindicated. The case illustrated the wisdom of exploring all chest wounds. The rib injury would otherwise have escaped attention until late complications arose. This man would have benefited by- a day- or two of primary drainage or one postoperative aspiration. 8. L. E. July 28, 1918: Bullet, through-and-through, sucking wound, right chest. Entrance over right third rib, parasternal line. Exit over ninth rib below angle of scapula. Small hemothorax. Condition poor. Duration (unknown). Operation: Excision of en- trance and exit wounds. Fractures of fourth, fifth, sixth, seventh, eighth, and ninth ribs resected. Hemothorax evacuated. Splenized lung not resected because of patient's poor condition. Pleural defect closed with muscle. Death within 12 hours. No notes on necropsy. This man was lethally- injured by- the time he came to operation. Never- theless the splenized lung should have been resected, as allowing it to remain could at the best only postpone death. Earlier operation and multiple trans- fusions could have been effective. 9. M. S. September 26, 1918: Shell fragment, perforating right chest. Entrance right upper chest, anterior. Exit right lower chest, at level of tenth rib, posterior. Foreign body under skin near vertebra. Right hemothorax, moderate. Abdomen rigid, indicating possible injury to diaphragm. Duration 9t^ hours. Condition good. Opera- tion: Eight and a half hours later. Wound of entrance excised. No rib injury. Pleural defect closed by stitching inflated lung to margins and by muscle flaps superimposed exter- nally. Incision over foreign body which was removed and dark blood evacuated. Again no rib injury. Hemothorax aspirated through pleural defect. No lung injury found. Pleura closed with muscle. September 30, 1918: Condition good. Little pleuritic fluid evacuated. January 15, 1919: Returned to duty. Disability (estimated) 10 per cent. Growing experience led to more effective operations and attempts were made to expose lung injuries. Same fault of not using primary drainage is noteworthy. 10. S. F. S. September 26, 1918: Shell fragment, through-and-through, sucking wound; right chest. Entrance at eighth rib, posterior axillary line. Exit at third rib above scapula. Small hemothorax. Duration 14^ hours. Condition poor. Operation: Begun after six hours' treatment for shock. Entrance wound excised. No rib injury. Hemo- thorax aspirated. Pleural opening closed. Exit wound excised. Fractured rib resected. Chronic adhesive pleuritis prevented any exploration. Large intrapleural cavity drained. Incomplete layer closure. October 4, 1918: Has done fairly well except for persistent effusion in lower chest from which 1,300 c. c. of blood-stained fluid was aspirated. Culture GENERAL SURGERY 411 negative. Hereafter improvement was more rapid. Evacuated in good condition. Returned to duty in six months. Disability (estimated) 10 per cent. Recovery would have been hastened by earlier aspiration of pleuritic effusion, though primary drainage would have been still better. 11. M. S. September 26, 1918: Bullet, through-and-through wound, right chest. Entrance wound, anterior, at margin of rectus muscle; exit wound posteriorly over seventh rib. Small hemothorax. Splenization in right lower lobe suspected. Duration 10 hours. Condition fair. Operation: After six and a half hours' preparation. Entrance wound excised. No rib injury. Pleural opening and superficial wound closed. Exit wound excised. Fractured seventh rib resected. Hemothorax aspirated through this pleural opening. Lung injury not repaired. No splenization noted. Parietal pleura defect plugged with muscle. Wound closed in layers. No drainage. October 5, 1918: Wound healing good. Pneumothorax absorbed. Pleuritic effusion persists, but not aspirated. Pneumonia left upper lobe. October 6, 1918: 500 c. c. bloody fluid aspirated from right chest. October 7, 1918: Partial pneumothorax evacuated; condition fair. August 4, 1921: Xo treatment subsequent to evacuation. Suffers from dyspnea and cyanosis on exertion. Chronic bronchitis, peribronchitis, fibrous pleuritis; dome of diaphragm adherent to ninth rib; myocardial deficiency. Vital capacity, 57 per cent. Disability allowance of 10 per cent much too low; should be 40 per cent. This man's treatment w7as improper partly because of battle pressure. A more finished operation with suture of lung wounds should have been per- formed and with drainage and postoperative care w-ould have hastened recovery and reduced disability, notably in preventing recurrence of pneumothorax. An excellent example of the wisdom of exploring all through-and-through wounds to exclude or to remedy rib injuries. The occurrence of a contralateral pneumonia is noteworthy because so infrequent with positive pressure gas analgesia. 12. J. G. September 27, 1918: Bullet, through-and-through, sucking wound, left chest. Entrance at second rib, parasternal line; exit below and posterior to angle of scapula. Fluoroscopic diagnosis: Moderate hemothorax. Both lobes perforated; spleni- zation of lower part of upper lobe; heart displaced to right; no rib injuries recognized. Duration 12 hours. Condition poor. Operation: Nine hours later during which he was treated for shock. Wound of entrance excised. No rib damage. Closed without drainage. Exit wound excised; revealed sucking wound, fractures of sixth and seventh ribs, which were resected. Fragments of sixth rib had penetrated visceral pleura and were removed; 200 c. c. of fluid blood aspirated. Clots not removed and lung not repaired because of weak condition of patient. October 5, 1918: Stormy convalescence. Considerable effusion with pneumothorax. Evacuated in fair condition. No subsequent treatment. October ?, 1918: Returned to United States. January 23, 1919: Discharged from service. July 29, 1921: Underweight. Dyspnea on extra exertion. Pleuritic thickening base of left lung. Dome of left diaphragm adherent to sixth rib. Shallow7 pneumothorax cavity beneath seventh, eighth, and ninth ribs covered by thick scar. Lung parenchyma corresponding to injury and to pneumothorax cavity does not function. Myocardium fair. Vital capacity 90 per cent effected by compensatory emphysema. Disability allowance of 18 per cent is low7 because heart muscle is only competent at rest and has narrowed reserve power. This man's experience emphasizes important points. The folly of con- servatism in treating through-and-through wounds. These rib fractures untreated would have led to persistent pneumothorax. Under favorable circumstances open thoracotomy and radical treatment of lung defects would have been indicated. Splenization may not always cause death but by the resultant scar restricts pulmonary elasticity and causes disability. The 412 SURGERY persistent partial pneumothorax is an example of the permanent total pneu- mothorax that occurs wiien differential pressures are not employed. Mutable drainage would have corrected this fault. Neglect of breathing j;*™"^** through absence of all continued treatment increased the total ^ disability materially and perhaps prevented this man from returning to his pre-war occupation. 13. H. B. September 27, 1918: Shell fragment, penetrating left chest. Entrance wound second left interspace, parasternal line; small foreign body moves with respiration. Hemoptysis marked: hemothorax large; considerable pneumothorax. Duration 24 hours. Condition good. Operation: Two hours later. Wound of entrance excised. Fractured fourth rib at costochondral junction resected. 1,000 c. c. of blood and some clots removed. Wound of entrance into lung not found. Foreign body not sought. Closure without drainage. October 2, 1918: Rapid recovery. Pleuritic exudate slight. No pneumo- thorax. Evacuated. November 5, 1918: Returned to duty 39 days after injury. April 21, 1919: Discharged from service. No further treatment. August 20, 1921: Complains of pain in left chest and dyspnea with slight exertion. Chronic pneumonia left upper lobe. Chronic pleuritis left base. Adhesions between diaphragm and ninth rib restricts its motion Myocardium, subcompetent, Vital capacity 112 per cent, due to contralateral emphysema Foreign body present near base of lung. Disability 25 per cent, due to heart. This man's disability is due to scar tissue inside the lung and out. His prompt recovery indicates that the immediate treatment was adequate. The ultimate results show that proper postoperative care, including well system- atized exercises, would have brought such a recovery as would have permitted him to return to his original occupation of farming. Again and again the heavy- toll placed upon the wounded through failure to provide suitable after-care is exemplified. 14. E. McF. September 27, 1918: Bullet, through-and-through, sucking wound, right chest. Entrance, third rib anteriorly; exit, ninth rib posteriorly. Small hemothorax; large pneumothorax. Duration nine and a half hours. Condition grave. Resuscitation for 25 hours. Operation: Thirty-six hours after injury. Excision of wound of entrance and of exit in posterior axillary line. Compound comminuted fractures of fourth, fifth, sixth, seventh, eighth, and ninth ribs exposed and resected. Lung badly lacerated and splenized. Lacerations trimmed and sutured. Patient's condition -was thought to contraindicate resection of splenized lung. Hemothorax removed. Pleural defect closed with muscle flaps over incompletely expanded lung. September 29, 1918: Transfusion 400 c. c. citrated blood. October 5, 1918: Partial pneumothorax above pleuritic exudate. Four hundred c. c. serosanguinous fluid exudate aspirated. Cocci in clumps. October 8, 1918: Somewhat improved. October 21, 1918: Died. Double empyema and peritonitis. Shock prevented earlier operation and was thought to contraindicate resection of splenized lung. Obviously, resection should have been performed and with suitable drainage demanded by7 a sucking wound of this duration (36 hours) would have saved this life. 15. I. D. September 28, 1918: Shell fragment, 0.5 by 0.3 cm., penetrating, sucking wound, right chest. Entrance over spine of right scapula, thence through lung, diaphragm and liver to lodge in upper pole of right kidney. Large hemothorax. Duration eight hours. Condition poor. Resuscitation for seven hours. Operation: Fifteen hours after injury. Entrance wound excised. Comminuted fracture of tenth rib resected. Wound in lung insignificant and not repaired. Hemothorax aspirated and clots removed. Parietal defects closed with muscle flaps. No drainage. October 3, 1918: Had done well for a few days. Signs of bronchopneumonia developed yesterday in left lung and fluid in right chest increased. Foul-smelling fluid containing many bacteria aspirated from pocket near angle of right GENERAU SURGERY 413 scapula. Open drainage. October 4, 1918: Died (sixth day after operation). Necropsy: Open drainage had caused some collapse. A second encapsulated empyema had not been reached. Left lower lobe and lower part of left upper lobe almost solid with confluent patches of bronchopneumonia. Abdomen contained small amount of blood. No peritonitis. Another of the exceptional instances of bronchopneumonia after positive pressure analgesia. Otherwise this man might not have succumbed not- withstanding his poor condition. Should have been drained. 16. O. O. M. September 28, 1918: Shell fragments. Wounds of legs and head, and penetrating, sucking wound, left chest. Entrance over ninth rib below angle of scapula. Moderate hemothorax. Heart displaced to right. Foreign body in left lung. Duration 39 hours. Condition poor. Long journey, exposure and anemia. Resuscitation five hours. Operation: Forty-four hours after injury. Wounds in scalp and thigh excised Wound of entrance to chest excised. Fractured ninth rib resected. Hemothorax aspirated through defect in parietal pleura. Inflation of lung brought lacerations in left upper lobe into view which were bleeding profusely and so were sutured. Foreign body could be felt in lung but removal was not attempted as patient's condition was critical. October 18, 1918: Uneventful recovery. Diffuse pleuritis, left lung. No consolidation. Foreign body, 1.1 by 0.8 cm., present near hilum. Evacuated in good condition. December 28, 1918: Returned to duty (three months). No subsequent record. Disability (estimated) 10 per cent. This recovery when operation on a sucking wound had been delayed 44 hours illustrates the wisdom of denying none of the wounded the chance to live no matter what the operative mortality rate might be. It would have been wiser under the conditions to have employed primary drainage as the recovery without empyema was most fortunate under the conditions. 17. S. G. October 12, 1918: Bullet, through-and-through wound, left chest. Entrance at tip of left clavicle; exit at vertebral border of left scapula at level of its spine. Small hemothorax. Hemoptysis. Mustard gas burns, right side of face. Duration seven and a half hours. Condition good. Operation: Six hours later. Wounds of entrance and exit excised. Fracture of (?) rib resected. Muscle closed into pleural defect to protect exposed lacerated but adherent lung. Gutta-percha drain. October 14, 1918: Mustard gas burns on face much worse. Few rales noted in right chest. Slight left pleuritic effusion. Evacuated in good condition. Official records show death from bronchopneumonia (mustard gas) 25 day-s later. Chest disability would have been less than 10 per cent. 18. H. B. October 15, 1918: Bullet, through-and-through w-ound, left chest. En- trance over second rib anteriorly; exit over fourth rib posteriorly. Moderate hemothorax. Duration 16 hours. Condition poor. Operation: Entrance and exit wounds excised. Fractured second rib anteriorly and third and fourth ribs posteriorly resected. Hemothorax aspirated. No lung repair. Pleura closed with muscle flaps. October 16, 1918: Patient continues cyanotic. Tachycardia. No increase in pleural effusion. Died at noon. No necropsy. Death attributed to myocardial fatigue. Less extensive operation incompatible with recovery; more extensive not indicated. Digitalis before and after operation w-ith hypertonic glucose in- travenously- might have been effective. May be called a lethal injury. 19. J. C. October 15, 1918: Bullet, through-and-through wound, right chest. En- trance at inner end of clavicle; exit beneath spine of right scapula. Small hemothorax. Much bone damage. Condition grave. Duration 29 hours. Resuscitation 10 hours. Operation- Thirtv-nine hours after injury. Entrance wound ignored. Exit wound excised. Scapula turned forward. Comminuted fracture of scapula and one rib resected. Hemo- 414 SURGERY thorax aspirated. No lung injury repaired. Closure with superficial drainage. Stations changed. Learned of death but not its cause. No necropsy. Death attributed to shock. Another example of a simple injury made lethal by delay and exposure. 20. L. L. October 19, 1918: Shell fragments, multiple wounds; compound fracture right femur; penetrating right chest. Entrance eighth interspace posterior axillary line. Foreign body, 2 cm. by 2 cm., immobile in right upper chest, Small hemopneumothorax; heart displaced to left; middle and upper lobes involved. No hemoptysis. Duration 20 hours. Condition serious. Operation: Entrance wound excised. Fractured ninth and tenth ribs resected. Small hemothorax. Clots and fibrin removed. Hole in lung sutured. Foreign body not removed. Area of splenization not resected because of lack of space. Closure with superficial drain. Wound of thigh excised. Compound fracture of femur splinted. October 22, 1918: Pleuritic effusion increased and was aspirated. Broncho- pneumonia and pleurisy, both lobes of left lung. Death. Necropsy: Bronchopneumonia left upper and lower with fibrinous pleurisy. Right lower lobe contained a tunnel wound in which were bone fragments; widely splenized. Fibrinous pleurisy. Upper and middle lobes normal. This man's chance for recovery depended upon his chest repair. It would have been wiser here to have opened the chest widely, excised the lower lobe and neglected the thigh wound even if this meant ultimate sacrifice of leg. Another example of the serious import of splenization and of contralateral broncho- pneumonia. 21. R. H. November 2, 1918: Shell fragments, left wrist; through-and-through wound, right chest. Entrance wound upper anterior chest; exit, posterior. Small hemothorax. Superficial wound left wrist, Condition good. Duration 24 hours. Operation: Entrance wound excised. Lung adherent. Closure with muscle flap. Exit wound excised. Slight rib injury resected. Hemothorax aspirated. Closed without drainage. Wrist wound dressed. November 11, 1918. Easy convalescence in spite of right-sided pleurisy and return of partial pneumothorax. Evacuated. Could not be traced. A more radical operation at exit would have repaired lung injury, pre- vented recurrence of pneumothorax, and reduced the pleuritic effusion which should have been aspirated. Drainage would have been better. SUMMARY OF GROUP II The number treated by limited thoracotomy (21) was about 20 per cent of the series. The number w-ould have been larger had the unit had more of the less severely injured to treat and had the possibilities of such operations been appreciated. Fatalities.—There were eight deaths (40 per cent). One (17), slightly- wounded, died on the 25th day from bronchopneumonia due to mustard gas. His chest disability- would have been less than 10 per cent. Three (8, 18, 19) were lethally- affected at time of operation because of delay and exposure. One (18) died from myocardial exhaustion which had been incurred before injury. Three developed pyothorax (1, 14, 15). Two (1, 14) might well have re- covered had more radical surgical treatment and primary drainage been em- ployed. The third (15) had advanced contralateral pneumonia which possibly was traceable to failure to drain. One (20) suffered from other injuries, includ- ing a compound fracture of a thigh. Had the thigh wound been given less attention and the splenized portion of a lung resected, a recovery-, perhaps with amputation, w-as conceivable. Duration from injury to operation was GENERAL SURGERY 415 from 9 to 39 hours, average 23 hours. Mortality chargeable to surgical errors, too conservative treatment of injured lung, and faflure to drain is 15 per cent. Disahiliti.es.—Late disabdity ratings are dependably-established for 11 of the 13 who recovered. Two (4, 5) made complete recoveries. Two (2. 6) are rated at less than 10 per cent; five (7, 9, 10, 11, 16) at 10 per cent; one (2) at IS per cent, and one (13) at 25 per cent. Two (11,12) have unjustly- low- ratings. The disability of one (13) is due to cardiac incompetence. Two (3, 21) w-ere not estimated. The average disability- is probably not far from 10 per cent, but is set at 13 per cent to err on the safer side. The few- notes available showed from 39 to 180 days interval before return to duty, average about 100 days. Pleuritis is the cause of disability in all but the one (13) due to myocardial deficiency. An average disability- of even 13 per cent is gratifying when it be considered that some of these wounds were "suckers" and their duration about 24 hours, and also that none received proper postoperative care. The two who received unfairly low ratings had complications, one (11) had pneumonia and the other (12) a persistent pneumothorax and a lung scar resulting from splenization. It is again evident that a reduction of the interval between injury and operation would have reduced mortality- and disabdity- rates; the latter (13 per cent) would also have been favorably influenced by less conservatism in operating, a more general use of primary drainage and constant after-care. The duration of disabilities estimated at one hundred day-s upon the few notes at hand is higher than the truth and avoidably high. DEDUCTIONS Operations that can be classed as limited thoracotomies are applicable to those wounds that can not be safely treated bv parietal excisions and to those severely wounded who can tolerate but little more than parietal excisions. The same methods, especially positive pressure gas analgesia, are indicated. Limited thoracotomy gives opportunity to repair less significant lung injuries, to aspirate pneumothorax with a cannula instead of a needle and at times to remove clots. Its disadvantages are incomplete exposures and the conse- quently great dangers of overlooking lesions that should be repaired. Its advantages are shorter and less trying operations and less interference with parietal integrity. CONCLUSIONS The more severe the injury, the greater the necessity- for prompt inter- vention. Operations of the limited thoracotomy- type were employed too infrequently- and possibly- can be used more generally- and more effectively hereafter if the routine after care is improved so that postoperative complica- tions w-ould receive prompt recognition and correction. During periods of active fighting many of the wounded w-ho might be well served bv limited thoracotomy- could be transported to evacuation hospitals for first treatment. A great danger lies in too conservative operating upon lung wounds. The objection to limited thoracotomy is its ease and rapidity- of per- 4C997—27----20 416 SURGERY formance and apparent safety wiien real conservatism would be a more radical operation. The need for preoperative resuscitation of those in shock and the prevention of postoperative shock becomes more and more evident. Gum acacia proved of value when properly- used and was a source of danger when improperly used, wliich was the rule. Hypertonic glucose and other solutions may be of more benefit than gum and should be provided. The most help comes from 1)1 ood transfusions. Larger amounts of blood should be made available. GROUP III. THORACOTOMY OF NECESSITY 1. A. B. July 21, 1918. Shell fragment, large, freely bleeding, sucking, tangential wound, left chest. Entrance at fifth interspace, midclavicular line. Tissue emphysema. Large pneumothorax. Small hemothorax. Condition poor. Duration unknown. Operation: Lacerated soft parts excised; broken ribs resected. Lung wounds repaired. Flap closure. Death in 12 hours. Necropsy: Slight hemothorax. Lung repair and parietal closures ade- quate and apparently secure. Multiple transfusions might have prevented this death. 2. H. K. July 27, 1918: Shell fragments; penetrating and through-and-through suck- ing wounds both chests. Main wound entrance seventh rib, right scapular line; exit seventh rib, left scapular line. Bilateral hemopneumothorax, right larger. Condition (,?,). Duration unknown. Operation: Entrance wound excised, exposing sucking wound. Frac- tured seventh rib resected. Crater defect in lung contained [bone fragments. Fragments removed, bleeding controlled, lung approximated over defect but incompletely as man's con- dition contraindicated wider exposure. Pleural defect closed with aid of wire rib stay. Superficial wound drained. Wound of exit excised. No rib damage. July 31, 1918: Good recovery. Postoperative tissue emphysema showed that repair of lung wound had not been airtight. Left side, effusion absorbed. Right side, effusion is increasing. August 1, 1918: Spontaneous discharge of serum from right side. Partial pneumothorax. Evacuated in good condition. February 1, 1919: Returned to duty in 180 days. Disability 10 per cent. Slightly wider exposure, more accurate closure of lung wound, right-sided drainage and aspiration of left chest would have been wiser. 3. V. I. P. July 27, 1918: Shell fragment, through-and-through, sucking wound, left chest. Entrance over 6th rib lateral to midclavicular line; exit ninth rib, poste- rior axillary line. Moderate hemothorax; heart displaced to right. Splenized lung seen fluoroscopically. Condition (?). Duration 30 hours. Operation: Entrance and exit wounds excised; fractured eighth and ninth ribs resected. Splenized lung excised. Pleural closure effected with wire rib stay. Layer closure. Superficial drain. July 31, 1918: Fluid in left chest receding. Patient sitting upright. Evacuated. Condition good. August 15, 1918: Pneumonia, left side, followed by empyema and treated with rib resection. Drainage tract closed spontaneously. February 8, 1919: Discharged from Army. July 21, 1921: Under- weight, languid, dyspneic. Scoliosis, reduced expansion, left chest; chronic pleuritis, limited motion and adhesions of diaphragm. Vital capacity 78 per cent. Disability 40 per cent (estimated). Pneumonia caused by compressed lung because of effusion. Drainage w-ould have lessened, had it not prevented this complication. 4. T. B. B. July 28, 1918: Shell fragment, through-and-through wound, left chest. Entrance seventh interspace anterior axillary line; exit tenth rib posterior axillary line. Condition (?). Duration unknown. Operation: Wounds excised; fractured ninth and tenth ribs resected; lacerated and splenized portions of lower lobe resected. Two tears in diaphragm sutured. Wound in liver not treated. Pleural closure incomplete even with GENERAL. SURGERY 417 rib stay so reenforced with muscle. July 31, 1918: Slight effusion; no pneumothorax. Motion of diaphragm reduced. Evacuated. July 30, 1921: Pain and dvspnea on extra exertion. Chronic pleuritis at left base with adhesions between dome of diaphragm and eighth rib. Excursions of diaphragm restricted. Wire rib stav has parted. Vital capacity 90 per cent. Heart competence slightly reduced. Disability rating of 35 per cent is too high. Wire stay should have been removed. Primary drainage and postoperative exercises would have reduced disability. 5. M. D. August 1, 1918: Shell fragment, penetrating right chest. Entrance wound ninth rib, paravertebral line. Foreign body, two cm. by three cm., in lung, which is cloudy. Moderate hemothorax; heart slightly displaced; diaphragm immobile. Condition good. Duration (?). Operation: Entrance wound excised; ninth rib, fractured just anterior to its angle, resected; hemothorax evacuated; foreign body removed from posterior aspect lower lobe. Lung wounds sutured. Pleura closed after ribs were approximated with wire stay. Layer closure of soft parts. No drain. July 21, 1918: Effusion to level of angle of scapula. Good condition. Healing satisfactorily. Subsequently evacuated in good condition. No further treatment. January 31, 1921: Discharged from service. August 19, 1921: Slight pain and dyspnea on exertion. Fibrous pleuritis at right base. Diaphragm adherent to eighth rib and excursions reduced. Heart competent. Wire rib stay broken. Vital capacity 81 per cent. Disability of zero is too low. Wire rib stay should have been removed. Aspiration, or better still drainage, w-ould have reduced pleuritis. Lack of proper exercises prevented a perfect recovery. 6. M. P. August 1, 1918: Shell fragments, multiple, penetrating, sucking wounds, right chest, liver and colon. Entrance chest, ninth rib, anterior. Condition poor. Dura- tion 10 hours. Operation: Resection compound fracture ninth rib. Multiple lung wounds, liver and colon. Wounds sutured as rapidly as possible because of man's condition. August 2, 1918: Died. Necropsy: Hemothorax right, splenization of middle lobe, collapse of lower lobe. Wound repair adequate. Lethal injury at time of operation. 7. A. H. B. August 1, 1918: Shell fragment, left scapula, sucking, penetrating wound, chest. Bullet wound, right shoulder, penetrating. Foreign body, 1.5 cm. by 3 cm. in left upper thorax. Chest hazy; diaphragm fixed. Condition desperate. Duration 12 hours. Operation: Excision entrance wound; resection left scapula and fractured fourth rib. Excision and suture of bleeding wound in upper lobe. Foreign body removed. Rib stay and muscle flap closure. Bullet wound ignored as patient had been carried this far with two gum-salt infusions. August 2, 1918: Slightly better. Blood transfusion. Fluid up to angle of scapula. Slight pneumothorax. August 3, 191S: Condition about the same. Unit moved to another station. August 5, 1918: Died. No notes. No necropsy. Severely wounded man in shock. Death probably- due to pyothorax. Should have had primary drainage and blood transfusions before operation. 8. E. K. August 8, 1918: Shell fragments, right wrist, superficial, and through- and-through, sucking wound, right chest. Entrance just to right of spine above angle of scapula. Tissue emphysema here. Exit at second rib midclavicular line. Right chest hazy. Condition poor. Weather hot, water scarce, troops fatigued. Duration 12 hours. Operation: Entrance wound excised. Compound fracture eighth rib resected. Lung adherent, lacerated and contains many bone fragments, resected and repaired as well as exposure and adhesions permitted. This area was drained as there was no connection with pleural cavity. Exit wound excised; fractured second rib resected. This tract also drained for same reason. August 15, 1918: Pyothorax and septicemia caused death. Aspirations, open drainage, and transfusions were futile. Xo necropsy. 418 SURGERY This man was operated upon during a pestilence of flies that could not be kept off dressings or out of wounds; doubtful if it would have been possible to avoid this death. 9. J. F. C. August 8, 1918: Shell fragments, through-and-through wound, right arm and right chest. Notes few and vague. Entrance at angle of tenth rib; exit, anterior aspect of chest, Condition (?). Duration 55 hours. Operation: Entrance wound excised; fractured tenth rib resected. Large hemothorax and many clots removed. Lung sutured. Pleural defect repaired bv stitching diaphragm to margins. Anterior entrance wound excised; rib not injured. Tear in lung not found. Wire rib stay used to obtain closure of pleural defect. Wound in arm excised and packed with gauze. August 17, 1918: Slight effusion persists. Evacuated in good condition. August 17, 1921: Notes by Doctor Byrne. "No parenchymatous lesions; dome of diaphragm adherent to seventh rib is flattened." Disability, vital capacity and myocardial competence unknown. Disability (?). This patient illustrated the need of breathing exercises to reactivate a diaphragm, particularly after it has been sutured to the parietes. An ex- cellent example of the wisdom, accepting all risks with faintest chance for recovery. Without operation this man's life expectancy would have been zero. 10. W. B. August 8, 1918: Shell fragment, large, penetrating, sucking wound, left chest. Entrance ninth rib, costochondral juncture. Condition good. Duration un- known. Operation: Wound excised; fractured ninth rib resected. Foreign body, found on diaphragm which was lacerated, w7as removed. Diaphragm sutured. Hemothorax and clots removed. Lung and diaphragm sutured. Closure with wire rib stay. August 17, 1918: Uncomfortable convalescence. Slight pneumothorax. Pleuritic effusion moderate and not aspirated. Suppuration occurred but did not cause pyothorax because the repair of parietal pleura had been adequate. Evacuated in good condition. February 13, 1919: Discharged from service having had otitis media which caused deafness. August (?), 1920: Wire rib stay removed. August 31, 1921: Some pain. No dyspnea. Underweight. Chronic pleuritis left base; diaphragm adherent to parietes. Reduced myocardial reserve power. Disability, 38 per cent, not all due to chest. Vital capacity, 78 per cent. Dis- ability, 15 per cent, due to chest, is liberal. Wire rib stay- should have been removed earlier. Excellent example of obtaining firm parietal pleural healing to prevent pyothorax. Aspiration and breathing exercises would have limited disability. 11. G. F. August 8, 1918: Shell fragment, perforating left chest. Entrance below middle of left clavicle; exit into soft parts beneath scapula. Condition poor. Duration six hours. Operation: Wounds excised; fractured ribs (second, third, and fourth) resected. Laceration and splenization left upper lobe. Laceration repaired; splenized lung not resected. Hemothorax aspirated. Pleural defect closed with muscle flaps. Posterior wound drained after removal of foreign body. Returned to shock ward with pulmonary edema. No re- sponse to treatment. Death in 16 hours. Necropsy: Pulmonary edema, hypostatic con- gestion both lungs. Dilatation, right heart. Splenization left upper lobe. Suture line intact. This patient might have been saved, probably would, had he been wounded later when experience was larger. He would have been better prepared for operation. Splenized lung should have been resected. Too high positive pressures were used in a futile attempt to re-inflate lung. Abruptly increased peripheral resistance added to that already- present sufficed to cause dilatation of right heart and thus to provoke pulmonary- edema. 12. German soldier. August 8, 1918: Shell fragment, seton wound over anterolateral aspect sixth rib, left. Condition poor. Duration 56 hours. Operation: Wound excised. GENERAL SURGERY 419 Fractured sixth rib resected. Lower one-half of upper lobe and most of lower lobe splenized. Fibrinous exudate on visceral pleura. Pleural cavity contained thin, red fluid (streptococ- cus?). Pericardium used to assist closure of pleural defect. Death soon after operation. No necropsy. Illustrates severe types of splenization caused by tangential injury without laceration of lung. Also shows the greater reactability- of visceral pleura upon which the fibrinous exudate had been formed. It is doubtful if prompt opera- tion could have prevented a fatal issue because removal of almost all of the left lung would have been necessary. 13. M.S. August 9, 1918: Shell fragment, penetrating wound, left chest. Wound of entrance over sixth costal cartilage at sternal articulation. Moderate hemopneumothorax. Condition (?). Duration four hours. Operation: Wound of entrance excised. Margin of sternum and sixth costal cartilage resected. Hemothorax evacuated. Foreign body re- moved. No notes on lung injury and repair. Lung completely inflated. Closure difficult because of a defect close to sternum. August 16, 1918: Interstitial emphysema about wound and reappearance of pneumothorax showed that pleural closure had been inadequate. Moder- ate pleuritic exudate. By this time, emphysema, pneumothorax and effusion all were less. Excellent general condition. January 4, 1919: No further operative treatment; indeed, none of any kind. Discharged from service. Disability 80 per cent. August 17, 1921: Tachy- cardia and dyspnea follow slight exertion. Frequent pain referred to lower left chest. Dome of left diaphragm adherent to parietes. Chronic pleuritis left base. Cardiac response to exercise poor. Left heart enlarged. Vital capacity, 55 per cent. Disability due in part to myocardial incompetence which in part is attrib- utable to intrathoracic lesions. Rating of 80 per cent is too high. Aspiration after operation and suitable care w-ould have hastened convalescence and reduced disability. 14. E. K. K. August 11, 1918: Shell fragment, perforating wound, left chest. Entrance second interspace just lateral to sternum. Exit through scapula to lodge in in- fraspinatus muscle. Condition poor. Duration five hours. Operation: Excision entrance wound; resection second costal cartilage and part of second rib. Hemothorax aspirated; clots removed. Lung drawn out and perforation sutured. Lung sutured to close defect in parietal pleura which could not be approximated even with two wire rib stays. Foreign body removed from infraspinatus muscle. No attempt made to open chest posteriorly, as no rib injury was present and patient's condition was poor. Despite blood transfusions and infusions, patient died within 12 hours. Necropsy: Moderate splenization left upper lobe. Posterior perfora- tion not closed. Hypostatic congestion right lung. Extent and duration of anatomic injuries and severity of operation do not explain death, which must be attributed to general and myocardial exhaustion previous to injury. Splenization should have been noted at operation. 15 W S. August 12, 1918: Shell fragment, penetrating wound, right chest. Entrance sixth interspace anterolateral aspect. Condition good. Duration four hours. Operation: Wound excised; ninth and tenth ribs, fractured in posterior axillary line, resected. Tangential wound of lung. Moderate splenization. Hemothorax evacuated. Resection and suture of lung. Pleural closure obtained with two wire rib stays. Layer closure of soft parts No drainage. August 17, 1918: Limited pleuritic effusion. Condition excellent. November —, 1918: Returned to duty. Disability less than 10 per cent. Vspiration should have been performed. Wire rib stays should have been removed. ' Despite errors and omissions in treatment, the man is reported to have participated in active fighting again. 16 P F M Vugust 17, 1918: Shell fragments (three), penetrating wounds, right chest. No' notes on condition or duration. Condition probably unsatisfactory, as was 420 STRGERY the rule with the wounded from this division. Moreover, the hospital facilities were wretched. For example, when this man was treated the electrical plant was not working. There was no X ray; no current for headlight. Operation: Wound of entrance over tenth rib in midaxillary line excised; fractured rib resected; pleural cavity opened widely and hemothorax evacuated. Injuries to lung not severe. Two small foreign bodies not re- moved. One perforating wound of diaphragm and penetrating wound of liver. Explora- tion failed to locate foreign body. Tract in liver packed with gauze which was brought out through laceration in diaphragm. The diaphragm wras then sutured to parietal pleura for partial closure and to protect pleural cavity from bile. Operation unsatisfactory because of no headlight. Balance of closure secured with aid of a wire rib stay. August 20, 191s: Condition excellent. Slight pleuritic exudate. Evacuated shortly. February 28, 1919: Passed through several hospitals in France. No further surgical treatment until to-day when wire rib stay was removed. April 29, 1919: Because of persistent pain two shell fragments were removed from lung. September IS, 1919: Pain still persists. Foreign body removed from liver. August 4, 1921: Pain in lowrer right chest; dyspnea on exertion; hemoptysis at intervals. Parietes affected by scar and removal of two ribs, one additional rib and part of scar from futile removal of foreign bodies. Restricted expansion of right lower chest; restricted motion of right diaphragm; chronic adhesive pleuritis. Heart competent. Vital capacity, 66 per cent. Disability of 35 per cent is fair. Foreign bodies might better have been removed at first operation, although they did no harm. Wire rib stay should have been removed in a few weeks. Subsequent care would have reduced disabilities. It is noteworthy that removal of foreign bodies did not relieve pain, introduced hemoptysis, and increased disability. 17. J. T. A. September 12, 1918: Shell fragment, sucking, tangential wound, left chest; entrance fourth interspace, left midaxillary line; exit ninth interspace, mid- scapular line. Moderate hemopneumothorax; tissue emphysema; heart displaced to right; left diaphragm motionless. Condition poor. Duration five hours. Operation three hours later: Wounds of entrance and exit excised and united. Fractured eighth and ninth ribs resected. Multiple tears in parietal pleura. Wound of entrance in upper lobe not exposed. Wound of exit, lacerated and contained many bone fragments, was resected and repaired. Hemothorax removed. Closure obtained with one wire stay; suturing lung to parietes was unsatisfactory and assured subsequent emphysema. Superficial closure also incomplete. Shock prevented exact methods. September 21, 1918: Recovery in spite of complications. Interstitial emphysema developed, followed, as it commonly is, by sup- puration, and finally an open pyothorax. Evacuated in fair condition. February 18, 1919: Suppuration continued. Ribs resected and wire stay removed. July 7, 1920: Hospitalized for three months because of suspected, but not proved, pulmonary tuberculosis. August 11,1921: Underw-eight; frail; pain and disability upon exertion. Parietal scars and defects limit expansion of lower left chest. Pericardium adherent to diaphragm and diaphragm to parietes; pleural thickening. Heart competent. Vital capacity, 106 per cent. Disability rating of 75 per cent is higher than findings warrant. A more finished operation should have been performed to secure better healing. Drainage could have been employed to reduce dangers of pyothorax. This patient illustrates the harm coming from provisional suturing of sucking wounds. His after-care was not satisfactory. 18. F. F. September 12, 1918: Shell fragment, perforating wound, left chest. Entrance posterior axillary fold at level of angle of scapula. Foreign bodv, .4 cm. by 1 cm., in erector spinse muscles. Condition (?). Duration six hours. Operation: Entrance w7ound excised. Fractured ninth rib resected. Hemothorax evacuated. No lung injury seen. Second incision posteriorly over shell fragment failed to discover the foreign body but revealed more serious rib injuries. A third incision made lateral to the second. Rib fractures resected; pleura opened, revealing tangential injury in lung containing bone frag- ments. Fragments removed; lung resected and sutured; more blood and many large clots GENERAL SURGERY 421 removed. Closure obtained with one rib stay. September 21, 1918: Some pneumothorax persisted. Slight pleuritic effusion absorbed after aspiration of 75 c. c. sterile bloody fluid. Temperature varied from 99° to 102° in spite of smooth healing; 97° on evacuation. 1921: Records show disability less than 10 per cent. Another illustration of the more serious injury occurring at exit wound and of the wisdom of thorough exploration of all possible parietal injuries. Had the posterior wound been neglected, pyothorax and possibly death would have occurred. The wire rib stay should have been removed. 19. J. R. September 12, 1918: Shell fragment, penetrating wound, left chest; entrance lateral to spine at level of tenth rib. Foreign body in lung (3.5 cm. by 3.5 cm.). Considerable hemothorax. Shock treatment. Duration unknown. Operation: Entrance wound excised. Fractured ribs resected. Entrance wound into lung not found. Foreign body not removed because patient's condition was critical. Large hemothorax evacuated. Closure with wire stay unsatisfactory. Prognosis for healing, poor. Shock treatment. September 21, 1918: Stormy convalescence. Superficial suppuration but no open pyothorax. Pneumothorax with pleuritic effusion; 600 c. c. serosanguinous fluid aspirated and superficial drainage instituted. Convalescent four months. Final records not available. Estimated disability 15 per cent. Attempt should have been made to repair entrance wound into lung. Primary drainage should have hastened recovery. 20. H. W. September 12, 191s: Shell fragments, multiple wounds, viz, compound fracture upper third, right tibia, foreign bodies in knee, calf and thigh; sucking wound, left chest. Entrance at eighth rib, anterior axillary line; foreign bodies in upper left chest and below dome of diaphragm, thought to be in lung tissue. Hemoptysis and hematemesis. Condition so critical that thorough examination was impossible. Shock treatment for eight hours before operation. Duration (?). Operation: Wounds in extremities excised and foreign bodies removed. Entrance wound into chest excised. Fractured eighth rib resected. Foreign body not found. Search for perforation in diaphragm unsuccessful. Large hemothorax evacuated. Closure with one wire stay. Transfused. September 13, 1918: Condition continued fair until sudden weakening at noon. Transfusions unavailing. Died at 2.30 p. m. Necropsy: Peritonitis, lesser cavity, hemoperitoneum, through and through wounds of spleen and stomach. Chronic nephritis. This patient's condition was so critical that preoperative examinations were restricted. Intra-abdominal injuries were suspected but a laparotomy was impossible. His one chance was that he could take care of his peritoneal wounds spontaneously. His injuries were lethal when he reached the hospital. 21. H. B. (German soldier). September 13, 1918: Shell fragment, perforating wound, right chest. Entrance, ninth rib posteriorly; foreign body beneath right clavicle. Condition fair. Duration 15j^ hours. Operation: Entrance wound excised. Fractured ninth rib resected. Upper lobe adherent, previous pleurisy. Lower lobe, craterlike defect, excised and sutured. Hemothorax evacuated. Wire rib stay. Inflated lung sutured into parietal pleural defect. Foreign body removed from beneath clavicle. No rib injury. Closure without drainage. September 21, 1918: Evacuated; condition excellent. Disa- bility estimated at 10 per cent. 22. M. R. S. September 17, 1918: Bullet, through-and-through wound, right chest. Entrance just below angle of scapula; exit just above nipple, both sucking. Slight hemothorax. Condition good. Duration unknown. Operation: Entrance wound excised. Ninth rib, incompletely fractured, resected. Large laceration, lower lobe, resected and repaired. ' Hemothorax evacuated. Pleural repair incomplete. Lung sutured into defect. Wound of exit excised. No rib injury. Lung wound closed with purse-string suture and sewed into parietal defect, September 20, 1918: Condition remarkably good. Healing excellent. 1921: Records show disability of less than 10 per cent. 422 SURGERY Treatment given to this man w-as effective except for postoperative exer- cises. Another example of the value of exploring all through-and-through bullet wounds even though the wounded are in splendid condition. 23. O. B. (German soldier). September 13, 1918: Shell fragment, through-and- through wound, left chest. Entrance below outer third of clavicle; exit below angle of scapula. Condition (?). Duration unknown. Operation: Excision of entrance and exit wounds revealed fractures of second, third, fourth, fifth, sixth, seventh, and eighth ribs in axillary line. Resected ribs exposed deep gutter wound in left upper lobe which was adherent and made lung resection and repair difficult. Large hematoma evacuated from beneath pectoralis major muscle. Plastic closure. September 20, 1918: This man's recovery was remarkable. None others survived such severe multiple rib injuries. Another example of the wisdom of operating despite unfavorable prognosis. 24. H. D. B. September 26, 1918: Shell fragments, through-and-through wound, left thigh, and penetrating wound, right chest. Foreign body, 8 cm. by 10 cm., beneath lower sternum. Entrance posteriorly over twelfth rib. Condition (?). Duration five hours. Operation two hours after admission: Through-and-through wound left thigh excised and drained. Large entrance wound of chest excised. Fractured eleventh and twelfth ribs resected. Foreign body had lacerated diaphragm and liver and lodged in diaphragm beneath sternum. No lung injury. Bile in pleural cavity. Large hemothorax removed, likewise foreign body. Wounds in diaphragm sutured. Drain inserted between liver and diaphragm and diaphragm sutured to parietal pleura to aid in closure and to exclude drain from pleural cavity. October 8, 1918: Satisfactory convalescence. Slight pleuritic effusion. Suppuration in superficial wound but no open pyothorax. Disabled for six months. Ultimate disability less than 10 per cent (estimated). Delayed recovery due to lack of proper exercise. Primary drainage indicated because of bile in pleural cavity and tendency to cause empyema. 25. C. P. F. September 26, 1918: Shell fragments, through-and-through wounds, left arm near axilla, and left chest. Entrance, seventh interspace, midaxillary line; exit, tenth interspace midscapular line. Paresis of flexors of first finger. Moderate hemopneumothorax. Heart displaced to right. Condition poor. Resuscitation 63^ hours. Duration 11 hours. Operation: Excision wound in upper arm; suture of injured nerve trunk. Wounds of entrance and exit excised and joined. Fractured tenth rib resected. Lacerations in lower lobe and in diaphragm repaired. Parietal closure without drainage. September 29, 1918: Condition and healing satisfactory. July 28, 1921: Duly severe symptoms referable to arm. Slight fibrous pleuritis, left base; diaphragm free. Vital capacity 97 per cent. Disability (chest) zero. Operation not only protected this man from death, but initiated a perfect recovery. Illustrates advantage of exploring all wounds and giving deep injuries proper treatment. Thoracotomy, even w-hen patients are in poor condi- tion, can be less dangerous than hemothorax. 26. W. S. September 26, 1918: Bullet, penetrating left chest; entrance, third interspace, parasternal line. Bullet beneath sternum moves with respiration, but not with heart beat. No hemoptysis. No hemothorax. Friction rub audible over precordium. Mediastinal emphysema (?); hemopericardium (?); pulse slow but irregular. Condition fair. Duration five hours. Operation six and one half hours later: Entrance wound excised. Bullet found with its nose penetrating the wall of a serous cavity, probably pericardial. Bullet removed and hole closed with suture. Path of bullet extrapleural. Wound closed tight. September 29, 1918: Signs and symptoms cleared since operation. Healing excellent. 1921: Disability less than 10 per cent. Kemoval of this foreign body was required. Kesult shows methods were good. 27. M. J. T. September 29, 1918: Bullet, through-and-through, sucking wound, right chest. Entrance, ninth rib, posterior axillary line; exit, slightly lower in anterior axillary GENERAL. SURGERY 423 line. Both plugged with gauze. Hemoptysis. Moderate hemopneumothorax. Resuscitation for four hours. Duration nine hours. Operation: Entrance and exit wounds excised and joined. Portion of ninth rib, found dangling into pleural cavity, removed, and ends of ninth rib resected. Gutter wound in lung excised and sutured. Lung could not be entirely rein- flated, so stitched to parietes. Large hemothorax evacuated. Closure unsatisfactory. Patient's condition prevented a finished operation. Given 700 c. c. of gum salt solution on operating table. October 18, 1918: Complicated convalescence ending in open pyothorax. December 1, 1918: Drainage ceased. No further operations. July 29, 1921: Suffers from pain and dyspnea on moderate exertion. Chronic pleuritis. Diaphragm attached high to parietes. Myocardial competence slightly impaired. Vital capacity, 77 per cent. Disability allowance of 20 per cent is low. Partial inflation of lung at operation indicated need of one-way- drainage, as it suggested probable empyema. Even this imperfect operation, made possible by exploration, contributed to recovery as it eliminated bone fragments and osteomyelitis of ribs as a complication of empyema. 28. C. H. September 26, 1918: Bullet, perforating wound, right chest. Entrance close to spine at level of angle of scapula; exit from chest at second rib to lodge be- neath the skin. Small hemothorax. Condition poor. Duration 14J^ hours. Operation: Sixteen hours later; delay for resuscitation. Wound of entrance excised. Incision made to remove foreign body. Wounds united. Fractured second, third, fourth, fifth, and sixth ribs resected. Parietal pleura lacerated; visceral pleura intact. Hemothorax (1,500 c. c.) removed. Airtight pleural repair. Wound closed without drainage. October 2, 1918: Rapid recovery. Healing smooth. August 19, 1921: No treatment subsequent to operation. Pain with sudden exertion. Overweight. Myocardium competent. Restricted parietal mobility due to malunion of fractured ribs. Vital capacity 87 per cent. Disability of 20 per cent is high. No better results obtainable without after-care. Removal of rib fragments and immediate reinflation protected this man against empyema and pulmonary compression. 29. T. E. L. September 26, 1918: Bullet, through-and-through wound, right chest. Entrance at level of twelfth rib posteriorly; exit at fifth interspace, anterior axillary line. Moderate hemothorax. Paralysis of right diaphragm. Hematuria. Condition fair. Dura- tion nine hours. Operation four hours later: Entrance wound excised; incision carried along twelfth rib, which was fractured and was resected. Kidney delivered. Subcapsular clots removed and large transverse tear repaired. Laceration in liver drained and in dia- phragm sutured. Hemothorax evacuated. Puncture wound of lung not repaired. Parietal pleura closed. Exit wound excised; no rib injury found. Closed tight. October 18, 1918: Good recovery. Slight amount of pleuritic effusion. Free drainage of urine and bile, but temporary. Evacuated in good condition. Later suffered from influenza. July 30, 1921: Complains of pain and weakness in right chest, Some fibrosis of lower lobe of lung. Dia- phragm but little affected. Pronounced scoliosis. Vital capacity 92 per cent. Disability rating 100 per cent is ridiculously high. Needs only vocational training to be self-supporting. Suitable postoperative care would have reduced this man's disability and enabled him to enter a profitable occupation. 30. J. A. September 27, 191S: Bullet, perforating, sucking wound, right chest. En- trance over eleventh rib, midscapular line; exit through diaphragm into liver. Large hemothorax. Condition fair. Duration 14 hours. Operation: Twelve hours later: En- trance wound excised; fractured twelfth rib resected. Perforations in lower lobe, diaphragm and liver repaired. Foreign body not found. Hemothorax, bile-stained, evacuated. Clos- ure unsatisfactory. October 3, 1918: Residual pneumothorax absorbed. Slight pleuritic exudate.' Condition good. July 29, 1921: Suffered from influenza before leaving France. Otherwise recovery without complications or after-care. Complains of pain in right chest 424 SURGERY and is easily fatigued. Cardiac competence is fair. Fibrous pleuritis at right base. Dia- phragmatic excursions limited by adhesions. Disability of 20 per cent is adequate. Recovery by good fortune. Bile in pleural cavity usually- produces an intense reaction and needs primary- drainage. 31. C. C. September 26, 1918: Bullet, penetrating, sucking wound, right chest. Entrance, sixth interspace, midaxillary line, lodgment back of heart. Condition wretched. Blood pressure 68/50. Duration 9t^ hours. Resuscitation treatment, pressures raised in 3 hours to 90/65. Operation: Eleven hours later: Entrance wound excised; fractured sixth rib resected. Three holes in lung repaired; fourth could not be reached. Bullet removed from behind heart. Difficulty in checking hemorrhage from azvgos vein. Large, clotted hemothorax removed. Tight closure obtained. Gum salt given at close of opera- tion. October 10, 1918: Developed contralateral pneumonia after operation. Empyema developed; wound opened revealing a bronchial fistula, the probable cause of empyema and possibly attributable to unclosed perforation. Death fourteenth day. No necropsy. Man's condition thought to be too precarious to justify opening chest widely enough to repair fourth perforation. This might have saved life. So far as known this is the only bronchial fistula that occurred. This is an excel- lent example of resuscitation. 32. G. S. (German soldier). September 27, 1918: Shell fragment, sucking, pene- trating wound, right chest. Entrance over tenth rib anterior axillary line. Foreign body three cm. by three cm. lodged in liver. Large pneumohemothorax. Condition (?). Duration 25 hours. Operation 5 hours later: Entrance wound excised; fractured rib resected. Hemothorax removed. Two holes in lower right lobe sutured. Foreign body removed from liver; hole in diaphragm sutured. Wound closed without wire rib stay. September 30, 1918: Aspirated; no fluid obtained. October 6, 1918: Wound ruptured; seropurulent fluid escaped. Tube inserted; end covered with gutta-percha valve. October 18, 1918: Evacuated in good condition. Lung expansion excellent. Sucking w-ound, 30 hours old; bile in pleural cavity-; all indicated primary- drainage. Rupture of incision from within of wound closed without rib stay- indicates the value of that suture. 33. M. L. September 28, 1918: Bullet, through-and-through wound, right chest. Entrance, third rib, parasternal line; exit, costal margin, anterior axillary line from which bile was escaping. Condition poor. Duration 38 hours. Operation: Entrance wound ignored. Fractured sixth, seventh, and eighth ribs resected. Hemothorax evacu- ated. Holes in lung and diaphragm sutured. Drainage to liver wound. No notes on convalescence or at discharge. January 7, 1919: Small amount of fluid aspirated. August 28, 1921: Pain and dyspnea only after sharp exertion. Fibrous pleurisy. Diaphragm fixed. Costophrenic sulcus obliterated. Disability 20 per cent. Vital capacity 71 per cent. This man's condition prevented complete operation. Had primary drain- age been used with proper after care disability would have been less. Aspi- rated second day, y7et fluid was withdrawn four months later. An example of slow absorption of effusions as well as the wisdom of operating even if there has been delay. 34. S. D. September 28, 1918: Bullet, through-and-through wound, left shoulder and chest. Entrance just to left of vertebra; exit, high in axilla. Condition very poor. Duration 23 hours. Operation: Seven hours later. Wounds excised; fractured second and third ribs resected. Laceration in lung repaired. Large hemothorax evacuated. Closure. Blood transfusion. Died in one hour. GENERAL SURGERY 425 Earlier operation w-ould have been effective. Other risks quite as for- bidding had recovered. 35. H. H. September 28,1918: Bullet, through-and-through, both wounds sucking, left chest. Condition poor. Duration 36 hours. Operation: Resection sixth, seventh, and eighth ribs. Excision of splenized lung; suture of hole in pericardium; repair of laceration in diaphragm; evacuation of hemothorax. Closure. Five hundred c. c. gum salt for shock. Death in two hours. Necropsy: Small amount of blood in pericardium. Left lung partially collapsed. Splenization incompletely removed. (Exposure inadequate at operation.) This man's death due to delay- and exposure, as he could have been saved with early operation. Another example of the necessity to secure adequate exposure. 36. F. McC. September 29, 1918: Shell fragment, through-and-through, sucking wound, right chest. Entrance below sixth rib, anterior axillary line; exit over eleventh rib below scapula. Condition bad—cold and shocked. Duration 10 hours. Operation: Three hours later. Entrance wound not treated. Exit wound excised; fractured rib resected. Lower lobe lacerated; contained indriven rib fragments and was bleeding profusely. Frag- ments removed; sutured; chest closed tight. October 2, 1918: Wound opened sponta- neously; discharged 300 c. c. turbid fluid containing streptococci. October 5, 1918: Dysp- neic, cyanotic, delirious. Contralateral pneumonia. October 6, 1918: Died. Necropsy: Purulent bronchitis, right; fibrinous pleuritis, right; collapse and splenization of lung, right; massive bronchopneumonia, left; pericarditis; vegetative endocarditis; infarction of kidney. Man's condition prevented extensive operation. The small chance there was was forfeited by failure to drain. 37. J. A. L. September 30, 1918: Shell fragment, penetrating wound, right chest. Entrance, seventh rib, posterior axillary line. Large hemothorax. Condition grave. Dura- tion 55 hours. Operation: Five hours later. Wound excised. Perforated rib resected. Hemothorax evacuated. Much bile present. Foreign body in liver. Thick fibrinous pleuritic exudate. Liver tear repaired. Diaphragm sutured. Man too low tovstand further operation. Peritonitis present. October 5, 1918: Homolateral bronchopneumonia. Octo- ber 6, 1918: Died. Necropsy: One thousand three hundred c. c. fluid in chest; lung col- lapsed. Tract of projectile in liver led to large thrombosed vein. Foreign body found, covered with fibrin, lying between columnse carnese of right ventricle. Lethal injury at time of operation after 60 hours. Early and more com- plete operation would have saved him. 38. O. W. September 30, 1918: Bullet, penetrating w-ound, sucking, right chest. En- trance, seventh interspace, posterior axillary line. Condition bad. Duration 66 hours. Operation four hours later: Entrance wound excised; fractured eighth, ninth, and tenth ribs resected. Pleural cavity cleaned and closed. October 4, 1918: Incision opened sponta- neously. October 5, 1918: Died. Necropsy: Lower lobe collapsed except where splenized. Empyema. Wounded lung contained bone fragments. Lethal injury at time of operation after 70 hours. Illustrated a common error. Operation should be sufficiently radical to give chance for recovery even at risk of death on table Early, complete operation would have saved. 39. C. K. October 14, 1918: Shell fragment, perforating wound, left chest. Entrance, eighth interspace, midaxillary line; exit, eighth interspace, midscapular line. Foreign body under skin. Moderate hemopneumothorax. Condition good. Duration S}4 hours. Operation: Excision of entrance wound. Fractured ninth rib resected. Bone fragments driven into diaphragm, which was repaired and sutured into defect to close pleura after evacuation of large hemothorax. Foreign body removed. 1921. Records available. Dis- ability less than 10 per cent. 426 SURGERY Early operation led to prompt recovery. 40. (German soldier.) October 12, 1918: Bullet wounds, right arm, and penetrating, right chest. Entrance over tenth rib, posteriorly. Condition poor. Duration 54 hours. Operation: Amputation arm; gas gangrene. Excision of entrance wound; resection fractured tenth rib. Repair of lacerated diaphragm. Evacuation of hemothorax. Closure. Death within a few hours. Injury lethal at time of operation. 41. H. C. October 15, 1918: Shell fragment, sucking, penetrating wound, right che>t. Entrance, third rib, high in axilla. Condition poor. Duration 28^ hours. Resuscitation 1Y2 hours. Operation: Entrance wound excised; fractured third rib resected. Old pleuritic adhesions and patient's condition made radical operation impossible. Foreign body in upper lobe not sought. Hole in lung sutured. Gauze drain. October 29, 1918: Died. Nec- ropsy: Abscess in lung and liver. Rare instance of abscess forming about foreign body. Hole in lung should have been left open. Fear of bronchial fistula is not well founded. 42. W. L. October 15, 1918: Shell fragment (1 by 1.2 cm.), penetrating wound, right chest. Entrance through middle of clavicle; lodgment in right, upper lobe. Condition poor. Duration 22 hours. Operation three hours later: Entrance wound excised; com- minuted fractures of clavicle, first and second ribs resected; fragments removed from lung. Lung repaired. Hemothorax evacuated. Pleural defect closed with muscle. Died during night; cause unknown. No necropsy. Severe injury made lethal by exposure and delay. 43. L. B. October 15, 1918: Bullet, through-and-through, sucking wound, left chest. Entrance just above left nipple; exit, ninth rib, paravertebral line. Moderate hemothorax. Condition poor. Duration 24 hours. Operation: Entrance wound not treated. Exit wound excised; fractured ninth rib resected; wound in lower lobe sutured; pleura closed; no drain- age. October 16, 1918: Died. Cause of death probably shock. Another moderately severe injury made lethal by exposure and delay. 44. J. K. November 1, 1918: Bullet, through-and-through, sucking (exit) wound, right chest. Entrance in anterior axillary fold; exit above eighth rib, paravertebral space. Small hemopneumothorax. Condition (?). Duration 11 hours. Operation one and one-half hours later: Wound of entrance untreated as it was found to be smooth on inside. Exit wound excised. Fractured eighth rib resected. Liquid and clotted blood removed. Wounds of entrance and exit in lower lobe sutured. Wounds in upper lobe not found. Parietal pleura closed fairly accurately with aid of one wire rib stay. November 16, 1918: Convalescence stormy. Despite aspiration, wound broke down from within with spontaneous discharge of pyothorax. Had asthmatic attacks. Returned to duty in 90 days. Dis- ability (estimated) 10 per cent. Imperfect closure of parietal pleura is always a source of danger. For- tunately, this rupture occurred after adhesions had formed so that collapse was obviated. Primary drainage was indicated. 45. A. R. November 2, 1918: Bullet, through-and-through wound, left chest. Entrance, fifth interspace, posterior axillary line; exit, ninth rib, midscapular line. Slight interstitial emphysema about exit wound. Fluoroscope revealed moderate hemopneumothorax; fracture of ninth rib and involvement of left lower lobe. Condition fair. Duration 11 hours. Operation: Exit wound excised; shattered rib resected; pleura opened widely; many rib fragments removed. Splenized and lacerated lower lobe resected and sutured after evacuation of hemothorax. Wound of entrance found on internal examination to be smooth so not disturbed. One wire rib stay. Pleural closure incompleted so reinforced with muscle. November 8, 1918: Uneventful recovery. Wire rib stay removed. November 11, 1918: Evacuated in excellent condition. No further records obtainable. Disability estimated at 10 per cent. GENERAL SURGERY 427 Treatment here was good. Illustrates the wisdom of attacking worst wound first and thoroughly, and letting the internal examination determine whether any further operation is needed. Early- removal of wire rib stay- w-as beneficial. Resection of injured lung assured recovery. Primary- drainage had been safer because pleural closure was inadequate and pyothorax w-ould likely have led to spontaneous opening. 46. F. K. November 2, 1918: Multiple wounds; shell fragments, one, through-and- through, three penetrating right chest; one bullet, penetrating abdomen. Chest wound sucking and emphysematous. Condition poor. Duration unknown. Prolonged resuscita- tion. November 3, 1918: Operation: Exit wound over ninth rib excised and fractured rib resected. Wounds in lower lobe sutured. Two wounds in diaphragm sutured to excluded herniated and wounded liver, in which foreign body was not sought because of patient's condition. Bile-stained hemothorax evacuated. Drained with tube armed with flap valve obtained from gas mask. Fair approximation of pleura. Skin closure not attempted because of empyema. November 4, 1918: Died in spite of attempts at resuscitation. Necropsy: Valve drain had functioned perfectly. Wounded lung inflated notwithstanding pulmonary edema. Bullet found in retroperitoneal tissues, only injury to kidney. Death due to myocardial incompetence. Severe multiple injuries with cold and exposure made condition lethal by time of admission to hospital. Recovery with early operation possible. Opera- tive treatment good. 47. J. R. A. November 2, 1918: Shell fragment, through-and-through, left chest. Entrance, third interspace, nipple line; exit, seventh rib, posterior axillary line. Wounds dirty. Condition serious. Duration 27 hours. November 3, 1918: Operation: Both wounds excised. Fractured rib at exit resected. Bone fragments in lung. Four injuries repaired. Liquid and clotted hemothorax (800 c. c.) removed. Both pleural reflections hemorrhagic. Entrance wound on inner aspect not examined. Pleural closure satis- factory. Operation hastened and terminated by patient's condition. November 5, 1918: Never regained strength. Seven hundred and fifty c. c. thin, bloody fluid aspirated. Strepto- coccus (?). Cyanosis and dyspnea. Died. Necropsy: Left chest contained 500 c. c. thin, bloody fluid. Fibrinous pleurisy. Pericarditis with effusion. Acute dilatation of right heart; pulmonary edema. Fracture of fourth rib at entrance wound. Wounds, not of themselves lethal, had become so through cold and delay. Recovery w-as easily attainable with early operation. Drainage should have been employ-ed, but could not have altered, merely postponed, the outcome. 48. J. C. November 2, 1918; Bullet wound, through-and-through, right chest. Entrance, sixth interspace, midaxillary line; exit, twelfth rib, paravertebral line. Moderate hemothorax. Mitral insufficiency. Dirty wounds. Condition poor. Duration 46^ hours. Operation: Entrance wound excised; no rib injury. Exit wound excised; fractured eleventh rib resected. Large hemothorax removed. Laceration in diaphragm and upper pole of kidney repaired. Lung inflated and laceration repaired. Pleura closed tight. Gutta- percha drain to kidney and liver. November 7, 1918: Developed jaundice, edema of ex- tremities and pleuritic effusion. Died. Necropsy: Large pleuritic effusion. One lacera- tion in diaphragm had been overlooked. Acute diffuse hepatitis. Liver wounds necrotic. Acute fibrinous pericarditis. Another reparable injury- made fatal by delay-. Line far in advance and transportation of w-ounded almost impossible. Drainage should have been employed. 49 \ D November 4, 1918: Bullet, through-and-through w7ound, left chest. Entrance above left clavicle; exit, ninth rib, paravertebral line. Large hematoma at en- trance wound. Left radial pulse absent. Condition poor. Duration (?). Operation: 42S SURGERV Wound of exit excised and fractured ninth rib resected when patient stopped breathing. Oxygen had given out. Injection of adrenalin into heart and direct massage started cardiac contractions. Incision closed. Death in two and one-half hours. Necropsy: Hematoma at entrance wound and absent radial pulse due to section of subclavian artery. Positive pressure analgesia too rich in nitrous oxide when oxygen supply failed. Cardiac resuscitation not prompt enough to save central nervous sys- tem from fatal degeneration. Man w-as probably lethally- injured. SUMMARY OF CROUP III Operations, called thoracotomies of necessity, were performed upon 4<), or approximately- 55 per cent of the series. Included are many of the most serious wounds, thus treated because more ideal methods wore impossible not- withstanding the exposures obtained wore inadequate for deep repair. Fatalities.—There w-ere 22 deaths, mortality rate of 45 per cent. It is noteworthy that the mortality rate in the first half of the series is 32 per cent and in the second 58 per cent despite the fact that after greater experience the later treatments were better. The difference is due to the colder weather, rain, and greater difficulties in transportation. One-half of the deaths occurred within 24 hours after operation. One (1) was due to acute anemia and could have been avoided with multiple trans- fusions; one (11) was due to too high positive pressures; one (49) to too high concentration of nitrous oxide (failure of oxygen supply) in the administration of analgesia. Four (6, 12, 14, 46) had received injuries sufficiently- serious to cause death even if treated promptly. Operation was performed 10, 56, 5, and 24 hours after injury; average 2(5 hours. Five (34, 35, 40, 42, 43) had received injuries not severe enough to jeopardize life if promptly relieved, but wore rendered lethal by exposure and delay. Operation was performed 30, 36, 54, 25, and 24 hours after injury; average 33 hours. Tw-o (20, 47) of the half of deaths that occurred more than 24 hours after operation took place within 3 days. One (20), within two days, was lethally injured, the other (47), within three day-s, had become fatally- affected by delay. The balance (7, 8, 31, 36, 38, 39, 41, 48) survived operation from 5 to 14 days. Five developed pyothorax (7, 8, 31, 36, 38), which was due to incomplete opera- tion, e. g., failure to excise splenized lung (38), to close a bronchial fistula (31), the only- one in the series, and to institute primary drainage. The average duration before operation was 34 hours. One (37) died because a shell frag- ment that had not been removed from a liver was transported to the heart and contributed to a fatal septicemia. Another shell fragment not removed from a liver (42) caused a fatal acute hepatitis. A shell fragment in a lung (41) caused a lung abscess because the track w-as sutured; this w-as the only- lung abscess noted. Four deaths were caused by- obvious surgical errors—a failure to transfuse (1), too high pressures with administration of anesthetic (11), too high concen- tration of anesthetic (49), and suturing instead of draining the tract of a foreign body- in an adherent lung (41). Five deaths wliich occurred in the second half (31,36,37,38,48) were operated upon on the average of 43 hours after injury. None w-ere given the benefits of a GENERAL SURGERY 429 complete operation, yet they survived on the average one week. Operation was hurried and unfinished in each instance because condition of the individuals was so poor. Hindsight seems to teach that one or two might have survived, if at the cost of greater immediate risk an opportunity- for ultimate recovery had been provided. Mortality chargeable to surgical errors and accidents (limited supply of blood for transfusions, exhaustion of supply of oxygen, use of too great positive pressure in analgesia, closure of tract in lung, failure to complete operations in spite of impending death and to use primary drainage) is 13 per cent. Disabilities.—Late disability- ratings are available for 23 of the 25 sur- vivors. Two were zero (5, 25); six less than 10 per cent (15, 18, 22, 24, 26, 39); four at 10 per cent (2, 21, 44, 45); two at 15 per cent (10, 19); two at 20 per cent (27, 28); tw-o at 35 percent (4, 16); one at 40 per cent (3); 75 percent (17); SO per cent (13); and 100 per cent (29). Two ratings are low (25, 27) and five are high (4, 13, 17, 28, 29) as shown by physical examination, fluoroscopy, resistance exercises and estimations of vital capacity. According to tlie figures the average disability was 21 per cent. This is higher than the facts would justify, but is accepted to be safe. Only four were returned to duty, 2 in 90 days (15, 39) and 2 in 180 days (2, 24), giving an aver- age of 135 days, which also is too high, but may be accepted as a safe estimate. Pleuritis remains a constant factor in producing disability, but there is added, because of the increased severity of injuries, greater interference with parietal integrity, notable in multiple rib injuries, more frequent diaphragmatic lacerations, and greater destruction of lung tissue requiring resections. Like- wise more complicating lesions appear—liver, kidney, pericardium, and peri- toneum. A disability rating even of 21 per cent is not entirely discreditable when it be considered that the average duration before operation was 19 hours and that none of these men received proper after-care. The evil effects of pre- operative delay- in the more serious injuries is apparent. Those who recovered with disabilities of 20 per cent or less were operated upon in 15 hours on the average; those above 20 per cent in 27 hours. It was noted above in discussing fatalities that more finished operations and more frequent use of drainage would have reduced the mortality rate. The same applies even more directly7 to reductions in duration and extent of dis- abilities because sucking wounds are common, soiling of pleura with bile is frequent, and with urine is occasional. The need for better immediate and continued after-care is self-evident. DEDUCTIONS Thoracotomies of necessity- will be performed upon the less severely injured wiien parietal excisions and limited thoracotomies reveal unexpected lesions that require more radical immediate intervention and upon those so severely injured that parietal and deep repair must be made through one open- ing. Advantages are the greater rapidity7, avoiding making a separate incision and thus not impairing parietal integrity by surgical wounds added to the projectile destruction. Disadvantages are the frequent failures to obtain satisfactory7 exposure to make proper intrathoracic repair and the temptation 430 SURGERY to avoid risks of operative deaths by performing incomplete operations when finished operations are needed to obtain ultimate recoveries. CONCLUSIONS Operations of this type will inevitably be more frequent than other serious procedures and demand greater consideration. Improved facilities in advance of mobile hospitals and the establishment of a thoracic surgical division would make better methods possible. If the thoracic wounded were provided with proper treatment from front to base, not only could the less severely injured be shunted to hospitals farther toward the rear when the fighting is active, but the more severely injured could be evacuated earlier. This might well provide for two-stage operations that would secure recoveries in types that now seem to be almost hopeless. The need for more effective prevention and treatment of shock which includes promptness as a first requisite as well as continued and consecutive care under unified control is indisputable. Simplifying and perfecting the technical details appear now to be easy. The combination is desirable and attainable. Returns to active duty7 were few and delayed. GROUP IV. THORACOTOMY OF ELECTION 1. F. P. July 30, 1918: Shell fragment, penetrating wound, left chest. Entrance, left sternoclavicular articulation; foreign body lodged in lower lobe. Large hemothorax. Heart displaced to right. Condition (?). Duration (unknown). Operation: Entrance wound excised; sternum resected; pleural defect closed with muscle. Fourth rib resected. Hemothorax evacuated. Lacerated lung repaired. Hematoma in lung and foreign body not removed. Wire rib stay. Layer closure. No drainage. Postoperative interstitial emphysema from wound of entrance. Moderate pleuritic effusion. Later was operated upon at a base hospital, anterior and posterior drainage for empyema. May 19, 1919: Drained again at Walter Reed Hospital and wire stay removed. November 14, 1919: Discharged. July 28, 1921: Dyspnea and pain on exertion. Deficient expansion, multiple parietal scars, chronic pleuritis, immobile diaphragm, heart displaced to left, cardiac compe- tence fair. Disability 50 per cent. Vital capacity 58 per cent. This an early experience; battle rush; no assistant. Operation incomplete. Foreign body7 should have been removed and intrapulmonary hematoma evacu- ated. This with drainage would have prevented empyema. Proper after-care would have reduced disability- at least by half. Rib stay should have been removed early. 2. D. July 31, 1918: Shell fragment, penetrating wound, left chest. Entrance wound over (?) rib, foreign body in upper lobe. Moderate hemothorax. Condition (?). Duration (unknown). Operation: Entrance wound excised; fractured rib resected; pleural defect closed. Thoracotomy at site of election. Hemothorax evacuated. Foreign body removed. Lung repaired. Wire rib stay. Layer closure. No drain. August 3, 1918: Limited pleuritic effusion. Continued improvement. Lost. Notes too meager for any judgment. 3. A. L. B. August 8, 1918: Shell fragments, left arm, shoulder, leg, penetrating left chest, which contained two foreign bodies. Entrance over fourth rib, axilla. Large hemothorax. Condition (?). Duration 18 hours. Operation: Foreign bodies removed from leg, elbow and shoulder. Entrance wound excised; fractured fourth rib resected; thoracotomy at site of election. Large hemothorax evacuated. Lacerations in upper lobe GENERAL SURGERY 431 repaired. No note of foreign bodies. Two wire rib stays failed to provide satisfactory closure at anterior angle. No drainage. August 10, 1918: Much interstitial emphysema from incomplete closure. August 13, 1918: Chill. Increased pleuritic effusion; 650 c.c. blood-stained fluid aspirated. August 16, 1918: Fluid reaccumulating. Aspirated and found to contain much fibrin. Rib resection and open drainage. August 17, 1918: Subse- quent progress excellent. Disability for seven months. Ultimate disability 15 per cent (estimated). Primary drainage would have hastened recovery and reduced disability. 4. W. S. August 9, 1918: Shell fragment, perforating, right chest; entrance wound, posterior axillary line at level of angle of scapula; foreign body lodged in mediastinum posterior to aorta. Enormous hemothorax. Condition bad. Duration eight hours. Operation: Thoracotomy at site of election to give immediate opportunity to check bleeding because of severe and increasing acute anemia. Injured azygos vein found and ligated with great difficulty. Death occurred as bleeding laceration in upper lobe was being sutured. Hemostasis imperative but attempted too late even at eight hours. Trans- fusions might have been effective. A serious and usually fatal injury. 5. M. B. August 11, 1918: Shell fragment, through-and-through wound, lower left chest. Large hemothorax. Burns to head and face. Both ear drums ruptured from shell explosion. Condition bad. Blood pressures 90/50. Duration six hours. Resuscitation attempted; pulse became barely perceptible. Chance of any recovery lay in immediate hemostasis. Operation: Thoracotomy at site of election to expose bleeding points surely and with least delay. Lacerations in lower lobe sutured. Death from acute dilatation of right heart. Injuries lethal at time of operation. Questionable if earlier intervention could have succeeded. 6. L. G. September 12, 1918: Bullet, perforating wound, left chest. Entrance wound, second interspace below middle of clavicle. Foreign body under skin below angle of scapula. Large hemothorax. Free hemoptysis. Heart widely displaced. Interstitial emphysema more prominent posteriorly. Condition (?). Duration unknown. Operation: Entrance wound excised. No rib damage. Closed. Bullet removed. No rib damage. Closure. Thoracotomy at site of election. Hemothorax evacuated. Wounds in upper lobe sutured. Entrance wound surrounded by zone of splenization which was not excised. One wire rib stay. Layer closure. Superficial drain. September 13, 1918: Greater emphy- sema about entrance and exit wounds because closure had not been effective. Good condition. September 16, 1918: Aspiration of sterile, pleuritic effusion. Continues to improve. Five months later he developed empyema and was treated by open drainage. Notes on present condition not obtainable. Imperfect closures of entrance and exit wounds was poor surgery. Splen- ized lung should have been excised. Note the late empyema. Phrenic nerve should have been blocked. 7. J. J. M. September 12, 1918: Shell fragment, penetrating, left chest. Entrance, sixth interspace midaxillary line. Foreign body lodged near heart, moving with each contraction. Moderate hemopneumothorax. Heart slightly displaced. Condition good. Duration five hours. Operation: Six hours later: Entrance wound excised. No rib damage. Pleural defect plugged with muscle. Fourth rib resected, hemothorax evacuated. Wounds in upper and lower lobes sutured. Foreign body at hilum, close to pulmonary artery and not removed for fear of injuring vessel. Phrenic nerve blocked with 1 per cent cocaine. September 14, 1918: Interstitial emphysema from wound of entrance. Considerable pleuritic effusion. Diaphragm on left side seen with fluoroscope to be in extraordinarily high position. September 17, 1918: Exceptionally comfortable convalescence but usual 4) the promptness with which relief is provided, and (c) its effectiveness. Fighting men can not always be well fed and watered or kept free from fatigue and the mental depression inevitable with reverses, all of which have untoward effects upon the w7ounded. Our Army experienced no continued and but few localized defeats, so this factor was eliminated. Cheerfulness was an almost unbroken rule. GENERAL. SURGERY 439 Promptness depends upon getting the wounded back to hospitals and in keeping hospitals as close to zones of conflict as relative safety- permits. Trans- portation is essential to both. Transportation handicaps, however avoidable or unavoidable, caused great hardships to the wounded and materially increased mortality and morbidity7 rates. Early wound dressing was very good. Sucking wounds should seldom be sutured provisionally-. Firm pressures sw7athes to provide support and fixation would have been helpful. Morphine should be given in full doses and repeated. Prophyiaxis and treatment of shock can be improved. In addition to means to get men warm and dry, provisions are needed for more general employ- ment of intravenous remedies, particularly in advance of mobile hospitals. A satisfactory method of preserving blood, based upon the work of Weil,49 will provide for a limited number of transfusions. In addition some hyper- tonic carbohydrate solution, insulin and digitalis now seem to be essential and should be used in spite of the less dangers of inducing secondary- hemorrhage to combat certain death from prolonged hypotension. The need for further preoperative care, including physical and fluoroscopic examinations, and of consecutive after-care, providing similar examinations, early and progressive activation has been established. The efficacy of surgical procedures based upon physiological principles in providing opportunities for recovery- with the least danger, delay and dis- ability- has been proved and warrants positive statements. All chest w-ounds, severe enough to demand more than temporary- dressings, should be treated by operations conducted under positive pressure gas anal- gesia. Parietal excisions, usually with paracentesis, suffice to protect the least seriously injured and to hasten recoveries without added danger. They may likely prove a first-stage operation in the care of those so seriously wounded that any additional primary intervention except perhaps aspiration or the insertion of an intercostal drain is prohibited. Limited thoracotomy is applicable in the treatment of the less severely wounded in wiiom deep repair can be effected through slight enlargements of entrance and exit wounds and from whom the bulk of hemothorax can be aspirated by large cannuhv introduced through a defect in parietal pleura. Limited thoracotomy can be employed as a first-stage operation when deep injuries require an amount of repair that could not then be tolerated. Under such conditions, hemostasis and primary drainage would be required. Thoracotomy of necessity, a more extensive application of limited thoraco- tomy, must be used when immediate deep repair is required and when there are reasons for using the wound defect in the parietes to secure exposure. If it be found that the repair required can not be effected with obtainable exposure or if the patient's condition prevents satisfactory operation, hemostasis, primary drainage and parietal closure can be secured and the complete operation post- poned &to be performed through a separate incision. Thoracotomies of election will find wider application as primary procedures, and if two-sta^e procedures are practicable, they will be the preferable secondary 440 SURGERY operations. They afford sufficient exposure for a satisfactory examination of a pleural cavity, permit repair of most visceral and diaphragmatic lesions, heal well and impose little disability. Indeed, with the development of simple and effective methods of primary- drainage thoracotomy of election may prove to be the safest treatment of massive pneumothorax unless the patient's condition be poor. The value of two-stage operations, should they prove feasible, will be greater than in affording better care. A good proportion could be sent, after the primary- operation, to evacuation hospitals where the final operation would be performed. Thus the mobile hospitals could be relieved for more strictly emergency service. We have attempted to indicate our therapeutic failures so positively that similar mistakes need not be repeated. Contributory causes for failure will be mentioned for the same reasons, namely, so that repetitions may be avoided. Success can be realized if personnel competent to give treatment and the materials essential to that treatment are so organized and disposed that the wounded may- be well and promptly served. From a medical viewpoint, service to the wounded men is all important; from a military standpoint, service to the fighting men is most important. The exaggerated individualism of civil surgeons lead them to misunderstand or to fail to appreciate the responsibilities of their colleagues in the Regular Service to Army organization and administration. Similarly, the medical officers of the regular service apparently underrated the personal aspirations of doctors and nurses to provide their patients with the best care. Both sides were unprepared to fulfill their obligations and neither hesitated to hold the other responsible, justly and unjustly, for their own deficiencies. Jealousy, suspicion, distrust, and resentment prevented cooper- ation. The wounded man paid the bill with avoidably high mortality and dis- ability rates. There was a rapidly- progressing improvement in all departments which showed that had the war continued solutions might have been found for even the most involved problems. Thereby was indicated a means to preparedness. An army must be an autocratic organization, but many evils peculiar to autocracies can be minimized. This can be accomplished effectively so far as the Medical Corps of the United States Army is concerned by developing cooperation in advance. Civil surgeons can and should prepare themselves not merely to give professional services but to give them under the restrictions of military methods, the worst attribute of which is inflexibflity. Similarly, the officers in the Regular Medical Corps, kept directly in contact with progress and changing requirements of surgical practice, will find more liberal inter- pretations of regulations, which are fixed products of past experiences and often are literally opposed to immediate necessities. National security should be enough of an incentive to produce the necessary personal adaptation and coordination of effort. GENERAL SURGERY 441 REFERENCES <1) Burlingame, C. C, Lieut. Col., M. C: Military History of the American Red Cross in France. On file, Historical Division, S. G. O. (2) Cannon, W. B., Lieut. Col., M. C, and Yates, J. L., Lieut. Col., M. C: Report on the "Services of the Laboratory of Surgical Research, American Armv at Dijon," December'7, 1918. On file, Historical Division, S. G. O. <3) Yates, J. L.: The Significance of Vital Capacity in Intrathoracic Therapy. Archives of Surgery, Chicago, 1925, x, No. 1, pt. 2, 477. (4) Miller, William Snow: Key Points in Lung Structure. Radiology, 1925, iv, No. 3, 173. (5) Graham, E. A., and Bell, R. D.: Open Pneumothorax: Its Relation to the Treatment of Empyema. American Journal of the Medical Sciences, Philadelphia, 1918, n. s. clvi (War Medicine), 839. (6) Barcroft. Personal communication. (7) Bowditch, Henry L.: On Pleuritic Effusions, and the Necessity of Paracentesis for their Removal. American Journal of the Medical Sciences, Philadelphia, 1S52, xxii, n. s., April, 320. (8) Pry or, John H.: Immobility of the Diaphragm Following Pleural Exudates. New York Medical Journal, April 22, 1916, ciii, 781. (9) Middleton, W. S.: Costodiaphragmatic Adhesions and their Influence on the Re- spiratory Function. American Journal of the Medical Sciences, Philadelphia, 1923, clxvi, 222. (10) Keller, William L.: The Treatment of Chronic Empyema where the Recognized Surgical Procedures have Failed to Produce Obliteration. Annals of Surgery, Philadelphia, 1922, lxxvi, No. 5, 549. Ibid., No. 6, 700. (11) Gwathmey, James T.: Anesthesia. The Macmillan Company, New York, 1924, 2d ed., 130. (12) Steiner. Personal communication. (13) Cloetta: fiber die Zirkulation in der Lunge und deren Beinflussung durch tJber und Unterdruck. Archiv fur experimentelle Pathologieund Pharmakologie, Leipzig, 1911, lxvi, Nos. 5-6, December 20, 409. (14) Karsner, H. T., and Ghoreyeb, A. A.: Studies in Infarction. III. The Circulation in Experimental Pulmonary Embolism. Journal of Experimental Medicine, New- York, November 1, 1913, xviii, 507. (15) Denny, George P., and Minot, George R.: The Coagulation of Blood in the Pleura Cavity. American Journal of Physiology, Baltimore, 1916, xxxix, No. 4, 455. (16) Elliott, T. R., and Henry, H. G. M.: Infection of Hemothorax by Anaerobic Gas- Producing Bacilli. British Medical Journal, London, March 31, 1917, 413; April 1, 448. (17) Delrez, L.: War Wounds of the Joints. United States Xaval Medical Bulletin, Wash- ington, 1920, xiv, No. 4, 537. (18) Yates, J. L., Middleton, W. S., Drane, Robert, and Gwathmey, James T.: Laboratory of Surgical Research, Central Medical Department Laboratory, American Ex- peditionary Forces, France, A. P. O., No. 721. Boston Medical and Surgical Journal, Boston, 1919, clxxx, 405. (19) Bradford, Sir John Rose: Gunshot Wounds of the Chest as Seen in Hospitals on the Lines of Communication. War Medicine, Paris, 1918, ii, No. 1, 10. (20) Soltau A. B. and Alexander, J. B. On Gunshot Wounds of the Chest as seen at a Base Hospital at Nancy. Quarterly Journal of Medicine, Oxford, 1916-17, x, Jul}-, 1917, 259. (21) Karsner, H. T., and Ash, J. E.: Studies in Infarction. II. Experimental Bland Infarction of the Lung. Journal of Medical Research, Boston, 1912, xxii, n. s., No. 2, 205. (22) Willems C: La mobilisation active immediate. Methode generale de traitement des lesions articulaires. Archives midicales Beiges, Paris, 1918, lxxi, No. 3, March, 225 Ibid., Traitement de l'arthrite purulente par l'arthrotomie simple suivi de mobilisation active immediate. Bulletins et memoires de la sociite de chirurgie de Paris, June 19, 1918, xliv, 1098. 442 SURGERY (23) Lockwood, A. L., and Nixon, J. A.: War Surgery of the* Chest. I. British Medical Journal, London, January 26, 191S, i, 105; II. Idem., February 2. 1918, i, 145. (24) Duval, Pierre: Les plaies de guerre du poumon. English translation by Col. Thomp- son, Masson et Cie., Paris, 1917. (25; Gask, G. E., and Wilkinson, K. D.: Penetrating Gunshot Wounds of the Chest and their Treatment. British Medical Journal, London, December 15, 1917, ii, 7si. (26) Gask, G. E.: Gunshot Wounds of the Chest. Transactions of the College of Physi- cians, Philadelphia, November 5, 191S, xl, 3 s., 199. (27) Bastianelli, R.: Treatment of Chest Wounds'. Surgery, Gynecology and Obstetrics, Chicago, 1919, xxviii, No. 1, 5. (28) Davies, H. M.: The Surgical Treatment of Gunshot Wounds of the Chest. Lancet, London, January 29, 1916, I, 232. (29) Bradford, Sir John Rose: On Gunshot Wounds of the Chest. British Medical Journal, London, August 4, 1917, ii, 141. (30) Tuffier, T.: The Secondary Surgical Treatment of Chest Wounds. War Medicine, Paris, 1918, ii, No. 1, 16. (31) Leslie, R. M.: The Medical Aspects of Chest Injuries. Practitioner, London, 1916, xevi, March, 301. (32) Soltau, P. B.: Wounds of the Chest. War Medicine, Paris, 1918, ii, No. 1, 1. (33) Cannon, W. B.: Traumatic Shock. War Medicine, Paris, 1918, ii, No. 6, 1367. (34) Depage, A.: General Considerations as to the treatment of War Wounds. Transactions of the American Surgical Association, Philadelphia, 1919, xxxvii, 15. (35) Cowell, E. M.: Plastic Transcostal Thoracotomy. British Medical Journal, London, November 3, 1917, ii, 581. (36) Cloetta: Beitrage zur Physiologie und Pathologie der Lungencirculation und deren Bedeutung fur die intrathoracale Chirurgie. Archiv fur klinische Chirurgie, Berlin, 1912, xcviii, No. 3, 835. (37) Capps, J. A.: Clinical Study of Pain Arising from Diaphragmatic Pleurisy and Sub- phrenic Inflammation. American Journal of the Medical Sciences, Philadelphia, 1916, cii, No. 3,333. (3S) Gray, H. M. W.: Notes on Surgery of the Chest. British Medical Journal, London, November 3, 1917, ii, 580. (39) Dobson, J. F.: A Preliminary Note on the Treatment of Infected Hemothorax. British Medical Journal, London, February 2, 1918, 148. (40) Mozingo, A. E.: The Surgical Treatment of Empyema by a Closed Method. Journal of the American Medical Association, Chicago, December 21, 1918, lxxi, 2062. (41) Blankenhorn, M. A.: A Closed System of Drainage for Penetrating Wounds of the Chest. Journal of the American Medical Association, Chicago, December 14, 1918, lxxi, 1994. (42) Whittemore, W.: A Series of 100 Consecutive Empyemata. Boston Medical and Sur- gical Journal, Boston, November 13, 1919, clxxxi, 575. (43) McKenna, H.: Operation for Empyema. Journal of the American Medical Association, Chicago, August 31, 1918, lxxi, 743. (44) Roberts, J. E. H., and Craig, J. G.: The Surgical Treatment of Severe War Wounds of the Chest. British Medical Journal, London, November 3, 1917, ii, 577. (45) Petit de la Villeon, E.: Extraction of Projectiles from the Pleura and Diaphragm. War Medicine, Paris, 1918, ii, No. 1, 24. (46) Roux-Berger, J. L.: Plaies de la pleure et du poumon par projectiles de guerre. Lyon chirurgical, 191S, xv, No. 1, 1. (47) Rist, Flandrin, Bernard, Somerville, et al. Discussion on "Do we Expect to find Pulmonary Tuberculosis Following Gas or Thoracic Wounds?" War Medicine, Paris, 1919, ii, No. 6, 982. (48) Pehu and Daguet: Recherches Cliniques et radioscopiques sur certaines sequelles lointaines des plaies pleuro-pulmonaires de guerre. Lyon chirurgical, 1918 xv No. 3, 291. (49) Weil, Richard: Sodium Citrate in the Transfusion of Blood. Journal of the American Medical Association, Chicago, January 30, 1915, lxiv, 425. CHAPTER XV WOUNDS OF THE ABDOMEN The man with an abdominal w-ound presents one of the serious problems which the military surgeon has to face. No other group of cases furnished anything comparable to it in testing the medical resources of an army or the technical skill of its surgeons. Although gunshot wounds of the abdomen comprise a small but indeterminate percentage of the total wounded (in the American Expeditionary Forces the relative frequency was 3.3 per cent of those admitted to hospital, no account being taken of the killed in action)1 the severity- of the lesions encountered and their complex nature call for the highest surgical judgment in diagnosis and treatment. The problem is full of interest to every surgeon and challenges his best thinking. In the war of 1914-1918, the attitude of surgeons with reference to abdom- inal wounds underw-ent a marked change. In the Spanish-American War and the Boer War the expectant treatment w-as followed,2 and few- surgeons then had the courage to argue for and practice operative interference in these cases. The occasional patient on whom operations had been attempted almost in- variably succumbed, chiefly because intervention had been too long delayed. This inevitably resulted from fighting over an open country with a rapidly- shifting line, for properly equipped hospitals could not be placed near enough to the firing line to be of any service to the seriously- wounded soldier. During the early- months of the great war, conservative management of the wounded abdomen was stdl generally advised and practiced. This w-as due to the open nature of the warfare and the impracticability of establishing well equipped surgical hospitals sufficiently near the front line. On the other hand, early in 1915, after the battle lines had become fixed, there began to be evident a movement, both among the surgeons of the Allies and German surgeons, for surgical intervention, and this effort gained rapidly in favor. The reasons for this change in surgical attitude lay largely in the growing appreciation of the truth of three factors: First, that the man with a wound of the abdomen, nonoperated, usually- dies. Gibbon 3 stated that in 19 months' active service overseas he did not see a single instance of recovery- following nonintervention in penetrating or perforating abdominal wounds. Second, that the time factor is vitally important because of the frequent presence of serious hemorrhage, and, with a hollow viscus injury-, especially7 the small intestine, the rapid development of spreading peritonitis. Third, that the intra- abdominal wounds in the war just ended were definitely more grave than in preceding wars because of the nature of the projectiles used. Machine-gun bullets and hio-h-explosive shell fragments in particular often caused extensive lacerations of the bowel wall, sometimes completely- severing it, and at other times excavating large areas. These lesions were in marked contrast to the clean-cut. punctured rifle wounds of former conflicts. 444 SURGERY Before proceeding with a detailed study of the wounds themselves, it is important and essential that consideration be given to certain subjects which are vital in the proper care of the abdominally- wounded. SPECIAL PROVISIONS FOR THE CARE OF ABDOMINALLY WOUNDED TRANSPORTATION AND THE TIME FACTOR It becomes evident at once that, wiiether with a fixed or moving line, the abdominally wounded man must be rapidly evacuated to the hospital where surgical treatment may be applied. Transportation, therefore, becomes an exceedingly vital problem. The motor ambulance made possible much of the advance in abdominal surgery by cutting down materially the time elapsing between the receipt of the injury and operation. Various factors, however, interfere with rapid evacuation, such as the severity of the fighting, the number of wounded men, the mobility or immo- bility of the line, the terrain, and the condition of the roads as to number, sur- face, and traffic requirements. Wallace 4 found that in a study of 1,200 cases of gunshot wounds of the abdomen most cases arrived at a casualty clearing within the first six hours. Only those evacuations accomplished within the first six hours were considered good; after that time the chances were against the patient. Ambulances should be provided with heating facilities, such as the British used, that patients may be evacuated in cold weather, warmed and, therefore, less shocked and with better chances of recovery following operation. The writer took many a dead man from an ambulance in which the other occupants were stiff and cold, with the firm conviction that some of those lost might have been saved had the ambulance been provided with a heating appliance. At times horse-drawn ambulances have demonstrated their usefulness when with roads absolutely blocked and motor evacuations at a standstill the horse-drawn vehicle has been able to carry patients over an open country and bring the seriously wounded where surgical aid was available. A certain number of such ambulances should always be included in a divisional organi- zation, that such special evacuation emergencies may be successfully- met. A well-organized front line evacuation is essential to the proper surgical care of the abdominal case. This effort is difficult enough wrhen trench warfare exists, but during an advance it requires the best in organization and heroism in order to insure the least possible delay. The most capable surgeon and the best equipped hospital are of no avail if the wounded do not reach the hospital within 12 hours. The time factor is recognized as an all-important element. In general, the patient must be seen in the first 12 hours if a wounded hollow viscus is to be successfully7 treated surgically. Those operated upon within the first eight hours yield definitely better results. No other consideration compares in importance to the element of time; recovery percentages are inversely proportional to the time factor rather than to the organ involved or the number of lesions encountered. GENERAL SURGERY 445 THE NONTRANSPORTABLE HOSPITAL Special provision had to be made far forward where abdominal cases could receive early and adequate surgical care. With a fixed line small hos- pitals naturally- came into being, placed 6 or 8 kms. from the firing line. They were w7ell housed, usually- in wooden huts or chateaux, with completely- equipped operating and radiological units and well organized wards. A surgeon of ability- was placed in charge of such a unit and the staff requirements, including a small nursing quota, were limited. The French and the Belgians made tins type of hospital an integral part of their organization, and as time went on each sector of the line had its advanced hospital for the transportable wounded to care for men with wounds of the abdomen especially, of the chest, and for those suffering from shock or hemorrhage. THE MOBILE UNIT No consideration of abdominal military surgery can be complete without taking into account the necessity for well-organized and equipped mobile units for the care of the seriously wounded, well up toward the front. When the w-ar of movement began in the spring of 1918 a different type from the stationary- nontransportable hospital had to be evolved, so organized that it could move with an advancing or retreating line and still provide satisfactory surgical care for the severely wounded. As told in Chapter V of Volume VIII of this history, the French had devised this type of advanced hospital, known as the auto-chir, and, likewise, a lighter form, the groupe complementaire, and had made use of them on numerous occasions. The American Army- adopted both these units, calling them the mobile hospital and the mobile surgical unit, respectively-.5 They were controlled by a capable surgeon with adequate assistants; the mobile hospital had trained nurses. The bed capacity of the mobile hospital was 120; upon its ultimate standardization, 20 3-ton trucks were required for its transportation.6 Such a hospital should be placed as far forward as is compatible with reasonable safety7 to patients and personnel, but no farther. It is very difficult to maintain morale and surgical efficiency when such a unit is under shell fire. Under these conditions the patients become terrified, it is exceedingly difficult to carry- on any effective work, and a hasty evacuation of all patients may be imperative. Patients with abdominal wounds who had done well after operation in such a mobile hospital have been known to die following their evacuation to the rear. It has been claimed that proper postoperative care could not be provided by the mobile unit if an offensive with an advancing line were in progress, as military necessity would compel the moving forward of the hospital and the evacuation of all postoperative cases. The organization of such a unit may include a rear echelon consisting of a certain number of officers and enlisted men who may be left behind with a portion of the tentage and supplies to com- plete the 8 or 10 day-s of postoperative care required for abdominal cases. When such patients finally are evacuated the echelon moves forward to join the major portion of the unit. Another effective way of dealing with this problem con- 44(5 SURGERY sists in making use of a second mobile unit, which passes the hospital already- established and establishes itself in a more advanced position, while the unit behind completes the postoperative care of the nontransportable cases. INCIDENCE The true incidence of gunshot wounds of the abdomen among the members of the American Expeditionary Forces is not known nor can it ever be; many- men so wounded died upon the battle field from shock and from hemorrhage. However, this cause of a discrepancy- in our statistical data is counterbalanced somewhat by the fact that many men, otherwise wounded than in the abdomen, also died on the battle field. Since diagnosis tags w-ere used by medical person- nel in the trenches and at battalion aid stations, and since these tags eventually became more detailed medical records, thus including men with severe abdominal wounds but who perhaps died while being evacuated to a hospital, it is reasona- ble to conclude that the relative incidence of wounds of the abdomen may readily be determined from the records so made. Thus, of the 147,651 men wounded by gunshot missiles, 5,631 w-ere wounded in the abdomen (including the pelvis),1 a relative frequency of 3.3 per cent. Considering the incidence from another viewpoint: Many of the men suffered multiple wounds, thus making the total number of wounds 170,841, and the relative frequency of wounds of the abdomen among these 3.8 per cent.1 MILITARY IMPORTANCE At first thought one would say at once that from the military standpoint the soldier with an abdominal wound is much less important than the man slightly wounded. The latter may reasonably be expected to return to the firing line at an early date while the former may be months in the rear or may never return to the front. Further, the small proportion of intraabdominal lesions encountered would seem to make them of decidedly less military impor- tance. But, as a matter of fact, the proper care of abdominally wounded men is exceedingly important from the side of the morale of the Army, for it gives its soldiers the conviction that any man badly wounded will receive the best chance for his life that surgery can give him. Humanity dictates that every combatant seriously hit by enemy fire shall have a chance to live. NONPENETRATING WOUNDS INVOLVING THE ABDOMINAL WALL These include gutter wounds; perforating wounds running tangential to the peritoneum; wounds, with the missile lodged in some portion of the anterior or lateral abdominal wall or posteriorly in the retroperitoneal tissues or muscles of the back. Any7 type of projectile may cause such a wound. The gutter abrasions make their own diagnosis. They call for complete debridement, with primary closure if the case can be held under the operator's observation for at least one week, during w-hich time any symptoms of wound infection may quickly be recognized and promptly- met. In times of great GENERAL SURGERY 447 activity, w-here a possibility exists of an early evacuation of the case, the wound, after debridement, should be left widely open and treated with Carrel-Dakin dressings, a delayed primary or a secondary suture being done at a later date. It is well to remember that some apparent gutter wounds are really penetrating wounds, the gutter in these cases growing deeper as the course of the projectile is followed. When any doubt exists, X-ray diagnostic aid must be made use of. With a perforating wound of the abdominal wall the shorter the tract the less likely is one to encounter a visceral involvement. With a through-and- tlirough wound the missile may change its direction, after entering the soft tissues, without any impact with bone, and travel along the abdominal wall, emerging at some distance from the point of entrance. Such a case may present great difficulties in diagnosis, for the two most important local signs of a visceral lesion—muscular rigidity and tenderness—are marked, as a result of muscle traumatism, even when no abdominal perforation has occurred. The patient's general condition, with lack of pulse elevation and gastrointestinal symptoms, is the important guide to a correct diagnosis. It is well for the surgeon to bear in mind that in visceral perforations seen very early- general signs may be absent. The X-ray examination is of little aid in the differentiation. With clean-cut rifle wounds no intervention is necessary-, but if definite doubt of abdominal perforation exists it is necessary7 to operate without delay. Wounds caused by shell or grenade fragments or machine-gun bullets should be completely- dissected and the rule for or against primary- closure outlined for gutter wounds should be follow-ed. The determination of the true nature of wounds of the parietal wall, with entrance only, is at times as difficult as that w-hen both entrance and exit exist. The same local signs frequently- are present and the differentiation from cases of peritoneal penetration must be made in a similar manner. The radiological findings, however, usually make the diagnosis for or against peritoneal penetra- tion, and too much stress can not be placed upon the necessity- for this type of examination. Dissection of the tract with removal of the foreign body is the course to be followed. The rules for suture are the same as those outlined SUBCUTANEOUS RUPTURE OF VISCERA The literature of civil surgery and of former wars has yielded many examples of this sort of abdominal lesion; that concerning the recent conflict has been equally prolific. In the Medical and Surgical History of the War of the Rebellion numerous types and variations of subcutaneous abdominal injuries are cited in ^reat detail.7 In war, as in civil life, injuries of this sort are caused bv the kickof a horse or a mule, by blows upon the abdomen during a fight, or bv falls from a height, the man landing upon the abdominal wall. In military surgery injuries of this type are caused also by shell explosions in the immediate vicinity of the soldier (the so-called "wind injuries"' of the Civil War)- they may be caused by flying pieces of wood or other solid objects in connection with shell bursts; they may result from crushing injuries from falling timbers or earth incident to the bursting of a projectile. 4(1097—27----31 448 SURGERY Two modes of injury- which are especially important because of diagnostic difficulties are laceration of the abdominal wall by a missile without penetration of the cavity but with sufficient explosive force to rupture a viscus within, and visceral perforations from flying bone spicules without peritoneal penetra- tion by a projectile. The former injury if unrecognized leads frequently- to a fatal result; the latter should always be thought of in connection with rib fractures in or about the hepatic or splenic areas or with comminuted pelvic fractures where the pelvic portion of the small intestine is the most frequently injured viscus, while injury of the bladder, rectum, and colon is less common. The organs most often ruptured are the liver, spleen, kidney, and small intestine; the mesentery- is not infrequently torn. The colon, rectum, and bladder are less often injured. The lesions encountered may be grouped under the headings injuries of hollow viscera and injuries of solid viscera. Hollow visceral lesions may in- clude contusions of the wall, minute perforations, extensive lacerations or even complete division in the case of the bowel or its mesentery-. Solid visceral lesions comprise subcapsular rupture of solid organs, especially the liver, w-ith usually a small hematoma beneath the capsule, slight tears, and extensive lacerations. The diagnosis of subperitoneal rupture of any viscus or of the mesentery must be made by a consideration of the site and mode of injury, the presence of more or less anemia from hemorrhage, especially with solid visceral and mesenteric lesions, and, where a hollow viscus has been opened, the usual signs of peritoneal irritation with subsequent symptoms of a rapidly advancing peritonitis. Patients with serious injuries frequently come to the hospital in considerable shock, particularly when the degree of hemorrhage is severe or the small intestine or mesentery- has been seriously injured. Rupture of a hollow viscus calls for immediate intervention; the principles of treatment outlined under penetrating abdominal wounds should be followed. A torn mesentery- with signs of hemorrhage requires immediate operation; resection is usually- necessary. With a suspected rupture of a solid viscus but without alarming symptoms or hemorrhage, an expectant attitude should be adopted. Most of these patients recover unoperated. If the hemorrhage has been severe in such a case the best working rule is to operate if the patient is seen very early, but to watch and ob- serve for a few hours if the patient is seen six or eight hours after injury. If then the anemia is not apparently progressive one should not operate, for the hemorrhage has to all intents ceased and laparotomy will cause a renewal of the hemorrhage with a probable fatal result. If there are signs of progressive bleeding the abdomen must be opened at once. Control of hemorrhage from a ruptured liver may be accomplished by packing or by mattress suture inserted with a large needle, blunt end first. Suture near the diaphragm or far back on the inferior surface of the liver is difficult and frequently impossible. Packing with sterile gauze should be resorted to when suture can not be effectively carried out. GENERAL SURGERY 449 In general a rupture of the spleen should be treated by splenectomy. The objection raised that convalescence is hampered by the impairment of the patient's blood forming mechanism is practically- unimportant. In all cases in which hemorrhage has been a serious symptom transfusion should be carried out as soon as possible after the bleeding has been controlled. The ease with which this procedure may be carried out, either with the aid of paraffin-coated tubes or by the citrate method, the prompt and striking im- provement in the wounded following transfusion for hemorrhage, and the abundance of robust individuals among the slightly wounded who may serve as donors, should serve to make this operation a routine procedure early in the treatment of hemorrhage. PENETRATING AND PERFORATING WOUNDS GENERAL CONSIDERATIONS The general principles of military surgery of penetrating wounds of the abdomen differ but little from those employed in civil life. However, many- factors obtain to make the problems of abdominal surgery complex and difficult, and each case must be studied in the light of accumulated experience in the wrar zone. Before the types of injuries involving special organs are discussed certain general principles influencing the diagnosis and management of abdominal wounds must be considered. As the patient is admitted the questions which arise are: (1) What is the man's general condition with respect to shock? (2) What is the diagnosis ? (3) Is operation indicated ? Several factors contribute to bring the soldier with an abdominal wound to the hospital in a condition of shock. These are lack of sleep and food, expo- sure to cold and wet, difficult evacuation to the hospital, traumatism of abdom- inal and visceral walls, hemorrhage, pain, and infection, the latter being espe- cially important in those arriving late. Hemorrhage, save in the late eases, is the great factor in the production of shock, and the degree of shock is usually proportionate to the severity- of the hemorrhage; undoubtedly- many- com- batants die on the battle field from rapidly fatal intraabdominal hemorrhage. The abdominal cases reaching the hospital show most extensive hemorrhage when the mesenteric or pelvic vessels or when the liver, spleen, or kidney have been injured. Hemorrhao-e mav also occur from the abdominal wall, the omentum, and from the retroperitoneal tissues. In the latter case the loss of blood may occasionally- be alarming and the diagnosis very difficult. Since hemorrhage is one of the principal causes of fatal issue in the abdominally wounded, it is tlierefore an important argument for the earliest possible intervention. In- active hemorrhage from a solid viscus does not constitute an indication for operation. ... . , Pain is usually- a distinct symptom. The pain in the wounded parts, increased by difficulties in evacuation, and the pain caused by an advancing peritonitis both contribute to the shocked state of the wounded. Moreover, the degree of shock found is in approximate ratio to the time elapsing before the administration of morphine. 450 SURGERY Cases with infection of the retroperitoneal tissues may show rather pro- nounced shock. Infection due to the presence of anaerobic microorganism- in badly lacerated muscles of the abdominal wall may be an important factor. The shock which accompanies an advancing peritonitis is readily recognized. A hurried examination having been made to assure the surgeon that no progressive hemorrhage is present and that no splint readjustments are ne<<-- sary, immediate treatment directed toward the relief of shock must be insti- tuted. The preoperative ward of a hospital for seriously wounded should he organized to deal particularly with this condition. Since the subject of shock and its treatment is covered in detail in Chapter ATI of this volume, no further reference is made to it here. Bound up with the question of an accurate diagnosis are the questions of abdominal penetration and visceral injury. A tangential abdominal wound, especially if the tract is a short one, frequently- gives no peritoneal penetration. With such wounds, where peritoneal irritation is lacking, the probability of abdominal entry is small. As demonstrated by Wallace,8 a wound above the pyloric level with entrance and exit to the right of the median line seldom results in visceral injury though the peritoneum may have been entered. Other through-and-through wounds mean certainly that the peritoneum has been penetrated but occasionally- without visceral injury-. With only a wound of entrance, diagnosis becomes more difficult, and under these circumstances the X ray- may give the greatest aid to the surgeon. Accu- rate information quickly obtained by means of a roentgenological examination is often the most important guide to the character of the wound with reference to visceral injury- and to the exact situation of the missile. SYMPTOMS OF VISCERAL INJURY The general symptoms are those of shock, hemorrhage, pulse acceleration, and vomiting; the local ones, abdominal pain, tenderness, rigidity, and dis- tension. The symptoms of shock are well known and its causes in abdominal injuries have been already enumerated. There may be no symptoms of shock even in the presence of serious visceral injury. Though hemorrhage may produce little in the way of physical signs, the cardinal symptoms are a rapid, soft pulse, a low blood pressure, and obvious anemia. Patients with hemorrhage may exhibit excessive thirst and fre- quently show signs of air hunger. With any amount of bleeding intraabdominal fluid may be detected in the flanks, and local peritoneal signs may be moderately- marked. The face is blanched and listless when the degree of hemorrhage has been considerable; it is anxious w7hen infection in the peritoneum is progressive. Whether there is hemorrhage or not, pulse elevation is the rule. With a peritonitis in progress the pulse rate steadily rises, and this sign is one of the valuable guides in demonstrating hollow visceral lesions. It is especially- important in excluding a parietal wound with considerable muscle injury where local signs of peritonitis may be closely simulated. Vomiting is usually present with a hollow viscus penetration and becomes more marked as peritonitis becomes more severe. Gastric wounds give earlier vomiting, with a vomitus frequently containing blood. On the other hand GENERAL SURGERY 451 wounds of the stomach sometimes occur with an entire absence of vomiting, so that this symptom can not be termed characteristic of gastric injury. There is a great variation in the degree of abdominal pain, and the surgeon can not pass judgment upon the severity of the visceral lesion from the amount of pain the patient suffers. The location of the pain usually- gives little aid in the attempt to localize the viscus injured. The most important feature of the pain from a diagnostic standpoint is its inception simultaneously- with the receipt of the wound. The soldier abdominally- wounded may- have received a considerably dosage of morphine prior to admission to hospital, and if this has been promptly given his complaint of pain may be absent, particularly- if he is seen early. The local tenderness is the most pathognomonic sign of a ruptured hollow viscus and is the most constant physical symptom of peritonitis. It is alway-s present and is localized over the region involved. It may be masked somewhat by morphine but it never disappears completely-. Tenderness is also present with parietal wounds and contusions, but the other signs of visceral penetration are lacking. Muscular rigidity is a very important sign of visceral injury, but it is less constantly present than tenderness. Charles 9 has seen cases of multiple per- foration with an entire absence of muscular rigidity and again has encountered boardlike rigidity in severe wounds of the abdominal wall. Wallace 8 and many others have enumerated certain injuries wiiich may be accompanied by marked rigidity without injury of an abdominal viscus. The more important are chest wounds with no abdominal lesion, wounds of the abdominal wall, and hemorrhage into the retroperitoneal tissues. The rigidity- of an advanc- ing peritonitis is generally progressive and increasing in intensity, while rigidity from introabdominal hemorrhage is less marked, and usually diminishes gradu- ally if the hemorrhage has ceased. Muscular rigidity- as well as local tender- ness may be all important symptoms in diagnosing a visceral perforation when the wound of entry is in some remote region and the possibility of an abdominal lesion seems very unlikely. Abdominal distension is not an early or important symptom of visceral penetration. It becomes more pronounced as peritonitis develops, but it is then of little value in diagnosis. INDICATIONS FOR OPERATION Certain groups of cases come to the hospital in which operation is contra- indicated and these may well be considered here. Moribund patients should be made as comfortable as possible with mor- phine. A so-called moribund ward is practicable and fills a good purpose. The patients in it must not be left surgically unattended but should be followed through to the end. Cases with general peritonitis from a hollow viscus injury 24 or more hours old are generally hopeless subjects for radical treatment: Nearly 100 per cent mortality occurred among such of our cases following operative interven- tion x The expectant plan should invariably- be followed. Morphine in liberal doses Fowler's position, heat, rest, alkaline fluids, sugar solution by rectum, 452 SURGERY and saline solution beneath the skin are the lines of treatment to be followed. These cases must be carefully- separated from the moribund class. Unless thev are kept under constant supervision the rare individual whose peritoneal defense mechanism may bring him into the operable class may lose his only- chance for life, because the psychological moment for operation is passed unnoticed. Except for the individuals in whom shock is due to progressive hemorrhage the badly shocked should be kept in the preoperative ward under the eye of the ward surgeon, but the final decision as to operability or nonoperability must rest with the operating surgeon. When there is no amelioration of the symp- toms of shock, operation should not be performed. As a working rule, the patient w-ho shows no tendency to reaction within two or three hours never reacts. Cases with through-and-through wounds of solid viscera without pro- gressive hemorrhage do w7ell without surgical intervention: the chances of recovery- are better when no operation is performed. The presence of hemor- rhage in these patients is usually differentiated from an advancing peritonitis by the pulse rate of 80 or 90. Such a patient should not be interfered with. Intervention frequently- results in a renewal of the bleeding when the abdomen is opened and disaster may follow7. Fluids by rectum or by hypodermoclysis with moderate morphine dosage are the indications. If the loss of blood has been considerable, transfusion may be resorted to when a fair degree of cer- tainty exists that hemorrhage has ceased. Short tangential wounds with unimportant abdominal symptoms, seen 8 to 10 hours after injury, are best left unoperated, but no such patient should be sent from the preoperative ward to one of the postoperative wards. During the height of an offensive military operation such an individual may easily- escape the eye of the wrard surgeon and a case in which operation may have become definitely- indicated may be overlooked. The basic indications for immediate operation are symptoms pointing to progressive intraabdominal hemorrhage or hollow visceral penetration. Walters10 and other surgeons speak of the obvious necessity-for operation in cases with visceral or omental protrusion; in cases with escape of gas or feces through the wound; and in cases with subcutaneous emphysema from the escape of intestinal gas, usually from the large bowel, into the tissues adjacent to the wound. Emphysema of such origin appears shortly- after the receipt of the injury- in contradistinction to the emphysema of gas gangrene. In a time of great stress the problem of the seriously wounded may be a difficult one to handle. Practically- it must be managed by- first operating upon the best operative risks. When the stream of badly- wounded becomes tremendous severe cases with wounds other than abdominal and with better hope of recovery must have the chance of life wiiich operation gives. A frequent revision of the cases in the preoperative ward must be made that the >urgeon may assure himself that no soldier with a fair chance of recovery with operation is passed bv. A good working principle is to operate if doubt of a hollow visceral lesion exists, for the mortality of such operation is exceedingly- low- when no visceral GENERAL SURGERY 453 penetration is found. In our evacuation hospitals the mortality for this type of operation was 6.5 per cent.11 Exploration of the abdomen with negative visceral findings is attended, therefore, with little risk, compared to the uncer- tain possibilities of a serious advancing peritonitis if the man is left unoperated. OPERATIVE TECHNIQUE Since no type of war wound presents such a complex problem as the pene- trating wound of the abdomen, the details of surgical technique must be studied with the greatest care. There is little doubt that nitrous oxide-oxygen is the least toxic and the best borne of all the narcotizing agents, but, unfortunately, it does not give the complete muscular relaxation which is essential to efficient abdominal surgery. Its administration requires a skilled anesthetist and a bulky apparatus. Ether is the agent universally employed and is by all odds the anesthetic of choice for abdominal cases. The ordinary open method of administration gives reasonably satisfactory- results; the equipment required is the minimum. Marshall,12 with an extensive experience, found fewer complicaticns when a warmed ether vapor was used, but in the American Army- this method was not given a trial. The shorter the period of anesthesia the less the degree of toxemia that will be produced and the better the prognosis for the patient. Two general rules may be followed to aid the surgeon in his choice of an incision: (1) Plan the incision to meet the visceral injury suspected; (2) avoid, if possible, the projectile wound site, and so diminish the liability to wound infection. Always make the operative w-ound sufficiently ample to insure an unhampered exploration. A wound of 8 or 10 inches usually suffices. Some advise the paramedian incision as the one for general use, while others favor an opening in the median line either above or below the unbilicus, depending upon the organ probably injured. The latter is the incision of choice in most cases. For the upper abdomen some operators prefer a transverse incision or an oblique one parallel to the costal margin. This gives excellent access to wounds of the spleen, liver, kidney, or upper colon. The greatest objection to this type of incision is the difficulty in making a neat, rapid, and satisfactory closure. With a lesion below the umbilicus, and a wound in the flank, a transverse or oblique incision should be made. Such an incision affords good access to the retroperitoneal tissues and wounds of the posterior aspect of the laro-e bowel. Transverse incisions in connection with abdominothoracic injuries are considered below under such lesions. The general principle of wound disinfection by careful dissection must be as carefully7 observed in abdominal surgery- as in wounds of the extremities. Careful excision of all soiled tissues must always be carried out if the patient's condition permits. At times this is best done before the abdomen is opened, and the instruments used should then be discarded. Sutures may be placed if the patient may be held for S or 10 days, but it is safer not to close the skin. It mav however, be wiser in very- serious cases to defer the abdominal wall dissection until the suture of the operative wound has been completed. Fail- 454 SURGERY nre to carry out an efficient debridement will result in an infected abdominal wall, with the possibility of serious consequences. Speed is important, but no false moves should be made. It must be remem- bered that an operation of more than one hour's duration usually means a shocked patient with little chance for recovery. Try to determine what organs may be excluded from the possibility- of injury, but err on tlie side of thorough- ness and keep the surgical traumatism to a minimum. Protect the skm adja- cent to the wound with towels and skin clips to avoid contact of the cutaneous surface with abdominal contents. Do as little as possible, at the same time making the operation a thorough one. If hemorrhage has been progressive or if upon opening the peritoneum there is more blood than w-as anticipated, seek at once for the source of hemor- rhage and check it by clamp, packing, or suture. Considerable hemorrhage from the mesentery means inevitable resection. Throughout the operation make the traction upon the abdominal wall as light as is compatible with proper manipulation of viscera. The detailed treatment to be applied in wounds of the various organs may be found below, where wounds of these viscera are discussed. Closure should be done carefully in lay-ers except in cases doing badly on the table, when through-and-through sutures may be employed. If the wound by the missile has crossed the line of operative incision it is better to leave the skin without sutures or but partially closed; and the same precaution against infection of the abdominal wall should be observed if a period of stress prevails and the work is necessarily somewhat more hurried. No drainage should be employed in sutures of the small intestines, unless a very- active peritonitis has developed. Xo drainage for stomach cases is necessary. On the other hand, drains of rubber dam (never gauze except to check hemorrhage) should alw-ays be used in wounds of the colon and rectum, especially those complicated by retroperitoneal injury. Gauze drainage for liver or spleen should be employed solely for hemostatic purposes. Drains are used to provide an outlet for leakage from the large bowel or to check hemor- rhage, but should never be thought of as effectively draining the general peri- toneal cavity. POSTOPERATIVE TREATMENT Practically- every one of these patients has suffered a loss of body fluids, and the administration of fluid is the chief indication. For wounds of the solid viscera, stomach, and small intestines a Murphy drip of 5 per cent sodium bicarbonate solution, with or without 5 per cent glucose, is the method of choice; or similar enemas at four or six hour intervals may be substituted. For wounds of the colon and rectum, hypodermoclysis with saline solution meets the indications. Saline infusion may be used in any case wiiere con- siderable hemorrhage has occurred, but only as a temporary- measure to tide over the man for a few hours until blood may be obtained. Transfusion in this latter group is frequently essential to recovery-, and it may be necessary to repeat it. Blood grouping should always be done before transfusion, as it takes but a moment w-hen Vincent's macroscopic test is used. Group IV GENERAL SURGERY 455 donors (Moss' classification) may be employed for a recipient of any of the four groups. Citrated Group IV blood may be collected at a distance and transported to the hospital in sterile bottles, and such blood may be kept for upward of 24 hours without fear of clotting. If there is no vomiting, water or very dilute alkalies may be given by mouth, but no fluid food should be taken for the first 24 hours. Restoration of the physiological activity- of the bowel probably- requires a still longer interval. Pain is a constant postoperative symptom and morphine is a very important therapeutic agent for its relief. It should be given freely during the first 24 hours, moderately during the second, and sparingly or not at all during the third 24-hour period. If the patient is doing badly such a rule can not be adhered to and morphine should be given freely to the end. Distension of the abdomen is a variable symptom, but is generally fairly marked and contributes much to the patient's discomfort. It is best treated by colonic irrigation, pituitrin, and local heat when the latter may be applied without discomfort to the patient. Fowler's position is particularly valuable in wounds of the lower abdomen, since it helps to localize the inflammatory process. It also helps to relieve the distension, especially when a rectal tube is made use of from time to time. The position may be maintained fairly continuously for the first 48 hours or 72 hours. Vomiting is usually present and may become a distressing symptom. It is caused by the postoperative ether toxemia, the peritoneal traumatism incident to the wound and the operation, to an advancing peritonitis, or to a dilated stomach. If withholding of fluids by mouth for a few hours does not result in an early cessation of vomiting, gastric lavage with warm water, with or with- out sodium bicarbonate, repeated at two or four hour intervals, is the most effective means of treatment. In all the conditions named, except the advancing peritonitis, lavage usually gives effective relief. The length of stay in the hospital in which operation has been performed and definitive treatment given should be from 7 to 10 days, or longer if military necessity will permit it. The period named brings the average patient far enough along in his wound healing and general convalescence to permit a safe evacuation to the rear. A certain small number of evacuated cases may develop postoperative complications, but mditary exigencies will usually allow the really bad cases to be retained forward for a longer period than the time used. Above all, careful nursing and continuous care on the part of the surgeon must be avadable, or many patients wdl suffer and a certain number succumb who otherwise might be saved. The dressing must be done by the most experienced hands avadable, the operator or his assistant doing this work when- ever it is physically possible. If a w-ard surgeon dresses the wounds the surgeon himself must supervise his work and personally direct the patient's convalescence. POSTOPERATIVE COMPLICATIONS The more frequent and, therefore, important complications are infection and the development of fecal and urinary fistulse; secondary hemorrhage, nephritis, and pulmonary- complications are less often seen. 456 SURGERY Infection is encountered in the form of local wound infection, as a localized peritoneal abscess, or as general sepsis. The wound healing is good or bad in direct proportion to the amount of infection present in the abdominal wall. The surgeon's first effort, therfore, in combating wound infection is the pre- vention of it by painstaking surgery at the time of operation. Careful debride- ment of the abdominal wall and proper placing of the abdominal incision with respect to the wound, combined with the nonsuture of skin and subcutaneous tissues in doubtful cases, are the most important details to be observed. The surgeon must also carry out only partial skin closure in the presence of an active purulent peritonitis, as the parietal wall will necessarily be more or less con- taminated. Very disastrous gas and streptococcus infection of the abdominal wall may develop, usually- early in the postoperative course, and such a condi- tion calls for wide incision, combined, where possible, with Carrel-Dakin treatment. Evisceration of considerable intestinal contents may occur with an infected abdominal wound, and such cases usually do badly. Immediate replacement of viscera must be accomplished with rapid resuture of the perito- neal muscular, and fascial layers. Localized peritoneal abscess is more often a later complication, occurring from a few days to two or three weeks after operation. It may complicate a fecal fistula. It is the most favorable outcome to be looked for in a case of diffuse peritonitis. Considerable difficulty in making a proper diagnosis of the location of the purulent collection may be encountered. It may be placed in practically any portion of the peritoneal cavity and may point in the buttocks, perineum, or flanks. Cases of infection following local leakage into the retro- peritoneal tissues are the most difficult ones to diagnose and treat successfully7. The indication in all these cases is drainage by the simplest possible procedure. General sepsis is relatively- infrequent. The fatal cases of peritonitis usually die within a few days before sepsis has become general. It may occur in connection with retroperitoneal infection or with badly infected operative or projectile wounds. Xo effective treatment has been found to combat general sepsis successfully. Fecal fistula is a frequent complication of wounds of the small and large intestine, being encountered most often after suture or resection of the latter. It also follows operation for inaccessible rectal injuries. It may occur at any time in the postoperative course of the abdominal wound, and the fecal discharge usually appears in either the operative wound or along the original wound tract where inaccessibility has made a careful dissection impossible. Makins13 cau- tions us to bear in mind that a bruised intestinal wall without complete entry of the lumen may at times break down with the formation of a fecal fistula. Such instances have been verified by the findings of a previous exploratory- operation. Frequently a fecal fistula will close spontaneously, particularly- one complicating operation. In a small proportion of cases, however, suture or resection may be required to relieve the condition. Every precaution must be taken in such an operation to isolate the general cavity from the operative field; and adequate drainage, preferably with rubber dam, should be provided. Such a type of operation is usually done in the base hospital when it has be- come evident that the fistula will not close spontaneously-. GENERAL SURGERY 457 Secondary hemorrhage is rare as a sequel to abdominal injuries. It may occur from septic erosion of a large vessel or from a reopening of a partially- healed w-ound of a solid viscus. The treatment is the same as for primary- hemorrhage. Any of the inflammatory processes of the lung or pleura may complicate the postoperative course of an abdominal lesion; they are, however, compara- tively infrequent. The most striking pulmonary complications encountered by the writer w-ere four cases of pulmonary embolism (diagnosis being made by symptoms, since no autopsy could be performed) which wore fatal in from one-half to two hours after the intravenous injection of gum solution. The further use of this agent was discontinued by the writer and his associates. Nephritic complications are comparatively infrequent. The indications for treatment are the same as in civil surgery-. TREATMENT OF VISCERAL INJURIES In a certain proportion of cases the peritoneal cavity7 is opened without any injury of the viscera. Practically this group may be considered in connection with nonpenetrating wounds of the abdominal wall. The possibility- of an infection of the peritoneum from the retained projectile, or from foreign mate- rial carried into the peritoneal cavity, makes them definitely- more serious than the nonpenetrating wounds. The missile, however, usually becomes encysted, when it may give no symptoms whatever. In rare instances a localized peri- toneal abscess may- result. Cases with short tangential wounds, and the occasional cases in which after 8 or 12 hours no alarming abdominal symptoms have developed and in which the patient's general condition is excellent, are particularly- the ones in which the question for or against operation may arise. When any doubt of the wisdom of intervening exists it is better to operate. As stated above, it is far better to open every abdomen when there is question as to visceral injury- than to abstain, for the mortality- after operation wiiere no visceral lesion is found is very- small and the hazard is a tremendous one if a true perforation of a hollow organ is left without operation. Further, opera- tion always furnished an opportunity- to search for and often to remove the foreign body itself. te ' WOUNDS OF THE STOMACH Stomach wounds comprise about 7 per cent of all abdominal injuries coming to the hospital for treatment. Two-thirds of all gastric lesions show no other accompanying visceral injury- discoverable at operation. Wounds of other organs most often encountered are those of the small gut, liver, colon, kidney, and spleen, in the order of their frequency.1 The wounds are usually- two in number and are most often situated on the anterior and posterior walls. If the anterior opening is small and the organ was not distended at the time of injury- there may be no protrusion of mucous membrane and no escape of gastric contents. Leakage may. however, occur into the lesser sac when none is present anteriorly-. If but a single wound is present it is usually of the anterior wall. Under the conditions, great care must be exercised in excluding a posterior wall perforation, for in comparison with the 458 srnoKKY injury of the anterior aspect that of the posterior may be much more difficult to detect. Lesion, of the borders and orifices are comparatively infrequent. Considerable damage to the gastric wall is more often seen with wounds of the lesser curvature and those parallel to the walls of the stomach. The more ragged and larger wounds are usually caused by shell and hand-grenade frag- ments and machine-gun bullets fired at close range. There are local signs of peritoneal irritation, but these are definitely less marked than with injuries of the small intestine. Only moderate shock is present in most of the cases; where a severe hemorrhage has occurred the degree of shock is profound. Exceptionally, there is no gastric leakage into the peritoneal cavity. The cardinal symptom is early and persistent vomiting. Rarely, however, vomiting may be absent. Escape of gastric contents or gas may- take place from the abdominal wound. Very rarely recovery has been reported without intervention. The safe rule to follow is operation in practically- every case. The best incision is the median or paramedian. The perforation of the anterior wall of the stomach is readily recognized. The opening in the posterior wall is best sought for through the gastrocolic omentum just below the stomach. Pauchet's approach, recom- mended by Eastman,14 is made through an opening in the mesocolon, the line of dissection passing just above the transverse colon. This frequently gives good access, but it is not recommended for general use, as repair work is more diffi- cult when this technique is used. A ragged wound should be trimmed off rapidly before suture. The greatest difficulty in accomplishing a good closure of the stomach wall will be found with wounds involving the lesser curvature and those high up near the cardiac orifice. Gastroenterostomy should be avoided if possible, for a higher mortality results in the cases in which it is performed. Drainage in gastric cases should be employed only where a fairly well developed peritonitis is present or if suture of the stomach wound is difficult or impossible. The most important precaution to be observed in the postoperative care of these cases is careful feeding. Only w-ater should be allowed by mouth during the first 24 hours and liquid diet for the following three days. The seriousness of gastric lesions is in no wise comparable to the grave con- ditions caused by wounds of the small intestine. A favorable outcome may- be possible even if the case is seen a considerable time after receipt of the injury-, as peritonitis advances comparatively slowly. Numerous cases have re- covered where operation has been performed from 24 to 36 hours after the receipt of the wound. The mortality of all gastric wounds is approximately 55 per cent.1 Uncom- plicated wounds of the stomach give a mortality varying from 25 to 50 per cent. WOUNDS OF THE SMALL INTESTINE The proportion of total small intestinal wounds, complicated and uncom- plicated, to all abdominal lesions is approximately 22 per cent.1 Wounds of the colon are much more frequently- encountered than those of any- other complicating visceral lesion. The injuries next in order of frequency are those of the stomach and bladder, while wounds of the liver, kidney, rectum, and spleen are still less often encountered. GENERAL SURGERY 459 Duodenal injuries are fairly infrequent, comprising approximately- 6 per cent of all small gut wounds.1 Injuries to the jejunum comprise about 23 per cent; to the ileum approximately- 71 per cent.1 Multiple lesions are almost universally- encountered, at times reaching the number of 15 or 20, but the average number to be expected is from 4 to 6. The wound may be small or large, depending upon the character of the missile, the velocity- at which it is traveling, and the angle of entry into the gut. When the projectile strikes the intestine vertically- two perforations are almost invariably found. As a rule there is a certain protrusion of the mucous membrane, but if the w-ound is a small one there may- be no pouting and such cases may show no leakage. The more nearly parallel the wound is to the long axis of the gut the more the damage to the visceral wall and the larger and more ragged is the wound itself. Ex- tensive laceration of the intestinal wall and even complete division of the gut are not so very unusual; in such cases a considerable tearing of the mesentery is frequently found. The mesenteric lesions are especially important from the standpoint of hemorrhage and because of the necessity for resection with its added shock and operative hazard. It is generally best to begin the exploration of the gut at the ileocecal valve, but if the wound is high up the duodenojejunal junction may be first examined. Work rapidly upward, if beginning at the ileocecal valve, or downward, if beginning at the duodenojejunal angle, being careful to replace within the abdomen every 8 or 10 inches of segment after its examination. In this way the entire ileum and jejunum with their mesentery- are carefully examined for perforations. When a wound of the intestine is encountered clamp the opening tightly, protect it with a pad, and hold it outside the abdomen, and as each lesion is discovered treat it in the same wrav. It is a good general rule to refrain from repairing any perforation until the entire length has been examined. The writer has seen a small gut suture, requiring 15 minutes, performed upon a segment of small intestine that later had to be resected because of mesenteric injury. Exception to this rule mav be taken when normal bowel and mesentery are present several inches to each side of the lesion or where a large number of perforations with their pad coverings would form a serious obstacle to efficient technique. Careful search for complicating wounds of the stomach should then be insti- tuted and the lesions appropriately- treated. Other visceral injuries should be sought for and the colon should as a rule be the last one explored, as lesions here may necessitate performing a colostomy-. If, during the course of an operation, a w-ound of the colon is encountered, it is wiser to treat it immediately if suture only is required. The vast majority- of small intestinal wounds are satisfactorily closed by a single purse-string suture of silk or chromic gut. Suture should always be practised if possible, as resection is attended with far greater hazard. With numerous small lesions close together, suture is preferable; if gut damage has been considerable, resection may prove to be the better procedure. The best rule is to resect only when it is impracticable to suture. A double row of sutures should always be employed when resection is done. 460 SURGERY The postoperative care of cases with small gut injury has been outlined above under the general discussion of penetrating abdominal wounds. The frequency of wounds of the small intestine and the high mortality attending operation for their relief make these injuries the big problem in abdominal military surgery. The mortality rate in cases of wounds of the small intestine in the American Expeditionary Forces, including the operated and unoperated, w-as as follows:1 Duodenum, SO; jejunun, 78.8; ileum, 73; small intestines (not specified), 70.9. Resection gives regularly a mortality 50 per cent higher than does suture. WOUNDS OF THE COLON Wounds of the colon represent about 22 per cent of all intra-abdominal visceral injuries.1 Perforating wounds of the colon are much less often multiple than those of the small gut because of the lack of numerous intestinal coils. The multiple lesions that occur usually involve the pelvic colon. Some of the smaller per- forations may be due to minute bone spicules penetrating the bowel wall, and this type of lesion is much more difficult to recognize than an injury primarily due to a missile. Some of the wounds are large and ragged and a complete division of the bowel may be found, but less frequently than in wounds of the small intestine. Retroperitoneal perforation with its consequent fecal leakage and cellulitis constitutes one of the difficult problems to be dealt with. The posterior perforation may be a minute one which is difficult to recognize. Injuries of the portions of the gut which are without a mesentery, the ascending and descending colons, are particularly liable to be accompanied by a serious retro- peritoneal infection. Retroperitoneal injury of the transverse colon may only be detected when the lesser sac is explored. The symptoms and diagnosis of wounds of the colon have been considered above in the discussion of abdominal wounds under the heading of u Diagnosis.'' The special factors which make diagnosis difficult are the liability to retro- peritoneal infection and the inaccessibility of the splenic and hepatic flexures, particularly the former. A grave acute sepsis may rapidly develop in connection with retroperitoneal cellulitis. Further, the type of peritonitis which the surgeon encounters in connection with perforations of the colon is very likely to produce more aggravated local and general symptoms than that associated with the involvement of the small intestine. Xo one incision will satisfy all requirements with wounds of the colon. A median or paramedian incision is best used when a lesion of the transverse or pelvic colon is to be dealt with. The best incision for wounds of the cecum or of the ascending and descending colon is a transverse one in the flank, for this allows an easy access to the posterior portion of the bowel and a better chance of discovering a posterior perforation. The incision of choice for either of the colonic flexures is a subcostal incision on either side, prolonged vertically downward if additional space is required. This incision is particularly- valuable on the left side because of the posterior position and inaccessibility of the splenic angle. The general principles to be followed are: Suture whenever possible GENERAL SURGERY 461 to secure a satisfactory closure, and always employ- a double row- of sutures. Avoid resection; colostomy is to be preferred. If a colostomy is performed a resection done at a later date sometimes gives a satisfactory7 result. Colostomy is to be advised with large ragged openings, particularly- those occurring in the cecum, descending colon, and sigmoid. Drainage is a most important factor with wounds of the large bowel. Always drain when any doubt of the integrity of the suture line exists and in every case of proved or questionable retro- peritoneal injury. There is a slightly lower mortality record with wounds of the large intestine than with those of the small bowel, the figure for the former being 59.6 per cent.1 The cases that do badly die from retroperitoneal sepsis, wiiich may7 be most acute, or from a peritonitis secondary to fecal leakage, preceding or subsequent to operation. The wounds that are sutured do better than those in which an artificial anus is employed; the latter group gives the high mortality- rate of 70 per cent.1 WOUNDS OF THE RECTUM Injuries of the rectum are comparatively7 infrequent, constituting 2.4 per cent of the lesions of abdominal viscera.1 Complication by other injuries is infrequent. Associated lesions which may- be encountered are those of the bladder and pelvic colon, or, less frequently, injuries of the small bowel. The lesions vary in size from small perforations caused by- a minute pro- jectile or a fragment of bone to extensive lacerations. Wounds of the rectum often show- a wound of entrance in the buttock or upper portion of the thigh or in the perineum. If the wound is an extraperitoneal one, fecal leakage pos- teriorly7 may occur, with the rapid development of a grave cellulitis. Intraperitoneal injury of the rectum gives rise to a rapidly developing acute peritonitis which is still more aggravated if complicating lesions are present. A wound of entry through the buttock or perineum in a patient exhibiting symptoms of peritonitis in the lower portion of the abdomen should always make the surgeon suspicious of a rectal injury-. Local tenderness in the posterior rectal wall made out by the examining finger in the rectum and associated with evidences of infection in the perineum always suggests an extraperitoneal rectal wound, especially wiien associated with general symptoms of a septic type. The extraperitoneal injuries are best treated by careful debridement of the buttock or perineal wound, the dissection being carried upward and into the rectum. It may be necessary to open widely the lower segment of the bowl in order that complete dissection of the tract may be accomplished and that adequate drainage may be most effectively- placed in the retroperitoneal tissues. Extensive lacerations of the lower segment may require a colostomy. Intra- peritoneal injuries are treated by a median laparotomy with suture of the opening wherever it is possible to accomplish it. Drainage through the lower angle of the operative wound should always be practiced, rubber dam being the best material for the purpose. If a suture can not be made, owing to the depth of the rectal wound in the pelvis, a colostomy should be performed. The mortality- with wounds of the rectum is 45.19 per cent.1 Usually death is due to a rapidly advancing sepsis in the retroperitoneal tissues or to a severe spreading peritonitis. 462 SURGERY WOUNDS OF THE LIVER Wounds of the liver comprise 13.3 per cent of all abdominal injuries.1 Approximately three-quarters of all liver lesions are uncomplicated ones. Associated wounds to be considered are, in the order of frequency, wounds of the colon, stomach, and kidney; injuries of other organs are much less often found. Clean-cut liver wounds are very unusual. There may be any type of lesion from a small perforation to a slit or a large ragged excavation, and in some cases a loss of liver substance is encountered. Whatever the type of projectile, a large wound of exit is to be expected, and lacerations in all wounds is the rule. Hemorrhage is always present, varying from a slight oozing to a severe and rapidly fatal hemorrhage. More often the bleeding tends to subside spontaneously. Peritoneal symptoms are to be expected from the presence of blood in the peritoneal cavity. A dullness in the flanks, particularly on the right side, may be made out if the amount of bleeding has been considerable. A case seen two or three days after the injury frequently shows a slight degree of jaundice; late jaundice usually means sepsis. Where the loss of blood has been considerable the patient exhibits a marked degree of shock. The diagnosis of liver injury is made from the position of the wound and the symptoms of intraabdominal hemorrhage. The early appearance of jaun- dice should make one suspicious of liver injury. As a general rule the expectant treatment should be followed. Operative intervention should be made when other visceral lesions are suspected, where the hemorrhage is serious and progressive, or where the foreign body retained is a very large one. The incision best suited for the management of liver wounds is a right subcostal one, though a median or paramedian approach may- give adequate exposure. When the abdomen is entered, if a small wound is found without active hemorrhage, it should be left alone. A larger wound from which the bleeding has ceased should be packed or sutured, preferably the latter, for secondary hemorrhage from such a wound is not unlikely. In placing sutures use a large round needle, blunt end first, the suture being of a mattress type. This form of suture should not be drawn tightly- in order to prevent its cutting through the liver substance. A properly placed suture will eff ectivcly control a very active hepatic hemorrhage. The retained foreign body, if of considerable size, should be removed in order to avoid the subsequent compli- cation of liver abscess. The shock present should be combated with heat administration of fluids, and adequate doses of morphine. When the loss of blood has been considerable and the hemorrhage is no longer active transfusion should be performed. The mortality rate of liver wounds is 66.27 per cent.1 A considerable number of uncomplicated wounds of the liver treated expectantly get well. The cases of this type operated upon give a mortality of about 5 per cent;1 the mortality rate to be expected if complicating lesions are encountered is in the neighborhood of the mortality- rate for liver wounds as a whole. Certain of the cases with retained foreign body in the liver develop a hepatic abscess and may- succumb to sepsis. GENERAL SURGERY 463 Wounds of the gall bladder and bile ducts are so comparatively infrequent that any special consideration of them will be omitted. Records of but 9 cases in the American Expeditionary Forces exist, with a mortality- rate of 77.7S per cent.1 WOUNDS OF THE PANCREAS The cases reaching the hospital comprise about 0.2 per cent of all abdom- inal injuries.1 The proximity of the organ to the great vessels may give a rapidly fatal result upon the field of battle, so that a certain proportion of these cases never reach the hospital. The accompanying lesions usually- found are those of the stomach; other organs are much less frequently involved. The one important element to success is adequate drainage. At least half of the cases prove fatal from an undiscovered or poorly drained injury. The writer had one case showing an anteroposterior wound in the epigastrium. Operation revealed a small shell fragment lodged in the head of the pancreas with an associated contusion but no penetration of the adja- cent duodenal wall. The foreign body w-as readily removed, and wound in the pancreas drained, and the patient w-hen last seen, seven days after opera- tion, was convalescing satisfactorily. WOUNDS OF THE SPLEEN Wounds of the spleen are much less frequent than those of the liver, 49 only having been recorded as occurring in the American Expeditionary Forces.1 Two-thirds of the splenic wounds show complicating lesions. The injuries may be of all types, from a small perforation or moderate laceration to a complete separation of a considerable portion of the organ, or an avulsion from its pedicle. The visceral injury- most frequently complicating a splenic wound is a lesion of the kidney; organs less often involved are the colon and stomach. As with wounds of the liver, hemorrhage is the chief symptom along with the shock resulting from it. The intraabdominal signs of hemorrhage described under wounds of the liver apply equally- to splenic wounds. The fluid, however, is more apt to accumulate in the left flank. The diagnosis is made from the position of the wound and the accompanying signs of hemorrhage and shock. The best incision of approach is the left subcostal, but a left rectus incision may give adequate access. In some cases a liberal median or paramedian incision may give abundance of room. The incision for abdominothoracic injuries is dealt with in a subsequent paragraph. Where the hemorrhage is inactive and has not been of large amount abstention is the best rule to follow- in an uncomplicated case. A small wound encountered at operation and show- ing no active^ hemorrhage should be left alone. Suture in the splenic tissue is less effective in controlling hemorrhage than in liver tissue1, and a continuation of the bleedino- is always a possibility-. Packing in cases of this sort is desirable. Splenectomy, though advised by some writers, notably- Depage,15 gave practi- cally a 100 per cent mortality in the American Expeditionary Forces.1 The treatment of hemorrhage and shock is the same as with liver injuries. The mortality rate is 63.26 per cent.1 Hemorrhage is the cause of death in practically all the uncomplicated cases. 4(i!)!>7—'27------IV2 464 SURGERY WOUNDS OF THE KIDNEY Wounds of the kidney constitute 6.3 per cent of all abdominal injuries;1 one-half of the cases are uncomplicated. Wounds of the right kidney are com- plicated by liver injuries in about one-third of all cases, and wounds of the eft kidney are attended with splenic lesions almost as frequently, lhe hollow- viscera most often wounded are the small gut or colon, while stomach lesions are less frequently encountered. Wounds of the hilum include injuries to the renal vessels or to the pelvis itself. Wounds of the renal vessels are usually serious and often fatal because of the severe hemorrhage. It is well to bear in mind that an injury to any oi the renal branches results in necrosis of that portion of the kidney tissue which the vessel supplies, as the anastomotic circulation of the kidney is very poorly- developed. Injuries of the pelvis itself are comparatively rare and require no further discussion. Wounds of the parenchyma may be of any type from a simple perforating or tangential wound to a very- extensive laceration or destruction of the organ. The X ray gives important aid in arriving at a correct diagnosis in this group of cases. ^Hemorrhage as well is an important symptom; the bleeding may occur from the external wound, it may appear in the urine, or may form a retroperitoneal haematoma. Bleeding into the peritoneal cavity may take place if the rupture has been intraperitoneal. Under such conditions one may expect a tender and rigid abdominal wall with dullness in the flank. Under any circumstance, if loss of blood has been considerable, the patient may exhibit symptoms of shock. Leakage of urine is present w-hen the pelvis of the kidney has been opened or the ureter has been torn, but seldom with wounding of the parenchyma itself. Retention of urine is seen in a certain proportion of cases. Sepsis is a later complication, which may develop where inadequate drainage has been estab- lished or where hollow visceral complications have resulted in a fecal fistula into the wound. Cases with sepsis exhibit all the symptoms common to this condi- tion. Vomiting is frequently seen. Out of 42 cases reported by Fullerton 16 arriving at a base hospital with kidney- lesions 9 suffered a secondary hemorrhage; 1 on the third day, 1 on the seventh day, 5 betw-een the tenth and fifteenth days, and 2 after four weeks. Conservatism should be the keynote in the treatment of lesions of the kidney. With a penetrating rifle wound and where these is no evidence of intestinal involvement rest and a liberal administration of opium are indicated. Alarming hemorrhage, urinary leakage, advancing sy-mptoms of sepsis, or a large retained foreign body are the principal indications for operative intervention. A complicating hollow visceral injury- requires immediate operation. The incision of choice is a transverse or oblique one, which may be extended as far forward as is necessary to give adequate exposure of the kidney or to treat other complicating visceral injuries. If a small lacerated wound with a retained foreign body is encountered the removal of the missile and drainage may be all hat is necessary for a satisfactory- recovery. Charles 9 advises under these GENERAL SURGERY 465 circumstances a debridement of the damaged kidney tissues, followed by suture and drainage. A rubber-covered clamp upon the renal vessels during thi> procedure gives satisfactory control of hemorrhage. If such dissection can be done with little sacrifice of kidney tissue it is a legitimate procedure. Xe- phrectomy should be avoided wherever possible, for in the push of advanced war surgery definite information as to the function of the other kidney- must of necessity be lacking. Xephrectomy, however, must be performed where the vessels themselves are seriously damaged or where the injury to the kidney itself is extensive. The mortality in uncomplicated cases varies from 25 to 30 per cent.1 The fatal cases far forward succumb to hemorrhage. In the rear areas sepsis and secondary hemorrhage are the chief factors leading to death. WOUNDS OF THE URETER Wounds of the ureter are infrequent. A gross injury calls for nephrectomy. Where a small wound is encountered suture may be attempted, but, in general, ureteral wounds will heal spontaneously- if left alone. WOUNDS OF THE BLADDER Injuries of this organ comprise approximately 5 per cent of all abdominal lesions and one-half of the cases are uncomplicated. In Fullertons17 series 70 per cent of the cases were complicated by intestinal or bone injuries or both. A wound of the rectum mav be expected in from 10 to 15 per cent of the cases. Injury of the prostate is comparatively rare. Cathelin,18 in a series of 29 bladder wounds, found that the entrance wa> placed posteriorly 18 times, anteriorly 7 times, and laterally- in the remaining cases. A wound of exit was present in but 5 of the patients. Bladder perforations may be caused by either the projectile or by bone spicules from the fractured pelvis. The lesion of the bladder may be extra- peritoneal or intraperitoneal and may vary considerably- in size. Legueu 19 reported 10 cases of fracture of the pelvis associated with bladder injury in wiiich a vesical calculus was demonstrable. Other observers have not so uniformly- encountered such conditions. Hemorrhage in connection with bladder wounds is usually not serious, but its occurrence into the bladder suggests an extraperitoneal lesion. With this type of injury a considerable haematoma is not infrequently found in the vicinity of the wound in the viscus. Urinary discharge through the entrance wound is fairly uncommon. An empty bladder should make one strongly- suspicious of an intraperitoneal perforation. Leakage of urine into the peri- toneal cavity causes a considerable degree of peritoneal irritation with definite local signs. Most of the extraperitoneal lesions result in pelvic cellulitis. In the long standing cases associated bone necrosis and calculus formation may be expected. and in most instances a cystitis still continues. Extraperitoneal lesions are best treated by wide incision down to the bladder wound, which sould be sutured if possible. Ample drainage of soft 406 SURGERY tissues must then be provided. Suprapubic cystotomy furnishes the best type of bladder drainage and should generally be employed. The patients suffering from intraperitoneal wounds, and especially those with associated visceral lesions, show such decided symptoms that little doubt exists as to the wisdom of laparotomy. Such lesions require operation with suture of the bladder wound and rubber-dam drainage down to the stitch line. A retention catheter or perineal drainage, preferably- the former, meets the indications; suprapubic cystotomy should be avoided if possible. Retained missiles are fairly frequent in the bladder. The projectile must always be sought for within the bladder, and if present removed. In the latter stages of bladder wounds one must consider the treatment of persistent urinary fistulaz calculi, and sepsis. Cathelin's method of dealing with persistent fistula, is an efficient one. He dissects a cuff of skin and infolds it by suture down to the bladder wall, later bringing muscle and aponeurosis over it. Calculi had best be removed by the urethra, with or without crushing, but a suprapubic cystotomy may be necessary. The treatment of sepsis is supportive but the cases usually- result disastrously. The presence of complicating injuries may require considerable modifica- tion in operative technique. If a rectal or colic injury is so extensive as to make a colostomy imperative a suprapubic cystotomy should be dispensed with. Very variable statistics will be found in the literature concerned with the mortality- rate following uncomplicated bladder wounds, but the average is about 50 per cent. Where the bladder injury is associated with a lesion of the small intestine a much higher figure is reached, running to 75 or 80 per cent. The causes of death are sepsis, general peritonitis, or, much more rarely, a secondary hemorrhage from the pelvic vessels. An important prophylactic precaution in the avoidance of bladder wounds consists in an invariable order that soldiers should empty their bladder before going into action. ABDOMINOTHORACIC INJURIES These wounds comprised 4.6 per cent of all the thoracic injuries coming to the evacuation hospitals, American Expeditionary- Forces, for treatment.11 The lesions encountered are thoracic, diaphragmatic, and abdominal. Duval,19 gives the general rule that with a wound of entry in the chest the thoracic lesions are more apt to be the serious ones, while with entry through the abdomen the abdominal injuries are more often the graver ones. Frequently there are several wounds of the lungs and more than one lobe is occasionally- involved. The types of lesion are the same as one encounters in simple thoracic wounds. A certain amount of hemothorax is always present, but the amount is variable. In approximately one-third of the cases a hollow abdominal organ is penetrated. An uncomplicated liver injury- is more common than one of the spleen. The wound in the diaphragm may be made either by the projectile or by a fractured rib. The diaphragmatic wound may vary from a small puncture to an irregular opening of large size; the shape is often slit-like, in which instance it GENERAL SURGERY 467 is usually not more than an inch long. In about 10 per cent of the cases herni- ated abdominal organs will be found in the chest cavity. The omentum is the structure most often seen, and if viscera are extruded into the thorax the omentum usually accompanies them. Next in order of frequency are the spleen, stomach, and transverse colon. Practically all herniations occur through a wound in the left side of the diaphragm. Through-and-through wounds involving both sides of the diaphragm are seldom encountered in the hospital, for most of them die far forward before evacuation can be carried out. The pathognomonic symptoms of abdominothoracic wounds are dyspnea, the breathing being rapid and labored; sudden pain in the abdomen at the time of the receipt of the wound; hemothorax; abdominal rigidity- over the corresponding half of the abdomen, especially in its upper part; and shock, which is partially- dependent upon the degree of hemorrhage and partially upon the respiratory distress. Other abdominal symptoms such as definite local tenderness and vomiting may also be evident. Course of Treatment Dependent Upon Type of Injury If there are separate wounds of entrance for the abdomen and chest and the latter one is not a blowing wound, the abdomen should be opened imme- diately if a hollow visceral lesion is suspected, and the chest should be left undisturbed. With a wound of entrance on the right side of the chest authors vary as to the procedure to be adopted. If the missile is a small one and X-ray- examination localizes it in the liver the wisest course is nonintervention. If the chest wound is a blowing one it should be closed by suture in which the muscular layer is included. Xo blowing chest wound should ever be allowed to get past the regimental dressing station without a closure of the muscular layers of the wound by suture. This rule should be adhered to even if asepsis can not be maintained. Many- advise operation in this group of patients, the steps being debridement of the chest wall, and exploration of the diaphragm and liver through an intercostal or vertical w-ound after the chest lesions have been cared for. The foreign body is removed from the liver when possible, the diaphragm sutured, and finally the chest itself closed without drainage. With a wound on the left side above the level of the eighth rib and an associated abdominal injury which is high up a different problem is presented. Excellent constructive surgery has been developed by Duval20 in cases of this tvpc. He uses a vertical incision upon the chest wall, beginning near the thoracic wound. The ribs are sectioned in order to allow access to the thorax, and the prolongation of the wound downward opens the abdomen; at times this lower extension may be continued obliquely- forward. Other surgeons employ7 a transpleural approach to the upper abdomen with an incision w-hich is rouo-hlv transverse. A rib may be resected, or access may be had through an intercostal space with the aid of Lilienthal's rib spreader. The chest wound is carefully dissected out and any soiled rib or loose bone fragments are removed. With fresh instruments the pleural cavity is explored and any lesions encountered are taken care of. The wound in the diaphragm is then sought for and enlarged up to 5 or 6 inches; this exposure gives a satisfactory 4(iS SURGERY approach to the abdomen. Any abdominal injury found is cared for and the diaphragm closed. It is generally- wise to obliterate the pleural space low- down by suturing the diaphragm to either the lung or the lateral pleural wall. The chest should be closed without drainage. With a wound on the left side and the point of entrance below the eighth rib the lesion within the abdomen is apt to be more serious. In this group of cases the abdomen should first be dealt with through a separate incision. At times it is possible to deal properly- with the opening in the diaphragm from below. If the pulmonary injury warrants intervention it may be ex- plored through an intercostal space. The closing off of the pleural cavity- is accomplished as described in the preceding paragraph. Duval to the contrary- notwithstanding, the mortality- rate is principally- due to the lesion in the abdomen, and is distinctly- higher wiien a hollow vis- cus has been penetrated. LESSONS IN CIVIL ABDOMINAL SURGERY GAINED FROM THE WAR The contributions of the war to civil abdominal surgery may be sum- marized as follows: (1) It has shown the types of tangential wounds w-hich are not infrequently without visceral lesions. (2) It has taught the un- wisdom in most cases of relying upon the so-called expectant treatment of abdominal wounds and the soundness of early radical operation. (3) It has demonstrated the wisdom of waiting an hour or so before operation is attempted in cases with severe shock. This rule applies, of course, only to those instances where shock is not due to active hemorrhage. (4) It has taught us the best methods of handling abdominothoracic injuries. (5) It has given an unusual opportunity- to review the whole subject of abdominal drainage, strengthening our convictions that the general peritoneal cavity- can not be drained, but that it is possible to drain a single focus within the peritoneal cavity-. (6) It has emphasized again and again that speed, dex- terity, simplicity7 of technique, and the minimum of traumatism are essential to success. REFERENCES (1) Based on Sick and Wounded Reports made to the Surgeon General. On file, Historical Division, S. G. O. (2) La Garde, Louis A.: Gunshot Injuries. William Wood and Company, New York, 1916, 2ded.,262. (3) Gibbon, John H.: Treatment of Gunshot Wounds of the Abdomen. Journal of the American Medical Association, Chicago, July 19, 1919, lxxiii, 187. i'4) Wallace, Cuthbert: A Study of 1200 Cases of Gunshot Wounds of the Abdomen. British Journal of Surgery, Bristol, 1916-17, iv, No. 16, 679. (5) General Orders No. 70, G. H. Q., A. E. F., May 6, 1918. (6) Organization and Operation of Mobile Hospital Units, by Col. E. C. Jones, M. C, undated. On file, Historical Division, S. G. O. '.7,1 Medical and Surgical History of the War of the Rebellion. Washington, Government Printing Office, 1876, Surgical Volume, pt. 2, 3-208. S,) Wallace, Cuthbert: A Preliminary Note on the Treatment of Abdominal Wounds in War. Journal of the Royal Army Medical Corps, London, December, 1915, xxv, 591. ;9) Charles, R.: Gunshot Wounds of the Abdomen at a Casualty Clearing Station. British Medical Journal, London, March 23, 191S, i, 337. GENERAL SURGERY 469 (10) Walters, C. Ferrier, Rollinson, H. D., Jordan, A. R., and Banks, A. Gray: A series of 500 Emergency Operations for Abdominal Wounds. Lancet, London, February 10, 1917, i, 207. (11) Based on reports of surgical operations at evacuation hospitals, A. E. F., undated. On file, A. G. O., World War Division, Medical Records Section. (12) Marshall, Geoffrey: Anesthetics for Men with Wounds of the Abdomen. British Journal of Surgery, Bristol, 1916-17, iv, No. 16, 733. (13) Makins, Sir George: A Study of One Hundred and Eleven Cases of Perforating Wounds of the Gastrointestinal Canal which Occurred amongst a Consecutive Series of Two Hundred and Two Perforating Wounds of the Abdomen in which the Presence of Visceral Injury was Certain. Journal of the Royal Army Medical Corps, London, 1916, xxv, No. 1, 1. (14) Eastman, James Rilus: The Question of Operation in Gunshot Abdominal Wounds. Journal of the American Medical Association, Chicago, September 28, 1918, lxxi, 1036. (15) Depage, A.: Note sur les plaies penetrantes de l'abdomen traitees a l'ambulance de l'Ocean a la Panne. Bulletins et memoires de la societe de chirurgie de Paris, March 14, 1917, xliii, 691. (16) Fullerton, Andrew: Gunshot Wounds of Kidney and Ureter as Seen at the Base. British Journal of Surgery, London, 1917, v. No. 18, 247. (17) Fullerton, Andrew: Observations on Bladder Injury in Warfare. British Journal of Surgery, Bristol, 1918, vi, No. 21, 24. (18) Cathelin, F. Blessures de guerre de la vessie. Lyon chirurgical, 1918, xv, No. 1, 109. (19) Legueu, F.: Des calculs vesicaux chez les blesses de la vessie. Bulletin de I'academie de medecine, Paris, December 5, 1916, lxxvi, 445. (20) Duval, Pierre: Plaies thoraco-abdominales. Comptes rendus de la conference chirur- gicale interalliee pour l'etude des plaies de guerre, 3d session, November 5-8, 1917. Archives de medecine et de pharmacie militaires, Paris. 191S, lxix, 355. CHAPTER XVI WOUNDS OF THE GENITOURINARY TRACT Shortly after the establishment of the American Expeditionary Forces a manual of urology0 was prepared and distributed to the Medical Department, A. E. F., with the view of standardizing, among other activities, the work of those medical officers in whose hands would fall cases requiring operative treatment for injury to the genitourinary tract, incident to battle.1 Since the text of this manual, in so far as the present subject is concerned, was based upon the existent literature, and since it proved of value in the work of medical officers, especially- consulting urologists, it has been largely drawTi upon in the preparation of this chapter. It is unfortunate that analytical studies of series of injuries to the genito- urinary tract could not have been made on cases while these were in hospital. Lacking these, recourse has been had to clinical records, which, being variously- prepared, frequently arc silent as to features that would have present value. WOUNDS OF THE KIDNEY Wounds of the kidney- in war are neither infrequent nor unimportant. It is true they are overshadowed in many- instances by the more frequent and fatal lesions of adjacent viscera and so are frequently overlooked. But since they- in themselves, though often fatal, are singularly amenable to intelligent treatment, the surgeon should not fail to focus his attention upon them. In 2,385 gunshot wounds of the abdomen in the American Expeditionary- Forces, the kidney was involved in 129 instances, a percentage of 5.44.2 To determine the relationship of the kidney injury with those of other organs, the clinical records of 66 members of the American Expeditionary Forces,3 show- ing injury to the kidney-, were analy-zed. In 38 instances no other viscus was involved. The association of lesions of other viscera was as follows: Liver, 11; spleen, 5; small intestine, 3; large intestine, 6. Thoracic viscera were injured in 11 instances in association, 2 of which are included above in connection with injuries of abdominal viscera. As to the nature of the missile, in 61 of the cases this was given as follows: Rifle and machine gun, 41; shrapnel and high-explosive shell, 20. PATHOLOGY A gunshot wound of the kidney itself may- involve only- the parenchyma, one of the larger renal vessels, or the pelvis. If the parenchyma alone is injured and the pelvis scarcely opened, the resulting microscopic hematuria may pass " The Manual of Urology for the Medical Department, A. E. F., was prepared by the author of this chapter in collab- oration with Maj. Edward L. Keyes, Capts. M. L. Boyd, Everard L. Oliver, W. H. Mook, and D. M. Davis, and Lieuts. J. E. Moore and William Jack, M. C. 470 GENERAL SURGERY 471 unnoticed and the renal injury- either escape detection altogether or be dis- closed by operation for other injuries or by a lumbar hematoma. If an artery- is divided or so contused as to become obstructed by clot, the renal parenchyma supplied by this vessel will become gangrenous, for the arteries of the kidney- are terminal; they do not anastomose. Division of one of the main branches of the renal artery, near the hilum, usually results in hemorrhage so severe as to demand operation, probably nephrectomy. Wounds of the renal pelvis of themselves imply only extravasation of urine, but, like those of the renal vessels, they are almost always associated with wounds of the renal artery and of the adjacent viscera as well. The wound in the parenchyma may be perforating, tangential, or explosive. The edges of the wound are usually contused; adjacent parenchyma may become necrotic through arterial injury, but the more remote portions of the parenchyma suffer no more than temporary congestion, expressed by a brief anuria. The later lesions are those of infection and extravasation, intraperitoneal or extraperitoneal. Destruction of fascial planes eliminates the usual anotomical restriction to their spread. CLINICAL PICTURE The patient arrives at the evacuation hospital labeled as a wound of the buttock, thigh, abdomen, or chest. The surgeon's immediate concern is with the state of shock, the amount of hemorrhage, the length of time since the patient was wounded, the general character of the wound itself, and symptoms pointing to perforation of the intraperitoneal viscera. Unless the situation of the wound itself, the presence of hematoma in the loin, or of blood in the urine call his attention to the probable existence of a kidney injury, this does not usually enter the surgeon's calculations, since injuries to the other abdominal or the thoracic viscera are of much more imme- diate importance and are far more common, the decision to operate or not to operate is also reached with reference to the patient's general condition and the presence of a "penetrating" wound rather than with reference to a kidney injury. SYMPTOMS The immediate symptoms of renal wounds are due to hemorrhage. Thus hematuria is absent only if the ureter is completely- divided or obstructed by clot, or if the w-ound does not invade the renal pelvis. This hematuria is total, but usually not so severe as to cause clotting in the bladder. Retention of urine is common. Shock is not so severe as that due to intraperitoneal injuries, unless the patient is exsanguinated. It is noteworthy- that the hemor- rhage from renal injuries, however severe, is rarely fatal. Hematoma in the loin develops rapidly- in wounds that do not drain freely. It excites tenderness and rigidity of the overlying muscles, and forms an ill-defined mass. Hemor- rhage from the wound is free. Intraperitoneal hemorrhage is obscured by the symptoms due to lesions of other organs. Gas gangrene, sepsis, extravasation, and secondary hemorrhage are the causes of death at the base. Secondary 472 SURGERY hemorrhage may occur as late as two months after the wound. It is quite common in the second and third week. It is more to be feared than the pri- mary bleeding because of its severity and its marked tendency to recur, from each of which recurrences the patient rallies less well than from its predecessor. Renal infection and stone are late complications. DIAGNOSIS All patients with abdominal injuries should be catheterized at the first opportunity, unless they can urinate freely. The urine obtained should be examined for blood. Large wounds of the loin present no special diagnostic difficulties. The diagnosis is obscure under two conditions: (1) In the presence of hematuria. If the wound gives no clue as to the source of bleeding the diagnosis is made by cystoscopy, which discloses blood from the ureter, or by exploratory- operation undertaken for the relief of other visceral lesions. (2) In the absence of hematuria. The renal injury is disclosed by cystoscopy and ureteral catheterization; operation for hematuria; retroperitoneal infection; lesions of other viscera. Ureteral wounds seemingly do not occasion sufficient bleeding to permit an immediate diagnosis, except by surgical exploration. TREATMENT AT THE FRONT When there is doubt as to whether or not to open the belly or the loin first, the loin should be opened. The loin incision should be transverse and extend approximately- to the edge of the rectus. It may be enlarged by a vertical transrectus incision or by a vertical incision along the outer border of the erector spinse muscle long enough to permit division of all muscular and ligamentous attachments to the last rib. The twelfth dorsal nerve and arterv may be avoided by placing the transverse incision a finger's breadth below the rib. Thus also one avoids the danger of inadvertently- entering the pleura, through mistaking the eleventh for the twelfth rib. If there is a wound of the loin and hematuria, or if the wound plainly leads to the kidneys, enlarge it transversely, deliver the kidney7 and examine the hilum for lesions of the renal vessels. If the main artery- or vein, or the upper main branch of the artery, are wounded, perform nephrectomy. If smaller arteries or the lower branch of the renal artery are wounded, or the renal wound is a relatively- slight one, there are three procedures: (a) For wounds that are not very extensive or ragged and do not involve any great destruction of the arterial sy-stem of the kidney- it may7 be wise to do nothing more than to pack the loin wound down to kidney. (6) But in case of persistent hemorrhage, extensive contusion, presence of for- eign bodies, or division of arteries, the kidney demands the surgeon's attention; the renal wound may be packed or a portion of the parenchyma excised and sutured, (c) At the evacuation hospital, where such primary7 operations are usually- performed, conditions are often such as to prohibit prolongation of the GENERAL, SURGERY 473 operation for the purpose of resecting and suturing the kidney or searching for shell fragments or bullets. Resection is, how-ever, the ideal operation for such cases—an ideal which has been realized in a few cases and one which the sur- geon should always bear in mind. When partial nephrectomy is performed the excised portion should include all that part of the kidney parenchyma which is deprived of circulation by division of its artery. If this has been opened, a small tube should'be left in the pelvis of the kid- ney two days, in order to evacuate blood clots and to hasten the return of kidney function by removing intrapelvic pressure. Always open peritoneum in front of the colon in order to examine the adjacent viscera. Drain and suture the wound in the usual manner. Complete nephrectomy should be performed when more than one-third of the kidney is contused. On the other hand, when less than one-third is con- tused resection may be considered. If hematuria suggests renal injury, but the wound is remote from the loin, the decision in favor of or against immediate operation should be based on the following data: If the patient is going to die of primary renal hemorrhage, he is likely to do so before reaching the dressing station. Though exploration of renal wounds usually starts a fresh parenchymatous hemorrhage, it discloses the fact that the primary bleeding has already stopped. Therefore unless an external w-ound leads directly to the kidney region the presence of hematuria or of a retroperitoneal hematoma is no indication for immediate operation. A retroperitoneal hemorrhage discovered in the course of a laparotomy mav be disregarded (it often does not arise from the renal vessels at all) unless it is of enormous size, in which event it should be evacuated extraperitoneally, before the intestines are much handled, for it has been found that immediate grave shock results from turning the patient over and operating upon his loin after laparotomy-. Transperitoneal nephrectomy- is generally- condemned. AT THE BASE All secondary- operations should be preceded by cystoscopy, to ascertain the condition of the opposite kidney, and fluoroscopy- to locate fragments of bone or missile. Large hematomata should be evacuated to forestall infection. Secondary- hemorrhage calls for transfusion and, usually, for prompt nephrec- tomy unless other complications prohibit this, for the hemorrhage is likely to recur and the effect of each return of bleeding is cumulative. Sepsis is com- bated according to general principles of drainage and antisepsis. Persistent urinary fistula1 in the loin should be treated by the insertion of a ureteral cathe- ter up to the pelvis of the kidney. The catheter mav be left in place for an indefinite period if changed every fourth or fifth day. If healing is to occur this may be expected within 10 days. If the fistula fails to heal, the kidney- may be explored for the purpose of reestablishing this urinary flow7 by plastic operation, or for nephrectomy, if the opposite kidney is proved sound. 474 SURGERY MORTALITY The mortality rate of injuries to the kidney, both complicated and uncom- plicated, proved to be o.YSl among cases of the American Expeditionary Forces treated in hospital.2 The clinical record of 66 cases showed a mortality of 50.3 ' To shock and hemorrhage may be attributed a certain number of deaths in kidney injury at the front. However, with improvements in evacuation, so as to hasten the arrival of the wounded at hospital, and improvement in methods of treating shock, obviously7 danger from the above-mentioned causes of death was lessened. Thus, of 37 of the series of 66 cases mentioned above, 2S were operated upon on the day of injury; eight, on the second day; one, oft the third day. In a series of 13 cases, in hospitals at the front, 3 died and 10 were evacuated to the base.4 When we consider the frequency of involvement of other important organs, the percentage of fatalities is not surprising. In the series of 66 cases, the intestines were involved in 14 per cent; liver, 16 per cent; chest, 16 per cent; peritoneal cavity-, 39 per cent.3 CASE REPORTS Case 1 R. H., sergeant, Company F., 355th Infantry, A. E. F. Gunshot wound of back, left kidney, received in action October 21, 191S. Evacuation Hospital No. 10: Through- and-through wound of back; wound of entrance, left post axillary line; wound of exit, right post axillary line. Urinary retention; catheter showed blood in urine. Base Hospital No. 15: During night of October 27, severe hemorrhage into bladder. Patient became pulseless. Salt solution infusion. Cystoscopy showed bleeding from left kidney. Left lumbar nephrec- tomy, suprapubic drainage of bladder. Base Hospital No. 6: December 15, 1918. Gun- shot wound of back, perforating left post axillary line to right back, nephrectomy wound, left loin, suprapubic wound, bed sore, paralysis below waist line, bladder satisfactorily drained by putting large catheter in place of suprapubic tube. Ultimate result, cure. A. E. F. Records Case 2. J. E. H., 1204342, Company L, 105th Infantry. Wounded August 5, 1918. Gunshot wound of side, penetrating abdomen, causing tear of ascending colon and damage to lower pole of right kidney. Operation, Canadian casualty clearing station, several hours after injury: Suture of intra and extraperitoneal tear of ascending colon. Liver and kidney sutured. Removal of foreign body from liver. Drainage. Tedious convalescence. Ulti- mate recovery. Demobilized January 8, 1919, 10 per cent disability. Case 3. J. G., Company D, 120th Machine Gun Company, 273042. Wounded October S, 1918. Gunshot wound entering right lumbar region, penetrating lower pole of kidney. Wound of colon. Operation, same day: Laparotomy, suture of colon and mesentery, drainage of right kidney, debridement. Foreign body removed. November 19, 1918, second operation for intestinal obstruction due to adhesions. January 29, 1919, cystoscopy, ureteral catheterization and functional tests negative. February 7, 1919, duty. February 18, 1919, demobilized; disability, 50 per cent. Case 4. H. C, 101333, Company G, 168th Infantry. Wounded September 12, 191 x. Gunshot wound, abdomen, rupture of left kidney. Operation, 10 hours later: Laparotomy, no intestinal injury found; closure; dorsal incision; kidney delivered; 3 clamps applied; kidney removed. Recovery. March 6, 1919, duty. March 13, 1919, demobilization, 50 per cent disability. . Case 5. E. M. P., 76925, shrapnel wound. Gunshot wound, right lumbar region, hip, right kidney, and left shoulder. Resection of colon. Operation, same day: Debridement, foreign body removed, right kidney perforated, drainage. February 5, 1919, nephrectomy, GENERAL SURGERY 475 right. Pyonephrosis. Fistula connecting hepatic flexure of colon to pyonephritic sac. March 20, 1919, duty. April 22, 1919, demobilized, 75 per cent disability. Case 6. C. A. B., 57153, Company D, 28th Infantry. Wounded July 21, 1918. Gun- shot wound, penetrating upper right abdomen; fracture of eleventh and twelfth ribs; injury to liver and kidney. Operation. Record of first operation lost. August 8, 191X, abdomen drained. November 30, 191X, nephrectomy, right; complications: Urinary fistula from right kidney, multiple abscesses, arthritis, sinus tract of abdominal wall. July 23, 1919, demobilized, disability 75 per cent. Case 7. H. J. K., Machine Gun Company, 356th Infantry, 3173056. Wounded Septem- ber 12, 1918. Gunshot wound, chest, penetrating right back at eleventh rib, perforating kidney and liver. Operation, nephrectomy. January 30, 1919, demobilized, disability 40 per cent. Case 8. E. KZ, 2858609. Wounded September 12, 1918. Gunshot wound, right side, passing through diaphragm, liver, and kidney. Operation, laparotomy. Considerable blood found in cavity; small injury to kidney, inaccessible. Drainage of abdomen. Foreign body removed from back, subcutaneously. Complication: Bronchopneumonia. February 11, 1919, to duty, convalescent center. January 15, 1920, demobilized, 30 per cent disability. Case 9. M. F. B., Company E, Seventh Engineers. Wounded September 17, 1918. Gunshot wound, left lumbar region over left kidney, bullet lodging in kidney. Operation: Foreign body removed from left kidney through extraperitoneal incision. Recovery. December 25, 1918, duty. Case 10. V. R., 1317456. Wounded September 29, 1918. Gunshot wound, back, pene- trating right kidney. Operation: Debridement, drainage. September 30, 191X, passing blood in urine. October 13, 1918. Operation: Eighth rib resected, liver drained; foreign body removed from right back. January 25, 1919, nephrectomy, right. June 16, 1919, demobilized, disability, 25 per cent. Case 11. J. McK., 1207623. Gunshot wound, left loin, penetrating kidney and dia- phragm. Operation, same day: Foreign body removed from upper surface of diaphragm, which was sutured. Kidney drained. Recovery. March 6, 1919, demobilized, no disability. Case 12. A. F., 3495499, Company D, 165th Infantry. Wounded October 16, 1918. Gunshot wound, penetrating peritoneum and injuring kidney. Operation: Debridement, drainage. Recovery. November 14, 191X, operation: Resection of rib for empyema. July 5, 1919, demobilized, disability, 30 per cent, on account of old suppurative pleurisy and obliteration of lung. WOUNDS OF THE URETER The brief mention of wounds of the ureter in medical periodicals throws little light upon the subject. There are records of four gunshot wounds of the ureter in the American Expeditionary- Forces.2 Apparently- the wound has always been associated with visceral injury requiring abdominal section. The ureteral lesion is disclosed by the watery quality and urinous odor of the intra or retroperitoneal drainage, or else by appearance of urine in the dressings after operation. The treatment is expectant. Several such urinary fistulas have healed spontaneously. In brief, the treatment of ureteral wounds is the following: Immediate repair by suture of the wound, if it is reparable and if the patient's condition permits. If these conditions can not be fulfilled, adequate drainage will be provided for the urine. The upper end of a completely severed ureter which can not be repaired mav be brought up and sutured to the parietes. Primary nephrec- tomy is not to be considered because of the added danger to life. 476 SURGERY If the ureter is sutured the finest chromic gut should be employed, for plain catgut will not hold. But great care must be taken to catch the ureter at its very cut edges so that as little as possible of the suture remains within the lumen of the canal, for fear of secondary stone formation. A small drain should be led down to the ureteral w-ound. If the completely- divided ureter is dislocated and sutured to the parietes. no tension whatsoever should be made upon it for fear of angulation. A few strands of silkworm gut left in the ureter will greatly facilitate the urinary- drainage. If the ureter is known to be irreparably divided, nephrectomy is the opera- tion of choice, after the patient has rallied from the immediate effects of his injury- and catheterization of the ureter has proved the opposite kidney sound. if the opposite kidney is not sound, a cup should be fitted over the ureteral fistula and permanent drainage established. If the wound is not knowm to be irreparable, a precise diagnosis should be established by pyelography; if possible the kidney should be drained by the indwelling ureter catheter. The failure of ureter catheter drainage indicates the necessity- for operative treatment. While it may be possible in certain instances to reestablish drainage by- plastic operation, such procedures are notoriously inefficient in the treatment of infected kidneys, and the masses of scar resulting from the wound would doubtless still further diminish the proba- bility of success. Nephrectomy- will usually be required. The following case, reported by Stevens, concerns a ureteral injury:5 Case 13. Gunshot wound, penetrating, of back; hematuria; bullet removed through perirectal incision. Patient was admitted with hematuria. Gunshot wound of the back above right costal margin; no wound of exit. Cystoscopy showed blood coming from the right ureter, but urethral catheter, which was passed up to the renal pelvis, gave clear urine, miscroscopically free from blood. Roentgen-ray examination showed machine-gun bullet lodged in the bony pelvis back of bladder in region of lower pole, right ureter. On rectal examination, missile could be felt high up in this region. Fluoroscopic and X-ray examinations with catheter in ureter showed that bullet had probably injured the ureter. Through a ateral perirectal incision bullet was removed without difficulty. WOUNDS OF THE BLADDER In the experience of the American Expeditionary Forces, battle injuries to the bladder bore about the same ratio to abdominal wounds as did injuries to the kidney: that is to say, of 2,385 abdominal injuries, 127 involved the bladder, a percentage of 5.32.2 In a series of 57 cases.3 rifle and machine-gun missiles injured the bladder in 46 instances; shrapnel and high-explosive shell, in 11. There is no record of piercing instruments causing injury- to the bladder in the American Expedi- tionary Forces.2 In the series referred to, the abdomen was involved in 17 instances; the rectum, in 5; large intestine, in 4; small intestine, in 15. CHARACTER OF INJURY The size and shape of the bladder perforation depend upon the type of missile producing the wound. The perforation varies from the small slitlike hole of the rifle missile to the large laceration of the shell fragment. Small GENERAL SURGERY 477 missiles may destroy very little of the bladder substance, but larger ones may destroy- a very considerable portion of the bladder wall. The projectile may7 enter the bladder from any angle, and entrance wounds high up in the abdominal wall or back, and wounds of the buttocks, thighs, and hips, or of the perineum, may involve the bladder, and should always be view-ed with suspicion, as it is often impossible from the position of the wound of entrance to tell whether or not the bladder has been injured. It is wise ulw-ays to consider the possibility of vesical wounds in doubtful cases. Foreign bodies, such as bits of clothing and spicules of bone have been carried into the bladder by the projectile, and the missile itself has sometimes lodged there. If not removed, these foreign bodies become nuclei on which stones may form. Experience of the World War has gone far to eliminate the classic distinc- tion of injuries to the bladder whereby they are divided into two groups, the intra and extraperitoneal. In the description of symptoms and treatment, how- ever, the distinction of extra and intraperitoneal injuries must be maintained for the sake of clarity. But in the field the surgeon will find that most of the intraperitoneal bladder wounds are associated with extraperitoneal wounds and that the diagnosis of extraperitoneal injuries founded upon the absence of abdominal tenderness and rigidity may ultimately be belied by a fatal peritonitis. The following classification therefore simply represents the various combina- tions which may occur, and artificially- dissociates the complex pathological conditions resulting from wounds of the pelvis or abdomen that involve the urinary7 bladder. I. Intraperitoneal injuries. (A) Wounds. I. Uncomplicated. II. Complicated by— (a) Perforations of other viscera. 1. The small intestine. 2. The colon. (_>) Fractures or injuries of bones. (c) Injury to large blood vessels. (B) Ruptures by concussion. I. Complicated. II. Uncomplicated. II. Extraperitoneal injuries. (A) Wounds. I. Uncomplicated. II. Complicated by— (a) Injury to rectum. (6) Injury to deep urethra or prostate. (c) Fractures of the bony pelvis or femur. (77) Injury to important blood vessels. 475 Machine-gun bullet wound, the entrance being in the left buttock and the exit in the'right wall of the scrotum. The patient had not tried to urinate. Nevertheless, it seemed extraordinary that no swelling, induration, or ecchymosis was present in the perineum. 4S4 SIRGERY The urethral lesion was diagnosed by the patient's inability to urinate and the physician's inability to pass a catheter. In its course the bullet had completely divided the bulbous urethra, and perforated an old right-sided hernia; this explained the presence of a mass of omentum protruding from the scrotal wall. The cord and testicle were uninjured. Opera- tion was performed eight hours after the wound was received. The injured omentum was excised and the hernia repaired. Then, through a perineal incision, an end-to-end suture of the urethra was done, and perneial drainage established proximal to the suture line. The subsequent course was entirely satisfactory up to the fifth day, when the patient was evacu- ated to the base. Case 26. P. H. G., private, 23d Infantry. Wounded June 14, 191S, at 2 p. m. Shell fragment entered posterior aspect of right thigh, passed just posterior to femur, exit wound being on the inner aspect of the thigh close to the perineum. Projectile then entered perine- um, severed the urethra close to the bulb, divided the left spermatic cord, and tore its way out through the abdominal wall in the left inguinal region without entering the peritoneal cavity. Operation 10 p. m., same date. Debridement of the thigh wound, left castration, and suprapubic cystostomy. Evacuated June 22, to Base Hospital No. 18, where, on June 23, examination revealed a large sloughing wound of hypergastric region involving the recti muscles; suprapubic drainage wound; wound of thigh; incisions in left groin, scrotum, and dorsal surface of penis. Dakin's solution applied continuously with frequent dressings. June 28, wounds were cleaner and condition better, but suddenly patient began to have clonic spasms, slight strismus present, and his reflexes were hyperactive. Diagnosis: Tetanus. Antitetanic serum, 20,000 units administered; general condition, worse the next day. A lumbar puncture withdrew fluid under tension. Patient received antitetanic serum 10,000 units subcutaneously each day. On July 3 a second lumbar puncture was done and 20,000 units given intraspinally. Steady improvement now began. July 6, external urethrotomy, suprapubic tube removed. The good effect of dependent drainage afforded by external urethrotomy was soon demonstrated in the condition of all the wounds. Several large sloughings separated from the suprapubic wound and the thigh wound filled in rapidly. Owing to the fact that this hospital was functioning as an evacuation hospital it was necessary to evacuate on account of the exigencies of the service. Again seen June, 1919. General condition excellent, all wounds healed, perfect urinary control, urine passed entirely through perineal fistula. Case 27. W. B., sergeant, 30th Infantry. Wounded by a rifle bullet, June 20, 1918. The missile entered left side of scrotum, severing urethra at peno-scrotal junction, entering inner aspect of left thigh and making its exit at gluteal fold of left thigh. Patient reached Field Hospital No. 27, where a paralysis of the left leg, retention of urine, and inability to pass catheter were noted. Suprapubic cystotomy was done and patient evacuated. At Evacuation Hospital No. 7 it was impossible to introduce a catheter (either anterior or retrograde). Admitted to Base Hospital No. 18 June 23, where thigh wounds were opened and pus evacuated—Dakin's solution. Found impossible to pass catheter. July 8, external urethrotomy and operative attempt made to approximate torn ends of the urethra. Tube was placed in bladder through perineal wound and suprapubic tube removed. July 13, catheter was passed through meatus up into the perineal wound where it was introduced into the bladder; perineal wound closed over it; small protective drain to take care of any leakage. July 20, catheter withdrawn but subsequently had to be reintroduced. August 10, necessary to evacuate the patient; all wounds granulating well, patient voiding, at normal intervals, clear uninfected urine, No. 24 F sound could be introduced into the bladder through small perineal fistula present but rapidly closing. Case 28. E. G., private, 39th Infantry. ' Wounded August 5, 1918, by machine-gun missile which passed through left leg, upper inner portion of right thigh into perineum, severing membranous urethra and causing fracture of ischium and extravasation of urine. Operation, Field Hospital No. 19, wounds debrided, external urethrotomy with plastic reconstruction of the urethra, suprapubic cystotomy done. August 9, admitted to Base Hospital No. 18; bladder was draining well through suprapubic and perineal tubes; suture wound of perineum badly infected; three stitches removed, pus evacuated. All wounds treated by continuous Dakin's solution. August 14, all wounds cleaner. Suprapubic tube GENERAL SURGERY 485 had been removed and all urine was passed by perineal tube. It was planned to treat this case like the preceding one, but in order to prepare for fresh convoys of casualties it was necessary to evacuate patient. This case illustrates the inadvisability of attempting ana- plastic procedure for the repair of the urethra at the first operation; resulting scar will seriously hamper future operative procedure for repair of urethra. The following case report has been taken from clinical records of members of the American Expeditionary Forces.3 Case 29. R. F. S., 105796, Company D, 2d Machine-Gun Battalion. Wounded July 18, 1918. Gunshot wound, entrance right buttock, exit left pubis, perforation of urethra and fracture of pubis. No record of operation, which was done in a French military hospital. Complications: Traumatic stricture of urethra and three urinary inguinal fistulse. August 14, 1918, operation, A. R. C, Military Hospital No. 1. Incision from wound in left groin to perineum. Fracture of superior ramus of pubis discovered. Evacuation of large abscess cavity beneath pubis extending to prostatic region of bladder. Urethra found completely severed in front of prostate. Catheters were inserted through penis into bladder and out suprapubic wound; bladder irrigation; Carrel tubes for other wounds. January 1, 1919, impassable stricture. Perineal urethrotomy; stricture divided; suprapubic opening enlarged and opening into bladder through sphincter determined; rubber tube passed through perineal wound into bladder and suprapubic wound closed. January 30, 1919, secondary hemorrhage, packing of perineal wound. September 27, 1919, demobilized, 30 per cent disability, on account of traumatic stricture of urethra, maximum improvement attained. FISTULA OF THE URETHRA Urethroperineal fistuhc are usually irregular and embedded in dense scar. They7 may heal even after remaining open for months. If healing is despaired of, they7 may be closed by a plastic operation; but before this is attempted several specimens of tissue, excised from the region of the orifice of the fistula should be stained and examined for tuberculosis, as a persistent perineal fistula is often due to this disease. If acid-fast bacilli are found, the treatment should be conservative, consisting of a thorough curettage of the fistulous tract with excision of all pockets and folknved by cauterization of the wound down to its urethra orifice. This operation produces surprisingly good results both in reducing the size and complications of the stricture and in some cases even closing it. In the absence of tuberculosis the following operation should be performed: A sound should be introduced into the urethra and the whole of the perineal scar excised, the strictured urethra being dealt with according to the require- ments of the case. Drainage is procured by a small tube introduced into the bladder through the suprapubic opening. The perineal urethra is then closed by fine chromic gut sutures, the perineal muscles carried over this line of suture and ample drainage left in the superficial tissues. FISTULA OF THE PENILE URETHRA A fistula of the penile urethra, if small, may be encouraged to heal by- touching lightly with the actual cautery. If the loss of tissue is considerable the urethra may best be closed by the following operation: 1. Drainage of the bladder by suprapubic tube. 2. The skin or scar about the fistulous orifice is divided at a point far enough away from this orifice to permit a flap to be lifted and turned in, so that the skin 486 SURGERY surface will form the floor of the urethra. This incision will usually have to be made about 1 cm. from the orifice. It is convenient to keep a sound in the urethra while making it. The flaps may be rectangular or the incision may be an ovoidal one surrounding the fistulous opening. In lifting up the flap, great care should be taken not to puncture the underlying urethral mucosa and to retain a fair blood.supply for the flap itself. The tissues will usually be so thin about the edges of the fistula that the flap can not be dissected up any nearer than about 0.5 cm. from its orifice. The flap edges are then turned in by one of two methods; viz, either the edges themselves are sutured together with plain catgut or else the whole cuff or flap is caught up in a purse-string suture, the ends of which are drawn into the urethra through the fistula, brought out at the external meatus and tied rather tightly over a small piece of gauze across the meatus. If the latter procedure is employed it is wise to insert a split tube of a few strands of silkworm gut through the external meatus into the urethra to provide for the exit of the secretions which accumulate in it. The superficial skin and fascia are then dissected free in a lateral direction half way around the penis on each side and brought together by mattress sutures of heavy catgut. URETHRORECTAL FISTULA This condition results frequently- from wounds by missiles, or from abscesses involving the prostate and posterior urethra. The escape of urine into the rectum and of gas and feces into the urethra lead to great discomfort. As a rule the condition is not associated with in- continence of urine, but if the internal sphincter has been injured urine may flow constantly from the bladder into the rectum, and if the external sphincter is impaired incontinence of urine and frequent escape of gas and liquid feces through the penile urethra may occur. Not infrequently a previous perineal operation upon the prostate, or the incision of a prostatic abscess through the rectum, may be responsible for the rectourethral fistula. TREATMENT When it is discovered that the wound involves both the rectum and urethra, its spontaneous closure should be encouraged by- providing suprapubic drainage to divert the flow of urine, and by dilating the sphincter ani widely to facilitate the passage of feces. No attempt at primary closure of the rectal and urethral openings should be made unless, in the removal of the missle, the rectal opening is small and the wound conditions are such as to justify- attempt at primary- closure. During the convalescence examination for urethral stricture should be made, and if present it should be dilated with filiforms, followers, and sounds, controlled by finger in rectum. In many- cases, especially where suprapubic drainage has been maintained, spontaneous closure of the fistula occurs, but where this does not occur, after many- w7eeks, operation should usually- be undertaken. GENERAL SURGERY 487 OPERATION TO CLOSE FISTULA The many procedures which have been advocated attest to the great difficulty which has been encountered in curing urethrorectal fistulas. A method which has shown almost invariable success is as follows:7 First, suprapubic drainage of the bladder is established, with the patient in dorsal posture. The patient is then shifted to the exaggerated lithotomy- position. A racquet-shaped incision, beginning in the mid-line of the perineum about 3 cm. anterior to the anal margin, is carried backward to this mar- gin, and then encircles it at the mucocutaneous junction. Through the circular part of this incision the mucosa of the rectum is dissected free all round until a cylinder of the membrane is stripped from its attachments well above the point at which the rectal orifice of the fistula opens, the fistulous tract being divided transversely- in this process. This dissection of the bowel is carried upward until sufficient mucous membrane is loosened to permit the pulling of the segment containing the fistulous orifice well out of the anus. The orifice and a small margin of normal mucosa above it, and all that below it, lying outside of the skin level are excised later. This procedure mav be de- scribed as an exaggeration of the Whitehead principle in operating for hemor- rhoids. The Young long urethral tractor is often very- useful in drawing down the prostate and in facilitating the separation of rectum and prostate. A minor point of some practical importance consists in beginning the dis- section of the mucosa at the posterior or dorsal part of the circle. By so doing, not only is it easier to find normal planes of cleavage here, where there is no scarring but also the field is rendered less obscure by- hemorrhage than would be the case if the anterior side be first attacked, as blood then runs down over the posterior half of the anus. The structures of the perineal body are next divided through the straight incision in the midline (the handle of the racquet) so as to expose thoroughly the urethral orifice of the fistula. If the sphincter ani previously- has been cut, the ends should be dissected free from sear tissue. In many cases the sphincter ani may be left intact, being pulled out of the way with a retractor as required. In some cases it may be advisable to divide it. The edges of the urethral fistulous opening then exposed are freshened and brought together with catgut sutures over a sound which has been previously passed through the urethra. These sutures do not penetrate the surface of the urethral mucous membrane. The levators, fascia, and smaller muscles are then brought together by interrupted catgut sutures across the midline of the perineum in several layers, reconstructing the perineal body much as is done in gynecological operations for relaxed vaginal outlet. Finally, the sphincter ani, if it has been cut is restored by uniting its ends with a mattress suture of catgut, and the midline incision is closed with interrupted sutures. The last stage in the operation consists in the excision of the protruding cuff of rectal mucosa in which the fistulous opening lies, and the union of the lower end of the rectum to the anal skin margin. This is done by interrupted silk sutures after four submucous-subcutaneous sutures of catgut have been placed at quadrant points to help anchor the bowel in place. 488 SURGERY It will be seen that there are four essential principles in this procedure. The first is the protection of the repair from leakage and muscle spasm by- diverting urine from the urethra through suprapubic drainage. The second principle is the complete ablation of the damaged portion of rectal wall and the reposition of perfectly sound mucosa quite to the skin edge. The third element in the operation is the closure of the urethral orifice; and the final essential is the interposition between rectum and urethra of a solidly built up perineal body. WOUNDS OF THE EXTERNAL GENITALIA Gunshot wounds of the external genitalia occurred in the American Expeditionary Forces as follows:2 Penis, 171; scrotum, 499; testicle, 237. In a series of 42 cases of injury to the penis, involving the penile urethra or the penis alone, rifle and machine-gun missiles were the cause of 27; shrapnel and high-explosive shell, 14; indirect injury, 1. The entrance wound involved the penis in 29 instances; the thigh in 9; buttock, 1; hip, 1; abdomen, 1. Secondary injuries numbered 20. In a series of 164 cases of injury to the scrotum and testicles,3 95 of the wounds were due to rifle or machine-gun missiles; 58 to shrapnel and high- explosive shells; 5 to grenade fragments; 2 to revolver missiles. In 83 cases of scrotal injury the testicles were not involved, or at least not sufficiently involved to require operative treatment. There were 81 cases in which injury to the testicles was recorded, necessitating a right orchidectomy in 31 instances, a left orchidectomy 23 times, and a bilateral orchidectomy twice. Among the 81 cases with testicular injury, there were 10 deaths, but among the 83 cases in which the scrotum was involved, 5 deaths occurred. WOUNDS OF THE SCROTUM, TESTICLES, PENIS, AND ANTERIOR URETHRA Gunshot wounds of the external genitals often involve both scrotum and penis, producing extensive laceration. The primary indications are the follow- ing: (1) Control hemorrhage. (2) Carefully excise all contused tissue so as to forestall infection. (3) Do not remove a testicle unless its blood supply is irreparably7 damaged. Even if the tunica albuginea is split open the wound edges mav be freshened and sutured with chromic catgut. (4) No attempt should be made at this time to replace the testicle in the scrotum. (5) A catheter should be tied into the urethra, both to prevent cicatrical contraction of its orifice and to insure the patient against retention of urine. If the urethra is completely divided this catheter will issue from the wound and a second section of catheter should be inserted into the anterior portion of the urethra so as to prevent cicatricial contraction of its cut end. (6) The penile wound should be dressed wide open. If the penis is partially divided, even though the slip of tissue by which it adheres is insignificant, every effort should be made to pre- serve the end of the organ while dressing the w-ound wide open and awaiting the opportunity for secondary plastic operation. GENERAL SURGERY 489 RUPTURE AND TRAUMATIC STRICTURE OF THE URETHRA Traumatic stricture following wound or rupture of the urethra has the following characteristics: (1) The gravest type of stricture may result from an injury so slight as to cause but little hematuria and no important disturbance of urination. (2) Traumatic stricture usually- appears, and recurs after operation, with great rapidity. Stricture resulting from even the slightest injuries may con- tract so rapidly as to cause complete retention of urine within a few- weeks, and, following simple external urethrotomy without resection of the urethra, such a stricture may recur and cause retention before the patient leaves the hospital. (3) Traumatic stricture is usually extremely resistant, rebellious to treatment by sounds and, as stated above, to the simple forms of operation. PROPHYLACTIC TREATMENT The most important feature in the treatment of traumatic stricture is its prophylaxis. Wounds of the urethra that do not completely- sever the canal are not likely to result in severe strictures, but all wounds severing the canal and all contusions or ruptures of the urethra, be they ever so slight, should be regarded with grave apprehension and serious efforts made to prevent the forma- tion of residual traumatic strictures, as follows: The indwelling catheter should not be employed, since it only- encourages infiltration and scar formation in the wound. Stricture of the prostatic urethra may be prevented by- the bladder drainage which the wound itself required. Rupture of the membranous urethra (usually caused by the so-called straddle injury) calls for immediate perineal section and drainage with a large tube for three or four days in order to estab- lish the lumen of the urethra and prevent infiltration of urine and subsequent stricture. This rule applies even to those cases whose only symptom is a slight urethral hemorrhage. Perineal section is likewise required to prevent stricture of the bulbous urethra. No special measures need be taken to prevent stricture following injuries to the pendulous urethra, excepting the use of the indwelling catheter in order to keep the cut ends from contracting during the first week after injury, and the frequent passage of sounds after reconstruction of the canal. Stricture will surely ensue, but it is readily controllable. OPERATIVE TREATMENT Stricture of the prostatic urethra usually occurs at the bladder neck and may be cured by the use of Young's prostatic punch. If the stricture is so tight as not to admit this instrument, it may be attached by the suprapubic route, the pin-point urethral opening being first divulsed and then the whole floor of the urethra at the bladder neck being removed by rongeur forceps, scalpel, or scissors. Traumatic stricture of the bulbous or membranous urethra requires excision. Through a median or curved incision the perineal urethra is laid bare, and the precise location of the stricture identified by the passage of urethral instruments. The stricture is then divided longitudinally- and one of three procedures follows: 490 SURCKHV (a) If the sear is relatively narrow, especially upon the roof of the canal, the ure- thra is resected by Cat or s method. The bulbous portion of the canal is freed for at least 3 cm. from its attachment to the corpora cavernosa. The scar tissue is split open on the floor of the urethra in the direction of the long axis of this canal and any dense masses of scar tissue are excised. A small sound is placed in the urethra as a guide and the gap in the urethral wall is closed about this by fine transverse chromic catgut sutures, beginning at the lateral angles of the wound and inserted alternately on each side, finishing at the median line. None of these sutures is tied until the last one has been inserted. Then a small puncture is made, upon a staff, in the urethra behind the suture line, and through this an IS F soft rubber catheter is introduced into the bladder for drainage. The sound is then reintroduced and the sutures tied in the same order as they wore imserted. The mobilized urethra is thus drawn down into the perineum and the urethral wound tightly closed. The bulbocavernosus muscle is now drawn across the line of suture and the dislocated bulbous urethra by a few- catgut sutures, the anterior end of the skin wound closed, but a wide opening left in the superficial tissues about the catheter in the perineum, so as to prevent infiltration. The catheter is retained for 10 days, (b) If resection of the roof of the urethra is required, a transverse section of the urethra is excised, suprapubic drainage established, the cut edges of the urethra drawn together by- a few- fine chromic gut sutures, and the urethral stumps carefully supported by three or four heavier chromic sutures so as to take the strain off the cut edges. The deep tissues of the perineum are fully closed, but the superficial tissues are drained, (c) If the gap is so wide that no reconstruction is possible, the scar is excised and the two cut ends of the urethra brought out into the perineum for subsequent reconstruction of the urethra. Traumatic strictures of the pendulous urethra are controllable by interna] urethrotomy. The rapidity with which the stricture contracts makes the Maisoneuve urethrotome the instrument of choice. REFERENCES (1) Manual of Military Urology, including Venereal Diseases, Skin Diseases and Wounds of the Genito-Urinary Organs. Masson et Cie. Paris, 1919. (2d ed. Published for the American Expeditionary Forces by the American Red Cross.) (2) Based on sick and wounded reports to the Surgeon General. (3) Clinical records, American Expeditionary Forces. On file, A. G. O., World War Division, Medical Records Section. (4) Surgical reports made to the chief consultant, surgical services, A. E. F. On file, His- torical Division, S. G. O. (5) Stevens, A. R.: Experiences in France with Surgery of the Genito-urinary Tract. Journal of the American Medical Association, Chicago, 1919, lxxii, 1589. (6) Colston, J. A. C: Observations on Gun-shot Wounds of the Urethra. Journal of Urology, Baltimore, 1920, iv, 185. (7) Young, Hugh H., and Stone, Harvey B.: The Operative Treatment of Urethro-Rectal Fistula (Presentation of a Method of Radical Cure). Journal of Uroloau, Baltimore 1917, i, 289. CHAPTER XVII END RESULTS, FRACTURES OF LONG BONES Before entering into the consideration of the end results of the fractures of the long bones that occurred during the World War, it is necessary to give the numbers of fractures involving not only the long bones but others as well, in order that their relative incidence and gravity may be more readily- appreci- ated. This will be done for both battle and nonbattle fractures. Table 28.—Battle fractures, including single and associated fractures " Location Lower extremity: Femur__________ Fibula__________ Tibia___________ Greater trochanter- Malleolus________ Patella__________ Acetabulum______ Tarsus__________ Metatarsus______ Ankle___________ Hip------------- Knee.....________ Leg------------- Total. Trunk: Ilium..... Ischium... Pubis..... Sacrum... Coccyx__ Vertebrae. Ribs____ Sternum.. Total. Number 14, 254 432 84 61 100 16 378 729 23 1,733 Face: Malar....... Maxilla— Inferior- Superior Nasal______ 1,123 323 77 Location Number Face—Continued Vomer______ Zygoma----- Total_____ Upper extremity: Humerus____ Radius........ Ulna_______ Clavicle_____ Olecranon___ Carpus....... Metacarpus.. Scapula...... Elbow______ Forearm---- Shoulder____ Wrist_______ 4,069 2,475 2,150 497 240 336 1,851 806 13 25 10 15 Total. Head: Frontal____ Mastoid___ Occipital__ Parietal___ Skull base.. Skull vault. Temporal. . Total______ Grand total. 12,487 375 67 251 408 326 360 244 2,131 32,331 0 Source of information: Sick and wounded reports made to the Surgeon General It is seen from the above table that there were 19,620 fractures of the extremities, as follows: Femur__ Fibula.... Humerus Radius, _. Tibia___ Ulna____ 3, 850 2, 697 4, 069 2, 475 4, 379 2, 150 19, 620 491 492 SURGERY Arranging the figures from the standpoint of the individual, and so as to show not only- the single fractures but also those that were associated, we arrive at the result given in Table 29. This table gives the true situation, particularly with respect to mortality-. Table 29.—Battle fractures, long bones, showing both single fractures and those in association, and deaths a Location Femur: alone_______ and fibula___ and humerus. and radius__ and tibia____ and ulna____ Total femur Fibula: alone_______ and humerus. and radius___ and tihia____ and ulna____ Total fibula Humerus: alone_______ and radius__ Number 3,296 46 194 73 177 64 Deaths S04 16 68 17 58 3,850 971 1,013 55 27 5 3 2 1,600 278 8 0 2,651 3,549 132 304 10 Location Humerus—Continued. and tibia________ and ulna-------- Total humerus.. Radius: alone____ and tibia. and ulna- Total radius . Tibia: alone____ and ulna. Ulna. Total tibia . Total. Number Deaths S3 S4 20 7 3,848 341 1,492 33 742 48 7 34 2,267 S9 2,471 15 2,486 1,237 251 1 252 26 16, 339 2,019 ° Source of information: Sick and wounded reports made to the Surgeon General. In addition to the fractures incident to battle, there w-ere 39,569 fractures, the result of nonbattle injury. Of these, 31,776 w-ere simple fractures, with a mortality of 664, or 2.09 per cent, and 6,006 were compound, with a mortality of 663, or 11.04 per cent. With the view of showing the relative frequency dur- ing the World War of nonbattle fractures of not only the separate long bones, but also of all the bones reported to have been fractured, the following table has been prepared: Table 30.—Nonbattle fractures a Simple Location Num- ber Deaths Head______________■ 961 Face______________ 2,218 Vertebrae_____________| 182 Ribs and sternum_____ 1,683 Clavicle and scapula___ 1.823 Humerus_____________ 1,024 Ulna________________! 980 Elbow___......______ 20 Olecranon____________ 231 Radius_______________ 4,432 Radius and ulna______ 23 Wrist.......__________ 51 Carpus_______________ 505 Metacarpus__________ 2,122 Hand.......__________ 25 Fingers______________ 1,309 Pelvis_______________ 233 Hip_________________ 6 366 14 50 22 4 2 ] 0 0 7 0 1 0 1 0 1 16 0 Compound Num- ber 599 577 17 33 54 218 112 1 31 237 5 0 35 334 9 835 23 0 Deaths 373 15 12 5 0 11 1 0 1 8 0 0 1 2 0 3 Simple Location Num- ber Deaths Femur _...... _ 773 Greater tuberosity__ Lesser tuberosity^ _ ___ 16 1 346 Fibula_______ 3,309 Tibia.........____ 2,627 17 Knee.. _ Tibia and fibula_______ Ankle___________ 31 65 Malleolus________ Tarsus.. . 1,149 569 Metatarsus___________ Foot____.....______ 1,144 15 Toe___________ 672 Miscellaneous______ 3,214 Compound Num- ber Total. 31, 776 0 0 0 8 S 0 2 1 5 2 2 0 104 318 1 0 56 357 754 2 13 2 51 124 379 6 317 506 644 6,006 Deaths 62 0 0 2 \x 32 0 2 0 2 1 1 0 0 103 « Source of information: Sick and wounded reports made to the Surgeon General. Table 31 shows the result, in so far as death and recovery are concerned, in the cases of both battle and nonbattle fractures, and w-hile the men involved were in the military service. GENERAL SURGERY 493 Table 31.—Battle and nonbattle fractures of long bones, showing immediate result Number of cases Location Battle Non- battle Total Battle Deaths Non- battle Recovery Total Battle Non- battle Total Femur: alone________ _. 3, 296 46 194 73 177 64 1,091 0 0 0 0 0 4,387 46 194 73 177 64 804 16 liS 17 5S S 971 89 0 0 0 0 0 89 893 16 68 17 58 8 2,492 30 126 56 119 56 1,002 0 0 0 0 0 and fibula______ and humerus____ 126 56 119 56 and radius and tibia______ and ulna........ Total femur______ . 3, 850 1,091 4,941 1,060 2,879 1,002 3,881 Fibula: alone------------- 1,013 27 3 1,600 8 3,666 0 0 44 0 4,679 27 3 1,644 8 27S 0 26 0 0 4 0 81 2 282 0 958 22 1 1,322 8 CO en *. j_ ooooo 4,598 22 1 1,362 8 and humerus____ and radius .... and tibia_____..... and ulna . ... .. Total fibula________ 2,651 3,710 6,361 340 30 370 2,311 3,680 5,991 Humerus: alone.. _____ ... . 3,549 132 83 84 1 242 0 0 0 4,791 132 83 84 304 10 20 7 13 0 0 0 317 10 20 7 3,245 122 63 1,229 0 0 0 4,474 122 63 and radius _. . and tibia_________ ___ . and ulna___..... Total humerus. .. 3,848 1,492 33 742 1,242 5,090 341 13 354 3,507 1,229 4,736 Radius: alone........ _____ . 4,669 0 28 6,161 33 770 48 34 15 0 0 63 34 1,444 26 708 4,654 0 28 and tibia ______ ___ 26 and ulna.......... ___ 736 Total radius_______________ 2,267 4,697 6,964 5,852 15 89 251 1 15 104 2, 178 4,682 6 860 Tibia: alone..._____ ___________ _ 2,471 15 3,381 0 40 0 291 1 2,220 14 3,341 0 5,561 14 and ulna______________ _ Total tibia________ _____ . ... 2,486 3,381 5,867 252 40 292 2,234 3,341 5, 575 Ulna_______________________ 1,237 0 0 0 0 1,092 21 19 63 51 2,329 21 19 63 51 26 0 0 0 0 2 0 0 1 1 28 0 0 1 1 1,211 0 0 0 0 1,090 21 19 62 50 2,301 21 Elbow_________________________ Knee____ .. .. _______....... _ 19 Ankle__________________________ 62 Wrist___________ 50 Total_________ .. .. 16,339 15,367 31, 706 2,019 191 2,210 14,320 15,176 29,496 To determine the end results among as great a number as possible of the recovered (from the Army- viewpoint) fracture cases showm in Table 31, a statistical study has been made of such of these men as applied for compensa- tion to the Bureau of War Risk, or subsequently, the United States Veterans' Bureau, w-hich replaced the Bureau of War Risk.1 This study, which was begun in December, 1919, by the Surgeon General, United States Public Health Service, acting for the Bureau of War Risk under the Treasury Department, was completed by the United States Veterans' Bureau.1 It extended over a six-year period, ending January 1, 1926, and shows the progress and end results of the cases in question. From the first, the importance of an individual study7 of the fractures of the lono- bones among veterans of the World War w-as recognized, so the use of a specially designed form was authorized to report the desired information whenever the condition was revealed at the time of physical examination of veterans applying for compensation. This form is as follows: VETERANS BUREAU, Medical Division. Form 2540. REPORT ON FRACTURES--LoNCi BONES Army Serial No.----------- Claim No.________________ Name-------------------------------------------------- Age___ Rank_____ Co.___ Organ._________ Army—Navy. Permanent Address_____________________________________________________________________________________ Date of Discharge-------------------- Date of Injury _____.....___________ Date of Report____________________________ Bone, Name of -------------------- R.—L.—Head—Neck—Up.—Mid.—Low.—Third—Int.—Ext,—Cond.—Mall.—Involv.—Joint, Form of fracture: Simple—Compound—Comminuted. Wound: Soft parts healed: Yes—No. Union: Firm—Faulty—None. Bone Graft: Yes—No. Bone Plate: Yes—No. Date inserted_____________ Date removed Osteomyelitis: Yes—No. Healed: Yes—No. Deformity: Bowing—Ant,—Post.—Outward—Inward. Nerve involvement: Yes—No—Which_____________ Shortening: Inches________________________________________ Atrophy: Yes—No. Extensive loss of muscle: Yes—No. Functions of joints: Free—None—Limited. Degrees of limitation___ Wrist-drop: Yes—No. Foot-drop: Yes—No. Ankylosis: Fibrous—Bony. Angle: Favorable—Unfavorable. Fsing crutch?--------- Brace?_________ Cane?_________ (Shoulder—Wrist—Elbow—Hip—Knee—Ankle.) Occupation before the war___________________________________________ Will he be fully able to do his former work? Yes —No. What occupation is he best suited for?__________________________________ Remarks: _______________________________________ Is he mentally and physically capable of being trained therefor? Yes—No. __________________________________________________ Date of last X ray __ __________________________________________________________________________________________________ Disability - Permanent— Temporary— Partial— Total—__________________________________________________ District reporting_____________________________________________ Examiner reporting______________________________________ Instructions.—Draw a line through terms not applicable. One card to be made for each bone injury. Card to be attached to Report of Physical Examination and forwarded to Medical Adviser, Veterans' Bureau, Washington, D. C, through the District Supervisor. GENERAL SURGERY 495 Since, in the tables which follow, the compensation rating is the index of the disability, it is necessary- to know what the schedule of ratings comprises, in order properly to understand the tables. The following ratings, in force in the United States Veterans' Bureau, is the outcome not only of experience in the bureau but also of expressed opinions of various leading surgeons in the United States; in addition, the schedule of ratings of England, France, Belgium, and Canada were taken into consideration in its adoption. RATINGS OF AMPUTATIONS, FRACTURES, AND THEIR SEQUELS In general, loss of muscle substance, cicatrices, and atrophies, when having an effect upon functions, from 10 percent to 25 per cent should be added to the specific rating. Shoulder Bony ankylosis: Major— Percent Favorable angle______________________________ 3g Unfavorable angle_______________________________ 45 Minor— Favorable angle___________________________________ 28 Unfavorable angle______________________________________ 36 Limitation of motion from full flexion to 90°, same as ankylosis. Inability to raise arm above 90°____________________________________________ 30 Elbow Complete bony ankylosis: Major— Favorable angle_____________________________________________ 35 Unfavorable angle____________________________________________ 50 Minor— Favorable angle_____________________________________________ 30 Unfavorable angle____________________________________________ 45 Limitation of flexion of the forearm from— 160°-110°— Major___________________________________________________________ 25 Minor___________________________________________________________ 20 160°-90°— Major___________________________________________________________ 20 Minor___________________________________________________________ 15 180°-70°— Maj or___________________________________________________________ 5 Minor___________________________________________________________ 5 Loss of extension of the forearm from— 60°-180°— Major___________________________________________________________ 50 Minor__________________________________------------------------ 40 75°-180°— Major________________________________ ------------------------ 45 Minor_ . _ . -------- 38 90°-180°— Major________________------- "° Minor_____ __.....- -------- 20 105°-180°— Major____________ ------------------------ 20 Minor______________ ------------------- 15 4-i 1 s 3 03 a 5 o -t; 2 -H fct b- X « i i; P In -H £h , ffl a ____' ai l E- Type of fracture: 628 3 619 14 fin 1, 85 20 38 81 9 50 10 16 4 15 11 738 33 3, 979 1,542 4,025 fi 30 1 2 1 4 12 b 21 1011,594 40 81 100 13 16'4, 271 313 87 •> 8 2 2 5 1 1 .. ! 331 90 814 75 1 2; i________ 3 .... 3l 824 '?. ____i 8____ ___ 85 Deaths: 22 1 23 47 __: . 1 ____ 49 104 ? ? 1 1 1 111 93 3 1! 4___ 1 ________ 102 6 6 8 _________1 8 Due to disease d_______ 5>8 28 16 ::::i""i ____________i 17 Total_______________ 4,807 78 112 30 122 05 27 20 45 5,306 6,620 37 54 12 133 17 21 -s 29 6,950 1 Bone or bones involved Fibula Humerus ce C. K ' 1 3 3 a 3 .a 3 1 3 24 22 24 547 641 2 41 91 ? 651 2,972 382 8 14! 30 22 4 24 64 86 130 3 346 Not stated _ _ _. ._. 211 _ 211 1 2 2 2 12' 12 14 427 Due to disease d_______ 8 Deaths: 1 ' Simple_____________ 9 13 9 13 9 84 I..-.I 9 Compound _________ 1 1 1 1 1 3 90 Not stated.. ________ 2 1 2 6 7 | | ' 6 Due to disease d______ Total_______________ 1,251 5 5!.. i 1 21 1 .... 3 .... 1,267 3,936 15 34 26 7 30 101 120 1714,440 " Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b The column captioned "Alone" indicates that there is only one long bone fractured. c The major fracture may be of either the "tibia or tibia and fibula" or the "radius or radius and ulna," as is shown in the sections so marked. d Fractures due to disease are cases of amputation for tuberculosis, etc. In this and the following tables amputa- tions are included with the fractures, the amputation being due to the fracture. GENERAL SURGERY 499 Table 32.—Fractures of long bones of United States veterans of the World War, hg type of fracture, showing bone or bones involved, and deaths, as of January 1, 1926—Continued Bone or bones involved Ulna Radius or radius and ulna -_ ~ ,? Type of fracture: Simple______________i 201 1 Compound__________ 758 3 Not stated___________ 174 Due to disease <*____ Deaths: Simple.........___..... l| Compound__________ 18 Not stated________ Due to diease d____ Total_______________1, 157 4 Eh &h e ^ 3 I _ __ X X i E- ..! 203 907 5 2 789 2,095! 3 1 177 547: 1 ..!____' 8' 1 21 18 02 5 10 .C £■ -i : 3 | ~ £ _- i __ ! _. I as 21 5, 1 7 19 4 3 3 .... IS 21 2 944 4,407 187 15, 223 557 2,527 8 191 3 1, 193 3,65." 112 399 37 58 43 3, 798 22,954 <• The column captioned "Alone" indicates that there is only one long bone fractured. « The major fracture may be of either the "tibia or tibia and fibula" or the "radius or radius and ulna," as is shown in the sections so marked. ■* Fractures due to disease are cases of amputation for tuberculosis, etc. In this and the following tables amputa- tions are included with the fractures, the amputation being due to the fracture. Table 33.—Fractures of long bones of United States veterans of the World War, by age group and bone or bones involved, and deaths, as of January 1, 1926 ° Bone or bones involved Age group Femur Tibia 21 620 930 414 79 46 173 50 Fibula 9 336 484 221 36 25 132 24 Tibia and fibula Under 20.. .......____.........___ 50 1,405 2,294 981 143 56 209 168 38 20-24.........________ 1, 207 1,806 827 147 74 386 126 25-29_________......______......------- 30-34.. ______________________ 35-39 .......____________ N'ot stated ______......_____ Deaths.. _____........._____ Total ....._________ 5,306 2, 339, 1,267 4,611 Hu- Ulna merus 40 14 1,245 319 1,889 495 810 205 109 44 66 16 103 76 112 24 4,440 1,193 Radius Radius and ulna Total 8 28 214 394 663 6,189 560 983 9,447 269 405 4,132 35 64 657 24 34 341 66 163 1,368 35 07 606 1, 391 2, 407 22, 954 ° Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. 500 SURGERY Table U.—Fractures of long bones of United States veterans of the World Wai, 1^ condition first examination, by location of fractures, and deaths, as of January 1, l.r.h on fir Location of fracture Condition on first examination Associated conditions: Osteomyelitis------..........------- Osteomyelitis and shortening, osteomye- litis, shortening, and deformity------ Osteomyelitis, shortening, and ankylosis Osteomyelitis, shortening, deformity, and ankylosis-------------------- Osteomyelitis, deformity, and ankylosis Shortening----------......-------- Shortening and deformity----------- Shortening, deformity, and ankylosis- -. Shortening and ankylosis------......- Deformity. -........-------------- Ankylosis or ankylosis and deformity. - Not stated----------------- Deaths Total Bone graft, plating or nerve involvement Nerve involvement-------------- Bone graft with nerve involvement.. Bone graft Bone graft with nonunion Bone graft with nonunion with nerve involvement Nonunion with nerve involvement Nonunion Faulty union Plating \\ iring Not stated Deaths Total Shortening: Under 1 inch Under 2 inches Under 3 inches Under 4 inches 4 inches or over Amount not stated Not stated Deaths Total Radius Ulna j Radius and Total ulna 1, VI 543 08 93 117 124 2,308 168 17 47 68 76 8 11 197 80 1,281 50 1 60 31 1 11 68 132 12 16 230 160 32 11 340 204 29 ? 39 27 4 •?, 27 45 3 102 382 405 157 40 157 308 49 934 2,506 2, 332 766 24 120 112 24 23 27 65 6 3 217 76 837 35 129 16 s 307 143 1,425 67 1,246 198 219 391 1, 260 1,403 170 192 1.944 977 12, 449 606 22, 954 Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. GENERAL SURGERY 501 Table 35.—Fractures of long bones of United States veterans of the World War, by character and degree of disability, bone or bones involved, and deaths as of January 1, 1926 a Character and degree of disability Temporary partial: 10-19....._____ 20-29__________ 30-39__________ 40-49__________ 50-59__________ ro-09____ ____ 70-79.. ______ 80-89__________ Temporary total... Bone or bones involved < o 165 127 42 24 441 20 1 5 1 3 3 _- 1 1 _. 5 Total temporary j ratings.....Z____ 617 Permanent partial: 10-19_______________ 603 20-29_______________ 637 30-39_______________ 312 40-49_______________ 254 50-59_______________ 513 60-69__________ ____ 830 70-79_______________ 128 S0-S9 . . _ ____ . .. 455 90-99_______________ 10 Permanent total_________ 34 Total permanent ratings.....------3, 776 Femur S S x t> as Tibia or tibia and fibula 3] 13, 170 142 48 33 25 19 4 186! 13 .. 29 7 682 1,125! Ill 3| 15 2 11 32 1 I 31 64 82 4 1 7 3 8 3 4 1 9 — . 1 19 "i 663' 1,615) 8 0981 807 7 351, 287 2 294 1,054!____ 5611 127 1 8591 49 _ 152; 23 1 4681 16___ 12......... 1.8 13! 2 I 2 2 5 3' 1 2___ 2.... 5___ ll.... 9| —. i!_--_ .3!___ >| 13 1 9 3 1 4 - 9 9 1 6 2 503 287 59 34 60 15 31 3 176 4 I, f! 2! I 31 I Total rated cases.. Deaths_________________ Less than 10 per cent... 4, 393! 160 254! 26, 105 591 22 10 28' 1 118 1 3 63 27 19 1 1 ? Grandtotal_________4,807| 78112 30 122 65: 27 20 36 4, 1.6.3,9911 231 48 !■ Ul 1 5__..| I3| 15i 5 845 1 301 31 074 2 140 1 67 1 32 2 32 1 4 99 43 4,808 5,110 34 1! 168 1041___ 1 270,1,340: 3 45 5, 300|6, 020, 37 10 123 1 0 1 4 18 541 12 133 17 21 194, 23 5, "". 1, 29 6, 412 176 362 950 Veterans' Bureau. » Source of information: Coordination Service, Evaluation Division. U. The column captioned "Alone" indicates that there is only one long bone fractured. The major fracture may be of either the "tibia or tibia and fibula" or the "radius or radius and ulna," as is shown major tracture may in the sections so marked. 502 SURGERY Table 'Mi.—Fractures of long bones of United States veterans of the World War, by character and degree of disability, bone or bones involved, and deaths as of January 1, 1926 ( ontd. Bone or bones involved Fibula Humerus Character and degree of disability Temporary partial: 10-19 § 1 2. c 126 1 44 1 1 Tibia Tibia and fibula | Humerus * Ulna Radius and ulna 128 183 3 c 1 _-1 .2 i "3 .3 | .C 3___ 2 2 2 1 1 4 0 1 c 2 4 1 1 1 1 1 3! C 3 196 20-29 i i 45! 125.... 7 146 30-39 11 5 2 1 Hi 51 ___ 54 40-49 2 28 50-59 1 ___ 38 15 1 l1 17 70-79.. i 13 10 1 "■-- 1 .... 5 20 80-89 1 | i 10 90-99 1 . :_. 1 3 192 1 3 33 i 9 i____ 2 3 3 2 2 1 3 2 1 13 13 18 18 li 12 2 1 12 21 22 15 16 11 4 1 1 19 42 Total temporary ratings__________ 2 1 i ! 1 i 195| 492! 2 332 709 1 3j 4 552 ===_ --- Permanent partial: 10-19 329 110 46 23 10 5 1 2 2 1 1 3 2 2 7 .... 3! 7 4!___ 18 775 20-29 1 .... 1 .... 1 ... 111 47 25 10 1 3 503___ 327 ... . 207 .... 17, 635 30-39 . -L.-L--- 18 384 40-49 1 1 1 2 ]!...._ 34 20 12 11 10 2 268 50-59 173 121 1 1.... 219 60-09 9 ? 3 150 70-79 163 1 002___ 74 1 2i 3 .. 193 80-89 .... 1 1 1 1 13 ?9 2___ 620 90-99 1 78 1 _ 4 1 3 4 1 2 4 8 6 22 29 1 1 82 95 1 5 101 1 96 108 " 12 120 38 _..J 2 1 -„| 3.... 538 2.943 13 21 7 25! 7 Total permanent 527 147 3,360 Total rated cases--- 719 24 508 733 24 510 3,435 15 106 .... 395 . . 32 1 1 106 3,912 31 112 1 1 i i 1 1 2 416 1 3!.... 1 15 30 1,251 5 ___1 2 I1___ 1 ?67 3 93f 34l 261 7 17114.440 1 h The column captioned "Alone" indicates that there is only one long bone fractured. GENERAL SURGERY 503 Table 35.—Fractures of long bones of United States veterans of the World War, by character and degree of disability, bone or bones involved, and deaths as of January 1, 1926—Contd. Bone or bones involved CI na 1 Radius or radius and ulna Character and degree of disability Alone * Double ulna 3 S 2 3 03 3 E 03 3 a The column captioned "Alone" indicates that there is only one long bone fractured. • The major fracture may be of either the "tibia or tibia and fibula" or the "radius or radius and ulna," as is shown in the section so marked. Table 36.—Fractures of long bones of United States veterans of the World War, by bone and joints involved, showing condition on first examination, as of January 1, 1926 a Location of fracture Femur. Tibia.. Fibula. Total. Joints with impared function Hip Knee 361 9 2 1,432 382 31 1,845 Ankle Hip and 'Knee and knee ! ankle 47 1,557 245 165 3 115 144 Not stated Deaths Total 3,018 4,679 957 168 176 24 5,306 6,950 1, 267 1,849 8,654 13, 523 Humerus. Ulna...... Radius... Total______ (Irand total. Elbow 1,332 425 233 1,990 Shoulder j Elbow and elbow and wrist Not stated 53 859 162 145 79 2,128 6 131 2,269 4 30 739 5,136 Total 112 4,440 102 | 3,798 24 ! 1,193 238 I 9,431 22, 954 - Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. 504 SURGERY Table 37.—Fractures of long bones of United States veterans of the World U ar, involved, location and character of the fracture and amputation, and death. 1926 « thawing bone January 1, Fracture Bones Femur_____ Tibia______ Fibula_____ Humerus--- Ulna......... Radius_____ Tibia, fibula- Radius, ulna. Total. . Bones Location Head Neck Upper Middle Lower j Condyle Malleolus Elbow 162 59 24 238 30 66 19 38 1 709 453 ... 107 4 794 335 198 300 1 261 413 123 858 14 3 170 539 212 231 708 309 795 967 4 75 130 119 | 303 6 3,163 1,337 3,470 1,551 530 1,108 297 550 1,570 854 410 81 13 7 145 309 2 4 232 17 104 6 6,458 l 951 57 i________ 1 !..._ 4 ......'_ .. 1 1 ________ 100 _-..; l 439 _._. 245 -__-! 0 Location Not stated o 3. Femur... 1 ___ 486 2 Tibia___________ 1 .-.. 017 .... Fibula__________ 1 ___! 340 .... Humerus_______________] 549 3 Ulna___________________I 282 .... Radius_________________I 289 |.._. Tibia, fibula_____ 1 ___I 631 j 19 Radius, ulna____________| 439! 3 Total______ 4 .... 3,633 27 Further location Amputation 382 251 207 259 97 204 560 329 Fracture Reampu- tation 354 1,181 281 670 175 294 292 1,361 107 320 159 349 498 852 253 477 2,119 5,504 1,200 738 346 1,298 458 424 944 514 330 322 218 422 177 210 501 343 698 ' 718 413 160 489 230 1,752 Due to disease as _3 , x 49 41 111 53 34 55 4 3 11 108 5,356 E0 2,312 24 1,264 112 4,432 24 1,183 35 1,381 120 4,622 67 2,404 110 : 81 i 200 253 £06 22,954 ° Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. 6 The difference in bone totals, in this table, is due to preference in tabulation being given to the'amputated minor bone, where the major one was not amputated. GENERAL SURGERY 505 Table .is.—Amputations as a result of fractures of long bones of United States veterans of the n oita n ar, by bone or bones involved, amputation levels, and interval elapsing between injury and amputation, and deaths, January 1, 1926 ° Bone involved and amputation level Femur: Upper____ Middle.... Lower____ Not stated. Total. ... Tibia and fibula: Upper_______ Middle______ Lower_______ Not stated___ Total . Humerus: Upper____ Middle.-. Lower____ Not stated. Total. Radius and ulna: Upper......_. Middle______ Lower_______ Not stated___ Total______ Grand total. 1-3 300 454 205 1 557 Interval elapsing between injury and amputation Days Months 8-15 317 20 121 13 118 9 1 _____ 16-31 i 2-6 7-12 ' 13-24 25-36 37-48 82 j 130 260 25 14 20 288 19 21 33 144 9 9 10 8 ., 32 34 13 10 I 11 30 18 23 1 19 20 ' 5 ! 7 : 10 1 i_____I 1 | 1 Over 4 De' Mis'' years 2 22 42 5 11 1 , 8 19 6 19 6 11 5 36 41 42 96 9 6 '1 1 I 3 1 9 114 2 3 3 2 2 4 0 5 3 9 144 1 1 . 1 2,632 251 161 , 222 93 102 S3 1 23 1 ! 12 1 I 4 1 6 6 1 11 1 - 4,178 a Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Death not necessarily a result of amputation. 5(H) SURGERY T -BLE 39.— Amputations as a result of fractures of long bones of United Stales veterans of the World War, by character and degree of disability, bone or bones involved, amputation levels. . by and deatits. January 1, 1926 a Bone or bones involved Character and degree of disability Femur Tibia and fibula Upper 1 Middle 1 Lower Not stated Total Upper ..... Middle Lower Not stated Total .... 1 Temporary partial: 30-39_____________________ 2 0 1 2 2 1 16 1 ______ 2 1 1 19 3 70-79 . . ___________ 3 ______ 14 9 6 1 ______ 9 1 53 1 Temporary total.........------ 21 22 58 Total temporary ratings... 22 1 22 10 1 ! 55 i 23 22 18 9 72 Permanent partial: 1 5 3 1 50-59_________________ 60-09 . _____________ 3 33 32 384 14 043 30 34 2 44 1 i______ 1 304 1 322 49 ______! 725 7 ■_. 1 75 11 !________ 429 2 | _______ 13 327 15 12 4 7 397 5 21 1 4 174 10 2 903 33 35 70-79_____________________ 80-89 - - ____________ 2 3 14 9 50 26 |________ 120 27 25 23 1 76 Total permanent ratings. _. 512 773 400 1 1,686 392 453 214 1 10 232 1 19 11 ______ 1, 009 Total rated cases________ 534 22 795 42 410 11 2 1 1,741 76 415 19 475 19 1 1,141 49 ...i 556 837 421 3 1,817 434 494 243 19 1,190 Upper I " " 1 Middle Bone or bones involved Character and degree of disability lumerus Ulna and radius Grand total Lower Not stated Total Upper Middle [ Lower Not stated Total Temporary partial: 30-39 _________ 1 40-49 __________ 2 50-59 _____________ ____|____ 2 60-69 . ___________ 3 70-79 ......... 1 1 11 7 80-89 - _____ - - 1 2 3 2 2 2 117 Total temporary rat- 3 3 6 !_______ 2 2 135 Permanent partial: 20-29____________________ i , 1 30-39___________________ t 1 1 40-49________......_____ . _ 1 904 50-59 _________________ 1 1 3 42 77 20 6 57 ■ fifi 2 1 124 79 181] 16 480 60-69 _________ 53 56 839 70-79 . _____________ 6 135 2 5 46 92 2 5 1 1 53 315 80-89. _________________ 313 56 16 ____ . ! 540 7 ', 4 5 999 90-99____________________ 1 : 01 1 | 27 74 5 i 5 m 20 243 Total permanent rat- 386 148 145 3 6X2 124 198 164 3 419 3, 856 Total rated cases____ Deaths_______________ . 389 23 151 12 145 4 3 . 688 124 _______| 39 I 6 130 164 j 3 6 | 11 '______ 421 23 3,991 187 412 163 149 1 3 727 130 136 1 175 1 a 444 4 178 1 Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. GENERAL SURGERY 507 Tables 40 to 73, inclusive, show the character and degree of impairment for each long bone or for associated bones, according to the progress made at intervals of three months. Separate tables have been prepared for each bone when there was a series of 100 cases or more to each 10 per cent. FEMUR FRACTURES The femur fractures number 5,138, or 23 per cent of the total fractures, and comprise the most serious group of injuries, not only because of the pro- longed duration of time required to reach a stationary level but also because of the very high degree of disability. Of the 5,138 cases, 259, or 5 per cent, required a period of 2 years to reach their stationary level; 435, or 9 per cent, required three years; 637, or 12 per cent, required four years; 1,185, or 23 per cent, required five years; and 2,622, or 51 per cent, required more than five years. Thus 26 per cent of the changes in rating occurred before the end of the fourth year, so that 74 per cent of the femurs required more than four years to reach a stationary level. These cases of fractured femurs were rated as follows: Two hundred and seventy, or 5 per cent, were less than 10 per cent: 1.673, or 33 per cent, between 10 and 29; 726, or 14 per cent, between 30 and 49; 1,671, or 33 per cent, between 50 and 79; 484, or 9 per cent, between 80 and 99; 314, or 6 per cent, were rated 100. Amputations of the thigh contributed largely to the higher ratings for, among the 1,671 cases rated 50-79, there were 1,122 amputations; among the 484 rated 80-99 there were 443 amputations; and among the 314 rated 100 there were 173 amputations. Of the 141 frac- tures rated 100 per cent yet not amputated, 53 were under hospitalization. It should be stated that 100 per cent is the rating awarded hospital cases. Short- ening occurred in 2,155 or 41.94 per cent of these cases, which also combined to increase the rating. The severity of many of these injuries was increased further by the complication due to an injury of an associated nerve in 418 cases. TIBIA AND FIBULA FRACTURES Tibia and fibula fractures number 4,485, or 20 per cent, of the total frac- tures. They make up another important group in which 226, or 5 per cent, required two years to reach their stationary level; 453, or 10 per cent, required three years; 562, or 13 per cent, required four years; 1,027, or 23 per cent, required five years; and 2,194, or 49 per cent, required more than five years. Thus 28 per cent of the changes in rating occurred before the end of the fourth vear and 72 per cent required more than four years to reach a stationary level. Their degrees of rating are as follows: Seven hundred and sixty-four, or 17 per cent, were less than 10; 1,968, or 44 per cent, were between 10 and 29; 1,272, or 28 per cent, between 30 and 49; 244, or 5 per cent, between 50 and 79; 21, or 1 per cent, between 80 and 99; and 216, or 5 per cent, were 100. Amputa- tions of the lower leg contributed to the higher ratings. Among the 1,272 cases rated 30-49 there were 906 amputations; among the 244 cases rated 50-79 there were 86 amputations: among the 21 cases rated 80-99 there were 15 amputations: and among the 216 cases rated 100 there were 134 amputations. Of the 82 fractures rated 100 per cent yet not amputated, 58 were under hos- pital care. There were also 273 associated nerve injuries. For nonunion, 97 50S SURGERY operations were performed in which bone grafts were employed; in 60 cases Lane plates were used. Shortening occurred in 982 cases, which also increased the ratings. TIBIA FRACTURES Fractures of the tibia number 2,289 or 10 per cent and are somewhat less serious than those of the previously mentioned bones; 118, or 5 per cent, re- quired two years; 212, or 9 per cent, required three years; 266, or 12 per cent, required four years; 478, or 21 per cent, required five years; and 1,129, or 4!) per cent, required more than five years; 86, or 4 per cent, unclassified; thus 26 per cent of the changes in rating occurred before the end of the fourth year and 74 per cent required more than four years. Their degrees of rating were as follows: Five hundred and ninety-eight, or 26 per cent, were less than 10; 1,314, or 57 per cent, were between 10 and 29; 196, or 8 per cent, between 30 and 49; 107, or 5 per cent, between 50 and 79; 15, or 1 per cent, between 80 and 99; and 59, or 3 per cent, were 100. In 160 cases there was an associated nerve injury. FIBULA FRACTURES Improvement begins earlier in these cases which number 1,243 or 6 per cent; 89, or 7 per cent, required two years to reach their stationary level; 123, or 10 per cent, required three years; 153, or 12 per cent, required four years; 221, or 18 per cent, required five years; 454, or 37 per cent, required more than five years; 203, or 16 per cent, are unclassified; thus 29 per cent of the changes in rating occurred before the end of the fourth year, and 71 per cent required more than four years. Their degrees of rating were as follows: Five hundred and ten, or 41 per cent, are less than 10; 616, or 49 per cent, between 10 and 29; 88, or 7 per cent, between 30 and 49; 20, or 2 per cent, between 50 and 79; 4, or 0.4 per cent, between 80 and 99; and 5, or 0.6 per cent, were 100. In 164 cases there was an associated nerve injury. HUMERUS FRACTURES These cases number 4,328, or 19 per cent, and make up another group of severe disabilities; 214, or 5 per cent, required 2 years to reach their station- ary level; 303, or 7 per cent, required 3 years; 492, or 11 per cent, required 4 years; 954, or 22 per cent, required 5 years; 2,365, or 55 per cent, required more than 5 years. Thus only 23 per cent of the changes in rating occurred before the end of the fourth year, and 77 per cent required more than 4 years to reach a stationary level. Their degrees or rating were as follows: Four hundred and sixteen, or 10 per cent, were less than 10; 1,752, or 40 per cent, were between 10 and 29; 734, or 17 per cent, between 30 and 49; 637, or 15 per cent, between 50 and 79; 709, or 16 per cent, between 80 and 99; and 80, or 2 per cent, were 100. Amputations of the upper arm contributed to the higher ratings. Among the 637 cases rated 50-79 there were 55 amputations; among the 709 cases rated 80-99 there were 602 amputations; among the 80 cases rated 100 there Were 31 amputations. The severity in this group was very largely increased because of an associated nerve injury in 1,086 cases, for which many operations have been performed. Also, more than 250 opera- tions were performed for nonunion, in which bone grafts, Lane plates and wire sutures were used. GENERAL SURGERY 509 RADIUS AND ULNA FRACTURES Radius and ulna fractures number 2,340, or 10 per cent of the total frac- tures. In this group 132 cases, or 6 per cent, required 2 years to reach their stationary level; 185, or 8 per cent, required 3 years; 311, or 13 per cent, required 4 years; 538, or 23 per cent, required 5 years; 1,154, or 49 per cent, required more than 5 years; 30, or 1 per cent, were unclassified. Thus 27 per cent of the changes in rating occurred before the end of the fourth year and 73 per cent required more than 4 years to reach a stationary level. Their ratings were as follows: Three hundred and ninety-nine, or 17 percent, were less than 10 per cent; 1,003, or 43 per cent, were between 20 and 29; 294, or 12 per cent, between 30 and 49; 581, or 25 per cent, between 50 and 79; 24, or 1 per cent, between 80 and 99; 39, or 2 per cent, were rated 100. Amputations of the lower arm contributed to the higher ratings. Among the 581 cases rated 50-79 there were 383 amputations; among the 24 cases rated 80-99 there were 16 amputations; and among the 39 cases rated 100 there were 22 amputations. There were also 417 associated nerve injuries. For nonunion 104 operations were performed, in which bone grafts were employed in 82 cases and Lane plates and wire sutures in 22 cases. RADIUS FRACTURES Radius fractures numbered 1,356, or 6 per cent, of the total fractures; 110, or 8 per cent of the cases, required 2 years to reach their stationary level; 109, or 8 per cent, required 3 years; 145, or 11 per cent, required 4 years; 300, or 22 per cent, required 5 years; 591, or 44 per cent, required more than 5 years; 101, or 7 per cent, were unclassified. Thus 27 per cent of the changes in rating occurred before the end of the fourth year and 73 per cent required more than 4 years. Their ratings were as follows: Three hundred and twenty- four, or 24 per cent, were less than 10 per cent; 745, or 55 per cent, between 10 and 29; 158, or 12 per cent, between 30 and 49; 111, or 8 per cent, between 50 and 79; 5, or 1 per cent, between 80 and 99; 13, or 0.9 per cent, were rated 100. In 272 cases there was an associated nerve injury. ULNA FRACTURES Ulna fractures numbered 1,169, or 5 per cent of the total fractures; 60, or 5 per cent of the cases, required 2 years to reach their stationary level; 83, or 7 per cent, required 3 years; 129, or 11 per cent, required 4 years; 230, or 20 per cent, required 5 years; 498, or 43 per cent, required more than 5 years; 169, or 14 per cent, unclassified; thus 23 per cent of the changes in rating occurred before the end of the fourth year and 77 per cent required more than 4 years. This large percentage is due to the fact that in 347, or 33.68 per cent of cases, there was an associated nerve injury which materially delayed the recovery. Their ratings were as follows: Two hundred and forty-seven, or 21 per cent, were less than 10; 664, or 57 per cent, were between 10 and 29; 169 or 14 per'cent, between 30 and 49; 76, or 7 per cent, between 50 and 79; ■1, or 0.4 per cent, between 80 and 99; S, or 0.6 per cent, were 100. 510 SURGERY Table 4().-Fracturcd femur, United Slates veterans of the World War. rated less than 10 per cent on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a Degree of impairment on last rating * Total Months (interval elapsing be tween injury and last rat- 10-19 20-29 30-39 40-49 50-59 60-09 80- 89 loo ! T Less than P^a" cent _____ 2 Tem-pora-ry Per-ma-nent To-tal « ing) Tem-pora-ry Tem-pora-ry Per-ma-nent Per- Per-ma- raa-nent j nent Per- i Per-ma- ma-nent nent Tem- Per-pora-' ma-ry nent 2 1 1 3 ____ 3 ___ 4 ...... A 1 ^ 4 T~ 1 -I...... 24 ____! 24 27......._____________________ 1 ____1 3 4 . i 4 4 33 ...... 1 1 1 | _-! 9 1 1___ 1 1___ 10 1 i _____1 8 9 1 | -.-I 4 4 42 !J::::::;:::::: 1 | 3 1 5 1 1 1 5 ... ....1___|___ 6 .. 4 4 Total 3 -1 -- i 2 | 40 5 1 46 .i | ....I 5 5 54 1 1 1 ________1_____1 5 1 2 1 2 2 7 57 1 __________1____1 6 1 i " 60 i : '3 2 1 4 63 1 ______ 3 66 1 | , 1 5 7 69 1 1 72 1 1 ! 1 1- 1 1 3 ----------------!-----------------------------------i------------- Total__________________ 2 2 1 ' 1 _____ 1 — 1 2 1 | 26 6 5 1 37 -r, 1 1 __l__ 1 3 1 2 2 1 i 78 2 ____ 2 1 .. ..|___ ■> 84. .. _______ . 3 87 .. _ ________ I 1 1 i 1 93 ... 1 I 1 1_____! 1 ------------1 Total________ 1 1 1 5 4 6 1 ■ H 1 99________________ l 1 1 1 1 1 ' 1 1 Grand total___________ 5 3 i 1 i li 2, ll 11 1 2 S 94 1 17 1 8 ' 119 a Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases; c Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 511 Table 41.-—Fractured femur, United States veterans of the World War, rated 10-29 per cent aisaoted on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1 1926 a Degree of impairment on last rating * Total Months (interval 10 19 elapsing between 20-29 % 5 % % H X —.1 1 Temporary M Permanent «= 40-49 Temporarv ' o< Permanent &> 60 -69 70-79 8( >> c a -89 a ct 6 X 100 '£■ E C- injury and last > rating) -' E S 3 a g E-1 5 a c e t_ S <_ E s X >> c g c o c. a a c 03 E Ph c c _. T c 1 ' 1 ■3 3.................., 1 5 i i 3 2 "T 17 3 6 5 8 9 11 13 18 73 22 26 26 47 58 70 59 ' 1 7 3 3 5 5 9 2 3 1 2 4 4 2 6 3 «..................1 3 4 1 1 10 9...........__.....1 2 4 5 1 15_____________1 2 3 1 2 : 2 6 ! 2 1 3 1 2 10 12 18_____________ 3 21_________..... 3 12 24................. 3 1 i 1 L.__ 1 ___ 13 -- ____ — 7 :<^i Total______ 19 18 7 24 09 5 27......._......_.., 4 1 ; 2 1 ^7 5 12 15 15 19 21 28 35 1 12 30.....__________ 2 5 7 10 8 3 3 1 38 7 1 4 7 5 3 3 9 7 9 8 12 13 63 21 20 32 44 55 .50 _... 1 1 !.... i i 1 3 8 3 14 8 ! 17 6 17 8 1 14 10 : 8 5 ! 11 23 33............... . 7 i 32 36_____________ 7 40 39._....._______ 8 1 1 42 42_____________ 10 1 i i 2 1 43 45_____________ 5 i l 46 48_____________, 7 1 .... 1 1 3 2 1 1 2 5 ! . 4 6 13 47 9 4 1 2 2 2 T l i 3 ;____ 51 I Total______ 50 5 2 1 3 3 1 7 3 7 1 | 1 i i l 3| 1 45 94 150 289 51.....__________ 8 2 1 2 1 1 2 1___ 1 _ 13 19 8 ' 8 7 11 48 50 66 105 125 135 134 97 80 54_____________ 4 1 .... l l 2 1 1 66 57_____________ 6 84 60_____________ 9 1 ■ 1 2 | 1 1 "T i .... l l 1 1 1 2 -- 13 17 17 7 7 20 13 18 14 12 138 63__________ 4 66_____________ 12 — 1 1 .... 155 ! 170 69__________ 5 6 : 53 .... i 2 1 155 72------------- 4 49 3 32 l 1 1 .... 2l____ 116 Total_____ 52 357 36 307 27 3 4 2 8 6 2 7 1 3!_... 5 12: i 89 115 760 | 964 75_____________ 3 30 9 !7 6 8 2 22 25 7 4 5 T 4 5 2 1 1 6 1 1 1 1 1 4 4 2 .... 4 21 4 , 15 4 8 76 55 24 18 17 9 5 1 101 78_______........ 4 1 74 81____........... 2 1 i 36 H4.__........_____ 1 1 8 1 .... 1 1 3 1 1 21 87____.....________1 8 _. .... 1 1 —- 18 90....._____________ 2 3 1 1 1 .... 1 11 93___________...... 3 I 1 ___ 1 ; 1 5 96................. 1 1 2 Total______ 11 77 18 67 6 20 l 11 1 17 1 10 — 1 1 2 11 13 50 205 268 99___ 1 1 2 2 1 102___ 2 ! 2 2 108_______ 2 Total 4 1 1 | | 5 5 Grand total. 132 528 10 445 10 72 2| 43 10 24 4 1 18 1 4 1 8 27 2 154 i297 1,144 1,595 0 Source of information: Coordination Service, Evaluation Division, U. S.Veterans' Bureau. 6 Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study. 46997—27- -35 512 SURGERY Table 42.—Fractured femur, United States veterans of the World War. rated 80-49 per cent disabled on first examination, showing interval elapsing bei ween injury and last tating ana degree of disability on last rating, as of January 1, 1926 " \ 10-c Degree of impairment on last rating h Total o c e 5 Months (interval elaps-ing between injury 19 _ c <_, Temporary to to Permanent <° 1 Temporary co ^ ' Permanent <° 40-49 50-59 Temporary ot - . — ? Permanent =° 70 79 80" 'C ' G C 1 : g i 1 E ' g I E-1 C_ Oh 100 o a g and last rating) 5 B. b* g E X 03 , 0/ t- : C 2 ' 03 E Z o g, E- | 0- £ 2 3 ] 1 2 2 2 3 ""\------n~~ 3 1 j 1 2 1 1 2 1 1 1 2 1 2 "i ] I 3 """1 3 24...........-.....--- 3 Total — — — 1 4 10 . 2 11 1 -=== 5 2 4 8 5 6 5 1 11 4 6 7 10 10 8 15 16 ~~ 1 2 1 3 3 2 4 2 1 18 2 3 1 = = = = -- =- 6 1 1 1 1 4 1 4 1 12 1 l ! 11 2 1 .... 3 4 1 4 2 3 1 i 15 3 1 3 15 2 .... 1 1 1 2 17 1 ' 4 i 15 2 3 8 32 4 1 1 16 18 1___ 2 ! 1 Total______..... 4 j 5 | 4 10 4 36 67 107 1 1 1 1 1 7 - "\ 2 1 ] 2 5 6 8 3 3 3 18 28 38 48 73 80 71 55 20 54..............------ 57 ........______ 2 2 3 3 | 2 8 10 2 15 5 5 s 11 19 12 12 "l 1 ~~2 4 3 4 6 4 6 5 33 3 in .... __1 1 ___ 1 ___1 4 ....'2 ___: 4 ...- 2 - —■ 1 1- i 2 1 1 1 46 60______....._________ 63_____________________ 66_____________________ 69 - 9 2 16 1 57 10 12 1 8 24 1 2 17 20 2 23 14 1 2 26 13 i 1 16 1 1 1 ____ i 77 84 1 1 79 72_____________________ 1 10 6 ___ 1 i 58 Total___________ 58 3 100 13 128 , 3 74 ' 4 33 ___1 14 1 1 4 3 ! 6 37 411 454 1 2 '___ 7 L... 10 1 10 2 5 --..' 3 ___ 1 .... 1 2 2 1 2 ! 1 2 ... i___ . 6 5 4 2 3 40 37 25 12 3 1 2 46 4 1 2 6 1____ 11 ___ 2 i 4 1 8 7 2 6 ___ 1 !___ 2 1 1 ___________i 1 42 1 __ 3 2 1 1 29 1 2 L (» 14 _______!___ i 1 1 6 90 1 1 ! i 1 ! ! 1 2 Total __________ 3 | 9 , 2 | 19 1 : 36 1 2 1 | 1 25 4 16 .... 11 .... 2 2 8 !____ 20 120 i 140 1 99 _________ 1 1 1 108......_________ ' ! .1 1 1 Total . ______ 1 1 ...J....L..J.-.. 1 1 : 1 2 2 ______ -------------------------j-------------------------- __'__......_ Grand total_____ 17 72 ' 9 130 26 206 24 117 s 50 2 j 27 1 6 3 11 I 10 98 611 719 "Source of information: Coordination Service, Evaluation Division, U. S. 'Veterans' Bureau. i> Where the column isjomitted there were no cases. t Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 513 Table 43.—Fractured femur, United States veterans of the World War, rated 50-79 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a Degree of impairment on last rating ' 100 Total Months (interval elaps-ing between injury 10-19 20-c o E- -29 _■ 03 s C X Temporary co Permanent ■ 40-49 50-59 60-69 Temporary -j Permanent to Permanent go o >, c ft E 5 E __ 2 1 3 1 2 1 2 and last rating) c ft E C E- c 1 >> C3 _, O ft E a E-i c c 03 E 0, Temporary Permanent Temporary 0 OJ a a Ph »> (h 03 O ft | Permanent ' Less than i cent 6 2 2 9 1_______ 1 1 2 ____1____ i 2 12 1 _. 3 15 _____. 1 1 i 1 18 ' . . . 2 1 | 2 21 ._________________i___________ "T — 1 1 i 2 2 1 1 1 1 .... 1 4 2 Total 5 L___ 6 3 ___: i ___ i i 1 _______ 4 1 1 5 12 6 4 3 8 12 11 _0 16 27 11 i .... 1 2 .... 1 i 1 8 30 1 33 1 1 2 2 1 2 3 3 5 ..._|.... 1 9 36 1 1 3 39 1 1 1 5 5 2 9 i 3 1 1 3 11 42 1 2 .... 1 3 1 3 1 6 .... 1 13 45 l ___ 1 13 48.......___________ i i 2 3 1 4 __ 3 23 Total_________ 3 2 25 5 19 i 5 1 1 -- 2 15 64 81 51 1 2 4 4 2 9 16 10 6 53 6 4 1 2 .... .... 1 2 2 1 .... 4 6 11 5 9 13 13 5 .... 1 .... 1 2 7 7 5 10 8 12 9 7 .... i 2 1 3 4 3 3 2 15 19 36 25 40 53 47 33 15 54 1 4 2 1 3 6 5 22 3 1 2 1 .... 2 i i 4 1 3 2 1 1 2 ---- ....1 1 3 4 6 4 6 3 22 57 5 ... 1 2 __ T .... 4 2 5 2 4 4 40 60 ______ 32 63 ______ 5 3 2 1 16 :::: 1 1 45 66 . ______ 1 59 69 72______.....______ i -- 36 Total_________ 1 1 .... 3 66 6 65 i 2 | 18 6 10 i 3 31 268 302 7 L...I 11 3 2 4 7 ..... 2 6 ;.._J 2 .... 2 3 3 1 1 .... 3 5 4 T i 32 15 16 13 3 1 1 37 19 2 ____!... J 1 .... ____ 1 17 1 1 1 — 15 2 4 1 1 1 1 1 Total_________ 1 2 IT __ 7 6 34 ...J 5 ___ 13 2 25 2 21 1 10 1 6 '____ 1 12 81 94 Grand total____ 1 28 2 69 15 121 13 111 4 IT 8 18 i 6 62 425 493 • Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. k Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. 514 SURGERY Table 44.—Fractured femur. United States veterans of the World War, rated SO-99 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a Degree of impairment on last n iting& 80-89 90-99 100 Total Months (interval elapsing between injury and last 20-29 30-39 Perma-nent 50-59 60-69 70-79 Tem- Perma-porary nent Tem-porary Perma-nent Total« rating) Perma-nent Perma-nent Perma-nent Perma-nent Perma-nent Tem-porary 18........_______ 1 1 1 27 ____________ 2 1 3 1 1 3 1 4 0 3 30 1 1 33 1 1 36 3 1 3 6 3 42 _____________ 1 ! i 2 45 1 4 48 6 Total..____ 1 16 2 i 1 i 19 20 51 1 1 8 6 0 6 5 11 6 10 5 8 10 8 9 10 54 1 7 57 1 1 1 60 1 1 8 63 5 3 9 16 69 -- - 1 2 3 1 8 72 - _______ ____ . 1 1 I 10 51 Total______ 1 2 | 2 5 1 4 _____ 1 68 69 -- 2 1 3 _____ 1 1 1 5 2 1 1 6 78 1 0 81 1 1 96 1 "1 1 Total______ 4 1 4 _____ 1 1 9 10 1 Grand total. 1 2 6 6 4 71 6 3 4 96 100 ° Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. 6 Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study, GENERAL SURGERY 515 Table 45k—Fractured femur, United States veterans of the World War. rated 100 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a Degree of impairment on last rating ' Months (interval elapsing between injury and last rating) 10-19 20-29 30-39 40-49 50-59 1 ___ 5 03 g S | , E Total______ i 1 .i 1 -J 2 ti::: i, i i .-. 2 1 -I 2 Total....... 6 51. 54____ 1 60________________ 1 63______________ 0 69 7° Total. Total. Grand total. 4 34 I 5 52 1 5 2 16 14 44 13 87 63 60-69 O 03 r- X 70-79 Total 90-99 100 X ; E* 359 -- --' 8 18 24 20 15 1 22 22 1 20 --"- 149 2 35 1 34 1 44 1 64 66 66 1 68 3 43 1 =H - E- X 2 2 1 4 1 10 4 10 3 22 1 32 74 3 ' 55 471 2 205 101 118 141 149 173 174 118 50 29 1 87 11,069 9 2 4 1 6 1 6 .... 696 12 104 2 1376 6 (119 1125 100 59 44 28 14 3 6 |204 1,902 • Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study. 107 108 125 159 161 182 188 127 1,157 115 68 53 34 17 3 1 1 2,112 516 SURGERY tibia, United States veterans of the World War, rated less than 10 per ■st examination, showing interval elapsing between injury and last rating Table 46.—Fractured tibia, cent disabled on first exa,,,. and degree of disability on last rating, as of January 1, 1926 Months (interval elapsing between injury and last rating) 30. 33. 36. 39. 42. 45_ Degree of impairment on last rating *> 10-19 Tempo- Perma- rary nent Total. 10-29 tem porary Total. Total. Total_____ Grand total. 100 tem- porary Less than 10 per cent Total Tempo- Perma- rary I nent Total "Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau * Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study 25 215 GENERAL SURGERY 517 Table 47 —-Fractured tibia, United States veterans of the World War. rated 10-29 per cent disabled on first examination, showing interval elapsing between injury and last rating and aegree of disability on last rating, as of January 1, 1926 a Degree of impairment on last rating ' Total' Moi iths (interval elapsing between injury and last rating) 10-19 4i— 20-29 30-39 40-49 50 -59 !" 03 70-79 2 1 100 g E o O a C3 03 J3 «J o. 1 1 1 4 2 3 03 C 03 a Temporary Permanent >> a 5 a S 03 a E >> 03 C ft g 4 3.. i 6.. 4 3 8 3 5 9__ , 3 12_______________ 2 : 1 6 .... ' 3 2 1 4 4 15_____.....____________ . 1 2 2 2 1 2 1 18______________________ 21. Total....._______________ 3 |.._. 5 2 11 24.. l._ 14 20 6 7 i 2 6 i 1 19 1 3 7 | 5 16 1 5 10 j 1 7 3 9 ' 11 14 6 14 34 12 60 27-. 1 2 , j 13 16 23 13 21 20 8 8 27 14 24 16 13 13 2 3 4 7 4 8 14 17 30.. 2 24 33.. 7 1 1 48 36.. 7 8 ___; l 36 39.. ■) 54 42.. 5 2 5 i 5 3 3 l 1 1 33 45.. Total.....____.......... ___l___. 42 48.. l .... — T — 81 31 7 20 10 34 10 44 10 52 14 67 4 76 7 79 5 66 67 438 5 28 7 20 2 ! 14 2 7 2 8 ___ 1 38 15 2 1 ___| 1 1 2 130 123 48 301 51.. 4 5 3 8 4 35 5 3 4 6 11 13 18 26 21 23 125 16 8 3 1 1 18 21 22 28 26 25 , 25 188 12 15 14 18 24 8 13 9 27 43 58 67 88 106 105 97 57 54.. 2 2 , 79 57_. 1 j 1 1 1 1 2 ....j 3 ._..| 6 3 14 ..__' 2 _... 3 1 1 2 .... 1 ' 94 60.. 1 113 63....._______....._____________ 1 1 135 66____ 1 2 1 2 140 l l _ 10 2 2 1 1 143 7"' 2 4 131 Total_______.....__________ 2 4 1 113 591 892 75.. 1 1 4 3 1 15 5 9 2 ■> 1 11 12 13 6 4 1 48 34 25 11 10 1 6 1 74 78.. 1 2 1 2 51 81.. 84., 1 1 1 47 19 87.. 14 90.. 3 93 Total_____________________ 1 1 1 19 80 —-!— 4 1 8 96. 3 12 35 1 12 ... 6 4 1 1 2 -- 10 36 47 136 219 99 1 1 1 102 J 1 ___[ i 1 Total __ 1____1____________ 1 l 2 187 556 99 181 1 6 27 l 16 6 l 6 2 2 16 369 317 788 1,474 a Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. 518 SURGERY Table 48.—Fractured tibia, United States veterans of the World War. rated 30-49 per cent disabled on first rating examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of'January 1, 1926 ° Degree of impairment on last rating & Total 10-19 20-29 Months (interval elapsing be- 30-39 Temporary *• Permanent to 50-59 e o a E X 60-69 a a a B 03 Ph 70-79 fl 03 P a a 03 Ph l 80-89, %, 1 o tween injury and last rating) c Permanent Temporary Permanent >> a o E a _, a C3 6 tH 03 Ph > c E b- a a 03 Temporary Permanent ____ Total« 1 6___...... 1 1 1 1 1 ' 2 9________ 1 1 24_____....... 1 1 1 -- Total.....-----........... i i | | i 1 2 2 4 -- = 27__..... 1 1 1 1 2 6 4 1 1 1 2 1 2 30___............... 1 1 3 33________ 1 1 3 36______________ 2 2 2 2 1 1 6 39_________ ... 2 .... 1 6 42____ 2 45_________ 1 1 1 48- _______ 1 1 1 2 6 Total______ 5 3 3 2 9 2 1 4 7 3 8 11 13 19 19 32 19 29 51______ 1 4 4 5 9 8 7 5 T 1 2 .... 1 1 1 2 1 1 2 1 1 2 2 3 1 3 3 2 4 54_____ 1 .... 1 1 4 3 3 4 12 6 1 1 1 .... 1 1 10 57___....... 1 1 l 1 14 60_______...... 3 4 5 10 6 2 16 63______....... 1 1 1 l 1 l 2 2 1 4 1 22 23 39 22 66_____________ 69_________..... 72____ ~T Total_______________ 3 33 6 32 ? 10 4 2 10 16 124 150 75_______ i 1 1 1___ 4 I 1 1 1 1 1 1 2 7 16 1 2 1 g 78_________________ 5 3 .... 5j.._. 2 17 S4_....... 87 ... i r " 1 1 90______________ i ____ 1 7 4 .... Total........_____ 5 9 1 „ 1 _____' 3 27 30 --- _ Grand total________ 10 ■' 2 19 -- 10U -i- . wi^ce ?l information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau » Where the column is omitted there were no cases. = Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 519 Table 49.—Fractured tibia, United States veterans of the World War, rated 100 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 ° Degree of impairment on last rating ' Total Months (interval elaps-ing between injury and 10-19 20-29 30-39 1 40-49 50-59 60-69 70-79 30-89 o 100 ;-Be, . ^ last rating) ft>> Is 03 , Bl — 03 o> a In o ft>> a >h ti 03 03 — =-• ( a , 31 -. 03 03 0 1h 6 E a 03 In Eh 03 __ Bl a> a Ph 6 3 a 03 - _i 03 a 3h 6 a>> E a 03 , Ep Sh 03 o) a Ph o E a *_-3| Tempo-rary Perma-nent a Ea [_ 03 03 p Ph Tempo-rary Perma-nent - o, a o 3 S ft =-H 1 2 4 2 2 Permane Total ' 1 1 .... 1 1 1 1 1 3 4 1 i 2 5 -- 1 1 2 1 1 1 ... 1 ... 1 1 i 1 6 21 l l 3 1 2 1 2 2 4 2 3 3 — 1 1 4 ! 1 2 I 11 9 | 22 27 = 1 !T ===== "-TT i 1 i .... i TJT i 1 1 1 '__-- 1 1 2 2 1 2 1 i 11,1 2 1 1 2 ___ 1 5 5 3 2 1 4 22 3 9 ..... 1 1 2 8 2 ? 1 2 6 1 1 2 ___ 2 4 2 1 1 i 4 6 2 2 1 3 1 5 2 12 10 9 1 2 1 1 5 8 ' 12 4 2 "T 2 1 2 = 1 1 7 1 1 9 2 Total__________ 6 2 1 .... 3 4 1 i 23 | 50 2 1 4 1 1 .... 2 1 1 2 3 3 3 5 3 4 6 29 6 4 4 2 7 10 10 1 1 1 1 2 ___. 2 1 1 14 1 1 2 1 _... 2 1 10 13 2 .. 2 -__| 2 .... 3 1 1 2 2 1 1 9 2 15 19 3 5 11 7 35 .... 2 i ! l 2 1 3 :::: 13 20 2 1 2 11 3 112 2 2 | 1 14 7 1 11 4 ...J 3 l ' 1 ! 1 3 ... 1 .... 1 .... 1 1 3 23 28 28 24 130 21 4 9 3 2 39 33 72 1 2 5 2 3 1 2 1 31 Total....._______ 3 43 | 4 4 1 7 _8_ 3 1 1 1 2 168 6 1 2 i 1 ! 1 1 29 1 ..-. 1 8 81.........____________' 1 3 1 1 1 1 .-.. 13 1 .... 1 .... 1 5 1 2 1 1 8 1 2 19 1 82 1 1 2 2 Total.....__________ 1 5 3 9 4 1 8 1 | 6 ___= 2 3 2 2 1 2 60 1-------. l 14 1' ■ 1 Grand total________ 11 52 12 53 4 16 3 27 18 4 7 1 5 10 27 13 18 201 301 » Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. "> Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study. 520 SURGERY Table 50.—Fractured fibula, United States veterans of the World War, rated less than 10 per cent disabled on first examination, showing interval elapsing between injury and last rating and dearee of disability on last ratina. as of Januaru 1, 1926 ° Degree of impairment on last rating 6 Total Months (interval elapsing between injury and last rating) 10-19 20-29 40-49 Less than 10 per cent 27 2 1 6 2 2 1 6 Tempo-rary Perma-nent Total« Tempo-rary Perma-nent Perma-nent Tempo-rary 3 27 6 2 9 ... 1 12 0 15 2 18 2 21 1 24 6 Total___________ ! 1 47 ----- 47 27 6 6 17 15 7 7 15 8 fi 30 6 33 17 36... 1 15 39 .. 1 - 7 42 ::l::........ 7 45 15 48 . . 8 Total....... 81 81 51___......._____________........ 1 7 5 9 4 5 7 2 5 1 8 54........._______________ 57........______________ 9 60.....___________________ i 1 2 6 63_________________ 5 66_____________________________ 7 69_____________________________ i i 1 1 3 72__________________......_____ 6 Total_____________________ 1 3 1 44 1 4 49 1 1 1 1 1 4 3 5 1 4 2 1 1 1 7 78_________________________..... 4 81........... . 6 84_______________................. 1 87_______ . ...______..... 1 1 1 1 1 5 90_____________________......___ 1 1 ----- Total_____________________ 3 3 1 17 4 3 24 Grand total______........___ 4 6 1 1 189 5 7 201 " Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. ' Where the column is omitted there were no cases. « Exclusive of patients who died during the 6-year period of the study. GENERAL SURGERY 521 Table 51.—Fractured fibula, United States veterans of the World War, rated 10-29 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 ° Degree of impairment on last rating » Total 10-19 ! 20-29 30-39 I 40-49 50-59 Months (interval elapsing between injury and last rating) -h Eh X E- r.' £ o B 0 a a o a E 03 03 O -H Ph r-< Ph Eh P- Total___________________________ 10 Total. 40 I 18 | 14 I 11 2 6 1 1 ___ 8 13 ■3 5 13 6 ___ 6 32 4 6 ___ S 40 1 6 1 5 49 1 9 ___ 8 39 9 ___ ' 32 4 8 ___ Total. 49 1224 ! 11 4i Total. 12 44 ! 2 17 J — J. Grand total. Ill 287 I 33 77 16 100 195 16 20 42 47 61 52 42 18 67 1 151 389 • Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. o Where the column is omitted there were no cases. « Exclusive of patients who died during the 6-year period of the studj. 522 SURGERY Fractured tibia and fibula among United States veterans of the }\ orh 10 per cent disabled on first examination, showing interval etapsing tn Table Z2.—F less than 10 per cent disabled on first ... and last rating and degree of disability on last rating, January 1, 19,-6 a World War, rated tween injury Degree of impairment on last rating b 0 a _, a E 03 Ph Total 10- u 03 ft o pc a -6 a c E o Eh E Months (interval elapsing between in- 19 20-29 SO-SO 40-49 50-59 70-79 80-89 10 b- jury and last rating) Temporary Permanent >> a (h o ft B 03 Eh Permanent Permanent Permanent b | a a o o I E ft 'A E E 5 o ft ft o ft E Zj Eh p 03 P a X E^ 25 2 4 1 6 3 4 25 •) 4 1 fi 3 4 ....J___ 7 1 52 52 1 == 27 1 4 10 26 17 17 10 12 13 5 10 26 36 1 1 1 1 1 1 2 1 1 1 19 39 1 19 42 .... 1 1 13 12 4.8 1 1 2 15 Total________________________ 3 1 1 .... 1 2 2 109 4 6 119 1 1 -- 9 8 7 7 11 8 2 --- 9 54 1 1 1 1 1 3 2 .... 3 2 5 .... 1 .. 1 1 1 1 2 1 2 2 1 2 1 5 4 2 2 4 5 5 15 57 1 12 60 . _____ 1 1 '_... 11 63 ______________ l .... 15 66........_____ 1 14 69 ____ _________________ 1 1 2 1 1 15 72 ____. . _____________......- 8 Total............___________ 5 1 17 2 2 3 3 1 1 1 2 1 4 1 1 ___ 1 4 1 61 11 27 99 -- 1 1 2 .... 1 ....i_._.. -- 3 2 3 1 3 1 2 1 ___ 1 4 6 3 3 2 3 9 2 1 9 81 . _______________ 6 84 ___________.....______ 4 87 - __________________ 1 1 5 90 ........_____________ ::T" 1 4 93 ________________________.....- i 1 1 9 1 Total________________________ 12 1 30 1 3 3 1 ? 4 10 1 1 _... 13 4 21 . 38 1 5 4 1 I 1 1 5 3 235 19 54 308 » Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. <> Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 523 Table 53.—Fractured tibia and fibula, United States veterans of the World War, rated 10-29 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a Degree of impairment on last rating -79 Total a E 03 Months (interval elapsing between in-jury and last rating) 10-19 20-29 30-39 I [ 40-49 50-59 60-69 70 loo | ° Lh a Sh o ft a 03 Eh 6 a>> So. 03 U Eh 2 1 03 __ « p Ph o ftt» So3 Q> ~ Eh Eh 03 03 a X o B a 03 tn Eh 03_-Ba tn 03 03 a Ph ft>> B 3 03 J-, Eh Perma-nent Tempo-rary Perma-nent 6 ft>> Eh 11 a, a X Tempo-1 Perma-1 nent 1 Tempo-rary Perma-nent ■- _ -. C3 73 03 •P ft X o 3__________________ j 2 1 1 6 3 5 3 7 1 5 3 7 2 I 1 9 11 12 14 14 6....._______________ 1 9......______________ 1 4 1 1 2 1 1 12__________________ 2 2 4 1 6 "~_~ i 5 1 I I 2 3 4 4 7 15__________________ . I 18.....______________ 2 i 1 21_________________ ■T ....|....|---- 24......_____________ 18 | 11 Total........... 10 3 2 20 28 16 __'__ 27.....______________ 4 i 3 7 3 23 5 10 5 21 i 5 20 ; 18 12 16 15 18 3 1 1 I 1 o 9 H 30 18 34 22 22 18 4 4 11 10 11 27 19 32 30_________________ 4 6 1 19 23 20 22 20 ::r, 34 33........___________ 6 1 36_________________ 8 I 4 11 i 3 2 9 7 2 2 ] 13 1 1 39________........... 2 2 .... 67 42_______.....______ 69 45_________________ ______! 1 ...J 1 3 1 77 48_________________ 9Q 79 Total__________ 112 73 | 43 ! 38 1 3 .... 2 1 2 7 !__._; 177 164 118 459 -- 51_________________ 17 , 33 12 51 13 65 11 : 77 15 i 91 13 111 12 : 92 7 ! 67 5 15 ___! 4 ___J 3 ____i 4 ...J 3 .___! 5 1 1 7 1 12 ...J 9 1 L.J 24 1 1 36 23 23 22 17 18 21 21 25 52 71 99 113 132 174 153 111 99 54.....______________ 9 ' 14 7 j 27 5 1 30 2 ! 36 5 | 51 5 | 43 13 | 28 1 2 2 1 _._. 1 130 57......_____________ 1 .... 1 1 1 !___ 33 29 39 38 27 19 154 60____________..... .... 1 .-.-j 1 159 63___________........ 189 66____......________ ::.. 4 4 4 2 ; l 2 '___ 5 .... 233 69______________ .. 1 1 ___ 1 201 72____________ 2 .... 1 155 Total__________ 100 587 51 244 2 ' 47 i 17 2 3 .... 4 1 1 1 13 2 245 170 905 1,320 75 11 3 1 5 47 5 35 ! 5 21 ! 3 17 ! 3 7 .... 5 ____ 1 ___ 1 2 22 20 13 7 6 2 1 ____! 6 ____' 7 ____! 1 ____! i ___1 2 ___________i 1 1 1 3 1 | 5 _._.! 3 ____ i ___| l 2 2 2 3 -- 14 10 6 5 4 2 2 21 11 8 11 2 1 4 78 68 40 26 18 10 2 2 113 78. . 89 SI .. ...j : 1 54 84 1 3 42 87 ...J 3 1 1 2 . 22 90 i :___ 14 93 1 1 5 96 1 l 6 Total__________ 22 |l34 18 71 _.__' IS 3 17 1 2 2 1 2 1 ...j n j.... 43 58 244 345 99 . 1 ________'________i________'_________________ i i 1 1 1 106 1 1 1 i i 1 Total I 1 1 1 ....'....L.J_____ ___Z_._J_.__I__________i...... 2 2 Grand total____ 252 '805 122 1 357 3 | 68 4 39 4 7 2 6 2 1 1 31 2 1 485 420 1,285 2,190 <• Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. 6 Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study. 524 SURGERY Table 54.—Fractured tibia and fibula, United States veterans oj the H arid \\ per cent disabled on first examination, showing interval elapsing between rating and degree of disability on last rating, as of January 1, 1926 a Degree of impairment on last rating * ir. rated SO-.',9 injury and last Total Months (interval elapsing 10-19 20->> a 0 ft E 03 Eh -29 p a a E X 30-39 40-49 50 c Eh -59 p a a a X 60-69 P 03 P a a X 70-79 u a 0 ft a 100 p 0 ft 0 p a J3 -0 03 a c ft E 03 a E ft 2 2 between injury and last rating) a § o 5 ft £ 1 1 § ft a c ft E 03 Eh a 03 a a E ft O ft a 03 Eh P 03 P a a Ih 03 Ph P. a 0 ft a 03 P 03 P a a Ih X a 0 1 1 1 1 3 1 1 1 1 2 .... 1 5 L 2 3 24_________________________ 1 1 1 1 2 " — 1 2 |___ 31 3 -- — ---- Total_________________ 6 4 11 ___ i i 3 |._-. ____1 1 1 1 1 4 1 2 4 2 6 3 1 1 5 5 5 9 6 7 15 i 5 30_________________________ 33_________________________ 36_________________________ 39 1 1 1 1 1 1 1 1 2 1 3 1 2 2 7 2 3 7 2 2 1 2 1 1 8 1 7 '} 11 1 2 ::.. 12 42......____________________ 45_________________________ "2 3 1 •? ; 9 .... 1 14 2:12 4 1 1 ! 1 11 .... 1 17 Total__________________ 6 3 4 13 1 11 | 10 1 25 .... 2 1 ___ 9 23 53 85 51_________________________ 54 j 1 1 6 2 5 13 8 2 .... 2 1 1 1 1 5 1 6 L-6 .... 9 1 5 1 6 8 6 14 7 8 _ 1 .... 8 5 11 10 17 17 10 1 ___ 2 1 2 1 2 6 2 1 6 6 1 3 6 15 17 25 30 47 46 42 27 23 20 57 -' 28 60___________...............— - ! 2 1 1 :__: 1 2 3 3 .... 2 .... 37 55 66 13 9 5 54 2 8 3 1 1 1 .... 1 1 1 3 1 47 69 _____ 1 3 10 45 72 3 3 33 4 4 55 1 | 2 1 2 ....; 2 4 I 85 — 6 4 8 Total__________________ 46 8 1 2 1 9 .... 31 249 288 75_____________ .... 11 3 4 3 1 1 3 3 4 3 28 15 13 6 3 1 1 29 1 18 ^1 ...... 1 .... 2 1 2 2 _. 1 17 s4 .... 2 1 1 10 1 6 93 . ____________ 1 90_________________________ 1 1 1 1 Total__________________ ?, 12 1 16 2 6 1 22 2 9 2 2 4 ___ 1 1 14 67 82 99 _______________________ 2 2 2 1 .... Grand total_____________ 13 61 14 84 19 71 9 137 2 17 5 2 15 '__._ 1 19 | 74 375 468 <• Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. ' Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 525 Table 55.—Fractured tibia and fibula, United States veterans of the World Wa r, rated 50-79 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 ° Degree of impairment on last ratingb ' Total Months (interval elaps-ing between injury and 1 last rating) Temporary g Permanent, «= 20-29 30-39 40- 19 a 03 a a E X 50-59 Temporary ! g Permanent, <° Temporary -4 , | Permanent ^ 80-89' 100 __ a a a a 03 .... c ft a b- P 03 P a a (H 03 Ph >> a k. o ft a Permanent Temporary 1 Temporary I Permanent Permanent | Temporary ; , Permanent ; I Less than 1 ; ; i cent ,_. < Temporary "a 0 E- j 1 1 ! ' l 1 ___; 1 _______i_______i_______ 1 I...J....L... __|-- ________1 2 2 i L... l 1 1 1 ________ 3 ________1___ 1 1 3 5 1 4 =,= = = ^= = = = ===== 1 1 2 1 3 1 1 | 2 1 .... 1 1 .. 6 ..11 3 1 ! .. 1 1 3 2 3 1 i 1 i i _______1 2 4 1 1 2 2 3 18 3 Total_________... -- 1 2 !._.. 2 j 1 5 1 4 3 .... 3 3 24 1 ,...' 3 2 2 4 1 ________ 1 5 10 7 7 11 28 8 6 2 .1 2 !.... 1 .... 1 1 1 _______1 2 12 2 2 1 2 1 ... 4 1 4 15 i.n ~~ IT 3 6 1 1 1 .. 8 3 1 .... 1 1 i_... 8 1 ________ 1 1 1 ___1 1 .... 2 1 ________ 1 12 66 _ _.....- 1 6 .... 4 .... 3 : 1 ! 21 1 1 1 1 !._.. ltl .... 4 2 1 1 1 3 .. 3 1 2 ___ 1 1 33 10 1 1 I..-L---4 11 , 1 TTj—. 2 | 1 , 5 11 | 1 | 20 .... 3 2 1....!.... -ii::.: 1 ...-I 3 ________ 4 13 17 .... 6 1 7 1 Total___________ 4 12 ___ 9 j 15 89 113 1 j 1 '_... 2 5 7 1 3 .... i -- 1 2 3 .. 4 8 1 8 4 4 2 1 6 2 ! 3 1 21 | 29 90______________________ 2 | 1 | 1 iii 4 | 1 5 1 .... 5 ...: 1 -- 3 --- 3 ... ... 1 1 ___ 8 = =;==--== 1 1 ; . .... 1 --I 1 Grand total------ 6 ' 14 4 24 2 17 1 3 31 5 i 21 1 7 1 13 1 1 8 1 12 30 129 171 Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. " Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study. 526 SURGERY Table 56.—Fractured tibia and fibula, United States veterans of the World War, rated 100 /- cent disabled on first examination, showing interval elapsing between injury and last rulimi and degree of disability on last rating, January 1, 1926 ° Degree ofimpairment on last ra .ing * 70-79 Total Months (interval elapsing between injury and last rating) 0... __________ 10-19 20-29 . 30-39 40-49 50-59 60-69 80-89 100 o a 5 E e 4 6 2 2 3 2 ,8 8 12 14 16 67 26 48 46 39 28 38 27 34 £ Permanent _ Temporary Permanent Temporary Permanent o Eh 1 a ft 1 1 2 5 9 11 10 c ft a o a E ft £ Temporary Permanent 1 E- R E c E-2 4 2 P a S ft _. 1 4 6 2 1 P P a o. X .... 6 9....... TiL 1 1 1 1 14 12 i 10 15.. i i i ______i 1 1 1 i " 9 18 1 1 16 21__________ i , i ;_____ l I___ 1 i 1 3 12 ___ 4 Is 24 l 3 4 1____ (1 20 l y~ Total 4 3 | 4 2 1 !..-_! 2 2 '___1 2 1 l 1 1 39 18 37 37 24 19 27 22 22 206 32 38 45 5 T -- -- 1 95 27________ I 1 ._._ 1 i = = 4 4 9 6 6 2 3 41 9 6 1 .... 1 r 1 5 5 10 4 2 4 8 27 30 .. 4 3 6 2 2 8 25 1 2 2 2 3 2 ■> 53 33...- L * 3 1 l 2 •> .... i 36. 2 1 1 .... i 1 .... 1 i 50 39 . i 42. 2 11__ 2 3 1 1 --I ' 40 45________ i i 3 48......____ __________i 1 2 4 2 1 1 * .... 2 1 2 i 43 2 1 1 | 2 1 Total_____ ___'_! i' i 2 . 3 5 | 1 5 I I 4 i 1 9 1 14 2 4 5 14 12 0 57 4 2 6 7 L... 4 1 3 3 2 1 39 5 8 5 8 8 8 4 9 286 328 51_____......___ 50 61 65 81 81 98 114 81 - 54...... ..-. 3 1 1 4 1 3 1 "T 5 1 5 3 _ v. 1 1 1 7! 57____ . 1 3 4 3 2 1 2 2 1 1 2 1 60_____________ 1 59 1 57 1 1 63_____________ 1 2 5 4 4 3 28 .... 1 90 106 119 90 66_____________ 59 1 1 4 79 1 ' 4 58 2 ' 4 1 2 1 69.....__________ 72_____________ 1 8 '.... 5 ! 1 ____j 2 . ; 4 ____ 2 __ 1 1 1 2 39 9 III 1 ___'___ 1 ___ 2 ___ ___: 2 i 2 427 1 10 1 30 3 21 Total_____ 9 3 1 8 | 14 18 8 55 11 8 9 631 694 7,",__ ___1 39 3 7 '___1 3 1 1 1 1 5 56 47 31 17 7 2 1 3 67 56 40 22 11 4 1 3 78__ 4 -. 2 1 1 3 1 ' 29 1 2 ____: 6 1 4 1 19 i 2 3 1 1 1 1 1 3 4 3 2 4 2 -._. 1 81______ ... 84________ . --.-■ 1 _________: 11 1 1 3 1 j 1 87________________ 1 2 1 1 4 2 90________________L-.l________ ____ 93____...........'....'_______ --- 96......_____________;_______ 3 . i 1 | 5 i 3 ---------- 7 15 | 1 | 10 3 Total_____ 10 2 9 | 2 |lll 3 --.. 1 20 j..__ i 1 j 39 164 204 1 i 99.....__________ 1 ____ 2 | i 3 1 3 102_____________'___1____ i 1 -- -----,---------- Total_____ ..--'-------------,—-i—-; i -...I ; i _4_ 1,152 4 1,325 Grand total. 9 | 52 17 S3 10 1 45 1 "86 26 53 1 4 34 14 j 9 2 , 11 | 71 79 13 160 Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau " Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study GENERAL SURGERY 52" Table ot.—Fractured humerus, Inited States veterans of the World War, rated less than 10 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a Degree of impairment on last rating 60-69 Total Months (interval elapsing between injury and last 10-19 20-29 30-39 50-59 100 Less than 10 per cent Tem-porary Per-manent Total ' rating) Tem-porary Per-manent Tem-porary Per-manent Tern- ! Tern- Tern- Tem-porary porary porary porary 3_______________ 21 4 2 3 3 4 3 1 21 li_______________________________________ ._________________ 4 9______________________ 12_____________________ A 15_........______ ! 3 21______________ 4 24______________ 3 "1 "" Total______ 1 40 40 27______________ 1 ________ 1 I | 5 9 9 9 13 10 7 4 1 1 1 6 30_____......____ 9 33 ________ . I ______ _____ 10 36______________ 1 10 39______________ i 13 42______________ 10 45 1 1 1 1 9 48 _________ ... 4 Total . 2 |______ 1 1 1 66 2 3 71 51....... 1 6 5 6 6 4 6 6 9 1 1 2 1 1 1 1 1 2 6 54 1 6 57 6 60 1 1 1 1 2 7 63 1 2 6 66 9 69 79 1 5 Total 3 6 2 41 5 6 52 -- 1 1 2 3 1 3 1 1 1 3 3 3 2 3 3 2 5 81 6 84 1 1 5 87 3 90 1 1 2 Total______ 9 1 ____ 1 1 11 158 2 9 10 23 Grand totaL. 3 17 2 2 1 1 _ 1 1 19 186 - Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. "> Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study. 46997—27- -36 >28 SURGKRY Table oS.—Fractured humerus, United States veterans of the World War, rated 10- 29> per cent disabled on first examination, showing interval elapsing between injury and last tating ana degree of disability on last rating, as of January 1, 1926 " Degree of impairment on last rating ' Total a 03 ft Months (interval elapsing between injury and last rating) 10-19 20-29 30- !9 p a E Temporary . •_■ Permanent «= 50-59 60-69 70-79 80-89 100 3 Temporary Permanent Temporary Permanent b1 a c E 03 5 E _H ^ 1 a 03 Ph j Temporary i Permanent a c ft E p o a E ft S» a tn O ft a ED a p a H 03 Ph a o ft a P 03 a a a 03 PH 03 X 5 0/ Eh 2 4 a o 1 2 3 1 1 2 6 1 2 | 3 4 1 3 15_______........ 18________________ 21 ----1 2 0 6 9 1 8 11 ' 5 _ 1 — " l 5 1 5 5 13 24________________ ;_.__; 1 3 10 m 19 1 1 1 1 ____ _ .._.... 12 Total_____ 27 S 1 1 1 ____ 13 1 5 24 17 54 3 5 11 . i___ 1 ===== " = = 4 1 6 5 10 16 16 18 26 10 30________________ 9 12 8 ' 25 27 14 9 ; in 2 1 [ 1 38 36_______ ______ 39_______________ 42_______________ 9 14 10 8 5 68 'TT 14 11 7 11 _ 3 4 ! 4 6 | 3 5 10 1 i 11 7 7 11 12 14 17 15 17 9 35 40 — - 2 ..— 2 38 46 48_______________ 14 | 4 ! 8 2 5 1 1 i 47 2 3 3 5 3 8 17 1 Total____ 45 ' 42 | 43 ', 1 24 5 i 10 ___ 30 1 11 —_ 33 7 16 1 l 1 | 70 113 98 281 1 51_______________ 54_______________ 57_______________ 60_______________ 63_______________ 1 | 14 13 16 18 19 13 16 17 5 7 38 47 56 88 140 180 163 111 OS :::. 1 1 2 4 12 4 4 2 2 | 1 .... 78 ______i i 88 54 5 27 71 5 1 53 99 7 46 86 1 i 51 56 2 33 1 1 1 1 1 .... 1 117 9 2 14 19 14 9 170 4 1 1 2 ___ 2 1 216 69_______________ 72________ ____ 14 , 1 11 1___ 6 1 182 — _l 3 _._. i i i 127 Total_____ _ 68 453 33 247 3 64 I 1 9 ____ 1 ... 5 28 4 11 ___ 7 ___ 9 1 3 | 1 1 1112 |11I 823 1,046 2 95 4 33 I 3 1 1 1 ! 1 TLLL7 .| 1 i_____ 8 ! 9 72 50 36 25 16 2 3 2 89 78 7 5 1 22 2 21 | 1 11 3 ! 15 ._._ 10 1 10 i. 3 _-_. 3 ______ 1 1 |___ . 4 12 ___ 3 1 8 66 81 3 ■ 2 : _ .:___ 47 84 1 4 I 2 ....! i ,.— 1 j____i____,____!-__. 1 , 2 28 87 2 i in i l 1 ,11 ___ 2 1 4 22 90 l -1---- 2 1 j 1 3 L-_. 4 93___________ __ 96 2 ____ 1 1 1 ------■—!—i— 6 2 _ 18 | 83 10 82 ' 1 Total____ 20 ___J 9 2 6 12 1 3 ____ 1 3 ____ 22 ! 36 206 264 102____________ ____________ 1 _______'___ ______________L__ ! ; 1 1 Grand tota J164 1 591 97 378 j 5 l 87 3 1 42 7 ! 19 2 9 ■ 1 13 1 4 4 , 2 217 |284 1 ! ! : i ! 1, 145 1,646 <• Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases. ' Exclusive of patients who died during the 6-year period of the study. GENERAL SURGERY 529 Table 59.—Fractured humerus, United Stales veterans of the World War, rated 30-49 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a Degree of impairment on last rating & Total Months (interval elapsing between injury and last rating) 10- 19 a o a a E 20-S a E b> 29 a B ft 30-39 40-a o ft E 03 E- 49 50- 59 60-69 70-79 80-89 100 a a a o. -_ 03 ^ | Temporary _ Permanent a _ a a a c ft E 0. Eh a a | a o a B o Eh a 03 a 03 3 o a a 03 Eh a p a a 03 Ph a o a a £ ft >> a 1 a 03 Eh -' E Z. 0. iT 1 1 1 2 __--1 L_. ...J 5 • 6_________________________ 2 15_________________________ 1 1 2 18.....____________________ 2 1 2 21____________............. 1 24_______........._________ l ? ____ 2 2 Total_____.....______ l 4 4 1 2 1 2 5 7 14 = ...J.- ----- 27_________________________ 3 ! 1 2___ 3 4 1 1 3 1 4 1 3 3 1 4 --I 7 .... 3 ~~2 2 1 3 1 2 4 1 2 _ 5 30_________................ 1 i l l l l 4 1 4 1 6 33______________.....______ i i 1 l 1 3 4 4 7 14 36_________........________ .... 1 2 13 39_________________________ 1 2 6 5 5 12 13 12 20 14 42_____....._______________!.... 2 2 1 3 .... 4 3 93 45.........._________.......... .... 1 ?0 48_________________________ 2 1 ?5 Total________________ 3 7 3 2 10 9 17 20 12 9 6 1 1 3 ~~2 3 2 13 14 . 20 9 "~2 1 3 27 6 6 6 .. 18 16 90 " T .... 2 2 2 3 fi 4 5 34 1 1 1 10 34 76 1?0 51_________________________ 3 ! 1 7 1 12 j 1 19 1 14 13 10 16 29 23 23 17 145 3 4 27 31 4'» 30 54-......______________.... 2 3 1 2 6 1 1 37 57........______ 1 2 1 1 1 1 1 1 5? 60______________________ 2 2 ..:: 3 ; 5,8 6 95 6 100 6 65 6? 63__________________ 26 28 13 15 123 3 2 13 .... 2 1 103 66__________.....__________ 11? 69.....___________ 3 83 72 7? 1 Total________________ 82 12 i 11 1 5 3 3 16 42 J493 551 75 10 _... 8 1 10 3 13 5 3 1 3 1 1 .... 4 5 4 .... 6 2 .... 2 1 1 .... 4 4 3 2 25 19 12 3 3 1 5? 78. 1 .... 30 81 1 6 4 .... .... 2 1 1 ,.-, 84 2 14 87 3 90 2 3 93 1 1 Total _______________ 1 11 12 101 1 19 30 5 26 2 20 1 16 — 4 2 2 1 1 1 13 111 125 167 36 201 1 15 139 3 52 2 16 4 7 4 4 29 94 '687 810 n Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. i> Where the column is omitted there were no cases. » Exclusive of patients who died during the 6-year period of the study. 530 SURGERY Table SO.—Fractured humerus, United States veterans of the World War, rated 50 70 per cent disabled on first examination, showing interval elapsing between injury and last tating ana degree of disability on last rating, as of January 1, 1926 a 10- Degree of impairment on last rating *■ Total Months (interval elapsing between 19 20-29 1 30-39 40-49 j 50-59 Temporary ot OT Permanent 1 «o 70->> a 0 ft a 03 Eh 79 P 1 a 03 Ph 80-89 90-99 100 a 0 gp 5 " 1 a 0 ft a 03 Eh E ft 1 .... 1 injury and last rating) ►. ! a u, O ft a a a ft b a o ft a 03 a 03 P a a fH X >> a o ft | *-P 03 P a a a o ft a 03 a <~ 1 a § 1 Ph i _h p 03 P a a (H 03 ft 1 P 03 P a a ft P O) p a a 03 ft >> JH a Ih O ft a ■3 1 1 1 1 1 4 2 1 1 1 2 24_______________ ... .... 3 5 1 1 | 1 1 5 Total________ 1 ll 1 1 7 3 10 27 = 1 = 1 = = = = = 1 --,-- -- 1 .... 2 1 4 4 1 2 2 6 2 5 7 4 7 6 3 13 4 30 2 1 1 1 ... 1 1:2 1 1 6 33 I 1 1 4 1 1 1 3 1 11 36 1 1 2 2 1 1 1 ...- 8 39 , 2 . 2 _..J 2 1 8 2 1 1 31 1 1 9 i i ' 1 5 4s_______________ 1 2 2 3 jllll 3 3 | 1 i 5 __ 1 .. 19 Total________ -- 3 3 4 1 2 4 7 12 5 I 10 1 11 1 1 | 1 22 47 70 51 2 2 2 3 4 1 2 4 20 2 i i 9. ...|....L— 5 i 1 2 "l .... .... 3 2 3 4 9 11 4 5 1 1 1 ___ 2 1 15 17 54 i 1 .... 2 1 5 2 4 _ _ 3 1 2 : 5 5 2 2 3 8 3 2 21 20 31 56 52 59 33 287 26 57 2 3 1 1 3 1 3 10 14 12 21 3 ____i 4 1 23 60 .. 1 ___ 6 6 7 .... 4 5 4 6 5 2 2 4 3 1 1 33 63 i 3 9 ~3~ 59 66 7 _.-. 9 I-..J 5 5 __.- 8 1 ' 9 4 ___ 4 ___ 5 2 60 69_______________ 1 1 — 62 72_______________ 35 5 Total_______ 27 1 | 40 2 35 4 71 4 35 3 41 14 4 3 1 27 315 7- 2 ...J 3 .... 3 6 9 1 .... 5 7 7 2 1 "2 5 6 4 2 3 2 1 2 1 1 — 2 4 3 2 .... 29 31 19 7 5 .... 31 1 3 1 3 .... 1 1 ! ? 3 !__._ 1 ___ 1 1 35 81.- 22 84 9 87 1 .... 1 1 .... 1 1 6 90 1 1 93 i 1 1 Total____ 1 2 j____ 10 | 1 9 1 8 2 17 1 22 2 17 6 1 4 1 12 92 105 Grand total - -. 6 24 8 40 | 5 | 53 | 5 47 18 101 11 68 7 70 21 5 8 3 68 429 1 500 0 Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. & Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 531 Table 61.—Fractured humerus, United States veterans of the World War, rated 80-99 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 ° Degre e of impairment on last rating ' T 3 a E Dtal p 03 P a E 03 ft 1 4 1 4 5 10 ! Months (interval elaps-ing between injury and last rating) 10-19 20-29 40-49 50-59 60-69 p 1 0, ft 70-79 80-89 90->. c a E 99 a E 100 03 C ft "3 03 P a a 03 ft _ E ft p p a a Ch 03 Ph p 03 a a a 03 Ph >. o a a p 03 P a a u 03 Ph >, a o a a 03 Eh p _ a a E 1 l o Eh 3_________..........._, 1 6........_........_____ ' 1 2 9__________.........____ . 4 4 12....._________________ 1 1 3 4 10 1 18____________.....____ . _____ 1 _____I 1 4 21________________...... ___1 1" 5 24______________________ 10 Total____________ ______ 24 3 27 27 27 ---------!--------- 2 4 2 7 8 9 9 10 14 16 2 30________........_..... 1 3 2 2 2 2 7 33_____..........______ 6 6 7 8 14 13 36______________________ .....____ 1 ______ 9 39________.......______ 9 42 _ _______________ I 10 45_____________________ i 14 48......________________ i 3 16 Total____________ 1 60 ______1 14 75 75 51_____________________ 1 1 18 1 4 1 3 2 5 5 2 20 17 24 38 34 42 32 14 20 .54 ___ _______ 2 11 23 33 28 30 24 9 17 i 24 liO________________________ 1 1 1 3 2 1 1 38 63 ?h- i! """ 3 34 66 ______ 42 69 ________ i l l 33 79 1 i I 15 Total............ 1 i 4 ! 1 5 1 10 1 176 23 2 221 223 1 _____1 1 14 1 7 2 1 1 _____' 1 _____ 1 1 2 2 1 17 2 8 4 1 19 1 3 si 8 S4 i 2 87 1 1 1 2 4 90 1 2 '3 Total .- 1 1 1 _______I 26 | 1 5 2 4 34 38 Grand total______ 1 i 4 1 6! 2 1 13 1 1 286 I 1 1 45 2 6 357 363 ° Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases. « Exclusive of patients who died during the six-year period of the study. 532 SURGERY Table 62.—Fractured humerus, United States veterans of the World War, rated 100 per cent disabled on first examination, showing interval elapsing between injury and last toting ana degree of disability on last rating, as of January 1, 1926 <• Degree of impairment on last rating! Total Months (inter-val elapsing between injury and last rating) 10-o 03 19 a 03 P a a ft 20-29 30-39 40-49 50-59 £ : a a . 03 1' 1 E ' _: 03 03 Eh X 60-69 70-79 80- 89 J0-99; 100 g. — a> 1 1 03 03 E- X £ a 3 i ° 0 E a 1 5 a e 03 03 Lt. 3 a a 03 E- a a a E 03 ft 0 P 03 ft a a E ft Temporary Permanent r j Temporary P 03 P a a 03 ft Permanent Temporary Permanent i Less than 1 cent Temporary p 03 P » a ' _ a 2 Ph , ** 1 2 1 ! 2 '" 6 X i 1" i 2 9 2 11 7 1 1 .... i 1 i 1 2 1 1 1 .... : ..1__ 2 9 n 18____ _______'---j___ 21 1 j 2 1 1 J 1 .... 3 8 H .... 1 i 2 ! 2 2 -- 1 17 18 2 j 10 | 13 1 3 2 ... Total -- i 2 3 1 2 ? '3 ---- 1 6 34 3 5 4 3 3 13 | 55 69 = TliT 1 =__-_-_= = - _-= T =,=-= -= 3 9 8 8 30 l 2 ___ 1 1 1 1 1 2 j 1 2 1 1 s ' 5 2 ] 3 4___ 1 ! 1 16 18 33 1 1 1 5 1 2 ! 1 2 _._.! 8 9 4 .... 3 2 1 1 3 3 L_. 5 16 19 36_____________ 39 .... _ _■ 1 .... 1 1 1 1 16 ! 20 i '...J 1 2 1 1 4 1 1 i | i 1 12 12.. 7 21 | 26 42 __ 4 "2 1 , 1 1 2 ___! 1 3 .. 6 21 2, 45 I 8 1 1 1 ______I 1 1 1______ 2 1 2 2 9 2 1 6 19 26 48 ________ 1 ___, 1 ___ 5 ___: 2 ___! 1 ___ 5 6 3 3 r. . 5 i 29 1 34 Total--____ 51 ___ 4 3 4 2 3 4 6 8 6 2 ! 8 r 3 3 2 1 2 3 6 5 3 2 24 1 3 7 3 -, 2 3 5 _ 1 .... 4 ... 7 9 .... 2 3 33 .... 3 2 13 1 ! 71 17 21 10 2 | 17 4 16 1 1 5 _.._ 28 19 1 , 27 6 j 31 15 ; 17 ... 5 , 2 1 18 23 ! 3 29 146 1 178 TlT 5 1 47 j 52 54. ____ 11 1 ...j 3 ___' 4 -- 1 i 1 5 1 39 45 1 3 5 2 2 1 3 2 6 1 8 9 2 1 1 5 1 39 45 60 1 1 2 2 4 3 , 54 57 63_____________ 66_____________ 69_____________ 72 .. ____ 1)4.1 '.'.'.J 5 :~T .___' 3 .__. .... 5 9 3 1 1 2 1 1 1 ___ 1 6 66 73 1 79 81 9 77 87 3 44 47 Total....... 31 3 1 8 1 1 36 2 | 27 3 ...J 2 1 .... 2 ___1___ 1 2 1 ! 38 ___i 3 3 57 j 5 ...J 7 ___ 3 1 175 9 7 3 3 1 16 , 8 8; s ] 37 445 1 3 ' 31 1 4 ■ 21 487 34 78- .__ . ____: > 3 ..- 1 2 ?5 81 ______ .... 1 1 1 ..-_ 1 2 1 1___:___1 2 6 2 8 8 84 1 1 2 ___' 1 11) 87 ____________ . .:___ 1 1 1 ! 1 1 4 5 90__________________ 1 .... 1 2 4 4 1 1 75 | 87 1 1 1 2 : 2 723 1 823 96______________________ "1 " 1 ---1—- 1 Total_____-. 102____________ 2 4 2 4 ___1 6 ___ 7 1 6 T~8~ 1 ___ 14 2 1___ 24 1 LTT 1---1---!'~" 1 | —-| 12 105____________ 1 .. 1"" 1 i | 1 1 'l 1 l i Total______ 1= 12 1 41 — J_________L... 1 1 1 '305 Grand total 20 47 7 43 5 36 9 j 46 1 51 6 1 90 "1 8 28 ! 23 | 36 1 9 91 "Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau >> Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 533 Table 63.—Fractured ulna, United States veterans of the World War, rated 10-29 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 * Months (interval elapsing be- tween injury and last rating) Total- Total____________________ U Total____________________ 33 Total______ Grand total. 29 Degree of impairment on last rating » Total 10-19 20-29 30-39 £ P o P a a t- ft 274 | 33 • 117 . 1 -i 2 J 3 -i 3 :L3_ -I 18 40-49 50-59 60-69 70-79 100 2 2 5 5 2 6 6 3 3 11 6 7 10 3 8 4 10 7 4 5 10 10 9 8 6 2 9 11 2 15 4 10 12 10 2 9 4 ' 4 1 4 3 23 « Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. » Where the column is omitted there were no cases. » Exclusive of patients who died during the six-year period of the study. 79 534 SURGERY Table 64.—Fractured ulna, United States veterans of the World War, rated 30-49 per cent disabled on first examination, showing interval elapsing between injury and last rating ana degree of disability on last rating, as of January 1, 1926 a Mo nths (interval elapsing between injury and last rating) 10-19 Degree of impairment on 1 20-29 30-39 40-49 ast rating b 50-59 60-69 70-79 o a 03 E- 03 ft O P P •E ° 03 Total P >. R >> o ft P c E- Permanent Temporary Permanent Temporary a a ft o ft a p E Permanent Total ' 6— \ ____ 1 1 1 _____ 1 l 1 1 9.-...__ ._.-.._. ._ 1 1 1 1 1 _____ 1 18 1 1 1 2 ■V,---- 1 1 _____! 2 1 Total_______________ . . . J ~ — 1 1 1 2 2 2 1 ...J_____ 1 4 3 8 TLTTTL..L "_L 1 == = = = = i 1 1 2 1 3 10 4 2 30. . 33 1 2 1 1 ___ 1 _. 3 1 2 4 1 2 2 2 36.. 39 1 1 1 2 5 | 4 42__ 45 1 1 2 9 8 1 11 1 3 48 1 2 1 1 i 6 Total_________________________ 1 , 4 1 i 9 2 10 11 2 1 2 _—, 2 J-.--, 2 __________ 1 13 21 35 3 5 ~T :::: 4 1 1 1 4 3 1 i ! 2 ___ 1 2 1 3 5 11 | 14 54 1 2 3 1 1 9 12 ____i i 6 7 60 2 1 2 11 4 2 2 i i 13 20 63 3 ____ 8 1 1 ___ 4 -__ ?, 27 1 27 66 ___ ___________ i~~ 2 ____________i 1 ___1 1 1 1 17 1 19 69__________________________________ 1 -— 4 __ 8 10 1 ! 2 14 1 16 Total________________________ 4 24 3 29 6 5 3 1 1 2 30 — 16 T 5 1 1 ! 9 11 105 125 75- 5 ____ 4 ___ 1 ____ .._-! 3 ____ 3 L l 3 _______ |:::T___i 1 17 18 78 1 5 . 2 l__ 19 19 81 __________________________________ ' 1 6 7 84___________________________________ 1 1 2 3 87_____ ___________________________ ! 1 1 Total_________________________ J 10 L-.l 16 1 ! 7 15 ! 5fi ___ 10 ___ 2 ! 2 1 45 ' 48 5 1 38 5 1 47 9 29 1 9 ! i 1 1 13 29 174 1 216 • Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. h Where the column is omitted there were no cases. <■■ Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 535 Table 65.—Fractured radius, United States veterans of the World War, rated less than 10 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a 1 Degree of impairment on last rating » Total Months (interval elapsing between injury and last rating) 10-19 20- 29 Perma-nent 30-39 Perma-nent Less than 10 per cent Tempo-rary Perma-nent Tota ' Tempo-rary Perma-nent Tempo-rary 3t______________ 17 17 6t____________________ i 6 ________ 2 ________ 4 ________ 5 ________ 5 ________ 2 i________ 10 j________ 6 9t_______ __ _____ ........_____TLLTLjL 2 12_____ ______ _ _ 4 15________ ______ 18t________________ 5 21_______________ ____ 2 42 . ____ . _ i i 10 Total_________ _ _ 51 51 — — 27. ______ _ _ 8 10 2 4 8 9 8 8 30 ______ ___ 10 33 . ___........ 2 36........__ i 1 5 39_________ 8 42________ 9 45 ____ ._ . . 1 8 48____ _ ___ 1 8 9 Total...... i 1 57 1 1 59 51 ______ . _.. 1 9 5 8 3 3 2 4 1 10 54 5 57 1 1 8 60 8 63 1 2 3 6 i 1 4 2 72 2 1 2 1 7 Total 3 4 2 41 3 6 50 — 2 1 1 1 2 2 1 1 2 1 1 2 1 1 5 4 1 2 1 2 Total_____________ 3 2________ 1 8 2 4 14 ________i 1 1 1 4 8 2 j 3 1 157 ! 6 12 175 « Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. <> Where the column is omitted there were no cases. ' Exclusive of patients who died during the six-year period of the study. 530 SURGERY Table 66.—Fractured radius, United States veterans of the World War, rated 10 -20 pet cent disabled on first examination, showing interval elapsing between injury and last taling ana degree of disability on last rating, as of January 1, 1926 ° Months (interval elapsing between injury and last rating) Total. Total. Total. Total. Grand total. Degree of impairment on last rating b 10-19 20-29 30-39 >> a a p a a a a a z z 3 zj 40-49 50-59 a ". i a 4 , 31 30 1150 70-79 Total ft E- X 17 3 6 7 15 8 10 9 10 3 11 5 0 Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there are no cases. c Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 537 Table 67.—Fractured radius, United States veterans of the World War, rated 30-49 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 ° 1 Degree of impairment on last rating b Total Months (interval 10-19 20-29 ! i 30-39 40-49 50-59 60-69 Z o al a - tn a 3 ft a 03 -H 1 elapsing between in-jury and last rating) Sh a o ft E E^ Permanent Temporary a 03 P a a 03 Ph >> lH a tn o ft a 03 a 03 a a a 03 ft >> a a b< Permanent Permanent Temporary Permanent Permanent Total « 1 1 1 1 2 ,-! _______ l 1 Total__________ -~!-~i------■-- 1 1 __________i__________ 1 1 1 3 ; 1 , 1 2 3 1 1 2 16 1 2 1 1 2 3 1 1 3 l i 1 2 1 1 1 1 1 1 1 3 1 1 2 2 5 3 ! 1 --------!------------------ 9 Total__________ l 2 2 i 3 2 8 2 2 1 |__________i 1 7 24 51 _. ._ ______ 2 ' 12 1 2 5 2 _____ 1 1 _____ 1 2'__________| 1 1 9 9 12 12 13 17 27 11 11 1 2 1 1 1 1 1 9 l 5 1 1 i 3 3 1 12 4 L 5 1 i 2 1 1 1 16 4 6 1 1 2 5 !_____ 4 ' 1 _ 14 1 17 6 1 11 28 3 2 3 1 -----, 2 1 1 1 4; i 1 4 28 Total__________ 1 26 | 3 27 | 4 2 12 11 _____ 3 2 | 10 107 119 --- l ii::: J 7 10 2 1 7 2 !_____ 1 1 1 1 1 1 11 3 1 ____ ___ ___ 1 1 1 3 ;_____ 11 1 2 1 1 |_____ 2 20 22 6 \ Grand total_____ 2 31 5 33 48 6 16 13 1 j 3 4 | 20 144 168 Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases. ■= Exclusive of patients who died during the six-year period of the study. 538 SURGERY Table GS.—Fractured radius. United States veterans of the World War, ratft?0J?J':"'fj disabled on first examination; showing interval elapsing between injury and last rating ana degree of disability on last rating, as of January 1, 1926 a 80-89 10 c | 0 20-E- Degree < 29 30-39 III ft T x )f impair 40-49 £' a a c. c c a 1 b- X ment on last ra ting6 70-79 b a a o o E a p a E H Ph Total Months (interval elapsing 10-19 50-c Z Eh ! i Permanent =o ! 1 cfi 1 1 Permanent 5 1 1 > Total Months (interval elapsing between injury and last rating) 10-19 20-29 30-39 80-89 ' Less Total c Perma-nent Tempo-rary Perma-nent Tempo-rary Perma-nent Perma-nent Perma-nent than 10 ^™-per cent ' 3........ .-......._______________ 22 1 3 3 2 22 1 3 3 2 6.....______________________ __ 9......______________________ _ 12....._____________________ . 15_______________________ 18_________________________ I ______ 1 ______ 5 1 r'l 1 24_______________.....______ 5 Total_________________ .... . -J 38 i 38 27________________________ 3 6 10 15 13 21 7 16 3 30_________________________ 1 6 33_________________________ 1 1 11 36......_____________________ 15 39________________________ . _ 13 42.....____________________ .- ____|_ ! . . 21 45..............____________ 48_______________________ 16 Total_______________ 1 91 1 92 51 ___ ____________ 9 3 7 4 8 5 8 9 54_____________________ 3 3 2 1 1 3 2 2 2 10 60_____________________ 6 63 . . 2 10 66____ ________________ 1 1 1 9 69 . .-...- 1 1 ] 7 72....._. .--___________ i ...-I 9 Total_____________________ i 7 1 2 1 51 2 10 i 63 7- 2 1 1 3 3 2 2 2 1 1 4 1 7 78 3 3 81 1 1 1 84 1 1 3 87 i 1 i! 90 1 1 Total_____________________ i 3 3 1 14 1 7 22 2 11 1 5 1 1 194 3 18 215 <■ Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau, b Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. 540 SURGERY Tab le 70.—Fractured radius and ulna. United Slates veterans of the W^iYZ\urTt!d~li»l per cent disabled on first examination, showing interval elapsing bdiceen injury ana last rating and degree of disability on last rating, as of January 1, 19-6 rating and degree oj disabil ity on I ast rati ng, as oj da on! nun ry , . J40 Degree of impairment ast rating * 90-99 *3> P 03 a ft 100 Eh Total Months (interval elapsing between injury and last rating) 10-Z ft 1 1 1 1 2 1 2 1 Permanent <° Temporary 10 Permanent, <° 30->> a o ft a a. 39 40-49 p | e o o E c 1 1 1 ft ft Temporary en 1 ? en Permanent * Temporary | g ' OS Permanent ; <° 70->> a o ft a 03 Eh 79 R o P a a ft o 03 K5 Temporary _ Permanent a o E- 1 1 2 1 2 2 3 2 1 _...! 1 3 1 1 2 1 4 2 2 3 1 3 2 2 3 5 4 12________ 2 .... i 1 5 18. _. 21_____ 24______ 2 5 4 8 i i : 2 | 10 Total 10 T 6 6 5 3 11 6 6 .1 .. 8 16 17 41 27_________ ___________ 30 1 1 == = -- -- -- — 6 5 5 6 14 8 7 11 4 4 9 11 8 8 9 10 2 1 6 11 8 10 12 17 12 1 x i—'— ' 10 4 4 5 4 3 2 5 ; 5 2 1 3 2 ! 5 2 28 1 2 30 1 1 1 _. 26 7 i 6 , 2 1 5 9 | 12 1 1 3 1 ... 1 .. 28 48 - -- ___1___ 38 Total_______________ 51_______________________ 54_______________________ 57_________ ___________ 60_______________________ 63_______________________ 66_______________________ 69_______________________ A ' i 62 13 13 16 16 63 12 7 6 14 67 29 43 34 71 76 192 ==- = == 1 -- 54 9(1 9 17 63 l ___|-._. 56 i 101 3 1 45 i 2 27 ___. 3 1 3 1 2 ' 19 5 100 1 2 ... i 14 i 13 110 9 1 6 i 74 137 2 3 45 ! 3 23 29 ' 2 11 5 ' i ! i 89 .... 8 | 3 1 i 3 5 1 52 60 489 56 Total_______________ 75_______________________ 78. 48 1 6 2 305 32 14 12 17 144 2 ' 15 2 6 9 Q 2 22 ! 4 1 ___ 2 ! 4 ___ ..-.. 4 3 ..__ 8 1 ----! 3 ._.. 2 1 ..__! 103 1 1 7 68 4 660 67 i "T 1 1 3 1 10 29 6 i 25 42 81_______________________ 84 __-.| 1 .... 2 1 1 1 1 1 .... . 1 32 6 :.... 4 7 1 14 8 14 87 1 5 9 90 2 ? 1 ;•) 8 93 1 2 1 1 1 1 Total_______________ 9 1 76 1 6 35 _...' 10 9 1 6 1 l 1 1 1 = 2 ' 17 20 'l38 i 175 99 1 1 -i 1 1 '___ 2 108 1 1 1 1 i i Total 1 . 1 ! | 1 1 1 3 i i 15 1 4 llll 429 : 45 209 5 35 16 1 3 1 3 1 2 191 168 712 1,071 1 1 i 1 ° Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. GENERAL SURGERY 541 Table 71.—Fractured radius and ulna, United States veterans of the World War, rated 80-49 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 ° Degree of impairment on last rating1 Total >> £ Months (interval elapsing between injury and last rating) 10-c. 19 20-29 30-39 40- ! 19 50-59 a c E Z 3 _ 60-69 70-79 Permanent Temporary a i p 5 5 2 ...J 1 1 c E 03 Permanent Temporary Permanent • 6 t 1 1 3 2 3 21 i ...- 1 3 24 ■ , 1 1 , | Total I i 3 ; 1 1 |____ 1 1 5 7 30 1 2 i L— 1 .... |—_ i 1 1 5 4 4 2 4 1 6 9 9 5 33 ____ 2 1 1 4 36 1 2 1 i 3 9 2 1 2 5 , 9 39______________________________ 42______________________________ 1 i i 5 1 , 111 19 2 i . 6 1 i i 4 , —-, 3 4 ___ 1 3 1 1 13 48_________________________ .... 1 113 1 ___ 1 11 Total_________________ 2 5 1 j 8 I 6 11 10 ..__ 1 1 --------1--------.------- 3 15 35 53 1 ! 3 3 2 4 7 8 9 2 2 .... .... 4 1 ___ 4 ___ 2 1 2 _ 2 3 2 1 3 11 13 17 22 25 41 31 25 13 54_____________________________ 3 1 2 j___ 5 3 '__-_ 6 1 1 7 1 1 15 1 : 18 60_____________________________ 63_____________________________ 66_____________________________ 69 .. _____________________ 1 1 1 1 !_______ 1 1 1 25 6 2 3 1 1 29 i 6 ,___-] 10 1 2 -.-i 11 __-. ■t| 5 r:: 5 40 1 _..- 1 i. — l 1 ! ! 43 32 13 16 ___ 9 --I-- X 28 Total________________ u 26 | 5 50 4 53 io L-- 2 !___ 4 2 ! 16 185 203 1 3 i .. 2 .... 2 ...j 5 .... 2,1,2 ___ 4 1___ 1 .... 1 ..... 1 14 13 12 3 3 1 14 78 1 2 1 ..... 4 ___ 2 1 . .. 2 1 1 15 81 ____________1 —- 3 '________! 1 4 13 1 ■: .... 1 2 .___ ________1—. i ! ______ 1 .... 1 3 ...J 1 ________|-----|----- 1 Total________________ , 7 | ._ 4 | 1 10 l___- 9 2 11 4 , 1 , 1 j 4 46 50 3 38 6 63 | 11 77 11 60 3 22 1 6 1 ! 5 6 36 271 313 1 , ] l 1 ' . 1 • Source of information: Coordination Service, Evaluation Division, U. S. \ eterans Bureau. b Where the column is omitted there were no cases. < Exclusive of patients who died during the six-year period of the study. 542 SURGERY Table 72.—Fractured radius and ulna. United States veterans of the World War. ratec\ 50-79 per cent disabled on first examination, showing interval elopsiug between injuiy and last rating and degree of disability on last rating, as of January 1, 19-6 a Degree of impairment on last ra ting 70- 79 a 80-89 | E 100 o ft E Total 1 1 2 1 Months (interval elapsing between injury and last rating) 10-19 20-29 30-39 40-49 50-59 £ a a _ - E Z 03 60-69 Less than 10 per ! cent | Temporary ; i b> Permanent Temporary Z a a Temporary Permanent ft E a E ft Permanent ______ Temporary ~ i 1 1 1 1 1 .... i 1 1 1 1 2 1 2 1 1 3 1 1 Total________ --,-- 1 1 i 2 1 2 1 1 3 5 s = =,= ^l=='==_ —z~ 1 1 i 2 3 3 1 5 4 9 2 1 1 2 2 3 2 3 1 ' : 1 1 1 4 j 1 i i 2 1 1 1 2 1 4 1 1 2 __ 1 6 1 1 i .) 48________________ _ ._i___________ 3 9 Total________ 2 3 —-1 2 1 l == 1 8 3 1 2 5 7 15 8 6 _____ 8 __i ___________ 2 4 27 33 = 1 3 12 15 20 26 43 24 13 3 ...... ,... 4 3 2 4 6 3 4 .... .... 4 6 6 6 3 1 12 57_____.....______ .... 1 1 1 2 2 2 4 4 1 2 17 2 1 3 2 ■> 20 2 ...J 3 .-.. 5 14 '.... 3 .... 4 .... 26 66_......_________ 1 3 1 1 46 69 25 14 Total-.......-. 1 ' 9 | 2 14 1 14 — 14 ...J 46 26 2 33 1 ______| ~ 156 163 75 1 1 .... 1 .... 1 1 3 .... 3 3 4 2 .... 2 5 2 1 1 2 11 10 10 2 3 2 12 78 1 1 12 81 1 10 84 1 1 1 2 87 1 2 .... 1 3 90 | 2 Total 2 11 -- 2 1 2 — 5 1 13 4 -- 10 1 3 38 41 3 Grand total___ 2 20 2 19 i 19 4 69 36 3 52 1 l 2 17 220 245 « Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. CORRECTION Word " timez fourth line from bottom, pa^e 548, to read "tissue."" GENERAL SURGERY 543 Table 7'.i.--Fractured radius and ulna, United States veterans of the World War. rated 100 per cent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on*last rating, as of January 1. 1926 a Degree of impairment on last rating Total Months (interval elapsing between injury and last rating) 10-19 20- -29 ft 30-39 ! 40-49 50-59 60-69 70-79 80-89 Z 1 Z 1 90-99 100 1 >* 3 ft 1 1 a 03 ft "T 7 9 9 6 34 8 11 12 13 18 16 16 18 112 20 34 29 22 33 34 43 32 247 16 13 7 5 1 1 1 Temporary Permanent . Temporary 3 E- Permanent Temporary a p 5 ft R a 03 ft Z a a 3 3 ft Z o Z ft a a >. 03 1 1 a 1 "a o Eh 1 1 3 1 2 1 1 1 5 4 1 12 . 5 6 5 2 2 2 4 10 2 4 3 2 5 4 4 5 29 9 7 .... 1 7 1 .... 9 1 1 .... 1 10 i ' _______ 6 " 1 .... . 1 __|__ ____ 2 2 1 3 1 2 1 2 1 2 3 Total 1 8 38 1 2 9 2 _ 2 2 3 1 2 14 3 4 1 1 .... .... 13 1 1 13 1 3 1 2 5 3 16 1 1 1 2 5 1 1 1 1 . —| 8 .... 6 .... 5 .... 2 .... 40 ... 3 1 19 1 1 2 18 1 2 20 48 1 1 2 1 3 1 4 2 1 .... 1 2 1 .... 1 1 18 _ 6 2 .... .... 12 1 2 2 1 1 3 3 3 16 Total......... ....j 2 17 3 126 51 21 51 1 5 1.. . 10 .... 3 1 37 57 2 1 3 2 3 4 15 .... 1 1 10 5 4 5 .. 7 .. 6 __ 10 31 60 1 . 6 9 7 9 9 66 5 3 1 1 .... 1 3 1 24 63 .... 1 1 1 3 1 9 2 3 2 .... 2 1 2 1 7 1 2 1 1 1 .... 5 .... 34 1 ___________i 1 .... 3 .... 1 7 .... 15 1 38 69 3 1 15 .... 10 1 76 .... 6 .... 2 .... 2 1 2 1 2 10 1 1 1 3 46 1 3 35 9 3 Total_______ .... 15 2 TLL 39 1 266 75 1 2 3 1 1 1 16 1 1 .... i 1 14 81 i 7 84 1 6 i 1 90 ! . 1 1 1 1 ___I___ i 1 Total 2 -- 5 19 1 4 1 10 115 8 72 1 ! 14 1 2 33 44 437 46 2 1 12 11 25 6 Grand total—. ~* 18 4 18 2 14 8 2 142 2 476 0 Source of information: Coordination Service, Evaluation Division, U. S. Veterans' Bureau. b Where the column is omitted there were no cases. c Exclusive of patients who died during the six-year period of the study. From the data in the above group of tables, Tables 74 and 75 have been prepared to show the number and per cent of cases which reached their sta- tionary level after definite periods (Table 74), and the changes in percentages of impairment which occurred between the first and last examination (Table 75). It will be seen that the average period of disability (Table 75) is greatly in excess of that among industrial fractures. In this connection it must be borne in mind that a large number of the fractures under consideration were complicated by an osteomyelitis; furthermore, there was a nerve involvement in 14 per cent, which, together with the destruction of time, resulted in a pro- longed or lasting impairment of function. Therefore, since the character of these fractures differ in a large measure from that of the industrial fracture, the final results are not comparable from a viewpoint of time. 4GW7—27——37 544 SURGERY Table 74 -Fractures of the long bones, United States veterans of the World ^"''f™^ ih? number and percentage of cases which reached their stationary hrel njtn p ii!i n ' ■ '!' ri'; '1 1 : i_bv i~_s* F RONT V I EW 'A t i»i L 'l M Hi ii i; &7 "■.........'..... .......Illlllllllllllll.....V.........- -■■ r ■ ■ ■lll1llll-..ll-..|llMIIIIFIIHllHT-.llIlllllll-.HIllM.I]]n l'"'"""""""J"1" SIDE VIEW DETAIL HINGE END VI EW Fig. 12.—Mechanical drawing of hinged traction arm splint. Uses: Injuries to shoulder joint; to shaft of humerus; to the elbow joint; to the forearm. Should always be used as splint for transportation 564 SURGERY Fig. 13.—Hinged traction arm splint. For application the rods should be opposite the anterior and posterior surfaces of the arm. The hand should be two-thirds fully supinated. The slings should be applied so as to best support the fragments and to interfere the least with the wound. This type of splint may be used for all the purposes of the Thomas traction arm splint. The Thomas traction arm splint, however, should not be used for a transport splint unless the rods are bent at a point 2 inches away from the ring so that the plane of the ring will make an angle of 30° with the rods instead of 90°, the normal position SI DE VIEW FRONT VIEW TOP VIEW Fig. 14.-M echanical drawing of Jones humerus traction splint. Uses: Injuries to the shaft of the humerus in which traction on the humerus and flexion of the elbow joint are desired; to the elbow joint in which flexion is desired- to the forearm uraueu' ORTHOPEDIC SURGERY 565 Fig. 15.—Jones humerus traction splint. This type of splint is to be used for fractures of the humerus at or below the middle of the shaft in which flexion of the elbow is desired. The splint is to be used largely for ambula- tory treatment. The hand should be two-thirds fully supinated. The traction should be obtained wherever possible by adhesive plaster to the skin. The strap across the opposite shoulder to support the splint should always be used and adds much to the comfort of the patient Fig. 16.—Jones "cock-up" or "crab" wrist splint and application. Uses: To retain the position of dorsal flexion of the hand in cases of injury to the wrist and in nerve and muscle injuries which produce wrist- drop; to obtain full extension of fingers add piece of ladder splint material, or use ladder splint material alone 566 SURGERY POSITION WHEN 5PLINT IS USED FOR LETT LEG Fig. 18.—This and Figure 19 show method of apply- ing traction to fractured lower extremity in the field. Note the stretcher bar suspending the trac- tion splint and the wire foot support holding the foot at right angle to the leg; also note the method by which the splint is secured to the stretcher bar by the use of bandages. The shoe should never be removed in the field FRONT VIEW DETAIL OF HINGE. Fig. 17.—Hinged half-ring thigh and leg splint, for trans- portation use in injuries to the shaft of the femur; injuries to the knee joint; injuries to the leg c Fig. 19 ORTHOPEDIC SURGERY 567 ADJUSTABLE. FOOT PIE.CE. Fig. 20.—Mechanical drawing of long Liston splint with interrupting bridge of iron wire Fig 21 —This and Figure 22 show the long Liston splint with interrupting bridge. Applied for stretcher transport only. Uses- Injuries of the pelvis requiring fixation in transport; of hip joint requiring fixation and abducted position in transport The upper thigh and hip should be supported in transport by a sandbag or pillow or spica bandage. Note the thoracic and leg bandages and bandage passing from thoracic bar over shoulder. Additional slings for support of [leg or thigh may be added as desired, and if the bones are much comminuted a piece of wire ladder splint material applied to the back of the leg and thigh under the slings furnishes more complete support 568 SURGERY Fig. 22 23—Mechanical drawing of Thomas traction leg splint. Uses: Injuries to the shaft of the femur; to the knee-joint; to the leg ORTHOPEDIC SURGERY 569 Fig. 24.—Thomas traction leg splint with traction attached to end of splint and splint slung from cradle. The posi- tion of the foot at the right angle is held by sole band, also attached to the cradle. The supporting slings upon the splint should be of sufficient number to give thorough support to the leg and by the adjustment of these the posi- tion of the fragments may be modified as is desired Fig 25—Thomas traction leg splint applied with suspension to the Balkan frame. Additional traction is attached to end of splint and suspended over pulley. The chief traction should always be obtained by attaching the traction straps dire ctly to the end of the splint and this adjusted with the Spanish windlass. Additional trac- tion may be added by direct pull on the splint. The position here shown is that which is desired for fractures above the junction of the middle and lower thirds and below the neck. The same position here shown is desirable for fractures of the femur below this level. By adjusting the position and tightness of the slings the position of the fragments may be modified. For fractures of the middle of the thigh the sling under the middle of the thigh should be tight, since the fragments usually sag downward. For fractures at or below the junction of the lower and the middle thirds the sling under this region should be tight, because of the same usual back- ward sag of the fragments. The traction bands should extend as near the seat of the fracture as the condition of the wounds will permit 570 SURGERY Fig. 26.—Showing the use of Ransohoff "ice tongs" in conjunction with the Thomas traction leg splint, to secure skeleta traction. At times, because of difficulty in replacing the fragments especially with fracture of the lower third of the femur, skeletal traction is desired until the healing is sufficiently advanced to make the more routine treat- ment possible. If such skeletal traction is needed the "ice tongs" are preferable to other methods, and if used the points should be inserted just above the widest part of the femoral condyles, as far forward as possible, avoiding the knee joint. This method of treatment is not compatible with transportation, and should be reserved for special cases. Subsequently if transportation becomes necessary before union has taken place the usual methods of treat- ment should be employed ORTHOPEDIC SURGERY 571 ^ZJ M & . t f nwt nf fpmur or fracture into the trochanter. Only such traction as is required to steady the leg should Fig. 27.-Position for fracture of neck 01:ie _^ ^ ^ fa ^.^ ^^ . f ^ extensive character and location of the be used, since the crowding of tne-on * ^ possible, and under such conditions the Hodgen splint straightened at the wounds the use of the I nomas spnm- knee should be used 2 SURGERY FRONT VIEW TOP VIEW Fig. 28.-Mechanical drawing of anterior thigl.and leg ^^^'JZZ TSSSSSZ from overhead support in injuries to the thigh and leg. Note. A; places ma notched or roughened to prevent the supporting straps from slipping out of place Fig 29 -Wooden bed frame, for traction by weight, and pulley and overhead counterweight suspension. Appli- cation for lower limb injuries, limb in anterior thigh and leg splint, Hodgen type. Uses: For suspension of limb from overhead support in injuries of thigh and leg. This splint is used simply for a frame to sling the leg in case the nature of the wo.nds makes the Thomas splint impossible. The traction straps should be attached directly to the weight and palley, and should not be attached to the splint. By careful adjustment of the slings the position of the bone fragments can be controlled ORTHOPEDIC SURGERY 573 FRONT VIEW SIDE VIEW BOTTOM VIEW Fig. 30.—Mechanical drawing of Cabot posterior wire leg splint. To be used with or without side splints. Uses: Injuries to the soft parts of the lower limb requir- ing fixation in transport; slight injuries to the knee or ankle requiring fixation in transport; fractures of the fibula; wounds of the ankle joint; injuries to the foot. The rods of the splint should be thoroughly padded, and they may be bent to allow flexion at the knee if desired. Side splint of wood or wire ladder may be used in connection with the splint if desired Fig. 31.—Cabot posterior wire splint applied with supina- tion of the foot. When used for injuries of the ankle and tarsus the entire splint should be twisted so that the foot piece will be inclined and hold the foot in the position of varus. The object of this position is to overcome the natural tendency toward the valgus deformity with the subsequent development of flat foot 574 SURGERY TOP VIEW END VIEW SIDE VIEW Fig. 32—Mechanical drawing of ladder splint material. Uses: For shoulder, upper arm, elbow, forearm, wrist, hand, lower leg, ankle, and foot splints; side splints in combination with Cabot posterior wire leg splint; coapta- tion splints; where malleable light splint material is to be desired Fig. 33.—Mechanical drawing of snowshoe litter. The snowshoe litter is not only useful in the evacuation of the wounded from the field, but is also useful ior transporting cases of spinal or pelvic injuries to the hospitals in the rear ORTHOPEDIC SURGERY 575 Fig. 34.—Maddox unit clamps, iron pipe and bed frame clamp. Applied for simple leg traction by weight and pulley Fig. 35.—Special use of Thomas traction leg splint. Applied over uninjured shoulder, for shoulder and arm injuries. Note.—Shoulder straps for sup- porting splint; thoracic swathe for counterpressure; supporting slings clipped to rods; traction bands; nail twister for maintaining and regulating traction 46997—27----39 SURGERY Fig. 36—Hand and wrist splint. This splint should be used for the lacerated wounds of the hand or wrist, being applied over the usual large dressing. While the splint is intended largely for use in the early stages of such injuries, it may be continued into the later stages, provided the padding is so applied that the position of the hand and fingers with reference to ultimate func- tion is maintained. When this later stage of the treat- ment has been reached, a molded plaster-of-Paris splint, or a carefully molded piece of wire ladder splint mate- rial, is usually more satisfactory Fig. 37.—Mechanical drawing of abduction arm splint. For injuries of the shoulder or of the humerus in the upper third it is desirable to maintain the abducted position after the patient is allowed to be up and about. For this purpose a well fitting plaster-of-Paris dressing may be applied. If wounds are present or if less rigid fixation is required, the splint pictured should be used. This is adjustable as to the amount of abduction by use of the shoulder chain, and can be applied with the arm fully extended, in which posi- tion light traction is possible, or the arm may be flexed to the right angle or the half this position by the adjustment at the elbow. The arm should be held with the humerus in two-thirds outward rotation. The splint is reversible, so that it can be used upon either the right or left side ORTHOPEDIC SURGERY O/V in obtaining raw material, manufacture presented many problems. A large warehouse was established 19 for the accumulation, sorting, and packing of splints as they came from the factories. During the months of October and November, 1917, there was much to do in the way of inspection of the output of the splint factories, the board felt keenly its responsibility in establishing a definite standard to which manufac- turers of splints should be held. The method followed was to look over the finished product of a factory, comparing it with the working model in the presence of the foreman. After an appreciable number had been collected, the chief surgeon, A. E. F., directed that a certain supply be kept always in that warehouse and that the remainder be shipped weekly to the two medical supply depots,19 one at Cosne and the other at Is-sur-Tille. The entire proposition was put on a good business basis. In this connec- tion an effort was made to look ahead in the purchase of supplies so as not only to prevent idleness in the factories for want of material to work with, but also to speed up constantly their output, much assistance being given in this direc- tion by the purchasing department of the American Red Cross. An accurate set of mechanical drawings of the standard splints was made. Early plans were made to have a shop where new ideas in appliances could be worked out; ulti- mately, this idea was of great value, as several new and valuable appliances were developed in the shops. Early necessity also was foreseen for having a splint repair shop, where broken and soiled splints could be renovated. At the beginning, however, this seemed very remote, and no definite steps were taken to get this very neces- sary adjunct to the splint supply of the Army started until well along in the spring of 1918. Then it was started at Dijon, where it served not only as a repair shop, but also as a factory for new splints, and it delivered, in the days of greatest stress, a goodly number of splints each day to the nearby medical supply depot at Is-sur-Tille.19 To determine approximately the number of various kinds of splints that would be needed by the American Expeditionary Forces, percentages of the various fractures, from statistics of the casualties that had occurred in the British and French Armies were figured. Upon this basis the splint board, earlv in October, 1917, placed with the American Red Cross an order for 28,100 splints.19 When about 50 per cent complete, the order was increased to 100,000 splints of all types, in the hope that this number would be adequate for the American Expeditionary Forces for a considerable part of the first phase of the military effort. The varieties and numbers of splints in this first order were based on the theorv that we would have about the same proportion of fractured arms and legs among our casualties as the British and French. On the whole, it was not a bad method of apportioning the numbers of the different types of splints, as subsequent orders proved. The full list of splints, splint accessories, and appli- ances at the disposal of the Medical Department when the 1st Division began to enter the line in the Ansauville sector north of Toul, January 14-15, 1918, was the following Splints: Thomas traction arm; hinged traction arm; Jones humerus traction; Jones "cock up" wrist; Thomas traction leg; hinged half- 578 SURGERY ring (Blake-Keller) thigh and leg; long Liston interrupted; anterior thigh and leg, Hogden; Cabot posterior wire leg; wire-ladder splint material. Splint accessories: Balkan frame; Maddox pipe frames; galvanized net wire gauze, in rolls; clamps, rope, pulleys, weights, etc. It is worthy of note that this was the entire splint equipment chosen by the splint board and held by it to be adequate for the Army's need. The num- ber of splints having thus been reduced to 10, it remained to be seen whether this number was sufficient, or perhaps would be susceptible of further reduction, in the practical test soon to be given it. As events soon proved, however, it became necessary on several occasions to order an extra supply of a certain splint, and indeed, to place large orders for additional supplies of the whole list. Thus in the latter part of June, 1918, when for over a month there had been the severest kind of fighting north of Paris, in which three divisions of the American Expeditionary Forces had suffered heavy casualties, an absolute shortage of splints occurred. On the first of July it was found that the quantity of splints and associated supplies was running very low in the advance area. It was also found that, due to the slow delivery of raw material, the shops were not able to produce up to their full capacity. Every effort had been made to secure delivery of this raw material which consisted of various sizes of iron wire rod used in making the splints. All forms of business in Paris were feeling the strain of the suspense caused by the approach of the German Army. On this account, most of the reserve stock in the Red Cross warehouses in Paris had been distributed. Feeling the necessity for some immediate decisive action, arrangements were made with the French for the immediate release of a considerable tonnage of the raw ma- terial needed. The "third Army order," which called for 54,000 splints, was then formu- lated. To complete it there was needed 45 tons of steel wire rods, and, as above stated, this was in large part obtained from the purchasing department of the Army.19 On October 26, 1918, the status of the splint question was as follows:19 The Army had ordered a total of 462,350 splints; of these 229,927 had been made up to that date. The total number supplied to the American Expedi- tionary Forces was 177,468. At this time the entire order was about 50 per cent complete, but since the raw material to complete the entire order was on hand in the storehouse in Paris, the remainder could have been executed by the early months of 1919.19 During the winter 1917-18 a weekly conference was held with the ortho- pedic surgeons from the different divisions in order that the details might be worked out and made standard. In order that the system would work uni- formly and successfully, it was necessary to settle points like the following: The number of splints which should make up the equipment of a division Tn the field; how these splints should be divided among the various units of the division; what should be the standard equipment of a battalion aid post; what should be the standard splint and dressing equipment of a field hospital, a mobile hospital, an evacuation hospital, and a base hospital. These and numerous other questions had to be agreed upon, with the realization that the ORTHOPEDIC SURGERY 579 men had had but little experience and that changing conditions would change a good many of the rules laid down. Certain minor pieces of apparatus had to be supplied to make splint appli- cation efficient, notably a stretcher bar. It was found while demonstrating the splints to the medical officers of the 20th Division that it was necessary to elevate the end of the Thomas thigh splint to a considerable angle when the stretcher was placed in the small Ford ambulance in order to close the tail gate of the car. An appliance to suspend the splint had to be devised immediately as it was expected then that the troops would be in the line in about two weeks time. A competent stretcher bar was worked out and adopted by the splint board, and 500 of them were ordered made. They were supplied in time to be distributed to the ambulance companies of the 1st Division before that division entered the trenches. On the night of January 15-16, 1918, the 1st Division moved into the trench positions in the Ansauville sector.20 This portion of the line had long been quiet, being dominated by Mont Sec, a high hill which the Germans at that time held. In consequence, the trenches were in a poor state and the entire problem of the evacuation of the wounded was one of great difficulty, as it involved long carries by stretcher. It was here that the first actual experience came. Soon there was a daily and nightly run of casualties arising from the increase of artillery activity and from raids. These wounded men had to be carried usually over a mile through a winding trench before they reached the battalion aid post. At night, it was frequently possible to carry the wounded out over the top of the trench, thus immensely lessening the burden of the long carry; in the daytime this was not practical, as a rule, because the country was very flat. In the town of Mandres an aid station was functioning as a " sorting station," the first post of this kind established in the American Expeditionary Forces. The surgeon in charge was much interested in the problems of the orthopedic department, and he devised a ''trench litter" on which, like the Stokes litter used by the Navy, a wounded man could be carried on his side, face down, or head up or down, without slipping off. This was found to be valuable, was approved by the Surgeon General and by the splint board, and was adopted as part of the standard equipment. It proved especially valuable to Artillery troops who as a rule had their aid posts in deep dugouts with narrow entries. During the last two weeks of August and up to September 12, 1918, efforts were directed toward getting a sufficient supply of splints and accessories forward to equip the First Army, in preparation for the St. Mihiel operation. Supply depots were organized at the Justice group of hospitals and at Souilly— the first to take care of the main effort which was to proceed from the old trench positions north of Toul; the second was to take care of the troops and hospitals on the left flank of the St. Mihiel salient. A system was planned for the return to the front of all splints that had been taken out, by having an order issued that made it imperative for ambulance drivers to exchange with hospitals where thev had unloaded wounded, one for one, in blankets, splints, and 580 SURGERY apparatus, so that there would be a return flow of these appliances to the divisions. Orders similar to the following were issued in army, corps, and divisions, which defined the use that was to be made of the splints: Headquarters First Army, American- Expeditionary Forces, Office of Chief Surgeon. Memorandum: For the purpose of securing uniformity of splinting and the best results in fracture cases, the following instructions are issued: 1. All fractures are to splinted at the earliest possible moment; this means, where the man falls. If this is impossible, the splint should be applied at the battalion aid post. No fracture should pass through the advanced dressing station, "triage," unsplinted. 2. The Thomas full or half ring traction splint will be used for all fractures of the lower extremities from the pelvis to just above the ankle. 3. The Cabot posterior wire splint or wire ladder splint is to be used for all wounds of the calf, ankle, and foot. 4. All wounds of knee, no matter how slight, are to be splinted. 5. The hinged traction arm splint will be used in fractures of the humerus, elbow, and upper forearm. 6. Ladder and wood splints will be used in fractures of the long bones only where traction splints can not be efficiently applied and to supplement such splints. 7. The fact that traction is the immobilizing factor in all traction splints should never be lost sight of and the utmost care should be taken to apply the proper degree of traction to obtain fixation. ******* MANUAL OF SPLINTS AND APPLIANCES, SECOND EDITION In October, 1918, a second board of medical officers was organized to go over the work of the first splint board.21 In this way, it was desired to continue this work, adding to it where necessary, and also eliminating anything that might be found to be superfluous. The new board went over the samples of splints and appliances then in use. The board used the first edition of the splint manual as a model to write another booklet, similar in every respect but containing the changes that the board had seen fit to adopt.18 In a few days the manuscript was ready; it was given to the American Red Cross to have 35,000 copies printed. By the first of February, 1919, its distribution began. In this second edition of the manual it was possible to set down the exact figures for the requirements of field medical units, and various types of hospitals, as to splints and splint accessories. ORTHOPEDIC DEPARTMENT, A. E. F. Early in November, 1917, when relatively few American troops were in France, a meeting of the senior orthopedic surgeons of the American Expedition- ary Forces was held to go o^er the situation and plan the course of action which the orthopedic service, A. E. F., should follow. It was decided that it was not the time for the institution of elaborate plans of organization, but one in which the best service could be given by undertaking in a small wav the evident problems that faced the American troops and hospitals, and "by using the nucleus of well trained medical officers who had been sent to England to serve as orthopedic surgeons with the British, a few at a time, in places where they ORTHOPEDIC SURGERY 581 could accomplish something. In that way, an organization could be built up that would fit accurately into the military machine that was developing at the same time. Headquarters, professional services, were established at Neufchateau, the center of the divisional training area.22 By the first of January, the organization of the orthopedic department had been worked out and another group of officers was ordered to the American Expeditionary Forces from England.23 It was realized that the fracture case needed what the French had termed a system of ''radial control"; that is to say, a wounded man passing from front to rear must* always be under the care of surgeons who understand what has happened before they treat the man and what is going to happen after he is sent on. This system should be under the direction of one man, this man to be responsible. It was decided that the department of orthopedic surgery should be held responsible for the "radial control" of fractures, and bone and joint injuries.24 Under this system, one orthopedic surgeon was made responsible for the splinting in the area of the divisions, corps, and army; another was responsible for the splinting and treatment given to the wounded in the mobile and evacuation hospitals. A third man was to have the responsibility for the fracture treatment in the base hospitals in the intermediate and base areas. Over this system, the chief of the department was to exercise supervision, maintaining the necessary personnel, inspecting the entire "radius" from front to rear to discover and prevent any deterioration in the character of treatment at any of the stages. In short, here was the organization necessary to see that the standard of splinting was first taught and afterwards carried out. In the reorganization of the professional services, American Expeditionary Forces, in June, 1918, the director of orthopedic surgery, A. E. F., became known as senior consultant, orthopedic surgery; his assistants, with supervisory duties over hospital centers and other formations were designated consultants.25 After some weeks of experience with actual combat conditions, the director of general surgery, A. E. F., arranged for division orthopedic surgeons to take over the responsibility of all the surgery that arose from the time a soldier was hit until he reached a hospital. The following circular concerns not only this subject, but also outlines the general assignment of responsibility to the ortho- pedic service, in so far as the share of that service in case of the wounded was concerned; Office of the Chief Surgeon, American Expeditionary Forces, France, 16 August, 1918. Circular No. 46: 1. Upon the recommendation of the chief consultant in surgery, and with the approval of the director of professional services, the following instructions are published for the information and guidance of all concerned. instructions concerning the treatment in orthopedic conditions including fractures and joint injuries 2 The work of the division of orthopedic surgery in the medical organization of the army divides itself quite clearly into two parts, one having to do with the preparation of the men for the expected combat, and the other assisting in their recovery if wounded. The first has to do with saving men for service who would otherwise be discharged as physically 582 SURGERY unfit and also as the result of careful training, increasing the number of days that should be expected of the men for active duty. The second has to do with the saving for service of men who but for such work might not have lived, or been so crippled as to be of no use to the army. 3. Without such methods of treatment available for those needing such care in the pre- combat or training period, large numbers of men will be lost for active duty as the ordinary medical measures can only give temporary relief. 4. Without such methods in cases of combat or other injury there will be much un- necessary loss of function and much of the acute surgical treatment will be purposeless. 5. In each of the large hospital centers, a base hospital with special personnel and equipment for caring for such cases will be installed, while in the detached base hospital special services will be established so that there will be the least possible transferring of cases from one hospital to another. 6. Consultants in orthopedic surgery will be assigned to groups of hospitals whose function it will be to keep in touch with the othopedic work of the given group. These con- sultants should be freely used by the staff of the respective hospital and can be reached through the commanding officers of the hospital centers. 7. To best accomplish the purpose of the division and to make the services of its members available, the following instructions will govern. amputations 8. Cases of amputation of either extremity will be assigned as soon as possible to the orthopedic service for the needed special treatment. A guillotine amputation for instance without other injuries, can usually be moved without risk in one week and with suitable measures rapid closure of the wound is usually possible so that an artificial leg can be fitted and the man get about without crutches many times in from four to five weeks from the time of the injury. It is desirable that transfer to the orthopedic service take place as early as possible before contractures have taken place so that the temporary artificial limb, in case that is desirable, can be most favorably fitted on and the most muscles used to the best advantage. tendon injuries or inflammation 9. The cases of injury to the tendons or inflammation in or about the tendons should be assigned, as soon as the primary wound healing is well established or as soon as the acute inflammatory reaction has subsided, to the orthopedic service. Early transfer to the special services is important in order that the treatment having to do with full restoration of function in the part that has been injured or inflamed may be established at the earliest possible moment and before adhesions have formed or have become organized. 10. Cases of flat, weak, or pronated feet associated with pain, swelling, or inflammation when admitted to a hospital should be transferred to the nearest convalesent camp. From here, in keeping with the degree of difficulty, the cases should be transferred for full duty or to the orthopedic training camp depot division for training to fully overcome the weakness, or for noncombat duty under "C" classification. 11. No cases of uncomplicated flat-foot should be exempt from service or recommended for transfer to the United States as all can be made useful for military service. SPINAL STRAINS AND WEAK BACKS, CHRONIC BACKACHES 12. Cases of weak, painful or lame backs, or of sprain of the spinal or sacro-iliac joints, should be transferred either for full duty, or for noncombat duty under class " C " classification. GENERAL BAD POSTURE 13. Cases of general bad posture, which is commonly associated with lack of vitality or general endurance as well as being part of the condition leading to weak feet and weak backs, should be sent for training to the orthopedic training camp, depot division. FRACTURES 14. For all cases of fracture of bones other than the head and face, or of extensive muscle injuries, it is of the utmost importance that proper splints be applied at the earliest ORTHOPEDIC SURGERY 583 possible moment so that the transfer of the patient to the hospital in which treatment is to be given is associated with the least possible damage to the tissues adjacent to the injured bone. The Thomas leg splint, the hinged half-ring splint, the Thomas hinged arm splint (Murray modification), the Cabot posterior splint and the ladder splinting are appliances most needed for such work. 15. In case the fracture is compound, the wound treatment at the evacuation or other hospitals should follow the principles outlined by the chief consultant of surgical services. 16. After the primary wound treatment has been given these cases should be transferred to the orthopedic service in which the most approved methods for the early restoration of function to the injured part will be available. An effort should be made to transfer the cases to such services, wherever possible, within a week or 10 days of the time of injury, this being the most favorable time as regards bone repair. All fracture cases which, for any reason, can not or should not be transferred to one of the services as indicated above should be reported to the senior consultant in orthopedic surgery, or the orthopedic consultant of the area. 17. Simple fractures should not be converted into open fractures except under very exceptional conditions or after consultation with one of the orthopedic consultants. A result which may not be as perfect anatomically as might have been produced by open operation, may nevertheless be functionally good. This is so commonly the case that the risk of infection which is greater under the war conditions than in civil life should be avoided whenever possible. JOINT INJURIES 18. All injuries of the joints should be protected with the same care for transport to the hospital in which the treatment is to be given that has been indicated for fractures. Suitable splints should be applied immediately and the standardized list of splints of the army provides types that will meet all the needs. 19. In case the injury is associated with open wounds, the principles of the wound treatment are those which have been laid down by the chief consultant of general surgery. 20. Since in all such injuries ultimate function is the chief requisite treatment having for its purpose the restoration of function should be instituted as soon as possible, and for this purpose, it is desirable that cases of such injury be transferred, as soon as the primary wound treatment has been given to the orthopedic service. It is important that such transfer be made before unnecessary adhesions have formed so that the restoration of function can be obtained in the least possible time. In all such functional restoration it should be clearly understood that while motion is to be encouraged at the earliest possible moment, it should consist entirely of active motions performed by the patient in which case the reflex muscular contraction will protect the joint from undue injury. All passive motion should be avoided. 21. Operations upon the joints that are not emergency in character should not be performed until after consultation with one of the consultants in orthopedic surgery. TRANSFER TO THE UNITED STATES 22. It will be the policy to send to the United States as soon as transportable, all cases that are of class "D" type, or cases in which prolonged treatment will be required for restoration to duty. This fixed the responsibility and also saved the situation from the con- fusion that would have arisen from having two sets of men doing practically the same thing, and perhaps not conforming to any standard system of instruc- tion . Thus it came about that each division surgeon depended upon his division orthopedic surgeon to carry out a definite course of instruction for the medical department of the division. The problem became that associated with evacuation of wounded and suro-icallv shocked men, in addition to the treatment in the advanced area of fractures and joint injuries. During trench warfare, the evacuation problem was not so difficult; ambulance routes could be marked out on the map, and 584 SURGERY posts could he located in definite places, and be well protected; most important of all, the hospitals where surgery could properly be done could be located within easy hauling distance of the zone of combat. Careful plans for tlie evacuation of sick and wounded and for furnishing a constant (low of supplies from rear to front lines by a system of exchange were worked out. It was found that the work done in the instruction of the medical department was bearing fruit, and that it was a rare occurrence for a man with a fracture to reach an aid post without a splint, usually applied very creditably. In June, 1918, when several of our divisions were actively engaged with the enemy, our plan of evacuation had to be changed entirely because of the relatively large numbers of wounded. Hospitals had to be hastily set up at the front and there were not enough of them to meet the demand for beds; the wounded had to be carried long distances in any available vehicle of trans- portation. It was at this time that the supply of splints began to run low in the front area, and the system of shops and distribution was so severely taxed. Just prior to the Meuse-Argonne operation one of the orthopedic surgeons conceived an idea that was to work out in a most fortunate manner. It was realized that a loss of time occurred in the army hospitals where much operating was going on due to the care and precision necessary to the proper application of splints to fractures after operation. This was often due to the fact that the operating surgeon usually entrusted splint application to one of his assistants. At all events, it was a well-known fact that fracture cases usually reached the hospitals much better splinted than when they left the hospitals for the journey farther to the rear. It was suggested that in each mobile and evacuation hospital, there should be one or more "splint teams/' each to be composed of one officer and two enlisted men. To this end a number of junior officers and enlisted men were collected at the hospital center, Bazoilles, and were given practical instruction in the application of splints and the treatment of fractures 26 (these officers were of the orthopedic department and had had considerable training beforehand). Thereafter splint teams were assigned to each hospital in the army area where their function was to take hold of the fractures as they were admitted to hospital and to follow them through. It was a most useful addition to the chain of good fracture treatment which had had a weak link at this point; it made it possible for the surgical teams to turn out from 30 to 40 per cent more work; it also encouraged the division ortho- pedic surgeons in the knowledge that the work they were doing would be carried on, and not terminate at the first stopping point. INSTRUCTION OF DIVISIONAL MEDICAL PERSONNEL It was recognized early that something must soon be done to acquaint the officers and men of the Medical Department serving in these divisions with the standard splints and how to apply them; accordingly, at the request of the director of the division of orthopedic surgery, several medical officers who had had six months' orthopedic experience in England were assigned to the Ameri- can Expeditionary Forces to help in the establishment of the work.23 These medical officers were all men of experience as specialists in civil life, and had become familiar with the use of the traction splints. They were distributed ORTHOPEDIC SURGERY o85 among the combat divisions then in training and to each of them the American Red Cross assigned a small automobile, thus making it possible for them to cover the territory occupied by their respective division. They arranged schedules for instruction of the various units of the division in the application of the standard splints. About March 1, 1918, in the four original combat divisions of the American Expeditionary Forces, the instruction as to splinting and the supervision of the distribution of splints and supplies had reached a satisfactory stage. The medical officers who served in the four first divisions to engage in combat gained an experience as division orthopedic surgeons that made them experts on much of the knowledge that is necessary to a divisional medical officer; this practical knowledge was gained none too soon for the pressure that was to be put on all departments by the arrival of the bulk of the American Expeditionary Forces. Alter a few weeks of actual experience in the evacuation of the wounded, it became very evident that the instruction of the enlisted men of the Medical Department was of the greatest importance. In consequence, a large part of the effort of the division orthopedic surgeon was spent in giving lectures and demonstrations to the personnel of the various divisions; stretcher bearer units were created and these men had to be instructed in the application of splints and first aid. These stretcher bearers felt a keen pride in learning to apply a splint quickly and perfectly and this too, when blindfolded or wearing a gas mask. The men of the Medical Department who went with the companies into action and who worked under the direction of the battalion surgeons became, as a rule, very proficient in all details of splinting. In addition to the instruction given within the divisions, there was given at the sanitary school at Langres to each class of medical officers a set of lectures that put before them the salient points of the system then in vogue for caring for the wounded in the area of combat. SPECIAL TRAINING BATTALION In December, 1917, a cam}) was established for training men phyiscally unfit for inarching and combat duty, men in whom physical defects had developed or had been accentuated since entering the Army.27 Many of them were able to conduct their work in civil life without much or any annoyance, but thev could not perform as soldiers. In some instances, the cause of the man's breakdown was not definite; in others, it was a combination of different elements such as mechanical strain, accident, change of living conditions, fatigue, and mental depression. Each man was a problem. Shirkers were amono-'those sent to the camp, but a large number of them represented men of insufficient muscular development. Headquarters of the special training battalion was established at Harche- champ, a town about seven miles northeast of Xeufchateau.27 There the men could be treated in large numbers, grouped as far as possible, and their ailments treated in such groups. Having determined the physical defects or habits of each individual entering the camp, treatment was established to correct the defect or defects and to develop a proper habit of carriage and life. 58() SURGERY Work for Restoration of Proper Function The work at the camp was planned (1) to remove the cause or causes of the defects, if the causes still existed; (2) to correct the deformity which had been produoed by the cause or causes; (3) to teach the men proper use of the joints and muscles of the body; (4) to increase the muscular strength of the men so that they could not only get themselves around the camp and through the day's work, but would be able also to carry the additional weight of the soldier's equipment. The treatment was planned in the above sequence. All the training at the camp had to be carefully planned and thoroughly carried out. Accuracy and precision had to be practiced by both the officers and the men. The men, as they arrived at the camp, were very imperfect specimens, but it was found that approximately 80 per cent could be made into useful material and returned to their organizations as fit combat men. A card the size and shape of the Army service record was filled out in dupli- cate ; it contained the name and number, rank, organization, age, and the date and source of admission to the battalion, and the date of entrance into the Army. Silhouettes were taken of the body trunk in profile. This was a very quick and simple method of recording posture. The personal history was recorded in brief, and, in the physical examination, especial note was made of the teeth, ears, back, feet, defects in posture, and method of using the feet. Treatment was prescribed. The feet were measured carefully, and then the shoes fitted over two pairs of heavy socks, always giving ample room over the foot and the toe. These shoes had the heels raised on the front inside corner to throw the weight on the outside of the foot. All the men were shod in this way unless there was definite rea- son for not doing so. No graphic records of the feet were made. While in receiving Company "A" the men were graded as to their aptitude and capabilities. They were given light police duty, easy calisthenics and games, with talks on the general principles of the training, and demonstrations on the care of their shoes and other equipment. Each man was issued two pairs of field shoes of proper size, adjusted as prescribed to correct his balance and whatever other defects existed. Straps and simple cleats only were em- ployed. When this had been done and their other equipment completed, if their physical condition had sufficiently improved, they were entered on the roll of Company "A", and began their active training. General Principles of the Training For the feet.—The men were taught that the foot and leg are muscular mem- bers of the body, to be used in locomotion. The triple exercise was taught to strengthen the leg and foot muscles after correction by the stretching of any existing deformity. In all marching and walking, the men were instructed to toe straight ahead and bend the knee out, carrying the weight over the small toes, the weight to be kept on the outer side of the foot at all times in marching and standing, either at attention or at ease. For the back.—The system comprised stretching of shoulders over a roll. The exercise of straight leg raising and trunk raising to strengthen the anterior ORTHOPEDIC SURGERY 587 abdominal walls; the men stood with a nearly flat back, hips very slightly back, abdomen held up, chin in. The position of attention is an easy, alert posture, with knees straight, not in hyperextension, the weight equally dis- tributed on the front and heel of the foot. The posture is somewhat like that taken by a man when he prepares to jump. He is ready for the command. The whole camp had a general program, and each company had a special program of its day's routine, the work in each succeeding company being made progressively harder and more continuous, with shorter periods of rest. A complete military organization was found to be necessary in order to establish and maintain discipline, without which nothing could have been accomplished in the training of these men. Once each week the chief orthopedic surgeon selected the men who seemed fit for promotion. These men were inspected in standing and marching, and their records for persistent work during the week considered. Silhouettes were again taken to record improvement in posture. A list of men thus selected for promotion was turned in to the company commander, and those considered eligible were transferred to their original organization. Medical Organization The duties of each orthopedic surgeon comprised the following: At company sick call, 7.30 a. m., all light ailments were treated; all men with a temperature or any severe symptoms were immediately sent, accompanied by a sergeant, to the camp surgeon. By this method, the number of men attending the morning sick call was reduced immediately; prompt treatment and return to duty were facilitated. No men were confined to their billets. If suffering from slight surgical or medical maladies which really prevented their taking part in the active training, they were given a day of kitchen police or other light duty. Everyone worked unless really sick, and if sick, was sent immediately to the hospital. If the diagnosis was not clear, no man was sent to the hospital without a thorough physical examination and a consultation with the orthopedic chief. In this way it was possible to detect men suffering from visceral ptosis, not discover- able without a thorough physical search into the relations of posture to digestive and general symptoms. The orthopedic surgeon accompanied the men at drill each morning and afternoon, correcting the errors in marching and statics. He had to be con- stantly on the alert, encouraging, explaining, demonstrating to the men what was expected of them. He carried duplicate record cards and made frequent notes thereon of each man in the field. During periods of rest between drill, the orthopedic surgeon gave talks to the men on such subjects as the care of the shoes and feet, the proper position of the body in marching, proper use of the feet, hygiene in the trenches, the fundamental purposes of the training camp. In the afternoon the men were given the onlv special curative exercises included in the curriculum. These exercises were reduced to the simplest. The triple exercises, i. e.: (1) Planter flexion of the toes, foot extended. (2) Hold this; twist foot in. (3) Hold (1) and (2); pull foot into dorsal flexion to strengthen the leg muscles; straight 588 SURGERY leg raising for trunk and abdominal muscles. These exercises, coupled with certain very simple stretching maneuvers, taken by the man himself either with his hands or by standing on the edge of his bunk, were all the special treatment given. All other training was given in large groups. Any alterations in the shoe adjustments were ordered by the orthopedic surgeon. Once each week, he rigidly inspected every man in his charge, as to the condition of his feet and shoes, noting improvement, seeing that the heels were tilted enough and in good condition, making sure the shoes were properly fitted. The same officer coached the men in their play, attempting, with the sanitary officer, to find games in which all the men w-ould take an active part. Among other things, the men were trained to run and jump in good form. Three evenings each week the chief orthopedic officer gave the junior orthopedic officers instruction upon orthopedic conditions occurring among the troops, special emphasis being laid upon the methods of treatment to be fol- lowed in the Army. The men advanced from Company TV" to Company "B," which de- manded greater endurance with longer periods of drill and games, and shorter and fewer periods of rest. The transfer was made to clearly mark an advance- ment. In this sort of training, it was considered necessary not only carefully to grade the training, but also to encourage the men by a clearly defined progress from grade to grade, separating the grades from one another as definitely as possible. In Company "A" the men drilled without the rifle, though they were taught the care and nomenclature of the piece, how to aim and fire, and had no long marches, while in Company "B" they carried their rifles during the morn- ing but had no rifles or any other equipment on the march which they took during the afternoon. From Company UB" the men who had proved their fitness to perforin the drill required, who showed good form at the Saturday inspection, and who could go through the exercises required of them at the examination, i. e., a demonstration of their foot exercises, were transferred to Company "L." For this company, the program was made still more exacting. The men therein began to be more like soldiers of the line, but they were given two 10-minute rest periods in the morning's program and one half-hour lecture period. Three afternoons weekly they took a long march, and on two days a short one, followed by some active games. In Company "M," into which they next progressed, after a similar exam- ination, the work became still more constant and strenuous. Each morning they were given calisthenics, followed by Butts' Manual, lasting an hour, dur- ing which only short breathing spaces were permitted. The orthopedic surgeon constantly watched their position. Then followed a bayonet drill of the most active sort, lasting an hour. After another 10-minute rest period, the morning program was brought to an end by an hour of company and squad drill, and the school of the soldier. In the afternoon foot exercises were given and'then the men fell in with full pack and equipment for a march of two hours, with one 10-minute rest at the end of the first hour. In this march the men were accom- ORTHOPEDIC SURGERY 589 panied by their officers and the orthopedic surgeon. Silhouettes, taken of a man as he entered and as he progressed from company to company, showed in a very graphic way how he learned the proper standing posture and improved carriage, and how the round shoulders and hollow backs were made to disappear. Between January 1 and March 20, 1918, the special training battalion received about 080 noncommissioned officers and men. From this number most of the camp personnel was recruited. One hundred and fifty men passed through the complete course of training, and were returned to their organization. They were fit when they left this camp. It was found necessary to investigate every man who staved longer than four weeks in any one company. In this way were culled out those who could best be used for other work. One hundred men who did not advance rapidly, or were otherwise unfit, were sent to Versailles to start the spring gardens for the Army. Twenty men unable to qualify as soldiers, but who had had experience in driving motors, were transferred to the Motor Transport Service. In the last of March, the 350 men still in training were returned to their commands, and the special training battalion, with a small permanent personnel, was transferred to the 1st Depot Division at St. Aignan and there continued its activities until the cessation of hostilities. During the St. Mihiel and the Meuse-Argonne operations, the need of men at the front was so great that many of the men under training, who could have been made of combat fitness had there been time enough for the training, were detached from the training battalion and sent to the front for noncombat duty. At one time 1,000 men were sent to the First Army area to assist in staffing the hospitals; 1,200 men were sent at another time for the same duty; 1,000 men were sent to act as prison guards. In this way, the size of the training battalion was reduced materially and the work from then on consisted very largely in the reclassi- fication of the men rather than the training which would have been possible had there been sufficient time. REFERENCES (1) Circular No. 23, \Y. D., S. G. O., August 13, 1917. (2) Memorandum, Surgeon General's Office, August 20, 1917. (3) S. O. No. 171, W. D., July 25, 1917, par. 130. (4) Announcement made by the Surgeon General of organization of Department of Military Orthopedics, August'20, 1917. On file, Record Room, S. G. O., 167136 (Old Files). (5) Letter from the Surgeon General to surgeons, August 20, 1917. On file, Record Room, S. G. O., 730 (Orthopedics). (6) Plan for organization and development of Orthopedic Department, submitted by Major E. G. Brackett, M. R. C, and Major J. E. Goldthwait, M. R. C, approved August 17, 1917. On file, Record Room, S. G. O., 210122 (Old Files). (7) Article on Division of Military Orthopedic Surgery, No. 11, 1917. On file, Record Room, S. G. O., 739 (Orthopedics). Reports and Correspondence. On file, Record Room, S. G. O., 353 (Orthopedics). (8) Correspondence on instruction orthopedics. On file, Record Room, S. G. O., 353 (New York City) (F); 353 (Orthopedics, General); 730 (Orthopedics). (9) Schedule of orthopedics instructions. On file, Record Room, S. G. O., 730 (Ortho- pedics) . 590 SURGERY Correspondence. Subject: Instruction Orthopedics. On file, Record Room, S. G. <)., 353 (Oklahoma Citv, Oklahoma) (F); 353 (Orthopedics, General); 730 (Orthopedics). Correspondence. On file, Record Room, S. G. O., 353 (Walter Reed General Hospital) (K); 353 (Orthopedics, General); 730 (Orthopedics). Letter from Brigadier General William H. Arthur, Commandant, Army Medical School, to the Surgeon General, outlining course for twenty-second session, November 3, 1917, par. 4. On file, Record Room, S. G. O., 730 (Orthopedics). Abstract of reports, Orthopedic Division, S. G. O. On file, Record Room, S. G. O., 024.14 (Orthopedic Section). Annual Report of the Surgeon General, U. S. Army, 1919, page 1104. Report of the activities of the division, Military Orthopedics, S. G. O., 1919. On file, Record Room, Surgeon General's Office, 024.2. Report of the Orthopedic Activities of the Medical Reserve Corps in England (Exhibit "B" attached to Weekly Report of the Division of Orthopedic Surgery to the Sur- geon General, August 10, 1918). On file, Record Room, S. G. O., 024.2. S. O. No. 73., G. H. Q., A. E. F., August 20, 1917, par. 17. Manual of Splints and Appliances for the Use of the Medical Department of the United States Army, 191S. Second Edition, Printed by the American Red Cross, Paris, 1918. The Military History of the American Red Cross in France by Lieut. Col. C. C. Bur- lingame, M. C. Copy on file, Historical Division, S. G. O., 124. Brief Histories of Divisions, U. S. Army, 1917-18. Prepared in the Historical Branch, War Plans Division, General Staff, June, 1921. S. O. No. 284, A. E. F., October 11, 1918, par. 169. Circular Letter No. 45, S. G. O., A. E. F., August 13, 1918. S. O. No. 181, December 8, 1917, par. 18; No. 8, January S, 1918, par. 12; No. 12, Jan- uary 12, 1918, par. 26, and No. 14, January 14, 191S, par. 47, Headquarters, A. E. F. Circular Letter No. 29, Office of the Chief Surgeon, A. E. F., May 21, 1918. G. O. No. 88, G. H. Q., A. E. F., June 6, 1918. Letter from Chief Surgeon, A. E. F., to Commanding Officer, Base Hospital No. 116, October 18, 191S. Subject: Orthopedic Training. On file, A. E. F. Records, Base Hospital No. 116, Doc. file No. 121. (27) Report of the activities of the section of orthopedic surgery with the American Expe- ditionary Forces, December 3, 1918, by Col. Joel E. Goldthwait, M. C. On file Historical Division, S. G. O. CHAPTER II THE FOOT AND ITS RELATION TO MILITARY SERVICE THE SOLDIER'S FOOT The importance of the foot in the development and maintenance of an army has long been recognized; with the advance of civilization this problem has assumed an even greater importance. The foot of primitive man, by virtue of his means of livelihood, was trained to go and so was ready for the warpath at a moment's notice. The foot of the man of to-day, equally by virtue of his means of livelihood, is called upon less and less for active function and is used more and more as a passive support in standing, with all the con- sequent attendant ills of weakened muscles and faulty foot posture. It is inevitable, therefore, that the number of men unfit for military service should be greatly increased by foot disabilities and that the care of the foot should become a question for serious consideration in the training of the recruit. In the World War the difficulty of this phase of the medical service was still further increased by the urgent need for large numbers of troops, the universal draft, and the location of the theater of operations overseas. In reviewing this work for the period of the World War, the features which seem to stand out as of especial importance and value are two—the instruction of the various branches of the service in foot requirements, and the examina- tion of the recruits, with the prophylactic care based thereon. Beginning with but few trained workers, a system which satisfactorily stood the test of time and of varying conditions was perfected gradually and fairly early by the division of orthopedic surgery. INSTRUCTIONS IN REQUIREMENTS WITH RESPECT TO THE SOLDIER'S FOOT Before the World War it had been pointed out that the satisfactory solution of the foot problem is possible only through the cooperative efforts of the medical officer, the line officer, and the soldier himself.1 Hence, from the beginning the necessity for the systematic instruction of these three classes of personnel was recognized. Obviously the plan which was finally approved 2 must be limited to the minimum requirements. As far as the medical officer was concerned, it was evident that knowledge of the foot and its relation to the military service needed to be systematized and made available for Army use. Accordingly, a concise description of the mechanics of the foot, its disabilities and their treatment, was prepared for the Suro-eon General by a few members of the American Orthopedic Association very shortly after our entrance in the war. This was first used in mimeographic form for distribution to camp surgeons. Later, it formed the foundation for the opening chapters of the War Manual of Military Orthopedic Surgery.3 This more o-eneral information was supplemented from time to time by circulars 40907—27---40 591 592 SURGERY and special instructions covering various phases of the subject, such as the ex- amination of the foot in border-line cases,4 the rapid examination of the feet of recruits, and the salvaging of foot defectives. Instruction in the affections of the foot was systematically carried out throughout the training camp period as a part of the minimum amount of general orthopedic training required of all medical officers in medical officers' training camps, and also in the special clinical courses in military orthopedic surgery for medical officers assigned to the orthopedic division. With the establishment of these special courses at Camp Greenleaf and in the various special schools in university centers, the opportunity was afforded of satisfactorily instructing officers before their assignment to camp duty, in the foot requirements of the soldier. At Camp Greenleaf a course of four weeks' duration was given to a class of 25, a new class being admitted each month.5 Not all of the men trained in this course were retained in the orthopedic group, as some finally proved better qualified for other branches of the medical service and hence were transferred. The university courses were of six weeks' duration. Later, in the perfected plan of instruction for medical officers conducted at Camp Greenleaf, a more intensive course in foot prophylaxis and treatment, as well as in other orthopedic affec- tions, was given to all medical officers. These special courses of instruction were supplemented finally in the training camps by lectures and practical instruction by the consulting surgeons and the camp orthopedic surgeons. Line officers and candidates for commission were required to have " a total of at least three hours of instruction in the care of the foot and its coverings" and in other simple orthopedic affections.4 This instruction was given at first by simple talks and later by the use of moving pictures. Of the latter, three reels were prepared at the Army Medical Museum to illustrate the chapters on the foot in the War Manual of Military Orthopedic Surgery. For all enlisted men it was prescribed that "at least one hour's practical instruction in the care of the foot and its coverings (and the treatment of minor injuries) be given once a month by the surgeon of the organization, under the supervision of the orthopedic department." 4 A course of instruction was also prescribed for selected enlisted men of the Medical Department to "be given at all training camps and other stations to fit them for rendering proper assist- ance in shoe fitting, the care of the feet (and the treatment of minor ortho- pedic affections)." As an aid in this work, a short pamphlet on Minor Foot Ailments was issued and two editions distributed. PERSONNEL FOR EXAMINATION AND CARE OF THE SOLDIER'S FOOT Recognizing that the examination and care of the foot was most important during the training period, the effort was made to assign for camp duty only medical officers who were known to have had orthopedic experience. The number with orthopedic training naturally soon proved inadequate and the positions then had to be filled with those trained in the special courses. In order to coordinate and systematize the work in the various camps, a corps of consulting orthopedic surgeons was next formed to fill the double function of consultation and inspection. To facilitate the work of these officers, the country ORTHOPEDIC SURGERY 593 was divided into zones, so that the camps in a given zone were, as far as pos- sible, within reasonable traveling distance of each other, and a consultant was assigned to each zone. These consulatants usually spent a week or 10 days in each camp. They reported to the Surgeon General by letter in the regular routine and personally as frequently as the distance of the zone from Wash- ington justified. The enlisted personnel also formed an important part of the Army foot service. A particularly useful group comprised the selected enlisted men of the Medical Department, to whom reference was made above, who were given special instruction in shoe fitting, the care of the foot and the treatment of minor orthopedic affections. A sufficient number of these were trained to permit assignments to be made to the various organizations as they were sent overseas. Assistance was also rendered by another class of enlisted men who were already trained in the treatment of minor foot ailments—the chiropodists. Those secured by transfer early in the war soon demonstrated their usefulness to such an extent that the desirability of having all qualified chiropodists who might be accepted in the draft made available for this work became evident. The necessary authority was secured and, through the cooperation of the officers of the National Association of Podiatrists in notifying the Surgeon General whenever a qualified chiropodist was ordered to camp, it was thus pos- sible to obtain his immediate assignment to the Sanitary Corps for work under the orthopedic division. A second group which rendered a most important service consisted of the cobblers. They, too, required some training by the orthopedic surgeons in the method of making shoe alterations. In order to secure a sufficient number to care for the early work with the recruits and the later needs of the organization, the most practical plan proved to be to secure the temporary assignment of cobblers, where found, to the orthopedic depart- ment. When returned to their organizations, they were competent to care for this important detail of foot work.6 ESTIMATION OF POTENTIAL FOOT EFFICIENCY The estimation of the potential efficiency of certain types of foot for mili- tary service was unquestionably most difficult not only for the medical mem- bers of the local draft boards and the camp surgeons of the earlier days of the World War but often even for the trained orthopedic specialist as well. Such an estimation calls for an adequate appreciation of the difference between foot form and foot function, an understanding of the demands made upon the individual's foot by both his occupation and his avocation, and the ability to evaluate the symptoms and signs of foot strain in its incipiency. When to this is added the confusion resulting from the frequent attitude of the individual toward the service, the attempt on the one hand to minimize or conceal past or existino- trouble through his desire for acceptance and, on the other hand, to simulate the comparatively well-known symptoms of foot strain in order to escape the draft, it is not surprising that an occasional athlete was rejected because of a low arch, while many individuals with normally high arches but with potentiality weak feet were accepted, nor even that many foot defectives were sent overseas. 594 SURGERY FOOT EXAMINATION The recognition and correction of remediable foot defects, the segregation of recruits requiring a more gradual system of training, and the elimination of any with actual disability who may have been inadvertently passed by the draft boards are among the first important details to which attention must be given at the time of the induction of the recruit into the service. This was most readily accomplished in the casual detachment or depot brigade, where the recruit was first quartered on entering the service. In case he was trans- ferred to a large camp or cantonment, it could be carried out satisfactorily in quarantine barracks, if he was first sent there, but if sent directly to his organi- zation, arrangement had to be made for the examination through the regimental commander and care taken to interfere as little as possible with the work of the organization. One obstacle to success in handling the work in the casual detach- ment or depot brigade was that there might be no issue of equipment until the recruit reached his permanent assignment and hence shoe alterations could not be made. The attempt to obviate this difficulty by attaching to the man's service slip a separate record of the examination with recommendations as to alterations was not entirely successful, owing to these separate records being lost or thrown away through failure to recognize their importance.6 In the beginning, as was to be expected, many difficulties were encountered. The number of foot defectives was relatively larger among the early recruits, due in part, at least, to the inevitable lack of experience of the medical members of the local draft boards with orthopedic principles and to the patriotic desire to ensure that no shirkers escaped. When these early recruits reached camp, the medical service was as yet too imperfectly manned and too insufficiently organized to carry out routine examination and treatment in the most efficient manner, and even their importance was not always fully recognized by all officers. The supply of shoes was frequently insufficient to enable the men to be fitted promptly and properly. Finally, an efficient method for handling those presenting the more severe types of disability and those suspected of malingering had not yet been instituted. With increasing experience these difficulties tended gradually to grow less or disappear entirely, and a system was perfected which proved most satisfactory. Routine Method of Rapid Examination With large numbers of recruits a method of examination is required which is both rapid and accurate. Various methods were tried in the different camps, of which the following may serve as an example :7 The men are examined standing on a table. The table should be high enough to come to the shoulder level of the seated surgeon. The man walks across the room and mounts the table, standing in front of the examiner. The way he walks across the room and the way he mounts the table are an excellent index of the functional ability of his feet. By inspection the surgeon notes visible defects, then putting a hand on each foot the position of the scaphoid is noted with the thumbs. The toes are pushed up next and any rigidity noted. Then the man is instructed to give his left foot to the examiner, holding the knee straight. The examiner's left explores the heel for any abnormality; the right hand grasps the forefoot and tests the functions of the sub-astragaloid and midtarsal joints. Lastly, the forefoot is pushed up and the condition of the ankle joint and the tendo Achillis is noted. In this ORTHOPEDIC SURGERY 595 position the sole of the foot is inspected for callosities. The right foot is examined in the same way, except that the examiner reverses his hands. W ith the use of this system, it was found possible for two orthopedic surgeons and four clerks to examine and record the results of 100 foot examinations per hour. ANALYSIS OF FOOT DEFECTS FOUND IN RECRUITS For practical consideration the foot defects may be divided broadly into four groups: (1) Defects correctible by simple shoe alterations; (2) those usually producing disability for full military duty; (3) those correctible by operative means; (4) defective muscular strength or development. The Surgeon General stressed the importance of taking especial care in the examination of recruits to detect those slighter deviations from the normal in foot form and posture which are potential sources of disability. Pronation, flattening of the longitudinal arch, limitation of dorsal flex- ion, flattening of the Fig. 38.—Tomahawk wedge, the standard shoe alteration for ankle valgus, to shift weight bearing to the outer side of the foot; supplied in three thicknesses. (This and figs. 39-41 are from Rich, E. A.: Static Defects of the Feet. J. A. M. A., 1918) transverse arch, and cavus, existing in a degree insufficient to produce dis- ability under the ordinary demands of civil life, are naturally aggravated and may become exciting causes of foot strain under the arduous demands of training and the increased weight imposed by the pack. Of all the orthopedic foot work carried on during the training period, the prophylactic correction of these defects was undoubtedly productive of the greatest good. Pronation, alone or associated with abduction of the forefoot, and flattening of the longitudinal arch, when there is no loss of flexibility and no structural change, are simple postural deviations which were most commonly found in those whose occupa- tion had been either sedentary or one re- quiring prolonged standing. The free use of the toes permit- ted by the Army shoe, with the active thrust from the forefoot soon acquired in training, tended naturally to the permanent cor- rection of these de- fects, providing the fatigue incident to the early days of training did not aggravate them to a de- gree where they became pathological. Assignment to special squads for more gradual training and the use of corrective exercises were of definite advantage in the more pronounced cases. In most, however, the simple wedging of the heel on the inner margin, or of both heel and sole (figs. 38 and 39), to a degree Fig. 39.—The tomahawk wedge in place 596 SURGERY proportionate to the amount of the deviation, fully met the indications. Limitation of dorsal flexion, or '''short heel cords," of moderate degree, required merely a slightly higher heel. In simple flattening of the tranverse arch and other defects of the forefoot, the anterior heel (fig. 40) was found to meet all needs most admirably. As used in the British Army, the anterior heel con- sisted of a simple cleet of leather fastened to the outside of the sole Fig. 40.—Anterior heel in position . . ■■ i » .i i ,, just back of the ball. In our camp experience, however, it was found more satisfactory to place the piece of leather forming the heel between the layers of the sole, as in this posi- tion it could be used even with a thick sole and also did not wear down as quickly. Cavus, or contracted foot, is a type of foot form of much more frequent occurrence than is generally realized. It was found to be " exceedingly common among our southern troops, especially from the Delta States."8 The greater strain thrown upon the metatarsal heads by the reduction in the weight-bearing surface of the sole through the high arch is greatly increased in military life by the active function required of the forefoot and by the burden of the pack. Under these conditions even mild degrees became potential sources of serious disability. In order to fit the " cavus foot" the shoe must have a high shank, and as cavus is more frequent in the slender type of foot a narrow width is necessary. The Army shoe, ideally as it is adapted to the great majority of feet, does not meet the requirements of the foot with cavus. In the milder degrees, however, it was possible to al- ter it so as to over- come the difficulty very satisfactorily by a slight modification of the anterior heel just described, the leather insert being simply made longer so as to extend far- ther back toward the heel (fig. 41). For the more se- vere cases additional pieces of leather were Fig. 41.—Position of rocker shank on the outer sole. The alteration for minor degrees of cavus. With more extreme types the rocker shank of two or more thicknesses of leather is demanded to redistribute weight bearing. The lower illustration is diagrammatic of positions of leather inserts when multiple inserted or a similar elevation was attached to an insole and fastened inside the shoe. With a little training the company cobblers soon became very proficient in making these alterations and were able to finish the individual ones in a few minutes. When the foot was so changed that the shoe alterations mentioned were insufficient to correct the defects, it was found possible in only a relatively few cases among white troops to make the individual fit for active overseas service. The conditions which proved thus disabling were "flaccid flat feet with marked ORTHOPEDIC SURGERY 597 abduction and eversion, rigid or spastic flat feet, rigid arthritic or post-traumatic feet, marked cavus, pes varus or valgus following fracture, extreme hallux valgus, with painful bunion or metatarsalgia, hallux rigidus, amputation, partial amputation or severe derangement of the joints of the great toe, and proved exostosis of the undersurface of the os calcis."7 In negro troops these conditions differed somewhat. The foot of the negro possesses greater flaccidity, which is compensated for by greater muscular development, and many negroes who had no subjective symptoms were found with flat feet associated with abduction and eversion.7 In the earlier months of the war it was a difficult matter to handle properly these cases with disabling conditions, but with the establishment of the foot camp, and later of the developmental battalion,9 a way was provided for testing them out and arranging their assignment to noncombat duty. The operative results of most abnormalities of the foot, such as hallux valgus contracted foot, hammertoe, had been long known to be generally certain and satisfactory, not only in civil life but also in the Army during peace time. Hence, after we entered the war it was felt that conservation of man power would be promoted by operating on all such conditions found among the recruits. It was soon recognized, however, that equally good results could not be secured under war conditions. The probable difference in the mental attitude of the drafted recruit, the arduous work which the operated foot was soon called upon to perform, and the comparatively short period which could be devoted to convalescence were apparently the main factors in causing this difference. This policy, ideal as was its conception, proved economically a failure, and hence a circular letter was issued by the Surgeon General, November 12, 1918, advising against such elective operations. Recruits with insufficient muscular strength apparently constituted, every- thing considered, the most troublesome group. They were of two kinds—those in whom the strength was below the requirement owing to excessive weight; those with insufficient muscular development. The first class readily responded in most instances to the rigors of training and required merely the corrective shoe alterations and a more gradual method of training. A large proportion of men with insufficient muscular strength also responded to the same measures. There still remained a considerable number, however, whose muscles could not be brought up to the strength required for active duty, even when detailed to special squads for preparatory training. This is not surprising when it is considered that not only had large numbers of them been engaged in sedentary pursuits, with little or no opportunity for outdoor activities, but also that in many a constitutional or esren a congenital cause for the defective development existed. Hence, its correction in the comparatively short period that was available, however scientifically training might be carried on, could not be expected.' The recognition of these muscularly unfit was naturally difficult for medical officers who had had no experience with the demands made by an active military campaign. So, in the efforts at conservation, some of these border-line cases were allowed to go overseas. Another class of this group, in which the muscular strength proved insufficient, but for an entirely different reason, comprised recruits assigned to fill vacancies in regiments partly or completely trained. Under these conditions it sometimes happened that feet which would 598 SURGERY have proved entirely adequate under the ordinary method of training broke down because the muscular strength was not sufficient to meet the great demand suddenly made upon them. SUMMARY* OF THE ESTIMATION OF FOOT EFFICIENCY In view of the importance of the estimation of foot efficiency for military service, a summary of the chief points brought out in our camp experience seems desirable. Since the abnormalities of the foot which have been found disabling are clearly defined in Army Regulations, only those deviations from the normal which may or may not cause disability need be considered. Experience shows that this estimation must be based on a study of the form and the function of the foot and the development of the muscles by which it is activated, careful consideration being given also to the relation between the work previously required of it and that demanded by active military duty. In considering foot form, the height of the arches alone has little signifi- cance. Considerable difference exists within normal limits, due to race, the character of the work done, and the type of foot coverings worn. Between the high arch of the decendants of the Spaniard and the low arch of the negro there is marked variation, and yet the two may be equally efficient. The arches of one who has done heavy work and those of the athlete, particularly when the work or play was begun early in life, are relatively low and the forefoot spread, and yet both have been trained to withstand great strain. Similarly, the foot which has never worn a shoe, as occurs among our mountain people, presents a lower, broader aspect, although its strength is beyond question. Pronation with abduction of the forefoot and eversion (toeing out) may be present in mod- erate degree as purely postural defects, and, provided the foot is flexible and the muscular development good, they are of importance only as far as prophylaxis is concerned. Only when these deviations of slighter degree are complicated by impairment of flexibility or poor muscular development, or when they are present in more than moderate degree, are they likely to prove disabling. It is the function of the foot, however, on which the final determination in doubtful cases depends. Foot form is necessarily always of secondary impor- tance to foot function. Hence, in the last analysis the essential requirements of the soldier's foot are normal flexibility and good muscular development, since without these normal function is impossible. Loss of flexibility even in a single joint or in a single direction must always be regarded with suspicion and its cause determined. Moderate limitation of dorsal flexion alone, however, is often the result of simple adaptive shortening of the calf muscles from the con- stant wearing of high-heel boots and responds readily to prophylactic heel altera- tion. Limitation of motion from old fractures or arthritis, even when present in only slight degree, is usually disabling, while loss of flexibility in more than slight degree from any cause is practically always so. The accurate evaluation of the potential muscular strength in doubtful cases is perhaps the most difficult factor of all in the estimation of foot efficiency. When poor muscular develop- ment exists in feet presenting deviations from the normal of sufficient degree to act as potential causes of disability, the decision is relatively simple. But ORTHOPEDIC SURGERY 599 when the poor muscular development exists alone, it is by no means so easy. In the latter instance all the factors bearing on the condition must be con- sidered—its cause and duration, that is, whether congenital or acquired, and, if the latter, whether due to constitutional defects, disease or simple lack of exercise, the attitude of the recruit toward service, and whether provision can be made for graduated training, are all of importance. THE FOOT CAMP AND THE TRAINING BATTALION In our early camp experience it was a difficult matter to handle satisfactorily the doubtful cases of defective feet and those which had broken down in train- ing, and to determine definitely the ones able to meet the demands made upon the soldier. This difficulty was solved by the formation of a special organiza- tion, called the foot camp. Apparently this plan was developed about the same time in several camps. The men were assigned to this camp on special detail. Lists for admission and discharge were made out twice a week. When the de- velopment battalion was formed, the foot camp naturally became part of it. Men were examined in groups within 24 hours after admission to the camp, the shoe measurements being verified, shoe alterations made, and the drill class suitable in each case designated. A division into three classes proved most convenient—no drill, drill, and heavy drill. Foot exercises, performed barefoot, were given all the men at setting-up drill, those in no-drill class receiving two half-hour periods daily and the others one. The no-drill class was given foot exercises and light detail, the drill class infantry drill, graduated to its ability, and the heavy drill class went on marches in addition to performing its other work. Three types of cases were encountered in the foot camp—the real defectives, the timid, and the malingerers. Men with actual remediable defects responded satisfactorily to the system carried out. The timid likewise usually responded to the effect produced by the careful examination, the assurance that there,, was no serious trouble, and the confidence acquired through the graduated work. The malingerers could soon be recognized in the foot camp and were then as- signed to the hard and disagreeable tasks. Privileges were granted only to men doing heavy drill, it being explained to the others that since their foot condition was such that they could not do full duty, it was inadvisable for any extra strain to be put on the feet. This method proved a great incentive to work. By this system it was possible to test the men out thoroughly and to return the physically fit for duty to their organizations, the others being disposed of otherwise, as the conditions warranted. Out of 822 men handled in the foot camp in four and a half months, 614 were returned to their organizations, 447 of these going back to full duty, while 167 were recommended for domestic duty or discharge.7 THE ARMY SHOE The standard shoe issued by the Army during the World* War proved to be all that could be expected of any shoe. It was found that practically 98 per cent of feet could be satisfactorily fitted with this shoe.10 Shoes on similar lines but with a more marked "inflare" were also used at times, but 600 SURGERY proved less suitable; for, while the feet of the younger soldiers would adjust themselves to these more pronouncedly curved shoes, those of the older ones could not, with the consequent development of corns on the toes where they pressed against the outer border of the shoe.6 Our camp experience as a whole merely verified the recommendations already made 1 in regard to the fitting and care of the shoe. The difficulties encountered in shoe fitting were not due, therefore, to the shoe itself but to an insufficient supply, irregularity in the time of issue, lack of men properly trained in shoe fitting, and the attitude of the soldier himself. These difficul- ties, too, had previously been recognized and fully covered in the report of the Army Shoe Board. An insufficient supply of shoes is to be expected in the early part of any war. particularly when large numbers of men are being called for service. When the supply of shoes is adequate, however, an early and a uniform time of issue is of distinct advantage. It was found that when the shoes were issued withm the first three days after the men were inducted into the service, the shoe alterations could be made before the period of quarantine was past. With the definite directions for shoe fitting given in Army Regu- lations, any reasonably intelligent soldier can soon be taught the necessary skill, and the chief consideration is rather whether he possesses the essential qualities of responsibility, patience, and the ability to handle men. It was possible soon to train sufficient men for all needs. The greatest obstacle to successful fitting was after all the attitude of the recruit himself. Many with poorly developed feet, and without experience in the demands made by outdoor pursuits, had no appreciation of the difference in shoe requirements and so, through ignorance, and also frequently through pride, used every expedient to avoid wearing shoes of the correct size. As the recruit developed into the soldier, this obstacle largely disappeared. The little that our experience added to our knowledge of the Army shoe was limited largely to the method of making the alterations for the correction of postural and other defects.8 To facilitate the work of making these altera- tions in the camps, the necessary pieces for insertion were furnished as a part of the cobbler's outfit and supplies. The effect of the Army shoe on the appearance and development of the foot and in the correction of many of its defects, particularly those of the fore- foot, was most striking. Of the minor foot ailments, corns gradually disap- peared, bunions ceased to be painlul, crooked toes tended to straighten, and ingrown nails gave no further trouble.11 Anterior arch troubles, which are promoted by the distortion and constriction of the forefoot caused by im- properly shaped and incorrectly fitted shoes, usually responded to the free use of the forefoot permitted by the Army last, aided, if necessary, by the anterior heel.10 Similarly, the normal use of the foot as a whole resulted in a marked development of its tissue and gave it "an appearance of health commensurate with the work it had to do." u ORTHOPEDIC SURGERY 601 REFERENCES T Munson, E. L.: The Soldier's Foot and the Military Shoe. George Banta Publishing Company, Menasha, Wisconsin, 1917. (2) G. O. No. 133, W. D., October 11, 1917. (3) Medical ^Yar Manual No. 4, Military Orthopedic Surgery Prepared by the Orthopedic Council. Lea and Febiger, Philadelphia and New York, 2d edition, 1918. (4) Circular No. 23, W. D., S. G. O., August 13, 1917. (5) Geist. E. S.: The School of Clinical Military Orthopedic Surgery, Camp Greenleaf. American Journal of Orthopedic Surgery, 1918, xvi, No. 8, 488. (Oj Rugh, J. T.: Foot Prophylaxis. American Journal of Orthopedic Surgery, 1918, xvi, No. S. .529. (7) Mebane, T. S. The Foot Problem. The Military Surgeon, 1918, xliii, No. 4, 377. (8) Rich, E. A.: Static Defects of the Feet. Journal of the American Medical Association, December 14, 1918, lxxi, 1980. (9) G. O., No. 45, W. D., May 9, 1918. (10) Rugh, J. T.: The Army Shoe. Journal of the American Medical Association, Chicago, October 12, 1918, lxxi, 1215. (11) Rugh, J. T.: The Foot of the American Soldier. Pennsylvania Medical Journal, Janu- ary, 1919, xxii, 198. CHAPTER III FRACTURES CAUSED BY PROJECTILES In Chapter III of the volume on general surgery, statistical data con- cerning fractures may be found. Only brief references to the relative incidence of such injuries are made here. As a measure of the importance of fractures in military surgery, it may be stated that among the 153,527 battle injuries (excluding trauma by deleterious gases) in the American Expeditionary Forces, there were 25,272 patients (16 per cent) with fractures, the major portion complicating gunshot wounds.1 When consideration is taken of the varied character of such fractures, their almost invariable infection, and the attendant difficulties to which they gave rise in transportation, it may readily be seen that they presented ever-varying problems to the military surgeon. PRIMARY MANAGEMENT The primary management of fractures accompanying gunshot wounds, as has been told in Chapter I, was a function of the Medical Department of a tactical division of troops. To effect this the equipment was set up in places as favorable as possible to the successful operation of a plan of evacuation, and in as close contact with the troops actually engaged in fighting as the military situation allowed. The precepts of such management, as outlined in the Manual of Splints and Appliances,2 are: (1) The application of first-aid, splints, and dressing, to the wounded soldier where he falls. (2) The trans- portation of the wounded soldiers to an aid post—usually by litter carry. (3) The treatment of shock and hemorrhage and proper splint and dressing application at an aid post. (4) The transportation of the wounded soldier to a hospital where proper facilities make it possible to carry out surgical treatment by motor or animal-drawn ambulance. The following supplies in splints and splinting material were to be carried by the various medical units and detachments in quantity sufficient to meet the casualties of 24 hours' severe combat: 602 ORTHOPEDIC SURGERY 603 Splints and splinting material carried by Medical Department units and detachments Straps and buckles__________________ Snowshoe trench litter______________ Thomas-half ring leg splint (Blake- Keller)____________________________ Thomas hinged arm splint (Murray) Cabot posterior wire splint _________ Wire ladder splint___________________ Wood splint assorted________________ Long Liston splint______......._____ Litter bars___________________________ Triangular bandages_________........ Cotton (wadding)___..........._____ Rolls (batting)__________________..... Muslin bandages 4-inch and 6-inch assorted_____....._________________ Z. O. adhesive 2^_-inch rolls_________ Wire foot supports___________________ Wire-gauze rolls........____......... Sinclair's glue________________________ Adjustable traction straps___________ Hand and wrist splint_______________ Splint distribu- tion for regiment of Infantry _ _, s» a o > o 2 •2 ft ■OT3 P'O *« & s. flg a> a a> o3 ■2 O 0 2 6 1 6 1 6 1 6 2 12 1 6 0 0 0 10 6 24 ► 0 4 6 24 1 6 0 10 0 0 0 0 1 6 1 3 Splint dis- tribution for each regiment of Artillery "^3 36 36 36 36 56 36 0 36 200 120 36 36 0 0 36 18 i 12-15 12-15 12-15 12-15 1 24-30 12-15 0 15-18 60-72 4-6 60-72 I 12-15 15-18 0 0 12-15 6-8 25 2 25 25 50 100 50 4 50 200 25 200 30 50 0 0 25 15 _; o X o ■a S3 o ■a « 25 2 25 25 30 50 25 4 25 200 200 30 50 25 i kilo. 25 15 1 The first column is for regiments of 2 battalions each; the second for those of 3 battalions each. 406 10 400 400 450 1,000 450 20 400 3,000 350 1,500 400 500 100 2 kilos. 400 250 Fig. 42.—Detrsuction of the head of the humerus, outer portion of the clavicle, head of the scapula, and comminuted fracture of the upper portion of the shaft of the humerus by rifle missile. Fragments of the shattered missile shown in the soft tissue 604 SURGERY As carried out in the American Expeditionary Forces the primary manage- ment of all fracture cases with reference to splinting was very similar in the front lines and may be outlined in a general way. The object in each case was to get the wounded man back to the evacuation, or mobile surgical hos- pital in condition for whatever operation was necessary, and. in order that he might arrive thereat in condition for operation, it was necessary, to minimize shock, to protect him as much as possible from cold, pain, and hemorrhage. This was accomplished by the following routine: After a man with a fracture had been removed to the first available shelter, a splint was applied, the wound Fig. 43.-X-ray picture, showing fractured clavicle and lodged missile in the outer end of the clavicle was exposed, and the dressing applied to the wound after the control of hemorrhage; antitetanic serum and morphine were administered whereupon he was ready for transportation back to the advanced ambulance dressing station. As soon as possible after arriving at the ambulance station, the dressings were inspected as to hemorrhage, the limb as to swelling the splint was adjusted if necessary, and the man's general condition observed He was given a hot drink and, if cold, was warmed either bv extra blankets or bv placing the litter over a Primus stove. He was kept at the ambulance station long enough to get thoroughly warmed before being placed in the ambulance for the triage or operating station. ORTHOPEDIC SURGERY 605 % Fig. 44.—Fissure fracture of the greater tuberosity of the Fig. 45.—Comminuted fracture of the upper portion of the humerus by shell fragment, which is shown lodged diaphysis of humerus, with moderate dispersion of bone fragments pIG 4g__Fracture of upper end of diaphysis of humerus by rifle missile, with much loss of bone. Fragments of the missile are shown dispersed in the tissue about the head of the humerus 606 SURGERY The medical personnel of the combat troops was informed as to the impor- tance of getting a gunshot fracture case back to the operating station as soon as possible so that the infection might be better controlled by early debridement, and that an important factor in keeping him comfortable on the way back was proper splinting of the fracture. Therefore, little attempt was made in the Fig. 47.-Wound of the upper portion of the shaft of the Fig. 48.-Fracture of middle of shaft of humerus by humerus. The fragments of bone are large and but little shell fragment; moderate separation of bone frag- separated, though there is considerable displacement ments. Shell fragment, relatively large, lodged forward area to cleanse the wound; it was impossible to do so properly, and by merely applying the dressing, more attention could be given to the applica- tion of the splint and control of hemorrhage. SHOULDER Gunshot wounds of the shoulder, either with or without fracture of the scapula, clavicle, or upper portion of the humerus, often were associated with ORTHOPEDIC SURGERY 607 chest injuries, and frequently it was not possible to splint these cases. The large triangular bandage was applied and the arm pinned securely to the side. UPPER EXTREMITY Humerus and Forearm It soon proved that the hinged traction arm splint was best adapted for arm and forearm fractures in the forward area, the reason being that with the Fig. 49.—Wound of diaphysis of humerus by rifle Fig. 50.—Compound, comminuted fracture, lower missile, with wide separation of bone fragments end of humerus, result of deformed rifle missile hinged arm splint, the arm could be carried at the side—an advantage for litter cases. Another important factor was that, because they were more compact, these splints could be carried forward much more conveniently than could the full ring splints. Sonic difficulty was experienced at first in securing traction in the arm splints, or rather too much traction was attempted. Since 4ti(.MU—27-----41 60S SURGERY a hitch or tie of any kind around the wrist often produced excessive swelling of the hand and pressure sores, it proved necessary to forbid its use. and instead it was suggested that adhesive plaster be applied to the forearm and wrist for extension. Experience proved, however, that it was not necessary to have any great amount of traction, and that the splint could be held in place by a bandage through the ring passed over the opposite shoulder. The slings, in which the arms were to rest, were made of ordinary muslin or flannel bandage, and were placed rather far apart. The wire-ladder splint or flexible board was used for support, and the arm was firmly bandaged to the side bars of the sphnt. In many instances, however, the Jones humerus traction splint was used in the forward areas: it was Wetter adapted for walking cases than for litter cases. When the humerus was fractured traction was made bv bandaging the forearm firmly to the splint, countertraction being secured by a bandage over the opposite shoulder, thus holding the ring well up in the axilla, wire-ladder or board splints being applied over the dress- ing and the arm bandaged to the splint. As the use of adhesive plaster required the removal of too much of the clothing, resulting in undue exposure, it was not practical for arm traction. In fractures of the upper por- tion of the forearm traction was obtained by a hitch placed on over the clothing of the lower third of the forearm and tied to the end of the splint, countertraction being secured by bandaging the arm to the upright side bars and securing the splint by a bandage through the ring across the opposite shoulder. (Xo bad effect was noted from the hitch in flexed arm splints.) Support by means of wire splinting was used and the arm bandaged. Fig. 51.—Rifle missile injury of shafts of ulna and radius, and indirect fracture of lower end of shaft of humerus orthoim.dk: surgery 609 Wrist and Hand For fractures of the wrist and hand, wire-ladder splinting, plain boards, or the Jones " cock-up'! splints were used. In all these cases, rather firm bandaging was practical over a large dressing which controlled hemorrhage, obviating the necessity of a tourniquet in cases of bleeding at the wrist or in the hand, and better immobilizing the fractures. Fig. 52.—Fracture of upper ends of ulna and radius by rifle missile. There is con- siderable displacement of the fractured shaft of the radius. The lodged missile shows the common form of deformation peculiar to the "spitz" or pointed bullet. This bullet frequently lends to lodge when it strikes cancellous and compact bone tissue LOWER EXTREMITY First-Aid Splinting For first-aid splinting of the lower extremity the Thomas half-ring leg splint was applied for all fractures from the pelvis to the ankle. After its adjustment and the injured soldier was placed on. the litter, this splint was suspended from the litter bar, otherwise it tended to be displaced and traction 610 SIJP.GKRV was lessened. The Thomas half-ring splint had advantages over the full-ring splint in the divisional areas; it is lighten-, more readily transportable in num- bers because it requires less space, and is not so apt to be broken during ship- ment as the full-ring splint. Fig. 53.—Fracture of shaft of femur, juncture of middle and lower thirds by rifle missile, showing explosive effect of missile striking compact bone. Comminution is extensive; the bone fragments are widely separated. Missile fragments are dis- persed in the soft tissues In applying the splint to secure the needed traction, three important points must be borne in mind: (1) The proper pressure upon the tuberosity ORTHOPEDIC SURGERY 611 of the ischium. Of course, in getting traction, one must have traction of the foot and countertraction at the head, and the countertraction is obtained by the pressure of the ring of the splint on the tuberosity of the ischium. One of the ' r Fig. 54.—Same as Figure 53, taken three months after the receipt of injury, showing progress of repair, such as callus formation and sequestration. There is marked angu- lation of upper and lower fragments creates, faults was to allow the ring to slip up over the tuberosity, thus losing all traction. (2) The traction anklet. The men had a great tendency to remove the shoe. This took time, it hurt the man, and there was no excuse 612 SURCKRY for it. The canvas anklet, which was developed and carried on every splint. was made to fit over the field shoe, and if the shoe was not left on one had to use the foot. Removing the shoe was one of the common mistakes made in Fig. ."..-..-Fracture of shaft of femur by shell fragment, shown lodged. There is some displace- ment but little or no comminution the application of this splint. The shoe would be removed, no cotton paddin^ would be used, consequently the anklet did not fit; it caused undue pressure on the foot and shut off the circulation. T The method of supporting the limb The simplest and quickest way to apply the Thomas half-ring splint under field ORTHOPEDIC SURGERY 613 conditions is with three triangular bandages. These are folded as one would fold a cravat, about 4 inches wide, and one of them is applied behind the middle of the thigh. It is passed through under the thigh and over the two side bars and then down around the back of the thigh again, crossed and tied in front. thus providing support from behind and in front. In the same manner one is applied at the middle of the leg and at the knee. This is all the support needed: already the dressings have been applied, there remains then but the necessity for a circular bandage around the splint and the leg. Needless to say, it is necessary to support the leg on the litter bar. Fig. 56.—Rifle bullet wound, lower extremity, femur. Be- Fig. 57.—Same as Figure 5 inches and S by (. inches). Personnel required: Operator. Xo. 1 assistant. No. 2 assistant (if available). When not in use the splint is kept hung up. The five slings of flannel bandages are rolled around the inner bar of the splint, the leather is kept soft by saddle soap, and the iron bars are kept smeared with vaseline. 614 STJRGF.RY INDICATIONS OF FRONT-LINE API LK'ATION 1. For all fractures of the thigh bone, except where there is an extensive wound in the upper part of thigh or buttock, which would interfere with the fitting of the ring. 2. In severe fractures about the knee-joint or upper part of the tibia. 3 Tn certain cases of extensive wounds of fleshy part of thigh. Fig. 58.—Compound, comminuted fracture, lower extremity of femur, with marked dispersion of fragments, resulting in a destruction of both condyles, due to a later- ally perforating rifle missile DETAIL OF THOMAS' SPLINT DRILL I. Warming (Rechauffement). On the word <2() SFKGERY XI. Suspension bar. On the word " Kleven." -The suspension bar is fitted to the stretcher with the "grip" away from the rackets. The splint is slung up three fingers' breadth from the horizontal part of the suspension bar. To damp down the side move- ments, lateral tapes are tied to the uprights. For the journey in the motor ambulance car an additional band may be passed from the splint round one handle of the stretcher. XII. Hot-water bottles and blankets. On the word "Twelve."—Hot-water bottles are applied. The third blanket is folded into two lengthwise and laid over the patient. The hanging folds of the first and second blankets are brought up over this so that the patient is evacuated with four folds of blanket on top as well as underneath. It was surprising how efficient the men became in the application of this splint, even if they had had but little training. As a matter of fact, the above technique could not be so methodically carried out in a shell hole, but tlie splint could be put on under almost any condition so that the wounded man could be moved back fairly comfortably to where proper adjustment could Fig. 69.—Cloth gaiter, applied over shoe for extension be made. The comfort of the patient was in direct ratio to the efficiencv of the application of the splint, and the task of the litter bearers was much easier if their patient was uncomplaining. Where there was an extensive wound of the thigh and hip the long Liston splint was applied in some cases and, while it was far from satisfactory, it was of value. For the knee-joint injuries and the upper leg fractures the Thomas splint was used almost exclusively, as it was found to be more com- fortable than the Cabot splint. The latter, however, was used to some extent in this group when there occurred a shortage of Thomas splints. As a rule, men with fractures of the lower extremity were in greater shock on arrival at the ambulance dressing station and required more care than did those with fractures of the upper extremity. The Cabot posterior wire splint was applied to fractures of the lower extremity occurring so far down the leg as to prevent applying traction to the foot without danger. The important points to be remembered in its use were ORTHOPEDIC SURGERY 621 the necessity for pressure pads behind the ankle and behind the knee and the additional use of lateral wire-ladder or board splints to more securelv fix the limb. OPERATIVE TREATMENT IN HOSPITALS AT THE FRONT As a rule every gunshot fracture was operated upon, with the exception of the through-and-through machine-gun bullet wounds in which there was little comminution of the bone. The operation (debridement, necessarily included attention to the soft parts as well as to the bone. Since debridement of the soft parts has been given full consideration in Chapter XI of the volume on general surgery no further mention of it will be made here. When cases of gunshot fracture reached those advance hospitals in which it was possible to do aseptic surgery, thev were inspected as to their gen- eral condition and as to the condition of their wounds. Patients in bad gen- eral condition were sent to resuscitation wards until their condition permit- ted proper surgical treatment. An almost invariable prelude to any operative intervention was an X-ray examination. The extent of operative treatment of the fractured bone was contingent upon the presence or absence of infection. Penetration of the diaphysis was usually considered as giving rise to infection of the medullary canal, thus necessitating laying open and exploring it. Detached bony fragments were invariably removed; such fragments are foreign bodies, and if left, necrose in the presence of infection, thus leading to troublesome subsequent bone fistuhe. [n the event it was expedient to remove fragments that were still attached to the periosteum, to effect the necessary exploration and cleansing of the medullary canal, these fragments were so removed as to leave the periosteum intact to insure future osteogenesis. It was the almost invariable rule not to close, by primary suture, any compound fracture wounds in the hospitals at the front, in view of the fact that patients so injured necessarily had to be evacuated at the earliest possible time and therefore could not remain under the observation of the surgeons orig- inally treating them. Usually, Dakin tubes were inserted and dressings applied, whereupon the patients were turned over to splint teams whose duty it was to make proper alignment of the fractures and to apply permanently the necessary splints. Since sepsis was met more commonly in compound fracture cases in the base hospitals, the treatment of this complication is given subsequent considera- tion in connection with the later treatment of compound fractures. FIXATION TREATMENT IN MOBILE AND EVACUATION HOSPITALS The splints for the treatment of fractures in mobile and evacuation hospi- tals, while necessarily embodying principles which would effect fixation and trac- tion, according to the necessity of the case, nevertheless, because of the transitory stav of patients in these hospitals, inevitably had to conform to the restrictions imposed bv the necessity of transporting the patients farther to the rear; that is to saw the splints must be few in number; they must be speedily and rapidly applicable so as to make immediate transportation possible. To this end ()22 SURGERY hospitals.1 Familiarize yourself with the exact number of each splint and splint accessory now in the hospital necessary to carry on the work. Check up with the following list and have the commanding officer requisition the splints not on hand. List of Sim.ixts, Splint Accessories and Dressings for an Evacuation Hospital 1,000 Beds Splints: Open-bite intermaxillary splint_______________ ------- -- 20 Snowshoe litters_____________________... __________ ------ 10 Hinged modification of Thomas arm splint- ___________ ---------- 100 Thomas traction leg splint______________________________ ---------- 12") Hinged half-ring modification of Thomas leg splint________________________ 100 Cabot posterior wire splint____________________________________________ 200 Wire-ladder splint______________________________________ 400 Long interrupted Liston splint________________________ __. _ ______ 15 Splint wood, 3 feet_________________________________ 200 Splint wood, 4 feet_________________________________ . _ _____ 200 Galvanized net cone gauze_______________ _ _____ ___ 20 Splint rests, wire_______________________ _____ ___ 300 Stretcher bars_________________________________ . _______ 50 Foot supports, wire____________________________ _ __ ______ 300 Wrist and hand splint________ ____________________________________ 150 Splint accessories: Safety pins, l^-inch, gross________________________________________ 10 Safety pins, 2)4-inch, gross_________________________________________ 6 Straps and buckles, 13^-inch by 5 feet_______________________ _________ 300 Straps and buckles, l^-inch by 6 feet__________________________________ 300 Slings----------- ------------------------------------------------- j^ 000 Canvas hammocks________________________________ _____________ 10 Plaster of Paris, cans_______ ____________________ 5 Jackinette, meters__________ _____________________ 10 Adhesive plaster, Z. O______________________________ 20 Sheet wadding, 5-inch by 5 yards, rolls________________ ________________ 500 Stockinette, sizes 1, 2, and 3, of each___________________ 1 Crinoline, bolts__ ____________ ______________ 10 Felt, yards____________________________________ 500 Supporting slings, 8 by 21 inches_____________________ 500 Supporting slings, 5C£ by 16 inches_______________________ 800 Supporting slings, 25 by 7 inches______________________ 500 Rubber cloth supporting slings, S by 24 inches______ 400 Rubber cloth supporting slings, 5% by 16 inches____ _ 400 Glue, resin, and turpentine, liters____________ 2 Glue, Sinclair's, cakes__________ ________ 2 Dressings: Gauze rolls__________________________ , qqq Sponges or wipes, 2 by 2% inches, packages . _ _ { Q00 Spouses or wipes, 4 by 4y2 inches, packages_______________________ l' 000 Absorbent pads_______ -' nnn Paper-back bed pads, size 1, 10 by 18 inches_________ 3 Q00 Paper-back bed pads, size 2,18 by 25 inches_______________"___"" 3' 000 Bandages, 4 inches by 5 yards, muslin____________________ ' 50q Bandages, 5 inches by 5 yards, muslin__________________ 500 Bandages, 6 inches by 5 yards, muslin__________________ 50o Gauze bandage, 1 size_________________ o m(1 Gauze, plain, yards___ __________________ ~ .„' m Scultetus bandages________________________ 'mn Jacket, pneumonia________________________ 1fl Absorbent cotton rolls, pounds_____________________ _______ onn ORTHOPEDIC SURGERY 623 2. keep this supply always on hand, by requisition on advance medical supplv depot or on emergency depot of your area. 3. Establish special splint depot for your hospital either in tent or room, as seems best, where splints are always under your control and ready for use. 4. Keep operating room adequately supplied with splints and splint accessories, so that they may always be ready for immediate use. 5. As soon as operation has been finished and dressings applied have your splint team immediately apply proper splint. Y'ou will be held responsible for the proper splint of each case. 6. Supervise the splinting of each case in the wards and see that the apparatus is in proper order at all times during the patients' stay in the hospital. 7. At time of evacuation see that all apparatus is properly adjusted so that it will effec- tually stand transportation. 8. Establish an exchange bureau at receiving ward where ambulance driver may receive a splint for the one left on patient. All ambulance drivers are required to obtain splints, stretchers, and blankets to replace those they have left with the wounded. Satisfactory fixation can not be obtained unless the splinting material used extends well above and well below the lesion. The fixation splints used in these hospitals were the snowshoe litter, the long Liston splint, Cabot pos- terior wire, and such fixation material as board splints, wrist and hand splint, and wire-ladder splinting. In certain exceptional instances plaster-of-Paris casts and shells. Wherever possible traction splints were to be used. For example, in frac- tures of all long bones and in war injuries to the knee and elbow joint. The traction splints recommended for use in these hospitals were: The hinged traction arm splint; Thomas traction thigh and leg splint; hinged half- ring thigh and leg splint. Traction was obtained by means of adhesive material fastened to the skin. Zinc oxide adhesive was provided for this purpose and was used preferably in fractures of the upper extremity. The adhesive bands were so applied as to avoid constriction of the limb. The strips were tied to the end of the splint and further traction made by the use of a small piece of wood or nail in the manner of a Spanish windlass. Many surgeons preferred to use a glue applied to the leg with a brush, the last stroke of the brush being upwards in the direction opposite to the growth of the hair. Extension strips of unbleached muslin were used for this purpose. Two types of glue were provided-Sinclair's, and resin and turpentine, per- mitting traction to be made within five minutes after the application. Sin- clair's glue consists of best cabinetmaker's glue, 50 parts; water, 50 parts; glycerine, 2 parts; calcium chloride, 2 parts; thymol, 1 part. This glue should be heated in a water bath at a temperature of about 100° F. before using. The addition of sufficient bicarbonate of soda will slightly alkalinize the reaction. The resin and turpentine glue consists of resin, 50 parts; alcohol, 50 parts; ben- zine (pure), 50 parts; Venice turpentine, 5 parts. Powder the resin, then add half the alcohol, then the Venice turpentine and benzine, washing the measure into the bottle with the remaining alcohol. This glue may be removed with alcohol or ether. The bottle containing the glue should be kept tightly stoppered else the proportions of the constituents mav change, and the glue become irritating to the skin. This glue does not require heating before use, and should not be applied too thickly. 41!. 1.17—27----42 024 SURGERY TREATMENT IN BASE HOSPITALS Because it frequently was necessary to move patients from base hospitals farther to the rear, or even to the United States, their transient status had to be kept constantly in mind, in so far as fracture treatment was concerned. Therefore, the principles used in the treatment of fractures for transportation always had to be borne in mind and the necessary apparatus maintained to carry them out. Fig. 70.—Fracture ward, Base Hospital No. 41, St. Denis, Paris In addition, however, more permanent apparatus was provided for fracture cases which remained in the hospital for the greater part of their treatment and convalescence. This apparatus included the following articles:1 List of Si-lints, Si-lint Accessories, and Dressings for a Base Hosi-ital of 1,000 Beds Splints: Open-bite intermaxillary splint_____ Hand and wrist splint_____________________ Thomas arm splint__________________________ Hinged modification of Thomas arm splint______ Jones humerus traction arm splint (right)____ Jones humerus traction arm splint (left)_____ Thomas traction leg splint____________________ Anterior thigh and leg splint, Hodgen type (right) Anterior thigh and leg splint, Hodgen type (left) _. Wire-ladder splint___________________________ Cabot posterior wire splint.__________________ 100 100 lot) 50 50 100 50 ORTHOPKDIC Sf HGKRY 625 Splints—Continued. Jones cock-up crab splint________ __ .__..... 50 Splint wood, 3 feet- __________________ ____ ._._..._. 100 Splint wood, 4 feet____________________ 100 Maddox frame tubing, 33^-foot lengths____ .________ 100 Maddox frame tubing, S-foot lengths______ _____ ___ 100 Maddox clamps______ . _.__________ _ 300 Special clamps______________________ 300 Balkan frame, complete with poles____ __ 150 Screws for Balkan frames_____________ _ _.._..__ 400 Strap-iron hooks for Balkan frames.. __ 200 Small iron pulleys________________ __ 200 Paper clips____________________ _ 500 Sash cord, size J/g-inch, feet________ __ . _ 200 Sash cord, size fV-inch, feet______ 200 Galvanized net cone gauze. ___ 10 Weight bag container______ 300 Buckshot bags, filled 250 grams _ . 200 Buckshot bags, filled 500 grams__ 200 Tool outfit____________________ 1 Nut wrench for Maddox frame_____ __ 2 Ice tongs______ ________ _.....— 5 Splint rest, wire_____________ —. _ . — 100 Foot support, wire_________ ---- 100 Splint accessories: Safety pins, lj^-inch, gross____ __ . _ _ ._....-.---- 10 Safety pins, 234-inch, gross_____ __ _ 0 Straps and buckles, l^_j inches by 6 feet. _ . — 100 Straps and buckles, 1^ inches by 3 feet--- 100 Slings. __________________________ -- 250 Elbow traction bands____ — ........ 50 Canvas hammocks______ ttl Plaster of Paris, cans_______ 20 Bandages for plaster________ ;>M Jackinette, meters____----- 10 Sphagnum moss pads, 7 by 11 inches . _ .__ 400 Sphagnum moss pads, 14 by 20 inches. .. . _----- 400 Heel rings________ w< Canvas swathes____________ •'" Adhesive plaster, zinc oxide._ 20 Sheet wadding, 5 inches by 5 yards, rolls 500 Stockinette, size 1, 2, and 3, of each--- 2 Crinoline, bolts________________ 1" Felt, yards______ ---------- 10 Supporting slings, S by 21 inches. -*00 Supporting slings, 5^ by 16 inches 500 Supporting slings, 23 by 6 inches_. 200 Rubber cloth supporting slings, 5^ by 16 inches. 200 Rubber cloth supporting slings, S by 24 inches 200 Glue, resin and turpentine, liters. _ 3 Glue, Sinclair's, cakes Dressings: Gauze roils___ ____ 300 Sponges or wipes, 6 by 2H inches, packages. 500 Sponges or wipes, 4 by 4lA inches, packages 500 Paper-back bed pads, size 1, 10 by IS inches 2, 000 626 SURGKRY Dressings—Continued. Paper-back bed pads, size 2, IS by 23 inche: Bandages, 4 inches by 5 yards________ _. Bandages, 5 inches by 5 yards___________ Bandages, 6 inches by 5 yards___________ Gauze bandages, 1 size________. _ 2,000 1,000 1, 000 1,000 1,000 Fig. 71.—Treatment of fractured humerus UPPER EXTREMITY To successfully transport a patient with fractured humerus back to a base hospital, the hinged traction arm splint was generally preferred because it allowed the arm to come down to the side of the body, thus facilitating the transfer; however, many patients reached the base hospitals in straight arm splints and in Jones traction arm splints. Efforts were made to maintain the length of the humerus even though a section of the bone had been removed, as it was found that new bone often formed to bridge such a gap, especiallv when any periosteum remained. ORTHOPEDIC SURGERY 627 Fig. 72.—Compound, comminuted fracture involving shoulder joint. Arm abducted; hand semisupinated 628 4RGERY Fig. 73.-Compound, comminuted fracture involving shoulder joint. Cast in position of abduction: hand supinated. Note windows cut for dressing and pelvic support ORTHOPEDIC SURGERY 629 \Mien a man with a fractured humerus arrived at the base hospital, the apposition of the fragments was considered. Up to this time, most of the attention had been centered on the control of sepsis, extension and fixation had been used to approximate the fragments as nearly as possible and to make the transportation of the patient as comfortable as could be. The case was X-rayed as soon as possible; better drainage was instituted if necessary, and attention was given to approximation of the fragments. In fractures of the upper third the arm was abducted, and if the patient had come back in a hinged Thomas splint, this usually was removed and a Thomas humerus traction splint applied. It was noted that often the arm was left extended at the elbow for too long a time, resulting in difficulty in getting flexion at the joint after the fracture had healed. It was also noted that too much abduction was maintained in some cases, but this produced no disability. In cases where the head of the humerus and the shoulder joint were involved abduction of about 4f)°, with traction, was maintained with the forearm in supination, as this is the best position in ankylosis. When the arm was fractured in the middle third, it was extended with traction and the forearm placed in about two-thirds supination. In the lower third, flexion of the elbow to a right angle with the forearm in complete supination, with traction on the forearm, was the most favorable position in which to maintain apposition. The Jones humerus trac- tion splint was most adaptable for this type. The arm was suspended by means of the Balkan frame in practically all of the cases. This suspension added to the patients' comfort and facilitated irrigating and dressing the wounds. Con- tinuous irrigation by the Carrel-Dakin method was used in most of the badly infected cases. The results were entirely satisfactory where it was possible to maintain the proper technique. The management of the sepsis often required additional drainage and the removal of sequestra. In other words, the osteomyelitis had to be treated. In some cases, too much operating was done with the result that the infection was spread into new areas and septicemia developed. It was found that the better policy was to allow the condition to become subacute and to wait until the sequestra had become loose before attempting their removal. After union had occurred in the cases of fracture of the upper third of the humerus, it was the custom to get the patients up and out of bed. This neces- sitated putting the fracture up in some form of ambulatory abduction splint. Inasmuch as very few airplane splints were available, it was necessary for orthopedic surgeons to devise and manufacture their splints, thus resulting in the use of about every kind and type that provided flexion at the elbow and extension of the abducted upper arm. Most of the hospital centers in the American Expeditionary Forces developed some kind of an orthopedic shop for making the needed accessories in the splint line. Manv cases required special splints that were not available on requisition and these also were made in the special shops. Forearm, '\Yrist, and Hand Compound fractures of the forearm presented great difficulty in their treatment. In fracture of both bones, on account of the usual comminution and projection of bone splinters into the soft tissues, cross union or callus 630 SURGERY interference frequently occurred; moreover, adequate drainage was difficult to maintain, owing to the numerous muscles and tendons. Kxtensive sloughing of tendons caused lamentable loss of function in several cases. It was important to maintain traction in fractures of the radius and ulna even when only one bone was broken, especially was this true in fractures of the lower portion of the radius as mesial deviation of the hand with marked loss of function occurred if the radius shortened. Usually the Jones humerus traction splint .vas applied in these cases, the traction being maintained by tying the adhesive strips to the end of the splint. These cases were evacuated early and after they reached the base hospital further extension was made by applying trac- tion to the splint by means of a weight and pulley after the splint was suspended. Fig. 74.—Method of treatment of fracture of both bones of forearm I hey were treated as bed cases until after the infection had been controlled In many instances, the hinged arm splint or the Thomas traction arm splint, when bent to a right angle at the elbow was well adapted to these cases. The hand was completely supinated in a large percentage of the cases treated. Uien partial union had taken place it was usually not necessary to change the type of splint m order to allow the patients to become ambulatorv. The chief difficulty encountered was maintaining traction; if the wound extended to the lower third of the forearm there was verv little room to apply adhesive tape; owing to circulatory conditions it was not possible to apply a bandage tightly to the wrist. To secure needed traction, Sinclair's method of gluing a cotton glove to the hand was verv satisfactory when used- also it was possible to secure considerable extension by applying strips of adhesive ORTHOPEDIC SURGERY 631 lompound comminuted fracture, carpal and metacarpal bones, showing banjo splint with traction of *ers and molded palm. Plaster splint fitted to palm of hand with moderate dorsal flexion of wrist 632 SURGERY tape to the fingers and tying the ends to the splint, due care being taken, just as with the glove, to equalize the pull on the fingers. Marked swelling of the soft parts was frequent, but very few cases of ischemic paralysis resulted, probably due to the fact that the wounds prevented destructive pressure on the muscle tissue. Frequent drainage operations were necessary but fewer operations for sequestra were required, as compared with other bones. Fractures involving the bones of the wrist and hand frequently were kept for too long a time in straight splints and often when the Jones "cock-up" splint was used, the fingers became stiff in extension. The reason for this is obvious. These injuries were not serious as to life and the surgeon's atten- tion was centered on the important cases. This condition, however, required much effort in the readjustment, such as dorsi-flexing the wrist and mobilizing the wrist and fingers. Fig. 76.—Application of finger splint, showing extension applied LOWER EXTREMITY Gunshot wounds of the femur were among the most fatal injuries that were dealt with in the war. A simple fracture of the femur occurring in civil practice is even more serious than it is usually considered, and often is difficult to bring to a successful result. If one stops to consider the problem of the management, in all its many phases, of a compound fracture of the femur as presented by modern warfare, it is remarkable that the mortality, while exceed- ingly high, was not higher. The most practical lesson taught by the World War in the management of fractures is to be gained by a study of the manage- ment of compound fracture of femurs. The British have estimated that the mortality from femur fractures including complicated cases was between 40 and 50 per cent in 1914-15 and in 1918 between 20 and 30 per cent, including all cases, and that in the uncomplicated fractures, treated bv the most modern methods the mortality was not more than 15 per cent,2 ' This change was brought about by improvement in their methods of first aid, operating, splint- ing, nursing, and after care, of which we were able to take full advantage, for, of the 3.367 men who had fractured femurs in the World War, 917 died, thus giving a mortality of 27.23 per cent.3 ORTHOPEDIC SURGERY 633 When the fractured femur cases were received at a base hospital, it was always a problem to get them properly adjusted, the cases required immediate change of dressings and such adjustments as would permit them to rest, as they were usually worn out from the journey and had the same dressings on that they started out with. The following extract from the report of the orthopedic consultant at Mesves Hospital Center to the chief orthopedic con- sultant, A. E. F., is quoted as an example of how the work was planned there: 4 The admission of fracture and joint cases was so great during the month of October that it became necessary to establish 16 fracture wards in the various hospitals. Owing to the fact that it was necessary to change the dressings on all these cases on admission, it was Fig. 77.—Balkan frame, showing suspension apparatus. Thomas splint impossible for the ward surgeon to adjust splints, erect Balkan frames, and apply extensions. Splint teams were organized, consisting of 1 medical officer, 1 sergeant, and 1 private. As soon as the ward began receiving patients, this team was sent in to erect frames and suspend the cases. Usually this could be done for all the urgent cases in a day. The ward surgeons could easily change the dressings on 52 cases in a half day if all were properly suspended. This allowed him the remainder of the day for the adjustment of apparatus. The industrious medical officer was able to make all of his patients comfortable and secure good alignment under this regime. It was also possible to control sepsis and our records show that the mortalitv of fractured femurs among our later cases was very low indeed. The rate in our hrst cases was rather high for the reason that the cases became thoroughly septic before we could arrange to handle them properly. The mortality among all cases was about 17 per cent. 634 SURGERY Practically all of the cases of fractured femurs came hack from the triage and evacuation hospitals in Thomas splints. After they had been received and examined at the base hospitals, it was often found that the Hodgen splint was better adapted for cases with wounds high up on the thigh or in the groin and consequently the Thomas splint was removed and the Hodgen splint applied. Very few long Liston splints were used and it was quite noticeable in many of the base hospitals that as the work progressed there were fewer and fewer attempts made to devise any new form of splinting and a greater tendency to use the Thomas splint exclusively. In cases where a Hodgen splint was indi- cated it was not uncommon to find that the medical officer had bent a Thomas half-ring splint at the knee and applied it upside down with the one-half ring anterior instead of posterior. No elaborate plans were used in connection with the splinting other than suspension by means of the Balkan frame. A few cases, however, with buttock and back wounds, were very difficult to manage. In these cases an effort was made to have the patient persist in pul- ling himself up off the bed by grasping with his hands a bar that was suspended from the top of the Balkan frame, and if he was able to do this, the changing of the dressings on the wounds was much easier for him. The position of the leg in fractured femurs varied of course with the loca- tion of the fracture. In the upper third, traction, nearly complete abduction and external rotation of considerable degree was insisted upon with the leg in suspension. Until these cases reached a base hospital no special effort had been made to secure apposition of the fragments, the care having been divided between prevention of sepsis and immobilization for the purpose of comfort during transportation. During the first few weeks after our casualties began coming in there was a tendency among some of the surgeons at the hospital to continue to ignore position and to wait for an improvement in the sepsis before attempting improvement in the alignment. It was found out rather early that securing and maintaining the best possible apposition was the best possible treatment for the sepsis. This was shown to be true in many instances and the probable explanation is that when full length of the leg is secured, with only moderate or no displacement, the sheaths of the muscles are taut and the muscle bundles are in normal relation so that there is less opportunity for pus to burrow along the muscle and thus infect new areas. The observation was repeatedly made that the infection extended along the fascial planes in the limb. Advantage of this fact was taken by changing the position of elevation in the badly infected cases, so that the pus would not gravitate down these planes. In fractures of the middle third of the femur, great difficulty was experienced in getting the ward surgeon to maintain sufficient outward rotation. The position of 30 to 35 degrees of outward rotation is necessary to secure apposition on account of the fact that the external rotators of the thigh pro- duce nearly complete outward rotation of the upper fragments. It was also necessary repeatedly to insist upon the normal anterior curve of the femur being exaggerated in order to prevent posterior bowing which gives raise to disability. Slight flexion of the knee and thigh was also insisted upon. Many ORTHOPEDIC SURGERY 635 Fig. 7S.—Fracture of femur, showing double extension. Inverted Hodgen splint 636 SURGERY devices were used to prevent lateral bowing which in some cases was difficult to overcome in fractures above the lower third. Fractures of the lower third of the femur were very trying, and we did not really succeed well with them until after the beginning of the use of skeletal traction bv Pearson's modification of the Besley "ice tongs." It is practically impossible to secure apposition in this type of fracture without 70 or more degrees of flexion at the knee, and it is then very difficult to apply any kind of skin traction.2 In the comparatively few cases in which the "ice tongs" were used, the results were most satisfactory. In the early spring of 1919, after some of our medical officers who had been detailed for service with the British were returned to the American Expedition- ary Forces, a number of compound fractures of the lower third of the femur were treated with tongs. In this series no bad effects were noted. and when the tongs were properly applied the patients were entirely comfortable, it being necessary only occasionally to remove and reapply them. The treatment of compound frac- ture of the head and neck of the femur, on the whole, was rather discouraging. Many of these cases were complicated by injuries to pelvic viscera and pelvic bones, and as a result offered very little from the treatment stand- point. They were difficult to care for and often it was not possible to make them entirely comfortable. Usually they were treated in abduc- tion with the Thomas splint, or some modification of it for support. A plaster of Paris spica was always preferred but, on account of the wounds and suppuration, it could rarely be used. The head and neck of the femur were observed to have very little resistance to infection. A through-and-through bullet wound of the head or neck, with no comminution or displacement. and with but little or no apparent infection, would often result in complete destruction of these parts. Abscesses would form in the pelvis in this group of cases, and because the}' were detected with difficulty amputation was fre- quently necessary. It was found that these abscesses could be drained success- fully by following the ilium. Many of these cases that were very septic would finally make good recovery, with healing of all the sinuses. Very few secondary closures were attempted in compound fractures of any kind, either after the primary operation or after the sequestrotomy. How- ever, experience indicated that under proper conditions a technique could be Fig. 79.—Pelvic lifter ORTHOPEDIC SURGERY 637 perfected that would permit secondary closure in a large percentage of compound fractures. A report of the fracture work in Base Hospital Xo. 27, Angers, France, which was made to the chief consultant in orthopedic surgery at the time the hospital practically finished its work is quoted in full:5 On July 16. 1918, following the return of the orthopedic surgeon to the hospital, the orthopedic department was made separate from the surgical, and so remained for a period of four montlis, during which time most of the casualties from the front were received. The department expanded rapidly in size, due to the influx of wounded with compound fractures, Fig. 80.—Method of using pelvic lifter necessitating a corresponding enlargement of bed space on the third floor of the main build- ing where the fracture cases had previously been quartered as a part of the surgical service. The first large convov of fracture cases arrived July 21, 1918, and as these were preoperative and from three to five davs from date of wounding, their condition was unfavorable and necessitated extensive and radical operations. Subsequently, many large convoys were received but none in which the majority of cases had not already been operated. The total number 'of occupied fracture beds rose from 80 on July 15, 191S, to about 250 by the middle of \ugust and over 300 in September. Likewise, the routine orthopedic cases, now being retained for treatment, averaged about 100 in this hospital, and considerably more in the hospital annex Aside from these two general types of cases, there was also handled by tin department mostlv through individual consultations by the chief orthopedist, a large proportion of surgical wounded presenting conditions threatening deformity, or functional 638 SURGERY derangement, many of which eases were later transferred to the orthopedic service for treat- ment. The gravity of the cases with fractures and joint wounds, and the demands upon the personnel for their care, soon centralized the department around these cases, and necessitated a change in the fracture wards to a location in the hospital offering more convenience and elasticity for expansion. The fracture service was therefore moved about the middle of August from the third floor of the main building to four connected wards in the principal group of ward barracks, from which as a nucleus the increasing demand for bed space could be met. From the first, attention was put on the simplification and standardization of methods and technique in handling these cases, to insure rapidity in completely caring for each case on admission of a large convoy and for uniformity of treatment throughout. Definite rules and routine were worked out for the management of cases on admission and discharge and for their mechanical and surgical treatment. With the use of standard splints and apparatus, the suspension technique of Blake was modified principally with a view to less complexity of weights and pulleys, all weights being carried to the head of the bed and the trolley suspension abolished. For the arm a right-angled traction bar, attached to the Balkan frame, was designed to take the place of the bed board and found satisfactory. Extrinsic traction, by weight and pulley, was employed in most cases, though the intrinsic method in the Thomas splint, with the splint attached to the running weight, was used in some. This standardized apparatus could be put up rapidly by trained orderlies, allowing the medical personnel freedom to meet the surgical conditions presented by the new cases, the correction of the mechanics to the individual condition following the bedside X-ray examination, after the patient had been suspended,. During the first few weeks of this four-months period, great effort was made to elaborate the mechanics in special cases, where unusual bone deformities presented as in fractures of the femur, near hip and knee, and in fractures of the humerus. Much of this was omitted following the adoption of more routine apparatus, being also coincident with the receipt of orders hastening the evacuation of all cases which could not regain "A" class in a reasonably short period. All efforts of the department, therefore, were directed toward preparing cases for early evacuation, and the splinting was correspondingly modified to better meet the demands of transport. The Thomas leg splint almost entirely superseded the Hodgen, while flexion of the knee and flexion and abduction of the hip were limited to 30 degrees. An arbitrary time limit of two months was put on all cases in the orthopedic department, as the maximum allowed patients to regain combat fitness so that practically all fractures and joint wounds were considered cases for evacuation from the day of their admission, and the principal attention of the personnel was directed toward the surgical cleansing of the wound (Carrel-Dakin method being employed throughout). It was, therefore, natural that the operative treatment should be largely confined to combating infection, about 100 operations for the establishment of drainage, removal of foreign bodies and devitalized tissue being performed in this four-months period, as compared with 15 secondary sutures. Despite the fact that during the first month many fracture cases were kept for complete consolidation and the return of function, the average length of stay in the hospital for all fractures was six weeks. The following figures give the number of fractures of each region with the average length of stay in the hospital for the four months, July 15 to November 15, 1918: Region Number Average stay ORTHOPEDIC SURGERY 639 Tibia and Fibula It was stated above that the Thomas splint, or its half-ring modification, was used for the first-aid splinting of fractures of the upper two-thirds of the tibia and fibula and the Cabot splint for fractures of the lower third, ankle, and foot. This rule also obtained after the primary operation had been per- formed at the advance operating station. Extension was made by adhesive strips for the upper leg fractures and very little difficulty was encountered in maintaining sufficient traction in this group of cases. However, in the lower third fractures it was extremely difficult to secure sufficient traction and many methods were used. Strapping or gluing a board to the sole of the foot after the method suggested by Sinclair was probably the most satisfactory, as it was found the rotation of the foot could better be controlled by this plan. In Fig. 81.—Bridge transportation splint for fracture of tibia all fractures of the lower extremity an attempt was made to keep the foot at right angles to the leg by applying a strip of adhesive plaster to the sole of the foot and attaching it to the overhead bars of the Balkan frame. Applying a cast to the foot and then making traction over the cast was not at all satis- factory, as it was found that pressure necrosis occurred on the dorsum of the foot in a large number of cases. The use of the ice tongs applied to the os calcis was satisfactory; no bad effects were noted. On the other hand, where a Steinman pin was passed through the os calcis, troublesome osteomyelitis often developed. Compound fractures of the upper third of the tibia extending into the knee-joint were always serious, and many amputations were done for this type of fracture. In many cases a prolonged attempt to save the leg resulted in loss of the patient. 4(.9!)7^27----43 640 SURGERY In fractures of the middle third, posterior sagging of the tibia too often occurred. This deformity leads to permanent disability of considerable degree. and is of greater inconvenience to the patient than shortening or outward Fig. 82.—Delbet plaster splint for fracture of tibia bowing. Internal bowing is also disabling on account of the strain produced on the ankle and foot. This deformity, however, occurred more frequently in Fig. 83.—Plaster splint for fracture of tibia, permitting mobilization of ankle the lower third fractures of the tibia. Nonunion was of greater frequency in the tibia than in any other bone. Compound fractures of the fibula alone seldom occurred and offered no particular problem when encountered. Usually the fracture of both bones ORTHOPEDIC SURGERY 641 was at the same level and the treatment of the fibula was incidental to the tibia. Nonunion of the fibula in the upper lower third and middle third produced but little if any disability and seldom if ever occurred in any other region of the bone. Fig. 84.—Bridge plaster splint for fracture of tarsal bones Compound fractures of the tibia and fibula required protection from weight bearing for a long period of time, and this fact no doubt contributed to nonunion. The walking caliper splint was not as effective in protecting these bones as it was in the femur, and no entirely satisfactory plan was worked out, probably the Delbet plaster splint being the best method tried. 642 SURGERY Tarsal Bones Fractures of the tarsal bones were often extensive. The Cabot splint was admirably adapted for the treatment of these cases. The infection was difficult to control owing to the extensive swelling that accompanied these injuries, with resulting interference with the blood supply. A diseased tarsal bone would seldom regenerate and, as a rule, it would become a sequestrum and be extruded as a whole. Fortunately, the ankle joint rarely became completely ankylosed and where some motion remained the stiffness of the foot was partially accommodated for. In tarsal bone fractures, as well as in carpal bone fractures, the Carrel- Dakin method of irrigation was not as satisfactory as it was in fractures of the long bones, due to the fact that free drainage of the infected area was not so readily obtained. Late amputation was more frequent in the tarsal fractures than in any other group of cases. This condition resulted from the fact that so much destruction occurred before the infection was controlled that the function of the foot was interfered with to such an extent that an amputation was to be preferred. In the hand injuries, the reverse was true, as almost any portion of the hand and fingers that could be saved was of more value than any artificial hand that has ever been devised. REFERENCES (1) Based on Sick and Wounded Reports made to the Surgeon General. (2) Manual of Splints and Appliances for the Use of the Medical Department of the U. S. Army, 1918. Second Edition. Printed by the American Red Cross, Paris, 1918. (3) Annual Report of the Surgeon General, U. S. Army, 1920, 277. 4) History of the Mesves Hospital Center, Part II. On file, Historical Division, S. G. O. 5) History of Base Hospital No. 27 (Hospital Center, Angers, France). On file, Historical Division, S. G. O. CHAPTER IV ORTHOPEDIC SURGERY IN EMBARKATION HOSPITALS, A. E. F.° The experience of those of our orthopedic surgeons who served first in Great Britain and then in France showed that the problem of dealing with the war wounded from the orthopedic standpoint was somewhat as follows: In general these cases were fractures, both simple and compound; joint injuries; peripheral nerve and spinal cord injuries: soft-part injuries, with tendency toward contracture deformity; static disabilities of the trunk and extremities (spine, sacroiliac, feet, etc.); amputations; and the making and application of all splints, braces, and prosthetic devices. Wounded soldiers returning from the front (either directly or through evacuation hospitals) early began to give evidence of the need of orthopedic treatment. Even the early convoys to the United States showed that more careful splinting and preparation of the patients otherwise than as had been done would be necessary if the American wounded were to be properly trans- ported from France to the United States. Accordingly, the organization of the orthopedic service in base hospitals was thoroughly arranged during the summer of 1918, with the following objects in mind: (1) To treat surgically, splint, and otherwise deal promptly with those who could soon be returned to duty as class A or B. (2) To prepare as many of the class D patients as pos- sible for early, safe, and comfortable transportation to the United States. (3) To arrange suitable hospital facilities and care for serious cases that must be treated and their reconstruction begun in France. Most of the American wounded who belonged in the first group were returned to duty without comimg to base hospitals at all. A considerable number, however, with strains, dislocations, fractures, sacroiliac injuries, weak foot, flat foot, and even minor amputations, came to base hospitals and were discharged to duty after a few weeks' treatment. Patients in the second group for whom it was desirable to arrange transfer to the United States as soon as possible, presented a large and difficult problem. It was found that patients arriving at base hospitals were often in poor surgical condition as regards drainage, position, and immobilization. It became the special duty of the orthopedic consultant to locate and deal with these patients before convoy lists for evacuation to the United States could be made up. At the Savenay hospital center (Base Hospitals Nos. 8, 69, 88, etc.) and more or less throughout Base Section No. 1 (Base Hospital No. 101, at St. Nazaire; Xos. 11, 34, and 38, at Nantes; No. 27, at Angers) the plan worked out for dealincr with these cases was as follows: (1) Cataloguing and inspection every orthopedic patient as he entered the hospital. (2) The written opinion of a The data in this chapter are based on The History of the Hospital Center, Savenay. Part II, 9.-146. Onfile; Historical Division, S. O. O. fi . „ (H4 SURCKRY every medical officer as to the patients that he saw. .3) Centralized operating, splint, and plaster-of-Paris rooms to which patients were brought for treatment. (4) A card-index catalogue, with a follow-up system by which recommendations made by medical officers were checked up and controlled until the patient was pronounced fit for transfer. The first centralized splint room, established at Base Hospital No. S, Savenay, about September 1, 1918, proved one of the most helpful features. In the course of a few days it reached a capacity of from 30 to 50 patients daily. Much has been said and written about the use of plaster of Paris in war injuries. The technique employed at Savenay was as follows: Wounds were carefully dressed, the entire extremity was covered with cotton wadding, and muslin or gauze bandage applied evenly and smoothly; then the plaster was put on firmly but not too tightly; large windows were cut over all open wounds and over patellas and heels; casts were not split. Plaster of Paris was used especially for fractures of the femur, leg, and upper arm. From September to December, 1918, about 1,000 plaster casts per month were put on and practically all sent to the United States. No complications as to casts were reported and in general the patients were found to have traveled safelv and comtortably. For patients who had to have manipulative correc- tion of deformity existing at the time of arrival at Savenay, plaster was the ideal splint because of the better immobilization and protection against motion irritation of injured and infected parts. The following circular letter indicates exactly how patients were to be cared for at Savenay during September, 1918, and later: From: The consultant in orthopedic surgery, Hospital Center, Savenay. To: All medical officers. In dealing with patients with bone and joint injuries, amputations, tendon injuries, or inflammations, soft-part injuries with contraction or impending deformity, spine injury, flat feet, etc., please observe the following points: 1. Medical officers will be supplied each morning with index cards containing for patients admitted during the past twenty-four hours, blanks for name, diagnosis, etc. Medical officers are to add to these cards by marking under the heading "Condition," whether the patient 1. Requires no splint; 2. Is wearing satisfactory splint; 3. Requires change of splint or operation; 4. Without splint but splint required. In case of "3" or "4" specify the patient's requirement under the heading of "Notes" or on the reverse of the slip. 2. Amputation cases are to be reported separately on special slips, or brought to the attention of the consultant by reporting patient's name and ward. 3. Under the heading "Diagnosis," the diagnosis number (as indicated on Special Diagnosis Table already furnished) is to be entered, e. g., 17 for GS\Y elbow joint. 4. The buff cards must be completed and turned in to the orthopedic office on the same day they are received. There must be no exception to the rule. 5. In the case of patients who are to be splinted in the wards the wardmaster's report is to be sent to the orthopedic office as soon as the application is finished. 6. If any patient requires operation recommendation for such operation must be sent to chief of surgical service, base hospital. The medical officer in charge of the ward will be notified as to the place, time, and by whom the operation is to be performed. Xo operation by any member of the orthopedic staff is to be arranged in any other way. ORTHOPEDIC SURGERY 645 t. Ambulatory patients requiring splints are to be referred to the splint room for the application of splints or plaster between the hours of 1.30 and 4.30 p. m. daily. All medical officers are requested to accompany and to apply splints and plaster to their own patients if they care to do so. Field medical cards should accompany patients so that proper entries can be made at the time treatment is given. 8. In sending in reports it should be specified in every case whether or not the patient must be detained in the hospital for treatment and if so, for what length of time. At Savenay the first special wards to be provided were those for fractures of the femur and for amputations. These were provided during September. The obvious advantages of this plan led to the approval of the commanding officer, early in October, of a larger plan, by means of which more than 1,400 beds were set aside in Base Hospital No. 8, with special wards for leg fractures below the knee (64 beds), gunshot wounds and fractures of the upper extremities (256 beds), gunshot fractures of the femur (196 beds), and amputation (250 beds). The following arbitrary diagnosis table was used to save writing out diag- noses in full: TABLE OF DIAGNOSIS 10. G. S. W. or other head injuries with 23. Fracture, pelvis, simple or G. S. W. paralysis. 24. Fracture, simple, hip. 11. G. S. W. neck with paralysis. 25. G. S. W. hip. 12. G. S. W. shoulder fracture (including 2t.. Fracture, femur, shaft. scapula and clavicle). 27. G. S. W. femur, shaft. 13. Fracture, simple shoulder (including 28. Fracture, simple, knee. scapula and clavicle). 29. G. S. W. knee. 14. Fracture, simple humerus. 30. Knee joint injury (not G. S. W. or frac- 15. G. S. W. Fracture humerus. ture). 16. Elbow injuries (not G. S. W.). 31. Sciatic, external popliteal or other nerve 17. G. S. W. elbow joint. injury, G. S. W. or otherwise. 18. Simple fracture, forearm or hand. 32. Fracture, leg, simple. 19. G. S. W. fracture forearm, wrist, and 33. Fracture, leg, G. S. W. hand. 34. G. S. W. and other injury, foot and 20. Median, musculospiral or ulna nerve ankle. injury. 35. Flat foot, foot strain, bunions, hallus 21. Spine disease or injury (not G. S. W.). rigidus, etc. 22. G. S. W. spine, with fracture. As a result of the experience in several thousands of cases the suggestions made in the following paragraphs were developed for practical use with just these points in mind and in the same order. HEAD INJURY^, WITH PARALYSIS Treatment required: Splinting to prevent drop-foot knee contractions, abduction, and flexion deformity of thigh. Splints required right-angle foot and leg splints, double or single plaster-of-Paris spica. The number of this class of cases was o per 1,000 total number of battle injuries in the given hospital. GUNSHOT WOUNDS OF THE NECK, WITH NERYE INJURY, ULNAR PARALYSIS (Musculospiral paralysis, ulnar paralysis, median paralysis, deltoid paralysis.) Splint required: Hand cock-up splint, airplane splint. In these conditions it is important to bear in mind that many of these nerve injuries 646 SURGERY are only partial and become complete in time through failure to splint early. If the necessary nerve and muscle tissues are conserved, during the entire period of convalescence, an entirely unexpected amount of function will be found to be present at the end of treatment. Failure to maintain in relaxation, muscles involved in even temporary paralysis, results in quite unnecessary permanent disability. One of the points to be constantly borne in mind in the splinting of war injuries is that it is necessary to protect against overstretching muscles or muscle groups for which the nerve supply has been temporarily or permanently cut off. This is of the greatest importance in cases which, within two or three months' time, require neuroplastic or tenoplastic operations. The number of this class of cases was 5 per 1,000 total number of battle injuries in the given hospital. GUNSHOT WOUNDS OF THE SHOULDER, WITH FRACTURE Immediately upon arrival at base hospitals either the airplane splint or a plaster-of-Paris jacket including the affected arm should be applied. In a con- siderable number of these cases, arthrodesis of the shoulder is the end to be sought. For this purpose, plaster of Paris is the ideal device. The upper arm should be at an angle of from 50° to 60° from the trunk, the arm carried well forward, the elbow at a right angle, the hand supinated and dorsally flexed. This position should be maintained from 12 to 16 weeks. This gives a very full range of motion for the upper arm and much earlier healing than treatment in any other splint. When preliminary healing with flail shoulder has been permitted arthrodesis of the shoulder should be sought by secondary surgical treatment along similar lines. The number of this class of cases was 5 per 1,000 total number of battle injuries in the given hospital. GUNSHOT WOUNDS OF THE UPPER ARM, WITH FRACTURE OF THE HUMERUS Practically all gunshot fractures of the humerus are received at base hospitals in the straight Jones splint, with the elbow straight and the hand pronated. For purposes of transportation and during the first two or three weeks following injury this splint has much to commend it. It is very com- monly poorly applied. Enough traction should be used to keep the ring firmly in the axilla and to contribute to the immobilization of the entire arm. Care must be taken to avoid the application of too much traction. Several cases have been seen in which 1 or 2 inches have been added to arms with humerus fractures by excessive traction in the splint. Not very much traction is necessary. Immediately upon arrival at a base hospital the straight splint should be removed and the elbow flexed with the hand supinated. The Jones humerus traction splint may be used as an ambulatory splint or with the patient in bed and the arm suspended. Often plaster of'Paris can be used to advantage. There was some disposition to question the propriety of flexing elbows in fractures of the lower third. It is especially important to do so however, even witli fractures in which the lower fragment can not be entirely controlled. Further modification of the arm at the point of callus is easier than if bony ankylosis of the elbow appears. The number of this class of cases was 75 per 1,000 total number of battle injuries in the given hospital. ORTHOPEDIC SURGERY 647 GUNSHOT WOUNDS OF THE ELBOW In general, the same remarks apply as for fracture of the humerus. It is important to remember that extremely serious damage to the elbow joint must be considered not as a contraindication to flexion, as has often been the case, but as an indication. Secondary surgery following complete ankylosis of the elbow is sometimes necessary to provide rotation of the forearm. This can be accomplished by removal of the head of the radius to a point below the orbicu- lar ligament. Various operations have been performed for mobilizing stiff elbows. In general, it may be said, however, that for most severe injuries of the elbow joint, ankylosis in the position of election has been proved superior to even the fairly successful mobilized elbow joint. The number of this class of cases was 50 per 1,000 total number of battle injuries in the given hospital. GUNSHOT WOUNDS OF THE FOREARM, WRIST, AND HAND, WITH FRACTURE For early treatment three principal considerations are essential: Immobili- zation, supination of the forearm, and dorsal flexion of the hand. This injury was one of the commonest fractures (200 per 1,000 total battle injuries in the given hospital) and one of the most difficult to care for. In old cases nonunion of the radius and ulna was rather common. Immobilization is the answer. No other splint is so satisfactory for the forearm as plaster of Paris. In wounds of the wrist and metacarpals a straight arm-and-hand splint was commonly used. This splint and the Jones full cock-up splint, except for very short periods, should be entirely discarded. The full cock-up position should be used, but with a splint which permits full flexion of the fingers. If there is a tendency toward contracture deformity of the fingers, they should be kept in the extended position a short time every day. GUNSHOT WOUNDS OF THE MEDIAN, MUSCULOSPIRAL, AND ULNAR NERVES The arm and forearm splints required are the same as in gunshot wound of the brachial plexus in the neck. Injuries to these nerves occur either inde- pendently or associated with fracture of the humerus. The nerve injury may also be complete division or only a partial division or contusion. The accom- panying paralysis in any case must always be splinted in the same way as long as it exists and until complete recovery results either spontaneously or following surgical treatment. Operative reunion of completely divided nerves can be un- dertaken on I v after some weeks of sound healing. The rule of the British was 6 to 12 weeks. It was also suggested by the British that 1 to 2 weeks' massage of the wound area as a preliminary to operation would serve to indicate whether or not operative trauma would be tolerated. Extensive loss of nerve tissue opens up also the question of tendon transference in these cases, as does also exten- sive loss of muscle tissue. Careful splinting after all operations and the best methods of electrotherapy, massage, and vocational therapy must all be employed, particularly in these cases, to obtain the best ultimate result. The number of this class of cases was So per 1,000 total number of battle injuries in the given hospital. 648 SURGERY GUNSHOT WOUNDS AND OTHER INJURIES OF THE SPINE The indications in either spine injuries or in secondary Pott's diseases (a few eases of which were seen) are usually for fixation, either in a plaster jacket or on a Bradford frame, for the transportation of these cases. By making use of the retaining straps on a rigid litter these patients can travel quite safely and comfortably. In very few of the cases seen was any immobilization or protection of any kind provided. In a few cases in which adequately early immobilization was used, early recovery from the paralytic symptoms was observed. Laminectomy must be done in carefully selected cases. The num- ber of this class of cases was 10 per 1,000 total battle injuries in the given hospital. GUNSHOT AND OTHER FRACTURES OF THE HIP Early and adequate splinting of gunshot fractures of the hip has yielded some of the most brilliant results in the treatment oi war conditions. The mortality has been greatly reduced for both transportation and treatment in base hospitals. No other single factor has contributed so much to the satisfac- tory results as the Thomas thigh traction splint. It is unfortunately true that the efficiency of the splinting has not always been maintained between the front lines and the hospitals farther back. The Thomas splint should be applied and cared for always in the same manner. The introduction of individual methods invariably leads to a loss of efficiency, as patients pass from the hands of one surgeon or hospital to another. The following points must be observed: A long splint and a well-fitting ring must be selected. It must be bent to an angle, of 10° to 15° at a point 1^ inches above the level of the knee joint. Having regard for wounds, the adhesive traction bands (of Sinclair glue or moleskin plaster) must include as much skin of the leg and thigh and extend as high as possible. The traction ropes for twisting attached to the lower end of the adhesive, should be of M-inch rope or of four-ply muslin fastened very securely into the adhesive, so that it will not give way under a pull of even 15 to 20 pounds. Muslin hammocks of not more than 4 inches in width should be placed across the splint for its entire length at a sufficient tension so that the leg rides well on the top of the splint. The splint is then put on and the traction strap is tied firmly over the lower end with the ring tight against the tuber- osities of the ischium. A right-angle foot piece is put on and the foot and knee bandaged in such a way as to put the entire extremity at rest in the splint. The twisting of the traction bands should have attention once or twice daily. The lower end of the splint should be tied to the outer end of the foot of the bed in such a position that the lower end of the femur rotates slightly outward. The foot of the bed should be raised 12 inches so that the patient's body acts as a counterweight to pull against the anchored splint. By following exactly this technique it was possible at the Hospital Center, Savenay. to demonstrate an average gain in length of more than three centimeters in a series of over 300 cases. In dealing with open wounds in this splint, it is only necessary to release one or two oi the 4-inch hammocks. Care must be taken so that the entire area of the fracture is not moved or allowed to sag below the level of the ORTHOPEDIC SURGERY 649 anterior of the femur. In fractures of the neck, as soon as feasible, good trac- tion and slight abduction having been maintained in the meantime, a plaster- of-Paris spica, with full abduction, should be applied. The Thomas double abduction splint should not be used except by those experienced in the use of this particular device. In complete destruction of the neck, with loss of sub- stance, early excision of the head through a posterior incision is advised. Fol- lowing the operation, also as soon as the wound permits, a plaster spica with full abduction should be used. Departure from the principle enunciated above for special purpose should seldom be made; lowering the foot of the bed or raising the head arc only justifiable under exceptional circumstances. The number of this class of cases was 10 per 1,000 total battle injuries in the given hospital. GUNSHOT AND OTHER FRACTURES OF THE FEMUR All of the remarks made above with reference to the application of the Thomas splint apply to fractures of the shaft. An astonishingly large number of femur fractures of the shaft apparently well splinted at the front, arrived at the end of 6 to 12 weeks with from 1 to 3 inches of shortening. A large amount of this must be charged to failure to make efficient use of the Thomas splint. This splint, either with or without overhead suspension in the Balkan frame, must be considered to have proven by far the best method of treatment. The number of this class of cases was 75 per 1,000 total battle injuries in the given hospital. GUNSHOT WOUNDS OF THE KNEE-JOINT Omitting from the present discussion the question of open or closed treat- ment of knee-joint injuries at the front, one must consider the treatment of septic knee joints by immobilization or with motion, and by drainage in the later severe septic cases. By the work of Willems it has been adequately shown that certain acute septic knees can be treated to best advantage with adequate drainage and active motion. It is obvious, however, that this motion must be intelligent and carefully controlled. It is not to be construed that such patients may be permitted to travel either from one hospital to another or overseas without such immobilization either in a Thomas splint or plaster-of-Paris splint as to protect against traumatism. Any of the septic cases may require addi- tional drainage. All the methods, including reflection of the patella, have been tried. One of the most valuable incisions for draining the popliteal space was worked out and used. It consists of about a 4-inch incision along the inner and posterior border at the upper end of the tibia. This is followed up through the space under the insertion of the popliteus into the knee-joint and drains one of the most dependent and inaccessible synovial spaces in the joint. This incision mav be extended upwards over the back of the internal condyle. By keeping in close contact with the bone, the entire popliteal area can be drained with much less risk to the vessels than through any posterior incision. The number of cases of this class was 25 per 1,000 total battle injuries in the given hospital. 650 SURGERY OTHER DERANGEMENTS OF THE KNEE-JOINT One of the constant orthopedic problems arising out of military service is that ordinarily placed under this rather vague heading. This class of cases, which numbered 10 per 1,000 total battle injuries in the given hospital, includes damage to the external and internal semilunar cartilages, rupture of or damage to the crucial ligaments or the extrinsic ligaments of the knee-joint. Treatment involves modification of boots, removal of loose bodies or of semilunar cartilages and even, in some cases, reconstruction of new crucial ligaments from hamstring tendons. Differential diagnosis of these conditions presents some difficulties. An operation should not be done until not only a diagnosis has been made but also the possibilities as to operative results following operations for compara- tively trivial conditions have been seen. The experience of civil practice has shown the wisdom of resection and arthrodesis for prolonged infections which eventuate in tuberculosis. GUNSHOT WOUNDS OF THE THIGH AND LEG, WITH NERVE INJURY These patients usually present themselves with foot-drop due to injury of the sciatic or external popliteal. Such cases must always be carefully splinted to maintain the foot at a right angle. For patients able to walk the right angle posterior splint of the British or the modification of the French splint with the double lateral iron outside the shoe should always be used to protect the patient against foot-drop. Walking patients should always wear a simple right-angle splint at night. Injuries of the anterior crural are rarely seen. When found, however, a long splint should always be worn to protect the knee which is inclined to genu recurvation. The number of cases of this class was 50 per 1,000 total battle injuries in the given hospital. GUNSHOT WOUNDS OF THE LEG, WITH FRACTURE This was one of the commonest of the war injuries (100 per 1,000 total battle injuries in the given hospital), and one of the most difficult to treat satisfactorily. Adequate fixation with the Thomas splint or with the ordinary posterior thigh and leg splints was rare. Especially was this the case when patients were being moved about. It is especially in this classification that plaster of Paris may be and should be used. It is the only device that uni- formly provides length, position, and immobilization. GUNSHOT WOUNDS OF THE FOOT AND ANKLE Adequate fixation of these wounds with the foot at right angles to the leg and slightly inverted must be the invariable rule. Practically all of these wounds, even including those of the toes, cause much disability. Where there is extensive damage to the calcaneum or the metatarsus, amputation must frequently be considered. When the angle joint only is involved, astragalectomy with adequate drainage, will often give a good result. After the period of active treatment, the use of right-angle foot splints as either inside or outside irons or with double lateral irons as so extensively practiced bv the British is to' be ORTHOPEDIC SURGERY 651 highly recommended. These should be used until stability of the foot and ankle is well reestablished. The number of this class of cases was 120 per 1,000 total battle injuries in the given hospital. SOFT-PART WOUNDS, WITH DAMAGE TO MUSCLES AND TENDONS OF THE UPPER AND LOWER EXTREMITIES These wounds, especially in the vicinity of joints, contributed a very large share of the serious war wound deformities (125 per 1,000 total battle injuries in the given hospital). It should always be remembered that any deformity of this sort represents healing in malposition that could have and should have been prevented in the first instance by proper splinting. Con- tracture deformity of the knee from posterior thigh and leg wounds was especi- ally common. This and associated foot-drop may always be prevented by the simple expedient of applying suitable apparatus before malposition develops and continuously until healing is complete. CHAPTER V AUTOGENOUS BONE GRAFTS FOR NONUNION IN ATROPHIC LONG BONES AND IN CHRONIC SUPPURATIVE OSTEITIS (OSTEOMYEL- ITIS)," FOLLOWING WAR WOUNDS0 During the four-year period ending December, 1928, 129 bone-graft operations were performed at Walter Reed General Hospital for conditions resulting from World War wounds followed by severe infection of bone and soft parts, for nonunion, and loss of substance in bones of the extremities. Fifty-two of these were unsuccessful. The majority of these cases were the result of war wounds in which, at the time of injury, severe damage was sustained by the bone as well as its surrounding soft parts. The bone showed marked atrophy and osteoporosis; its osteogenetic power was at a minimum, latent infection was present in the bone and the surrounding scar tissue, and the circulation in both was markedly impaired. In practically all of these cases the fractures were received during the summer of 1918; some even earlier. The majority occurred in France and had active infection in the bone for from four months to two or more years, causing a destructive1 osteitis, the usual infecting organism being the hemolytic streptococcus. Ordinarily this condi- tion of chronic bone infection has been referred to as osteomyelitis, from which it differs in many respects, but by usage has come to mean the same. Repeated operations for the removal of sequestrum, establishment of drainage, and prepa- ration of the wound for dakinization, further limited the blood supply, increas- ing scar tissue formation and bone atrophy. Added to this was the atrophy of disuse which further impaired its reparative osteogenetic properties. As other Army general hospitals closed, many of the failures there, as well as the nonunion cases that were still septic, were gradually transferred to Walter Reed General Hospital, the easier and more successful cases having been cured and discharged. Others were sent in for treatment by the Veterans' Bureau. In this group, 26 had been grafted elsewhere unsuccessfully; 15 had been plated or wired, and 6 had had some type of "stepping" operation. For a 2-inch loss of substance in a radius, one surgeon had used a toothbrush handle unsuccessfully. Atrophy was probably most marked in the humerus and next in the tibia, and usually where there was loss of bone substance the bone ends were atrophic, rounded off, or pointed. Eburnation in bone ends with pseudo- arthrosis occurred in the tibia and bones of the forearm, without loss of sub- stance, and occasionally in the femur and humerus with loss of substance, since there was no second splinting bone to hold the ends apart. This was - The data in this chapter are based on " End Results of One Hundred and Fifty-eight Consecutive Autogenous Bone Grafts for Nonunion In Long Bones (a) in Simple Fractures; (6) In Atrophic Bone Following War Wounds and Chronic Suppurative Osteitis (Osteomyelitis)," by Maj. N. T. Kirk, Medical Corps, U. P. Army. The Journal of Bone and Joint Surgery, Boston, 1921, vi, No. 4, 760-799. 652 ORTHOPEDIC SURGERY 653 more often the case in the femur than in the humerus, as bone-end apposition was more frequent. Loss of substance was the rule in this group, the amount varying from a fraction of an inch to 5 inches. The whole shaft of the humerus except 2 inches at each end was destroyed in eight cases. Several cases with 3 inches loss of substance in the tibia were grafted successfully. In a case having a 5-inch loss of substance, the head of the tibia formed the proximal fragment. This case was grafted once elsewhere and twice at Walter Reed General Hospital, all three operations being unsuccessful; the first due to infection and in the latter two operations atrophy and fracture occurred. Eventually the leg was amputated. No attempt was made to graft in any case until it had been healed for at least six months without signs of infection, unless the roentgenogram was negative for sequestrum or evidence of infection in bone, and only after vigorous repeated massage in the physiotherapy department, If scar tissue was present m skm, it was removed and a skin closure done, at which time any scar tissue in soft parts or about the bone ends was removed. It was found that scar tissue in skin in these cases would invariably break down if at all in proximity to the operative field, and often cause exposure of bone and disaster. If infection followed the scar excision, the graft was not attempted for another six months. If healing was by primary intention, the graft was done four to six weeks later. Even with this procedure, infection caused 22 failures, and 9 other cases were severely infected, but union occurred, although the graft was later removed in 3. Very severe infection causing failure has been encountered after the original wound had been healed one year and no reaction occurred after a preliminary scar excision. There appears to be no assurance as to when all danger from latent infection is past. In the leg it was sometimes necessary to do two scar excisions and skin plastic operations before all scar tissue was removed and there was sufficient healthy skin to cover the bone. TYPES OF GRAFTS The types of grafts included inlay, intermedullary, osteoperiosteal, peg (not intermedullary). Grafts of the inlay type included true inlays, outlays, ('fish-tail" type, and "massive" grafts. Most of the grafts were cut with the single Albee saw from the healthy tibia. In 1920 and 1921 the crest of the tibia was used in the humerus, radius, and ulna, but this was later abandoned and the graft was taken from the inner surface. The inlay type of graft was always used in the tibia, usually in the forearm, occasionally in the humerus and femur. The intermedullary type was found best suited in the atrophic humerus. The cortex was so atrophic that there was practically nothing left but the medulla, in which there was an increase in fat. The ends of the bone frag- ments were cut off and the graft introduced, causing a minimum of interference to the blood supply of the bone by way of the periosteum attached to soft parts. Again, the graft was driven into the medulla of the upper fragment and inlaid into the bone of the condyles and supracondylar region. These 654 SURGERY grafts were reinforced by osteoperiosteal grafts wrapped about them and sutured to the periosteum of the upper and lower fragments. The osteoperiosteal type was used successfully on a fractured patella with nonunion, of four years' duration the result of a gunshot wound. The first attempt in this case was unsuccessful, due to the failure ol the absorbable suture to maintain fixation of fragments sufficiently long. A second failure occurred in the use of this type of graft on a fractured graft. The size of the graft and its contact with healthy bone is essential to its circulation, life, and proliferation. The general rule followed is to cut a graft at least three times the length of the loss of substance to be bridged or of poor bone in which it will be in contact, though it is not always possible to get a graft long enough from the healthy tibia to meet these requirements.6 At first these grafts were heid in place with kangaroo tendon and chromic catgut through drill holes in the side of the trough. It was found, however, that the circulation was so poor that this absorbable material did not absorb but acted as an irritant, causing sinus formation, and was more than once the cause of infection and loss of the graft. The writer has removed it as long as one year after it was placed in the bone. Its use was discontinued and the grafts made self-retaining without the use of ligatures. This was accomplished In- cutting the graft to fit snugly, and a half inch longer than the trough in the inlay type, undercutting the ends of the cortex on both fragments and sloping the graft ends from above downward so that they could be wedged under the cortex at both ends. The graft is then fitted in position with one end under the cortex, forced down to position at the other, and then, using a mallet and an instrument with a sharp point and a shoulder, slid down until the lower end becomes fixed under the cortex. This method is now being used in all grafts. There were eight cases in this series of bone grafts of the tibia operated upon by an associate of the writer in which an entirely different procedure was used; all were successful. He used a small graft cut from the inner surface of the tibia and, after removing all of the endosteum, secured the graft into the fragments without opening the medulla. The graft consisted of perios- teum and osteum only and was placed in contact and made self-retaining in the cortex by cutting a wedge, sloping the graft ends from above downward, and sliding the graft in from the side, the end becoming engaged under the notch that had been cut in the cortical bone. Chances of infection were lessened because there was less bleeding, the medulla not being opened; bone growth was slower than in the inlay type, but occurred. He applied his plaster cast before operation and operated through a window in the plaster. The tourniquet was not used except in operating upon both bones of the forearm when the bloodless method was employed, but it was removed and all bleeding controlled before the graft was put in position. Hemostasis was difficult in these chronically infected cases, due to oozing from scar tissue. but was as complete as possible before closure. The skin, except when two incisions were necessary in the forearm, was sutured with silkworm gut, a window was cut in the plaster cast two days b The average size of inlay graft used in the tibia for nonunion was 6 by one-half inch; the largest measured 1054 by three-fourths inch, in a tibia with 3-inch lost substance. ORTHOPEDIC SURGERY 655 after operation, and the wound dressed daily until all stitches were removed, when the window was filled in with plaster. This was necessary because of possibilities of infection. When infection occurred, stitches were removed and the wound at once dakinized. Nine cases in which infection was severe were saved by this method and many small local skin infections were controlled early and severe infection avoided. Plaster was removed at the end of three months in the tibia and forearm, a roentgenogram taken, and plaster reap- plied for another three months in the chronic healed osteomyelitis group. Some required immobilization even longer than this. A well-padded body cast was applied at least two days before a humerus was grafted to insure its proper fitting and setting. The arm piece was put on after the graft was completed. This afforded more comfort to the patient, gave better fixation, and lessened the time on the operating table. In a few cases the arm piece as well as the body cast was applied before the operation and the operation done through a window. This made the procedure much more difficult and was finally abandoned. The arm was put up in abduction unless the nonunion was between the pectoral and deltoid insertions, when it was adducted and brought across the chest for fear of fracture of the graft from muscle pull. These casts were not removed until the end of six months. The following table shows the bone grafted and the results: Bones Humerus_______ Radius_________ Ulna___________ Radius and ulna. Metacarpus____ Femur........... Tibia__________ Patella_________ Metatarsus_____ Total_____ » Radius only successful in 1 case—represents 5 successful grafts. & Both tibiae fractured in 1 case. From this table it will be seen that there were six patients in whom two bones were involved; five involved the forearm, the sixth was a patient having an old gunshot wound with compound comminuted fracture and incom- plete union in both tibia?, lower third. One tibia had previously been grafted elsewhere and had fractured. Both legs presented adherent scars. The patient begged for a double amputation. This was refused. Four operations were done, one at a time, two scar excisions and two inlay grafts taken from the upper third of the bone being grafted. Both were successful. In addition, the patient had bilateral drop-foot, due to loss of muscle and tendon. One side was corrected by tendon suture at the time of the bone graft. In the other the tendons were hopelessly destroyed. The patient is now walking without braces, except a light one to correct the foot-drop in the left leg. There were two cases in which the shoulder joint, head of the humerus, and from 2 to 3 inches of the shaft had been shot away, along with the deltoid Number Success-ful Un-known More than one graft 30 15 6 5 1 4 &45 1 1 15 10 5 «3 5 2 36 1 1 1 4 1 9 1 108 7S 1 15 656 SURGERY muscle. In one case the acromion process and outer end of the clavicle were missing. The nerve and blood supply to the arm had not been disturbed. A long adherent scar replaced the deltoid muscle and the long head of the biceps. The arms were useless. After anchoring the remaining shaft of the humerus to the glenoid cavity, at an angle of 90 degrees abduction and in a neutral position as regards flexion and extension, an excellently functioning result was obtained by use of scapular motion in both cases. In the first case, after clean- ing out the glenoid cavity, cutting off the end of the humerus, the acromion process was incompletely fractured (green-stick), brought down, and a peg from the crest of the tibia was driven through a hole bored in the acromion, the humeral shaft, and into the glenoid. In the second the glenoid was cleaned out and the humerus cut off and fitted to it, A hole was made 1 inch deep and three-eighths inch square in the glenoid. A 4-inch graft was cut from the tibia, driven into what remained of the medulla of the humerus for 3 inches. The humerus with the protruding 1 inch of graft was then fitted to the glenoid with the hole that had been prepared to receive the graft. The humerus was then anchored to the scapula with a piece of silver wire. One forearm had nonunion of both bones with marked deformity, pseudo- arthrosis, and severe eburnation of the bone ends, with two large adherent scars. The scars were excised, both ends of the bone were resected, and later, using an osteoperiosteal graft on the radius and an intermedullary peg in the ulna, union occurred. In another case there was malunion in the ulna with bad deformity in two directions, and nonunion in the radius, which contained a piece of broken silver wire. The ulnar deformity was corrected by osteotomy and an intermedullary peg, the wire was removed, and a 5-inch inlay self- retaining graft placed in the radius. Excellent bony union occurred in both, correcting the deformity. Six times the nonunion in the radius was in the lower end, presenting the characteristic radial deviation deformity. This required an osteotomy and shortening of the ulna from an inch to an inch and a half to correct the deformity. The smallest graft in the series was 1}4 inches long and three-sixteenths of an inch square, and was used to replace the shaft of the second metacarpal bone. The result was excellent. The tendons had not been destroyed, and after a capsulotomy posteriorly of the metacarpophalangeal joint, the soldier was returned to duty with normal function. One tibia was grafted with a heterogenous graft, taken from the tibia of another patient of the same blood group, after amputation through the middle third of the leg. This was used because of an old healed chronic osteomyelitis in the opposite tibia, and a sliding graft was impossible on the one having the nonunion, there not being sufficient bone. Absorption and infection followed; the osteoclasts appeared to be very active. One tibia had malunion with a large unhealed scar 3 inches in diameter. The lower fragment was displaced outwardly 20 degrees from the long axis of the upper fragment in the position of weakness for weight bearing. The scar was cauterized with the actual cautery, excised, a correcting osteotomy was performed on the tibia, but there was no attempt at union; some of the bone sequestered. After another scar excision, the tibia was successfully grafted, ORTHOPEDIC SURGERY 657 the deformity being corrected. Fifteen cases were grafted a second time. Seven were successful; three of these had been unsuccessful^ grafted elsewhere, making their third graft. Four were tibias, one was an ulna one a patella, and one a humerus. Of the eight failures, five had been unsuccessfully grafted elsewhere before, this making the third graft, The tabulated results of the total scries are: Grafts______ _ _ _ ___ ___ 12!) Successful_________ 7i. Percent_______ ._...__ ____ .59 Unknown_______ 1 Failures _ _______ ___ ___ ____ 52 Patients_______________________ ______________________ _____ 107 Only cases which had definite bone union and had a functional result on discharge were classified as successful. Patients were not discharged until after there was sufficient bony union in the lower extremity to allow them to walk with the use of a brace only to guard against undue stress, and those of the upper extremity were held for a like period. This period was anywhere from (i to 20 months after the graft, Union was never sufficient to allow weight bearing before the sixth month and in some cases not until the ninth and then only with properly fitting braces which were made in our own orthopedic shop. The war demonstrated that gunshot fractures which united without graft required twice the time to form solid bony union as was the case in peace-time fractures, and required splinting or bracing for a like period to prevent refracture or deformity. The same observation was made in this series of grafts; the period of time required for complete union to occur was from two to three times as long in the chronic osteomyelitis group as in a noninfected group. Two cases that were originally classified as failures due to infection sub- sequently returned for reexamination, when solid bony union was found. It is not impossible that a certain number of cases reported here as failures have united since discharge. The one case carried as unknown left the hospital in plaster and has not been heard of since. The cause of failure was: Infection . _ ___.. . . . -- Atrophy_______________________________ ---- ^ ° Fracture in plaster before seventh month---------- 7 Fracture after seventh month. _ _ ----- <> Faulty fixation of patella 1 Death from shock--- Lnfection was the cause of the greatest number of failures due, no doubt, to latent infection in the bone and soft parts, rather than to accidental infection at the time of operation. The same technique was employed and the same operators operated upon these cases, as in like operations in simple fractures, vet there were no grafts lost from infection in the simple fractures. 658 SURGERY The cause, then, is considered to be latent infection, diminished blood supply in the bone and soft tissues, and the presence of subcutaneous scar tissue and bone atrophy, thereby lowering the vitality of the part. Sequestra not infrequently formed at the end of the fragments along the edge of the trough; apparently the interference with the circulation of the bone in cutting the trough caused its death. Two sets of instruments were always used when a graft was done, one for the extremity being grafted, and the other for the healthy tibia. Infection was carried into the tibia of the healthy leg once by the use of the same twin saw. Its use was promptly discontinued. Atrophy was apparently the cause of 15 failures. This may have been the result of using too small a graft with insufficient bone contact to nourish it, improper fixation, or insufficient blood supply and osteogenetic power in the bone which was grafted to keep the graft viable. The failures actually occurred in those cases showing most marked bone atrophy or loss of substance and in cases with some underlying constitutional disease such as tuberculosis and syphilis, or were in generally poor physical specimens. Fracture of the graft before the seventh month caused failure in seven cases. Atrophy undoubtedly played a part in these. Other factors were muscle action, poor fixation due to atrophy of the soft parts and shrinkage of the extremity in its cast, and to too much activity, carelessness, and non-cooperation on the part of the patient. There were nine fractures after the seventh month while wearing braces, some of these as late as the ninth month, all due to trauma. All originally had loss of substance of from 1 to 3 inches. All these might readily be classified as successful. One patient discarded his brace and apparently deliberately refractured his graft, as he did not desire his discharge. In three cases the bone reunited without operation, leaving six failures due to this cause. Two patients were reoperated upon successfully with inlay grafts along the fractured graft; one unsuccessfully, using an osteoperiosteal graft; one continued to run a systolic blood pressure of from 80 to 100 and was refused further operation. Two left the hospital without further operation; one devel- oped a sinus after three months, and the graft was lost through infection the eighth month, due, it is believed, to irritation from the kangaroo tendon ligature. One failure in a grafted patella occurred, due to absorption of absorbable suture used to hold the fragments in position until consolidation occurred after an osteoperiosteal graft. This case was regrafted, the fragment being held with silver wire. Union occurred, and the knee flexes to 90° and the patient has sufficient power in the quadriceps to go up and down stairs. There was one death from surgical shock in a graft of the upper third of the femur. A blood pressure reading was taken during all grafts every 10 to 20 minutes, and a careful check kept on the patient's condition. ~Shock was much more easily produced than is ordinarily the case, due to the Ion* hospitalization, with absorption of toxins from chronic infection and repeated ORTHOPEDIC SURGERY 659 operations. When it occurred it was treated with saline intravenously and blood transfusion. A word about the tibia from which the grafts were taken. As was stated, infection was carried into the healthy tibia once. When the graft is taken from the inner surface, the defect is soon filled in with new bone. The writer has removed a second graft, 8 by one-half inches, six months after the first; the cortical bone did not appear as well calcified, but was thicker than normal. He has removed a third large graft from the same tibia and still found good bone. When the crest is removed, however, it is not wholly replaced and the patient can easily feel the bone defect with his hand. All patients, when they again became ambulatory about the third week after operation, were fitted with a tibial caliper which was worn for from 8 to 10 weeks, depending upon the amount of bone removed. Two fractures occurred in this series; one patient, not wearing his brace, got too close to a motor truck, and another fell down a flight of stairs while intoxicated. Both healed without deformity. CASE REPORTS Case 1.—A. H. Gunshot wound, left leg, causing compound comminuted fracture, and loss of 3 inches of substance in left tibia, followed by chronic osteomyelitis and marked bone atrophy. A large part of the musculature, as well as of the skin, was destroyed. Two scar excisions and plastic skin closures were necessary before a graft could be attempted. Opera- tion, December 2, 1920, Walter Reed General Hospital. Bone graft 7 inches by one-half inch was taken from the right tibia and inlaid into both fragments and made self-retaining. The graft was covered on three sides at the site of nonunion with skin only, and a small sinus developed, which required operation in July, after which the wound healed. Patient was fitted with ischial caliper in December, 1921. He was discharged October ,1922, with good bony union. Case 2.—N. W., Pvt., Inf. Gunshot wound of right forearm, causing compound com- minuted fracture, nonunion both radius and ulna at junction of upper and middle third, followed by chronic osteomyelitis. There were two large adherent scars, marked deformity, and eburnation of both ends of both bones. Operation, March 5, 1920, Walter Reed General Hospital. Scar tissue excised from skin; the eburnated ends of both bones excised and de- formity corrected. A Lane plate placed on radius to keep position. This was removed August 4, 1920, when fibrous union was found to be present. September 23, 1920, operation Walter Reed General Hospital. Osteoperiosteal graft wrapped about the point of nonunion in radius and an intermedullary peg placed in the ulna, both taken from the left tibia. Excel- lent bony union occurred in the radius and fair union in the ulna. The patient was playing ball with this arm when discharged. Case 3.—C. B. H. Gunshot wound, right leg, causing compound comminuted fracture and loss of substance in tibia, followed by chronic osteomyelitis. Three-fourths of the breadth of the shaft in the middle third of the tibia was lost. Operation, May 4, 1921, Walter Reed General Hospital. Bone graft 9 inches by one-half inch was taken from the inner surface of the left tibia and inlaid into the normal bone of the upper and lower fragments and outlaid along the 6 inches of the remaining bone in the middle third. Healing occurred by first inten- tion. Immobilization in plaster until February, 1922. Fluctuation was at this time found present and a bloody fluid was removed. The fluctuation recurred and the wound had to be incised and Dakinized. In July, 1922, a skin suture was done, and it healed by first inten- tion. The bone was not infected. Patient discharged with good union, September 6, 1922. Case 4.__E. R. Gunshot wound, with compound comminuted fracture and loss of sub- stance, both bones upper fourth of left leg, followed by chronic osteomyelitis. In addition, patient had paralysis of the external popliteal nerve. On admission the upper end of both 660 SURGERY Fig. 85—Case 1. Loss of bone substance and bone atrophy Fig. 86—Case 1. Roentgenogram 3M months after graft ORTHOPEDIC SURGERY 661 Fig. st.—Case 1. August 1, 1922. Roentgenogram'showing excellent bony union 662 SURGERY Fig. 88. -Case 1. Roentgenogram, May, 1924, showing hypertrophy of graft in tibia Fig. 89. -Case 2. Marked deformity and eburnation of bono ends where the pseudarthrosis had occurred ORTHOPEDIC SURGERY 663 Fig. 90.—Case 2. After resection of bone ends and removal Fig. 91.—Case 2. March 23,1921. Excellent bony union of plate. Deformity corrected and hypertrophy of radius 664 SURGERY Fig. 92.—Case 3. Roentgenogram, December 10, 1921, showing bone being thrown across between graft and old eburnated bone Fig. 93.—Case 3. Roentgenogram, July 28, 1922, 14 months after operation. There is excellent bony ORTHOPEDIC SURGERY 665 lower fragments of the tibia and fibula were in apposition with the lower end of the head of the tibia. Xo attempt at union occurred. Operation, August 31, 1921, Walter Reed General Hospital. Bone graft taken from inner surface right tibia was driven into the remaining head of left tibia and inlaid into the upper end. of the lower fragment of the tibia. A small slough occurred in the suture line, which healed. Plaster was removed the seventh month and an ischial caliper substituted. Patient discharge one year after graft with excellent bony union in the tibia, as well as union between the head of the tibia and the shaft of the fibula, which occurred only after the tibia was grafted. Fig. 94.—Case 4. Condition before operation Case 5.__W. J. T. Gunshot wound, with compound comminuted fracture, lower third both tibia, and fibulae, followed by chronic osteomyelitis and loss of muscle substance from extensor muscle group in both legs. Before admission patient had had a bone graft in right tibia which had fractured. He requested that both legs be amputated. This was refused. A scar excision was done on each leg, at Walter Reed General Hospital December 15, 1921, a bone graft 5 inches long was taken from the upper third of the same tibia and inlaid in the lower third alongside old fractured graft, and made self-retaining. A tendon suture of the rieht extensor tendon group was done at the same time. February 6, 1922, the left tibia was 666 SURGERY grafted, using a graft 4\4 inches by one-half inch, taken from the upper third of the same tibia, and made self-retaining. Healing of skin was delayed in both cases but no infection occurred. Excellent bony union occurred after each graft. Case 6.—D. A. H. Gunshot wound, with compound comminuter fracture, and loss of head, neck, and upper 2 inches of humerus, as well as deltoid muscle, followed by chronic osteomyelitis. The blood and nerve supply to the rest of the arm was not disturbed. The arm hung uselessly by the side. Operation, October 13, 1921, Walter Reed General Hospital. Body cast was applied two days before operation. Arthrodesis left shoulder. Glenoid was cleansed out, the acromion process was ncompletely fractured (green-stick) and brought down; the end of the humerus cut off and fitted to the glenoid in a position of 90 degrees abduction and neutral as to flexion and extension. A bone peg from the crest of the tibia was driven through a hole that had been drilled in the acro- mion process through the upper end of the shaft of the humerus and into the glenoid, fixing the humerus in position. The arm- piece of the cast was applied. The cast was removed at the end of six months and good bony union was found. The arm was kept on an airplane splint for four months. Patient discharged with good scapular function. Case 7.—W. H. M. Gunshot wound, with loss of head and upper fourth of shaft of humerus, acromion process, and outer end of clavicle. This was followed by chronic osteomyelitis. The deltoid muscle and long head of the biceps was replaced by scar tissue; the circulation and musculature of the rest of the arm was normal. The arm hung uselessly by the side. Operation, November 9, 1922, Walter Reed General Hospital. Arthro- desis of left shoulder. The glenoid was cleaned out; the upper end of the humerus sawed off. A graft 4 by 3.8 inches was taken from the inner side of left tibia and fitted in a hole 1 inch deep made in the glenoid; removed and driven into the medulla of the humerus. The humerus, with the protruding 1 inch of the graft, was then fitted to the glenoid and its cavity. Through a drill hole in the shaft of the humerus and the coracoid process, a silver wire was passed, securing the humerus to the scapula. Immobilization in plaster with the humerus at 90 degrees abduction and in a neutral position as regards flexion and extension. Body cast was applied two days before operation and armpiece at time of opera- ion. Five months after arthrodesis, plaster was removed and excellent union was found to be present. Discharged the ninth month with excellent scapular motion. Case 8. L. E. Gunshot wound, sustained in action, causing compound comminuted fracture and loss of substance middle third right humerus, and paralysis of musculospiral Before admission humerus was "stepped" Fig. 95.—Case 4. Solid bony union January 17, 1922, five months after graft nerve. There was also a chronic osteomyelitis. ORTHOPEDIC SURGERY 667 and a 4-inch bone peg introduced into medulla, followed by nonunion. Operation, April 20, 1922, Walter Reed General Hospital. Intermedullary bone graft 6 by ^ inches taken from the right tibia, made self-retaining in medulla. Cortex of fragments had consistency of an eggshell. Cast removed at end of six months, wound having healed by first intention. Roentgenogram showed good bony union. Discharged July, 1923. Fig. 96.—Case 5. Anteroposterior view of both tibiae before bone graft Case 9. O. P. Patient sustained, along with other injuries, a gunshot wound causing compound comminuted fracture of the right patella. On admission in August, 1922, there was union between the two upper fragments of the patella and separation of some 2 inches between the upper and lower fragments. Knee flexed to about 45°; muscle power in quad- riceps was poor. Operation, September 1, 1922, Walter Reed General Hospital. Scar tissue was removed from between fragments, which necessitated opening knee joint; patella 60S SURGERY Fig. 97.-Case 5. Right tibia four months after graft Fig. 98.-Case 5. Left tibia four months after graft ORTHOPEDIC SURGERY 669 was held in position with chromic catgut, using a circular purse-string suture and suturing the lateral capsule. An osteoperiosteal graft was placed over and in contact with the anterior bony surface of both fragments. The cooperation of this patient was poor. The absorbable ligatures did not hold and the fragments separated. Reoperation, December 4, 1922, Walter Reed General Hospital. The same procedure was followed as in the first operation, except that the patella was drilled and two pieces of silver wire used for fixation through the drill holes. A new osteoperiosteal graft was Fig. 99.—Case 6. Roentgenogram showing loss of bone substance before operation placed in contact with the anterior surface of the patella and a third piece of silver wire run through the patella tendon and the insertion of the quadriceps tendon, reinforcing the fixation. Excellent bony union occurred, and when the patient returned in January, 1924 to have a piece of the silver wire, which was broken, removed, he had solid bony union, 90° motion, and sufficient power in his quadriceps, to go up and down stairs. Case 10. A. B. L., private, Infantry. Gunshot wound of right hand causing compound fracture of second, third, and fourth metacarpal bones, followed by mild infection and loss of shaft of second metacarpal July, 1922. Operation, March 21, 1923, Walter Reed General 670 SURGERY Fig. 100.—Case 6. Good bony union six months after arthrodesis Fig. 101.—Case 6. Photograph showing function ORTHOPEDIC SURGERY 671 Fig. 102.—Case 7. Roentgenogram before operation, showing loss of substance Fig. 103.—Case 7. Union five months after operation 46997—27---45 672 SURGERY Hospital. A bone graft \% inches by three-sixteenths of an inch square was driven in a hole made in what remained of the base of the second phalanx and likewise introduced into the proximal end of the remaining shaft and head. Graft was self-retaining. Solid union occurred in two months, with union in the fractured third and metacarpal as well July 1923, a capsulotomv of the posterior capsular ligament of the metacarpo- phalangeal'joint was performed, followed by normal function in the hand, there having been no injury to tendons. Returned to duty October, 1923. Case 11 J F., captain, Infantry. Gunshot wound, with compound comminuted fracture and loss of substance, right tibia, lower third, followed by osteomyelitis. Prior to admission, Fig. 104.—Case 7. Photograph showing function one bone graft had been done which was lost through infection. A large scar was removed, Walter Reed General Hospital, and a plastic closure of skin done. Operation, December 1, 1922, Walter Reed General Hospital. Bone graft 103^ inches by three-fourths inch square taken from left tibia. The lower end was driven into the cancellous bone of the lower fragment. The upper end was inlaid into the upper fragment and the end of the graft fixed under the cortex, making it self-retaining. Patient was allowed to walk beginning the ninth month, wearing an ischial caliper. He was discharged December 2, 1923, with excellent bony union. Case 12. I. K. Gunshot wound causing compound comminuted fracture, 2J^ inches loss of substance, lower third left tibia. Operation, April, 15, 1920, Walter Reed General Hospital. Sliding graft brought down from the upper fragment; bone held in place by kangaroo tendon. Periosteum sutured with catgut. Operation was followed by superficial infection, which healed. January 13, 1921. Patient fractured graft nine months after operation. Plaster cast applied and later a tibial caliper. Discharged January, 1922, wearing brace; clinicallv ORTHOPEDIC SURGERY 673 Fig. 105—Case 7. Another view showing function Fig. 106.—Case 8. Loss of substance and atrophy present in humerus before graft 674 SURGERY- FIG. 107.-Case 8. Excellent bony union at end of six Fig. 108.-Case s. Another view showing union at end of six months ORTHOPEDIC SURGERY 675 union was present. Returned for examination August 12, 1922, when there was solid bony union; more bone proliferation at the site of the fractured graft than anywhere else along the graft which bridged the loss of substance. Case 13. J. C. K. Gunshot wound, sustained in action, causing compound comminuted fracture, and 3 inches loss of substance upper third left tibia, followed by chronic osteo- myelitis. Operation, August 30, 1921, Walter Reed General Hospital. Bone graft, 7 inches by one-half inch, taken from inner surface right tibia, inlaid into both fragments and fixed with two kangaroo ligatures. Wound healed by primary intention. Roentgenogram Xovember 17, 1921, when the original plaster was removed and replaced showing graft in excellent condition. Graft was fractured in plaster some three weeks later. Immobilization in a walking plaster cast or on an ischial caliper until May, 1923. Roentgenogram showed Fig. 109.—Case 9. Lateral view showing comminuted frac- ture of patella and separation of fragments Fig. 110.—Case 9. Union present January, 1924 an attempt at union, but a pseudarthrosis occurred. May 15, 1923. A second bone graft was done; a graft 7V£ inches by 3* inch taken from the right tibia was inlaid into both frag- ments and outlaid along fractured graft, after freshening graft. The ends of the graft were fixed under cortical bone, making it self-retaining. Roentgenogram in August, 1923, three months after graft, showed union in the old fractured graft, and the new graft in excellent condition. Plaster was removed at this time and ischial caliper fitted. Patient discharged in January, 1924, with excellent bony union. Cask 14. C. W. Gunshot wound, causing compound comminuted fracture of tibia, right, and loss of substance lower third, with a chronic osteomyelitis. The left leg had been ampu- tated through the middle third as the result of a gunshot wound. Operation, August 30,1920, Walter Reed General Hospital. Bone graft taken from the upper third of the same tibia, 676 SURGERY Fig. lll.-Case 10. Roentgenogram showing loss of substance and deformity ORTHOPEDIC SURGERY 677 Fig. 112—Case 10. Two months after graft—deformity corrected, with bony union 678 SURGERY consisting of periosteum and osteum or cortical bone. A trough was made in b<>1 h fragments, without opening into the medulla, with a notch cut in each end. The graft ends were sloped from above downward and the graft pushed in from the side, the ends fitting snugly in the notches in the cortical bone. The leg was immobilized in plaster before operation and the operation was done through a window in the cast. Solid bony union occurred, although the proliferation in the graft was slow. Patient discharged March, 1922. Case 15. H. W. Gunshot wound, with compound comminuted fracture and loss of substance and chronic osteomvelitis, lower third of both bones, right leg, 13^ inches above Fig. 113,-Case 10. Showing function on completion Fig. I14.-Case 10. Another view showing function on completion the ankle joint. Patient had had an unsuccessful "stepping" operation before admission. Two large scars were excised one on the outer and the other on the inner surface of the leg before graft. Operation May 19, 1922, Walter Reed General Hospital. Bone graft 4j| inches by one-half inch aken from the inner surface of the left tibia. The lower end driven into a hole centrally placed m the lower fragment of the tibia to the depth of IV inches and m aid into the upper fragment, the end of graft being fixed under the cortex, making t self-retaming Excellent bony union occurred in the tibia, and in the fibula as weU Patient discharged wearing brace in May, 1923. He is now wearing no support ORTHOPEDIC SURGERY 679 fc*i QD Fig 115-Case 11. Roentgenogram showing loss of sub- Fig. 116.—Case 11. Roentgenogram three months after st;ance graft showing excellent condition of bone 680 SUHC.KRY FiG.117.-Case 12. Roentgenogram showing loss of sub- Fig. 118,-Case 12. Roentgenogram three months after stance ft ORTHOPEDIC SURGERY 681 Fig. 119.__Case 12. Linear fracture ninth month Fig. 120.—Case 12. Xote absorption two months later 682 SURGERY- FIG. 121.—Case 12. Solid bony union 19 months after fracture Fig. 122.—Case 13. Roentgenogram November 17, 1921, fracture of first graft during ^fourth month and loss of substance bridged by graft ORTHOPEDIC SURGERY 683 Fig. 123—Case 13. Excellent union in old fracture in original graft and in new graft Fig. 124.—Case 14. Roentgenogram of graft six weeks after operation 684 SURGERY Fig. 125.—Case 14. One year after Figure 124, or !V/2 months after operation, showing pro- liferation which had occurred in graft which bridged loss of substance ORTHOPEDIC SURGERY 685 Fig. 126.—Case 15. No attempt at union in old fracture. Note proximity to ankle joint Fig. 127.—Case 15. Lateral roentgenogram three months after graft 686 SURGERY Fig. 128.—Case 15. Roentgenogram 11 months after graft. Outline of graft can barely be distinguished. Note union in fibula CHAPTER VI AMPUTATION SERVICE, A. E. F. ORGANIZATION AND DEVELOPMENT It was recognized at an early date by the chief surgeon, A. E. F., that the proper management of amputation cases constituted a problem for which special provision ought to be made. This was in conformity with the advice of the senior consultant in orthopedic surgery, A. E. F., who had had special opportunities for acquiring knowledge of the various orthopedic problems encountered in France and Great Britain, prior to our entrance into the war. The first step toward meeting this problem was taken in August, 1918, when, in an order which defined the responsibilities of the general and special pro- fessional services, the supervision of amputation cases was assigned to the division of orthopedic surgery.3 Foreseeing the need of a special amputation service, the senior consultant, orthopedic surgery, immediately set machinery in motion, looking toward the training of a medical officer for this special type of work. Facilities for study were available in the bureau of artificial limbs of the American Red Cross in Paris and through the cooperation of the Allied Governments these facilities were extended to the chief amputation centers in England, Belgium, France, and Italy. Ample opportunity thus was provided for the acquisition of familiarity with all aspects of the amputation problem. It soon proved that the chief difficulty in the way of providing proper treatment for this important group of cases was the general lack of under- standing among military surgeons of the functional requirements in amputation cases. An amputation stump is useful only in the light of the prosthetic appliance which can be worn and of the degree of functional restoration obtained by its aid. Therefore, it is evident that the entire treatment, from the ampu- tation itself, up to and including the fitting of the artificial limb, must be planned with a clear vision of the end result which may be obtained, and with knowledge of each and every danger which must be avoided in order to achieve this ideal. Familiarity with the functional value of amputations at different levels, with the physical requirements of a good stump, and with the different types of prosthetic appliances, is essential to the attainment of this goal. The opportunities for acquiring this knowledge prior to the war were few and what there were had generally been neglected. Both in England and in France the need for improvement in the treatment of amputation cases was forciblv brought home, early in 1915, when end results in the early war ampu- tation cases began to be viewed. Many of these cases were in lamentable condition. The vast majority presented fat, congested stumps, with powerless muscles and serious joint contractures. Many had lost important segments of their limbs due to the mistaken notion that a longer stump would be an incumbrance- and many others had to undergo reamputation and to lose 40997—27---46 687 688 SURGERY valuable segments which might otherwise have been saved had suitable treat- ment been applied. A large number had to go back to the hospitals for long periods of treatment before artificial limbs could be fitted. All made very slow progress and some never succeeded in learning to walk. It was in order to avoid similar results in the American Expeditionary Forces that the senior consultant, orthopedic surgery, planned to organize a special amputation service through which all amputation cases would pass before being evacuated to the United States.2 It was not until April, 1918, that American battle casualties occurred in sufficient numbers to justify the organization of an amputation service. At this time a small beginning was made at Base Hospital No. 9. Chateauroux, France.3 All amputation cases were segregated in special wards, a gymnasium was established and a prosthesis shop organized. By July the service had expanded to 120 beds. It had been the intention to have all amputation cases pass through this center. This plan proved impractical, however, when casualties began to occur in large numbers. Following the American battle activities along the Marne there was a sudden great influx of wounded into the base hospitals, American Expeditionary Forces, and some of the amputation cases were evacuated to the United States without receiving special care. To prevent a similar happening in the future the amputation service was transferred, in July, 1918, to Base Hospital No. S, at Savenay.2 This location was selected because of its designation as the main distributing point for the evacuation of the wounded to the United States. From August, 1918. until the signing of the armistice, no cases were evacuated without going through the hospital center at Savenay. All cases of amputation, therefore, could be seen and special treatment instituted when necessary. Early in 1919, the hospital centers at Bordeaux and at Brest also were designated as points of evacuation,4 and in order to meet this situation it was necessary to organize special amputation services at these points. Medical officers who had received training at Savenay were available for duty elsewhere and little difficulty was experienced in supplying an experienced personnel. Prothesis shops also were organized and equipped at these points. FUNCTIO_\ZS The basic idea underlying the organization of an amputation service was to provide a center where the special problems encountered in the treatment of Avar amputations would be understood and where all facilities would be available to solve these problems with a view to the ultimate recovery of the maximum degree of function. Since it was the general policy that reconstruc- tive surgery in totally disabled cases would be deferred until arrival in the United States, the functions of the amputation service consisted essentially of the following: First, to provide proper surgical, physiotherapeutic, and prosthetic treatment for amputation cases. Second, to gather information as to proper methods of treatment, and to spread this knowledge among the surgeons of the American Expeditionary Forces. Third, to prepare cases for evacuation to the United States, and to insure their arrival there in the best possible condition. ORTHOPEDIC SURGERY 689 The first function had to do with the actual treatment of the patient, pro- vision for which was made by the organization of three departments—surgical, physiotherapeutic, and prosthetic. The surgical department naturally was the most important; its work was essentially the same as that of any other sur- gical organization, including operating, ward dressing, and records. Physio- therapy was under the direction of an athletic instructor of great ingenuity who conducted daily classes for the ambulatory cases. The men were put through stump drills, which were exceedingly valuable both for strengthening weak muscles and for teaching balance. This instructor also conducted classes for the men who had been fitted with provisional legs, and much of the success attained here was the result of the training in walking which he gave these patients. In addition, a certain number of reconstruction aides attached to the service administered massage and exercise to the bed cases. The pros- thesis shop was under the direction of a sergeant, first-class, Medical Depart- ment, who was an artificial limb maker by trade. He quickly learned to make the plaster of Paris sockets for the provisional legs, and as the demand for appliances increased, trained others of the hospital detachment in the work so that there was never any delay in supplying apparatus. The skeleton legs, complete in every detail except for the socket were supplied by the American Red Cross. The second function, that of disseminating knowledge of proper methods of treatment and of the common mistakes that were being made, was taken care of in two ways: By written reports to the senior orthopedic consultant; by personal visits to most of the hospital centers in France where opportunity to talk with the officers actually engaged in treating the cases proved most helpful. All amputation cases received at the hospital center, Savenay, were inspected upon arrival and careful note made of their condition.2 When there was evidence of improper treatment, this was checked against the hospitals from which such cases had come, and thus it was possible at the end of every month to send full reports to the senior consultant who could make such use of the information as he deemed proper. The third function of the amputation service was to prepare cases for evacuation to the United States and to insure arrival there in good condition. This was chiefly a matter of judgment and policy in selecting cases for evacua- tion, since by virtue of authority vested in the local orthopedic consultant no orthopedic patient could be evacuated without his approval. Such a super- abundance of transportable patients was always available that it was necessary merely to make a systematic effort to keep them listed in order to be able to hold the nonevacuable cases for treatment. TECHNIQUE OF AMPUTATIONS In order to understand the special problems encountered in the treatment of amputation cases in the American Expeditionary Forces and the work of the amputation service, it is necessary to review the surgery of military ampu- tations from the time when the limb was removed to the period of convalescence when it was possible to evacuate the patient to the United States. 690 SURGERY IX THE ZONE OF THE ADVANCE In considering the technique of amputations when performed in the zone of the advance, it is important, first of all, to stress the subordinate role which military surgery necessarily occupied in relation to military tactics. Primarily, military surgery had to be adapted to the varying conditions of military ac- tivity. With stable trench warfare the casualties were not numerous, and aside from raids and local actions the facilities of the evacuation hospitals were not strained. During such periods it was possible to give each case individual at- tention and careful after treatment, and special cases could be kept for consid- erable periods without evacuation. In periods of battle activity conditions were quite the reverse. The influx of casualties was enormous, the demand for beds quite in excess of the possibility of supply, and all hospital facilities were strained to the utmost. Each case had to be treated with a view to imme- diate evacuation, and the surgical procedures had to be adapted to meet this need. Further, because of the difficulty of evacuating the wounded from the field of battle under intense fire, the time between receipt of injury and of reaching evacuation hospitals in given instances was usually much greater than in quiet times. Contaminated wounds often became infected wounds before they readied the hands of the surgeon, therefore different operative procedures had to be employed. In such cases the prime endeavor was to obtain adequate drainage. In respect to amputations, this fundamental rule of military surgery was strikingly illustrated. During the periods of quiet in the interval between February 5, 1918, and June 1, 1918, along sectors of the front occupied by American troops, the surgeons of the evacuation hospitals worked under almost ideal conditions. Postoperative cases could be followed for as long a period as was necessary before evacuation. Debridement, with closure by primary, delayed primary, or secondary suture, applied even to amputations. The am- putation usually was performed at the level of the wound or immediately above it, with careful excision of all soiled, damaged, or devitalized tissue. Flaps were formed, not according to the classic modes of amputation, but in the way they could best be otbained from the sound tissues of the limb, with the view to conserving the greatest length of stump. If the time since injury was short and the amount of soft-part damage was well localized, it was occa- sionally possible to close the wound by primary suture. The more common procedure was to fix the flaps in eversion, leave the wound open, and await developments for 24 to 48 hours. At the end of this time the wound was care- fully dressed and bacterial examination made. If the condition of the wound appeared favorable, the flaps were then drawn together and sutured (delayed primary suture). If, instead, there was suggestion of infection, the wound was left open and Carrel-Dakin treatment instituted. A certain percentage of stumps treated by the latter method were closed at the end of 12 to 21 days by secondary suture; the remainder were evacuated and went on to cicatrization, later requiring some type of reconstruction operation. In periods of battle activity the operative procedure was quite different; amputation cases had to be evacuated almost immediately. It had been shown that this immediate secondary evacuation could be done with little risk to the ORTHOPEDIC SURGERY 691 patient if the wound was left open. The great danger was infection, especially of the anaerobic type. Cases could not be watched carefully when being trans- ported on a train, and in the case of a partially sutured stump or of one with flaps, even though these were not closed, infection might develop and assume fatal proportions before the patient reached a hospital where proper treatment could be instituted. It was to meet such a situation that the flapless amputation, unfortunately misnamed the guillotine amputation, had been devised by the surgeons of the Allied Armies early in the war. The skin was divided by a circular incision at the lowest possible level, taking into consideration the condition for which the amputation was performed. The skin was allowed to retract and then the fascia and outer layer of muscles were sectioned at this level and in turn allowed to retract. The inner layer of muscles was then cut and the bone was in turn divided at a still slightly higher level. When the amputation was completed the cut surface was in the shape of a slightly inverted cone or if the retraction had been great, a flat surface. The reproach which has been directed against this operation is not so much against the flapless amputation itself as against the surgeons who mis- understood it and performed it as a guillotine division of the limb. By the latter method no allowance was made for retraction and upon the completion of the operation the wound appeared as a conical surface with the bone pro- truding at the apex and the skin margin representing the base. By this method there was an unnecessary sacrifice of soft parts. Undoubtedly better results might have been obtained if more heed had been given to the conclusions reached by the Interallied Surgical Congress at its meeting in 1917 which, in so far as concerns amputations, are as follows:5 Primary amputations or those delayed 24 to 48 hours will be made as nearly as possible at the site of fracture by simple section of the soft parts or with slight trimming of the bone; in less grave cases the amputation will be made as near as possible to the level of the fracture. Amputation for infection will be done by simple cross section or with very short flaps fixed in eversion. The stump will be regularized, if this is necessary, when the wound is disinfected and when all possible extension of the soft parts has been obtained. A study of the end results justifies the conclusion that the flapless type of amputation had a definite place in military surgery. It possessed the advantages of preserving the maximum length of stump, of providing wide drainage and of requiring a minimum of time for its performance. It had the disadvantages of requiring a protracted period of after-treatment and of necessitating in most instances secondary reconstruction operations to prepare the stump for prosthesis. Cases operated by this method at the front usually were kept under observation for 48 hours, at the end of which time they could be evacuated in safety. If necessary they could be evacuated immediately with only slight risk. Their after-treatment was exclusively a matter for the base hospitals to which they had been evacuated. IN THE BASE HOSPITALS Nearly as many amputations were performed in the base hospitals at the rear as in the evacuation hospitals at the front. The great majority of these amputations were performed for sepsis and were of the open or flapless type. 692 SURGERY The procedure here was similar to that of the front, but with the difference that the patient who was usually very ill did not have to be evacuated. The after-treatment was under the control of the surgeon who performed the operation. In the case of infection involving the upper end of the tibia or the knee joint, disarticulation of the knee by the flapless method proved a useful pro- cedure. The operative risk was much less than with amputation of the thigh and it also possessed the advantages of opening up a smaller amount of fresh tissue to infection and of not giving: rise to troublesome retraction of the soft parts. Later, when disinfection was obtained, reamputation for the purpose of regularizing the stump could be performed under ideal conditions. Fig. 129.-Use of Thomas splint in application of fixed extension to an amputation stump to overcome soft part retraction A good many amputations were necessitated by secondary hemorrhage. Such hemorrhage was always caused by burrowing sepsis, and it was in order to control the latter rather than to stop the hemorrhage that amputation was indicated in most instances. In a certain number of cases amputations were performed, not for sepsis alone, but because of the presence of hopelessly mutilating injuries or of chronic sepsis in which it was apparent that a better functional result would be obtained with an artificial limb than with the injured member even if the treatment of the latter should prove unexpectedly successful In practically all amputations of this latter group the part involved was the toot, ankle, or lower leg. It was well recognized that the possibility of saving any part of a hand justified a long uphill fight, whereas, with the leg, the func- tional result with an artificial limb was in many cases better than if a badlv damaged foot or ankle had been preserved. ORTHOPEDIC SURGERY 693 Treatment Immediately Following Amputation The chief problem of after-treatment was the large number of open amputa- tion wounds. Very little difficulty was experienced in the case of amputations treated by either primary or delayed closure. Unfortunately, the number of these, from the nature of the military situation, was extremely small. This is shown by the following figures obtained from a group of 550 cases treated at the Hospital Center, Savenay.2 Of these, 323, or 58 per cent, were either flapless or guillotine amputations; 170, or 30 per cent, were amputations with flaps but without closure, and only 62, or 11 per cent, were amputations with closure. Of the 550 cases, 493, or 88 per cent, were open amputations as against 11 per cent closed. It is also interesting to note that of the 62 cases with primary or delayed primary suture, only 75 per cent remained closed. Fig. 130.—Use of a spreader in sliding extension applied to an amputation stump to overcome soft part retraction Soft-Part Retraction With an open stump, the chief danger in respect to future function was that of retraction due to the contraction of the severed muscles. Thus, in an amputation of the thigh by the flapless method, if the stump was examined a few days after operation it would be found that the skin had retracted consid- erably above the level of the bone and that the surface of the wound instead of remaining a plane had become frankly conical. If the process was allowed to continue, at the end of two to three weeks the end of the stump would have 694 SURGERY become a long tapering cone with the bone protruding a distance of - to 3 inches, and the distance between the bone tip and the retracted skin margin 5 to 6 inches. If nature was permitted to pursue her course, the marginal cicatrix contracted, shuttmg oft the blood supply to the distal part, and after 8 to 10 weeks there remained only a protruding length of bare bone which in the course of time was sloughed away. The process of retraction and nat- ural reamputation was seen in its most extreme degree in the thigh but it could also be observed in amputa- tions of the upper arm, forearm, or lower leg. It always led to a consid- erable diminution in the length of the stump, and in the case of the thigh this often amounted to as much as 5 or 6 inches. In addition it rendered the F.G. I31.-This and Figures 132 and 133 show amputation stump COnical and leSS Suitable for of the thigh by the flapless method in various stages of prosthesis while at the Same time de- healing under the influence of continuous extension. In . TTV-,,,,.11,-. .. l.^/-.^.! this figure, the first stage, aii possible extension of the creasing its power. Usually a broad, skin flaps has been obtained with the result that the thin terminal SCar resulted which Was skin has turned in over the end of the stump ,, , , , ™ „,.,-. J adherent to the bone, and a second- ary operation usually was required before an artificial limb could be worn. But a stump is, above all things, a lever and, except in certain special regions which are mentioned else- where, its most important asset is length. Therefore the importance of counteract- ing this process at its incep- tion was obvious. Soft-], art retraction could be prevented or, if already present, could be overcome in large part by the proper use of extension. Extension was obtained by the applica- tion to the skin of adhesive plaster strips which extended from as close to the skin mar- gin as possible, wTell up to the base of the stump. The Fig. 132. -Second stage. The scar is contracting, but a fairly large open area with indolent skin margin remains free ends of the strips were attached to tapes and these were fixed by buckles to a spreader of suitable size and shape to which the extension cord was fixed. Traction was obtained either by leading the cord over a pulley at the end of the ORTHOPEDIC SURGERY 695 Fig. 133.—The end result which may be expected in the absence of bone infection. The scar has shut down, pulling the skin with it, and there now remains a thin, adherent puckered scar bed and fastening it to a weight (sliding extension), or by applying a short Thomas splint and the cord fastened to its end under tension (fixed extension). Sliding extension usually was best for hospital treatment, but the fixed extension with the Thomas splint was required for transportation. The adhesive strips did not interfere with the application of the dressings, and the strips were unbuckled from the spreader when complete exposure of the wound was required. The wound treatment could be carried on as adequately with the extension as without. Tnder the influence of extension retraction was pre- vented and healing proceded rapidly. With the circular, flapless type of amputation, the end result was a thin round cicatrix at the end of the stump with or without sinuses, depending upon the degree of bone infection. In open amputations with short flaps the result was often a linear scar, and such stumps were quite suitable for prosthesis with- out other intervention. The great majority of the open amputations, even when treated with extension, required secondary operations to get rid of the scar and the infected tip of bone. Most of these operations were of a simple nature, however, and did not constitute formal reamputations. Sepsis Septic stumps constituted an important part of the amputation problem. Infection was usually only the continuation of the process for which the amputation itself had been performed. It is safe to say that all open amputations were in- fected. All types and degrees of infection were seen and all of the possible septic complications were encountered at different times. Such complications were treated according to the usual surgical principles and require no special mention. In respect to the special manifestations of infection as seen in amputation stumps the most important feature noted was the little difficulty experienced with the flapless type of amputation and the endless trouble encountered when a partial closure had been attempted or when flaps had been formed which tended to fall together. Fig. 134.—Amputation of the thigh by the flapless method with oblique section in order to save the maximum amount of soft tissues. The stump has healed under extension, but there remains a chronic osteomyelitis with multiple sinuses 696 SURGERY Many of the infections terminated by the formation in the stumps of residual abscesses which required drainage; occasionally the infection extended to tlie neighboring joint with the production of a septic arthritis. In a below-the-knee amputation, with secondary infection of the knee joint, if the septic arthritis __P^7 7 _. - 1 ••*• mi z.^.-, 'L.-',\lkm jL " '%' zh **\Sa Jf,\j^0BM ^rMm : *m*a7: ^fc;*Tl_i___ ■■H-- Martin: In "Interallied Conference on the Care of Disabled Sailors and Soldiers. Lancet, London, June 22, 1918, i, 881. (9) The Military History of the American Red Cross in France, by Lieut. Col. C. C. Bur- lingame, M. C. Copy on file, Historical Division, S. G. O. (10) Annual Report of the Surgeon General, U. S. Army, 1919, ii, 1106. CHAPTER VII CARE OF THE AMPUTATED IN THE UNITED STATES ADMINISTRATION The experience of the European nations at the time of our entrance into the conflict was already sufficient to indicate clearly the possible magnitude of our amputation problem. The general use of high-explosive shells and the prevalence of gas gangrene had increased greatly the frequency of amputa- tion and had counteracted the gain due to improved surgical methods; so that, in the face of an estimated total at that time for all the countries engaged of nearly 300,000 amputations, the artificial limb problem had naturally become a serious economic question abroad. While our own country was particularly fortunate in possessing a thriving artificial-limb industry, its usefulness was in great danger of being seriously curtailed both through the loss of its skilled workmen in the draft or by transfer to munition work and also through difficulty in securing supplies. It seemed wise therefore, for our country to make provision for meeting the greatest possible demand under the most unfavorable conditions. It is evident that the highest degree of functional use with the artificial limb can be assured only through an organization of the work which takes into account every phase of treatment. Hence provision must be made for systematic attention during each of the five stages into which treatment naturally divides itself: (1) The amputation itself; (2) the care of the stump; (3) provision of the artificial limb; (4) general functional training; (5) special vocational training. During these successive periods the amputated pass under the care of the surgeon, the artificial-limb maker, and the educational officer. Furthermore, success in training depends in no small degree on the attitude of the general public. To secure the effective cooperation of all these agencies called for a definite program of education. EDUCATIONAL PROGRAM On the part of the surgeon, considerable uncertainty still existed as to the preferable sites of amputation, little attention had been paid to systematic stump care, the use of temporary appliances with plaster-of-Paris sockets as a means of securing early functional use of the stump was practically untried in this country, and but little was known of the general principles of prosthesis. Moreover, the circular method of amputation, which had been found so neces- sary and advantageous in counteracting the dangers of infection, required an entirely different character of after-treatment from the customary amputa- tion of civil life. All these points were covered in articles relating to amputa- tions, fittino- artificial limbs, and the care of the stump,1 and were distributed in reprint or other forms to Army surgeons. Further instruction in the subject was o-ivon to student officers by means of didactic and clinical lectures and practical demonstrations in the various courses of instruction in military 713 714 SURGERY orthopedic surgery. In these courses the artificial-limb makers were fre- quently called upon to explain the design and construction of artificial limbs and the principles of fitting. Later, as the amputation center at Walter Reed General Hospital developed, medical officers were sent there for courses of instruction in the care of the stump, the principles of stump surgery, the tech- nique of the construction of the temporary peg legs, and the general principles of artificial limbs. To educational officers and reconstruction aides, talks, supplemented by the use of moving pictures, were given, covering particularly the details of the later stages of treatment. For the amputated themselves this general educational work consisted of talks to all the men by those in charge of the service, and also practical demonstrations in which civilian amputated who had acquired especial skill showed what is possible with and without an appliance. Facts which every amputated individual should know were formulated and issued in pamphlet form.2 To this was added later information concerning obtaining permanent artificial limbs.3 The slight degree of incapacity for most occupations caused by the loss of a leg, provided a proper appliance be worn, was a matter of common knowl- edge on the part of the general public in our country, but the possibilities in loss of the upper extremity were not so generally known. Moreover, with rare exceptions, employers were prejudiced against the hiring of such men for manual occupations. It was imperative, therefore, that the public should be taught to what extent and in what occupations the amputated were able to carry on productive labor. The success of this part of the work, which was taken over by the division of physical reconstruction, Surgeon General's Office, as a part of its general campaign of education,4 was made possible largely through the generous assistance rendered by the many amputated men through- out the country who had attained positions of competence. AMPUTATION CENTER In planning for hospital accommodations, consideration of efficiency and economy indicated the desirability of segregating the amputated, as far as possible, in one center preferably reserved exclusively for such cases. This was in accord, too, with the experience of other countries. With such a unifica- tion of the work, the fitting of appliances would be greatly facilitated, training in all its forms more readily carried out, and the study of "the various problems in the care of this type of case carried on under the most favorable conditions. Unfortunately, the size of our country offered too great an objection to this arrangement, since the distances involved in the majority of cases were so great as to make it impracticable for the returned soldier to be furlouo-hed to his home or to be visited by his friends. The situation seemed to be be°st met, therefore, by arranging for a chief amputation center, near the ports of de- barkation, with a limited number of subcenters in other parts of the country.5 Walter Reed General Hospital, Washington, was accordingly chosen by the Surgeon General as the chief amputation center, and Letterman General Hospital, San Francisco, General Hospital No. 26, Fort Des Moines, Iowa and General Hospital, Fort McPherson, Ga., were designated as subcenters' ORTHOPEDIC SURGERY 715 A little later, United States Army General Hospitals No. 29, Fort Snelling, Minn., No. 3 at Colonia, N. J., and No. 10, at Boston, were also designated as subcenters. Early in 1919, a change was made in this arrangement, No. 3 at Colonia being designated as the distributing center for all cases of amputa- tion arriving at the port of New York 5 and Walter Reed General Hospital for all those arriving at Newport News.5 Since the port at New York was the one finally used, this resulted in making these services practically equal, each maintaining an average of between 600 and 700 cases during the late spring of 1919. The center at Fort Des Moines became third in importance. That at Letterman General Hospital proved to be the smallest in point of numbers, but it maintained a very high standard of work. THE HOSPITAL SERVICE The ward organization of a large amputation service proved to be an important factor in its success. It was found that not only could treatment be carried out more easily but that discipline was more readily enforced when the cases were divided according to the stage of treatment. A division into the following groups proved the best arrangement: The unhealed; the pre- operative and postoperative; the prefitting and postfitting; the training groups. In the unhealed group, the further separation, as far as possible, of the recum- bent and ambulatory cases aided materially in the control of those who were recumbent. An appliance shop for artificial-limb fitting was provided at each center except at Fort Snelling; here it seemed more expedient, owing to the proximity of one of the manufacturers of the provisional appliances, to have the fitting done at the factory. In arranging the shop facilities, it was not found neces- sary to install an extensive equipment, since parts whose construction called for unusual or expensive machinery could easily be secured from regular artificial-limb manufacturers. This greatly simplified the problem, the equip- ment thus required being no more than that needed for the ordinary orthopedic brace work. Considerable floor space was necessary, however, in order to take care of a large number of cases easily and rapidly; one of the regular one- story pavilions met the needs very well in the smaller centers while in the larger, one of the regular reconstruction shops proved most satisfactory. The medical personnel of the amputation service consisted of its chief who had also professional supervision over the shop, one or, in the larger centers, usually two assistants, one or sometimes two officers in charge of the shop, and the usual number of ward surgeons. The assignment of an addi- tional officer to both the postfitting wards and the shop was found most help- ful in securing better supervision and fitting. The task of securing the required skilled personnel, for surgical and for prosthetic work, proved more difficult than was anticipated. Lack of training in the care of the amputated was largely responsible for this in the case of the surgical personnel, but it was due also to the qualifications demanded by the work, a considerable mechanical ability in addition to the surgical knowledge being necessary. Furthermore, few men were anxious to confine themselves to such an apparenthT restricted field for the duration of the war. In the case of the personnel for prosthetic work, the artificial limb workmen accepted 716 SUROERY under the draft were few in number and on account of their age naturally of only moderate experience. Moreover, owing to the regulations covering overseas duty, it was difficult or even impossible to reserve them for domestic service. The number secured was so small that it became necessary to train men for the various details of limb construction and fitting. ARTIFICIAL LIMB LABORATORY The Surgeon General recognized from the first the importance of making adequate provision for the study of the design and construction of prostheses, particularly from the standpoint of standardization, and for the proper testing of the many new appliances and devices which were being constantly presented, as well as for the carrying out of experimental work. He accordingly author- ized the establishment of an artificial limb laboratory for this purpose.6 The equipment for this laboratory, which it seemed wisest at first to restrict to a comparatively simple character, was installed at the Army Medical School, Washington, D. C, in January, 191S,7 but was moved to the Walter Reed General Hospital in March of the same year,7 in order to secure better coor- dination between the experimental and the clinical parts of the work. A certain amount of both experimental and routine prosthetic work was still carried on at the Army Medical School, however, throughout the war, in the shop of the orthopedic section. SUPPLY OF ARTIFICIAL LIMBS The artificial-limb situation in the United States was such as to put on the question of Government manufacture an entirely different aspect from that which obtained in other countries. The large number of amputations in the Civil War, with the enormous yearly addition from industrial accidents which occurred before the introduction of the "Safety first" movement, had tremen- dously stimulated endeavor in this field, so that our artificial-limb industry had become the best developed in the world. Not only was the industry a large and thriving one but in addition it was well distributed geographically, so that there was hardly a city of importance that did not have one or more artificial- limb concerns. While the output of some of these was small and the shop facilities far from modern, a number of our larger firms had been engaged since early in the World War in supplying limbs in very considerable numbers to our Allies, thus showing their ability to handle a large volume of business. Also it was learned by means of a questionnaire sent out by the Surgeon General that the industry as a whole, with its existing equipment, could produce a thousand limbs per month in addition to the number required for civilian needs.8 Furthermore, in order to be better prepared to handle the problem and to utilize to the fullest extent the resources of our country in this respect, the manufacturers, at the suggestion of the Council of National Defense', had formed The Association of the Artificial Limb Makers of the United States.9 In view of the ample facilities afforded by the established industry, therefore, it seemed unnecessary to attempt Government manufacture. Our relation to the question of standardization also seemed to differ from that of other countries. Examination of the product of a large number of concerns showed a surprising uniformity in all essential points. While differing ORTHOPEDIC SURGERY 717 in minor details, they were with few exceptions similar in design, substantial in construction, and excellent in workmanship. Since the established policy of bonding manufactures who desired to supply limbs to the Government furnished a means of eliminating the incompetent, it seemed unwise during the stress of war to subject approved manufacturers to the expense and inconvenience that would be caused by the insistence on the production of definitely standard- ized types. Moreover, while the needs of the Army might have been met in a very satisfactory manner by the arbitrary choice of any one of several established models as a standard, an actual standardization was clearly out of the question at that time. To be of any real value standardization can not be based on opinion but must rest on scientific study. It is an undertaking which is obviously not to be considered during war but which offers a very proper subject for the attention of the Government in times of peace. Our artificial-limb problem was made somewhat more difficult by the enactment of the War Risk Act, October 6, 1917.10 Up to this time artificial limbs had been issued by the Medical Department, and hence under the authority of the War Department. In this act, however, Congress provided for their issue to discharged soldiers and sailors through the Bureau of War Risk Insurance, thus transferring the authority to the Treasury Department. The situation was thus complicated in that the case passed from the control of one branch of the Government to that of another at an important stage in treatment. For, to retain the amputated soldier in the service as a patient in an Army hospital during the long period necessary for the stump to attain its final form and so be in proper condition for the fitting of the permanent artificial limb, was obviously inadvisable from the standpoint of the Army and of the soldier himself. Yet it was just as obviously essential to provide for his proper training in the use of an appliance of the final type, such training being regarded as one of the most important parts of modern treatment. To meet all these conditions the provision of prostheses of regular design, so as to fulfill the requirements of training, but constructed with the intention of meeting the demands of the wearer only during the first six months, or if necessary the first year, of stump life seemed most satisfactory. An artificial leg of this sort can be constructed on the "ready-made" plan. Fiber may be used in place of wood and sufficient parts carried in stock to fit individuals of different height and size of stump. The fiber socket can be adapted very satisfactorily to thigh amputations, while in below-knee amputations it can be used to hold the plaster-of-Paris socket. The artificial arm can be constructed on this plan more easily than the artificial leg. The advantages of such a method are many: (a) The minimum demand is made upon industry, since all the work of manufacture may be done in established plants and only such shop facilities have to be provided at the amputation center as are required for fitting and repairs, (b) Production in any quantity is possible, and hence in the event of the number of the amputated being so great as to overtax the established artificial-limb industry, a means is thus provided for meeting the need until such time as the permanent limb can be secured, (c) The maximum number of amputated can be cared for, the time required for fitting the ready- made appliance being much less than for the special one, and no more than 718 SURGERY when the temporary leg is used, (d) The educational value of the provisiona leg is an important feature, the wearer learning how an artificial leg should feel and act and how to care for it; this knowledge naturally makes easier the work of the skilled artificial-limb maker and is at the same time the most certain means at our command for eliminating the unskilled one. (e) The conditions imposed bv the War Risk Act are met most satisfactorily. (/) An equitable distribution of the work of supplying the permanent appliance is favored, since it is not secured until the amputated have reached their homes; this not only makes possible the maximum output but is in accord with estab- lished Government policy. TREATMENT OF AMPUTATION STUMPS In order to record fully the results of experimental development and clinical observations of the surgical and prosthetic treatment of stumps in all centers, a questionnaire was prepared covering all the salient points. This was sub- mitted to the former chiefs of amputation centers with a request that a detailed statement of their observations and experiences be given, using the outline as submitted in order to facilitate the study of comparative methods and results. The experiences herein related and the conclusions drawTn constitute a review of the reports received from the former chiefs of amputation sections.11 AMPUTATION CASES RETURNED TO THE UXITED STATES The following is a list of the total number of amputation cases which were returned to the United States:12 LOSS OF EXTREMITIES Upper extremity: One arm above elbow______________________________________---------- 550 One arm at elbow____________________________________________________ 41 Both forearms____________________________________________ _________ 3 One forearm____________________________________________ __________ 212 One hand at wrist_____________________________________ ________ 26 Both hands__________________________________________ _ . . 1 One hand________________________________________ _____________ 18 Part of both hands___________________________________________________ 4 Part of one hand_____________________________________________________ 1, 481 One arm and one forearm_____________________________________________ 1 One arm above elbow and part of hand____________________ ____________ 4 One arm below elbow and part of hand____________________ ____________ 1 One forearm and one hand___________________________ __________ 2 One hand and part of hand_________________________ __________________ 2 Total------------------------------------------------------------ 2, 346 Lower extremity: Both thighs________________________________ ___ __________________ 11 One thigh----------------------------------------------------------- 1, 137 Both legs at knee____________________________________________ 1 One leg at knee_______________________________ _______________ 95 Both legs below knee__________________________ _______ 9 One leg below knee____________________________ ______________ 327 Both legs at ankle________________________________________________ 3 One leg at ankle___________________________________________________ 131 Both feet_________________________________________________________"~ 1 One foot________________________________________________________ 20 ORTHOPEDIC SURGERY 719 Lower extremity—Continued. Part of both feet______________________________________________ 3 Part of one foot__________________________________ _____ 280 Thigh and leg at knee___________________________________________ 2 Thigh and leg below knee___________________________ 5 Leg at knee and part of foot____________________________ ______ 2 Leg below knee and foot__________________________ 2 Leg below knee and part of foot___________________________________ 3 Total-----------------------------------------------------2, 032 Upper and lower extremities: Arm above elbow and one thigh___________________________________ 3 Arm above elbow and leg below knee_______________________________ 1 Arm above elbow and one foot____________________________________ 1 Arm above elbow and part of one foot.:______________________________ 1 Arm below elbow and one thigh______<_____________________________ 2 Arm below elbow and leg below knee__'_____________________________ 4 One hip and part of hand________________________________________ 1 Leg at thigh and part of hand_____________________________________ 8 Leg at knee and part of hand_____________________________________ 1 Leg below knee and part of hand__________________________________ 3 Total_____________________________________________________ 25 Grand total________________________________________________ 4,403 COXDITIOX OF STUMPS J)N ARRIVAL IN THE UNITED STATES In 1918, when the number of amputations was yet small, the majority of stumps were healed when they were received in base hospitals in this country, Fig. 153— This and Figures 154 to 157 show the average Fig. 154 sagittal stumps from four to eight months after trauma and many of them were fitted with temporary appliances. Later, when the number of wounded rapidly increased, most of them were only partially healed. Contractures of adjacent joints were only occasionally seen, the most common 46997—27-—4S 720 SURCKRY being short thigh stumps showing a varying degree of flexion and abduction deformity; flexion contracture of leg stumps less frequently; Chopart stumps in equinus; forearm|stumps with limited supination and arm stumps with limited abduction. The vast majority of the amputations were of the sagittal [Fig. 155 Fig. 156 (guillotine) type, or the modified sagittal with irregular skin flaps. These stumps usually showed a terminal circular or an irregularly shaped granulating area with partial marginal epithelization, often unhealthy in appearance, and Fig.157 Fig. 158.—Same as in Figure 157 after reamputation and healing almost invariably giving positive cultures of staphylococcus and streptococcus, and occasionally diphtheria. A limited number showed visible sequestration of bone. Ldema of the soft parts adjacent to the wound was the rule and its extent was dependent upon the degree and nature of the infection and upon the ORTHOPEDIC SURGERY 721 site of the amputation, being more marked and more persistent in amputations below the middle third of the leg, and in the lower third of the forearm. It was evident in most cases in which primary aseptic amputations had been per- formed that the published official in- structions regarding sites for amputa- tion13 had been adhered to. Inspiteof the fact that infection was the rule in stumps requiring secondary surgery, conditions were favorable when con- trasted with those existent at the time of the primary amputation overseas. In the latter case the primary consid- eration was the eradication of a poten- tial life-destroying pathological proc- ess with the minimum sacrifice of limb length, whereas under the compara- tively favorable conditions existing at the time Of the Secondary Stump FlG 159—stump showing terminal edema and other evi- SUrgery it Was possible to give full dences of latent infection consideration to the prosthetic and functional requirements of the stump. STUMP PATHOLOGY Referable to Bone In nearly every case it was evident that the bone as well as the soft parts had been exposed to infection with a resulting localized osteomyelitis of varying degree. The process of sequestration and involucratization, with associated low-grade infection of the adjacent soft parts, did not differ materially from osteomyelitis under other conditions; it was usually limited to the terminal portion of the bone on account of the fact that drainage was thorough. This terminal osteomyelitis was one of the chief causes of long delay in healing and required roentgenograph^ study and special treatment before secondary final plastic operations could be successfully done. The most common type of sequestrum seen was ring-shaped, usually about 1}4 cm. in thickness. It was usually loose and partially visible or palpable; less frequently it was more or less concealed by excessive bone production extending down from the bone cortex. In some instances it was seen to be practically encapsulated by new bone formation with a small sinus leading through the latter. Excessive terminal bone production in guillotined stumps was the rule. The most common form was an irregular mushrooming, with a tendency to spurs on the inner aspect of the femur. Occasionally sharp exostoses were seen. These often were sharp enough and long enough to cause sufficient pain to warrant their removal. 722 SURGERY Interosseous bony union was seen in both the forearm and leg. In the former, operative interference was instituted only when the forearm stump was long enough to preserve the movements of pronation and supination. Treatment consisted in removing the connecting bony overgrowth and the mter- Fig. 160.—Typical ring sequestrum position of muscle. Obviously in the leg this condition is helpful rather than detrimental, unless associated with terminal sharp exostoses. Displacement of the patella in the Stokes-Gritti amputation and of the portion of the os calcis in the Pirogoff operation were seen. Nearly all ampu- ORTHOPEDIC SURGERY 723 tations of the types were unsatisfactory and required additional surgical treat- ment. Comminuted fracture complicated by extensive osteomyelitis of the shaft was met with occasionally. Preliminary treatment of the osteomyelitis was of course instituted before stump surgery was attempted. Fig. 161.—Complete ring sequestrum surrounded by new bone formation. The stump is healed except for small sinus from the sequestrum Inequality in the lengths of the bones in amputations of the forearm and of the leg occasionally demanded correction. In leg amputations the prosthetic requirement that the fibula be approximately 2 cm. shorter than the tibia, as a rule had been met in primary amputation. In certain short leg stumps it had evidently been possible at the primary amputation to save several inches of fibula but a much smaller amount of tibia. Such cases naturally form an exception to the general rule. 724 surgery- Referable to Soft Pakt. Stumps with redundant soft parts were seldom found. When this con- dition did occur it was usuallv associated with late necrosis of bone or with Fig. 162.-Excessive terminal bone production, "mushrooming." Note that muscles are above this area extensive comminution of bone without equal damage to the soft parts, in which case it was, of course, wise to save all viable soft parts available,' as thereby greatly facilitating the late plastic surgery. The secondary removal orthopedic surgery 725 of soft parts for surgical or prosthetic reasons was not done until the necessity for and the possibility of utilizing them in connection with osteoplastic methods to increase the length of the stump had been considered. Fig. 163.—Bony spur in below-knee amputation Tender nerve ends occurred most frequently in amputations of the upper extremity. Thev seldom make themselves manifest until an appliance has been worn so that in the treatment of unhealed stumps it was considered safest to assume that every nerve which was palpable might give trouble, and 72(i SURGERY its treatment was indicated at the time of the secondary plastic procedure. Simple high division after crushing and ligature seemed to give results equally as good as those obtained after more elaborate neuroplastic methods. Fig. 164.—Interosseous bony union in below-knee stump. Spurs PREOPERATIVE AND XOXOPERATIVE TREATMENT In a preliminary report of experiences in treating the first 500 cases, pub- lished in 1919,14 a very conservative policy in the surgery of unhealed stumps was advocated. It seemed then that by the use of skin traction and other ORTHOPEDIC SURGERY 727 nonoperative measures, healing could be obtained in a reasonable time and that secondary operative surgery of the stump could be dispensed with in the majority of cases. Subsequent experience showed that it was impossible to obtain complete healing in guillotined stumps, but that a very long time was required and that the resulting scar was not sufficiently tolerant of the usual traumas of an appliance to be practical. It was also found that many stumps either actually required reamputation at a higher level or that a limited amount of bone could be removed without damaging the stump from a functional viewpoint; so that finally plastic methods designed to obtain a firm closure, with freely movable skin, were employed usually before cicatrization was complete. The importance of surgical rest and in most cases actual recumbency in the treatment of large infected wounds of the extremities was frequently observed and can not be too strongly emphasized. Nothing was gained by hastening prosthetic treatment to the point of applying temporary prosthesis before the stump was considered surgically sound. In the majority of cases it was found best to treat all cases judged to require secondary surgical pro- cedures in recumbency until wxounds were in the required condition for opera- tion. It was noted repeatedly that wounds which had remained practically stationary under ambulatory treatment would promptly improve in recumbency. Skin traction was used as a matter of routine both in recumbent and am- bulatory treatment. In the former, direct extension was employed by means of adhesive strapping with pulley and weights and in the latter counter- extension with a modified Thomas splint. It is interesting to note that the former method is accurately described in "The Medical and Surgical History of the Rebellion."15 Traction was, of course, most effective when applied immediately after the amputation. Its effect then was to actually reduce the extent of uncovered area. If it had not been applied early and the skin had been allowed to retract and to become adherent to the edges of the ulcer, traction did not tend to reduce the unhealed area materially, but it relieved tension at the edges, thus favoring healing, and was particularly helpful in subsequent plastic operations by rendering the skin more redundant. In a few cases in which there was wide retraction of the skin in short stumps, it seemed best to dissect the skin free and then apply traction for a time before attempting final plastic closure. The favorable influence of stump traction in the prevention of joint contractures was repeatedly observed. WOUND ANTISEPSIS The Carrel-Dakin routine treatment was used in all infected stumps as long as the unhealed area was large, concave, and discharging pus freely. Dichloraminc-T was substituted when the wound became smaller in area, the granulations healthy and reasonably clean. Massage of the terminal part of the stump was found to be beneficial in several ways. In healed stumps with small scar areas adherent to bone, mas- sage was effective in loosening the scar and improving its circulation and thus increasing its tolerance to trauma. In unhealed stumps massage of the skin 728 SURGERY adjacent to the scar area assisted in removing edema and generally improving the circulation, as well as rendering the skin free and more redundant pre- paratory to the final plastic procedures. ATTENTION TO ADJACENT JOINTS The following prophylactic measures against joint contractures were used: In so far as it was possible, the recumbent position of the patient and the adjustment of traction was such that the usual contractures would tend to be prevented. At each dressing the stump was moved to the full limit in the opposite direction to that in which a contracture was most likely to develop. WHEN SECONDARY STUMP SURGERY SHOULD BE DONE Attempts to perform early secondary closure of infected guillotine stumps resulted in a high percentage of failures. It seemed that the most impor- tant factors causing the failures were (1) the poor general condition of the patients following the more or less recent severe trauma on the battlefield in conjunction with the subsequent operative and postoperative treatment, and (2) absorption of toxins from latent infection of the stump, which is not only present in the terminal granulating area, and in many cases in the terminal portion of the bone, but, as has been conclusively shown by Huggins 16 and others, also exists in the lymphatic channels for a considerable distance proximal to the unhealed area. It was found that it was not justifiable to attempt plastic closures or re- amputations adjacent to the unhealed area until at least five or six months had elapsed from the time of the original injury. An attempt was made to establish definite preoperative indications by bacterial counts from the wound surface, but it became apparent that this method of control was not reliable, as it gave no exact indication of the extent of latent infection in the lymphatic channels further up the limb. It was found better to depend upon observa- tions referable to the clinical appearance of the stump and the general condi- tion of the patient. As long as the stump remained swollen, boggy, and edematous it was found that there was latent infection present which defeated attempts at plastic closure. The disappearance of the edema was usually coincident with the gradual improvement in the general condition of the patient and in the local appearance of the unhealed area. Final closure was deferred until (1) the skin and subcutaneous tissue was soft, dry, and wrinkled, freely movable and absolutely free from edema, (2) all sinuses leading to bone or other foreign bodies had been radically treated and cured, (3) cultures from the unhealed area were free from streptococcus and the field count was reasonably low (less than five to the field) for other less virulent pyogenic organisms. OPERATIVE TREATMENT OF UXHEALED CASES From the standpoint of treatment stumps could be conveniently and advantageously divided into three distinct groups, as follows: Group I.— Stumps in which a limited amount of bone may be removed without diminish- ORTHOPEDIC SURGERY 729 ing the ultimate functional value of the stump. Group II.—Stumps which are already too short and which will, consequently, not permit of additional sacrifice of bone. Group III.—Those in w-hich sagittal amputation has been done at a site considerably distal to the ultimate secondary site to be selected. Group I The question of bone length required careful consideration in every case, and there were times when it was justifiable to sacrifice ideal conditions regard- ing the soft parts in order to preserve it. On the other hand, in perhaps the majority of the sagittal amputations, little was lost in ultimate function by removing a limited amount of bone and much probably was gained by the additional freedom allowed to eradicate more thoroughly tissues subject to Fig. 165.—Long thigh stump requiring secondary plastic operation. Example of Group I possible pathological changes in the terminal portion of the infected stump. The following are examples in this group: Sagittal amputations 9 inches or more below the knee-joint; infected sagittal knee-joint amputation. Before attempting final plastic closure of stumps in this group it was necessary that all indications previously pointed out regarding the proper time to operate be present, except that the actual size of the unhealed area could be safely disregarded. The following method seemed to give the best results and was quite generally used: The unhealed area and the scar are completely covered with a gauze spono-e which has been saturated with tincture of iodine. The incision is now made in healthy skin one-half cm. from the edge of the scar. It should follow the general contour of the scar area. Xo attempt should be made to form specially designed skin flaps. The distal skin is clipped to the iodined 730 SURGERY gauze as the incision is being made, thus completely isolating the terminal infected area. The skin and scar are then dissected distally, separating them from the muscle, to the place where the latter are attached to the bone. It will usually be found that this is above the area of new bone production and well away from the unhealed area, usually 1 to 1^4 inches. The periosteum is incised just within the area of fibrous tissue which extends somewhat distal to the muscle fibers. The bone is sawed at this point. If the preoperative treatment has been properly carried out and the scar area is not excessive, it will now be possible by careful disposition of the skin to cover the end com- pletely. If it is found that the available skin is not sufficient, additional bone or muscle may be removed. It is better to avoid cutting through the muscles and deep vessels. The nerves are found usually by palpation and should be pulled down and severed through a small longitudinal incision in the muscles. The wound should be drained for 4S hours through a posterior stab wound This type of drainage was found to be preferable because it gave the best drainage, being dependent, and, in the event infection occurred, sufficient drainage was afforded to prevent the incision line from separating. Primary union in the incision line was often obtained and maintained in the pres- ence of purulent discharge which was satisfactorily taken care of through the posterior drainage incision. Group II In this group it was found to be imperative that at least six to eight months should have elapsed since the initial injury and that in addition to the pre- operative requirements already enumerated, it was preferable that the wound be completely cicatrized or that the unhealed area be very small and practi- cally sterile. The aim of operative procedures in this group was to remove intolerant scar and to replace it by freely movable healthy skin. The following methods were used and found successful. In short below-the-knee stumps the presence of the fibula is usually not desirable; moreover, by its removal, sufficient skin can be mobilized to cover successfully a fair-sized scar area. In addition, muscular tissue of the calf may be removed quite extensively without injuring the stump in any way. In conjunction with these measures it was usually necessary to employ one of the following methods of skin mobilization: (1) Single or double pedicle swing, in which case flaps of skin and subcutaneous tissue of various shapes were swung from the lateral surface to the terminal surface of the stump, closure of the donor area being accomplished by diminishing the circum- ference of the stump. (2) Double pedicle transplant. A rectangular flap taken from the posterior was dissected free and moved to a terminal position with double pedicles, internal and external. This method was very successful in short leg stumps with a broad, smooth, bony surface. Total end bearing was usually made possible. (3) Distal pedicle transplant. This is a well- known method and requires no further mention here. In short thigh stumps closure was usually made possible by using the single pedicle swing flap. Occasionally it was necessary to remove a limited amount ORTHOPEDIC SURGERY 731 of muscles. It was found best to remove a triangular section with the base external. Muscles on the inner surface could be removed with the least damage. Thiersch and Reverdin grafts were occasionally tried. Healing was of course hastened, but closure was not firm enough for practical purposes. Group III Amputation through the ankle joint may be cited as an example of this group. In this case the Syme amputation could not be considered, as sufficient soft parts are not available, so that the middle and lower third of the leg is the site to be selected. Another example is sagittal amputation one-half inch below the knee joint, requiring a formal amputation. In this group it was possible largely to disregard pathology referable to the terminal part of the stump and to proceed with the final amputation much earlier than in the other groups. In all cases, however, it was found advisable to adhere strictly to the rules regarding delay until the general condition was sufficiently improved to withstand a major surgical procedure, and to those regarding edema of the soft parts and associated lymphangitis and lymphadenitis. The treatment in this group was formal reamputation. A reamputation is equivalent practically to a primary amputation under ideal conditions and necessarily involves careful consideration regarding the site of amputation and its influence upon the ultimate functional result. The value of a stump in terms of function can be correctly estimated only when the stump and its prosthesis are considered as a composite functioning unit. It follows then that in order to choose the proper site one must consider care- fully the comparative value of prosthetized stumps. SITE OF AMPUTATION OR REAMPUTATION WITH REFERENCE TO PROS- THETIC REQUIREMENTS LOWER EXTREMITY Foot Phalangeo-metatarsal amputations and transmetatarsal amputations.—These were infrequent, but it was noted that amputations anywhere in the metatarsal area gave good function. All the bone length possible should be saved. It is a mistake, however, to attempt to preserve bone length in the foot at the ex- pense of perfect skin covering. A scar on the foot healed by granulation, directly overlying bone, inevitably will ulcerate and cause intermittent dis- ability which eventually will lead to a reamputation. Every effort should be made to obtain a dorsal linear scar, the ends of the bones being well covered with a plantar flap. The use of the distal pedicle transplant will sometimes obviate the necessity for reamputation in these stumps. Lisfranc's amputation.—Amputation at the transmetatarsal joint gives reasonably good function. Dorsal flexion of the foot is better preserved by anchoring the dorsal flexors to the ends of the bones. The same general sur- gical considerations apply here as described for metatarsal amputations. The 732 SURGERY* only appliance necessary for this, as well as the former, is a filler for the toe of the boot and a steel inset in the sole to prevent turning up of the toe. TranstarsaJ amputations.—Transtarsal amputations distal to Chopart's joint seemed preferable to Chopart's amputation, as proper balance of the dorsal and plantar flexors of the foot is better preserved. However, the same prosthetic objections apply to this amputation as to the Chopart. Chopart's amputation.—Mediotarsal (Chopart's) amputation usually re- sulted in bad function for surgical as well as prosthetic reasons. The majority seen were sagittal amputations at this site, in no sense classical Chopart's amputations, but rather guillotine amputations at or near the mediotarsal joint. It was assumed that it was not the intention of the surgeons who per- formed the primary amputations that these should function as Chopart stumps. Most of them required reamputation. Attempts to improve them by plastic methods were usually not successful. The conclusion drawn from experiences in treating a limited number of classical Chopart stumps are as follows: (1) Surgical difficulties—(a) The type of injury requiring a Chopart stump seldom Fig. 166.—A typical sagittal Chopart stump leaves sufficient plantar flap to permit the scar being well placed on the dorsal surface, (b) Equinus deformity of the stump eventually develops in spite of efforts to preserve foot balance by tenoplastic procedures. As equinus develops the scar which is usually terminal and poorly vascularized is pressed upon, and end bearing, the greatest asset of this stump, must be forfeited. (2) Prosthetic difficulties—The stump is too short to properly anchor the necessary "fill" in the fore foot, so that constant friction between the toe "fill" and the end of the stump takes place, usually resulting in ulceration and consequent disability. Lack of stability in the toe part of the appliance prevents the neces- sary forward thrust in walking so that slight limp is invariably present. In many Chopart stumps it is necessary to anchor the fore foot by extending a steel rod to the ankle joint and connecting this by a joint to a steel upright which is laced to the leg. This appliance requires a special shoe with a very unsightly ankle. The percentage of surgical successes in Chopart is so low and the pros- thetic difficulties so considerable that it is not a justifiable amputation unless it is intended that a simple elephant boot be worn continually instead of the ORTHOPEDIC SURGERY 733 articulated appliance. This point is mentioned because there are undoubtedly cases in which occupational considerations should predominate over the esthetic. Pirogof's osteoplastic amputation.—Two cases are recorded which required reamputation on account of displacement of the remaining portion of the calcaneum. The added risk of an osteoplastic procedure is not compensated for in any way, as the percentage of total end-bearing stumps following the Syme amputation is quite as high as in the Pirogoff. The added length in the Pirogoff requires that the other shoe be raised at least an inch to make up for the space required for the ankle movement. Syme amputation.—The chief advantages noted in the perfect Syme ampu- tation were that it is total end bearing and that the length of the limb is approxi- mately preserved, so that the patient can move around in the nude without his appliance, and that either the straight boot or the appliance with an articu- lated foot can be worn with reasonably good function. Unfortunately, the percentage of perfect Syme stumps was not high. Failure was usually attributed to one or more of the following causes: Sloughing of the planter flap due to cutting the pedicle too narrow; lateral displacment of the flap; sawing the bones at right angle to the terminal axis of the tibia rather than to the long axis of the leg; making the bone section too near the joint to allow space for the mechanism of the artificial ankle. Functionally, a perfect, total end-bearing Syme stump is a satisfactory stump. The choice between this amputation and one at the ideal site in the leg is one which involves an analysis of the occupation and habits of the patient. A laborer is better satisfied with the Syme amputation because he can wear a straight, nonarticulated boot during the working hours, and he is less likely to be dissatisfied with the bulky, unsightly ankle mechanism when "dressed up" than a professional man, for example, would be. The Leg Amputations in the lower third.—The rare opportunity of observing a con- siderable number of amputations in the lower third of the leg was offered. Ail required reamputation mainly on account of poor vascularity and asso- ciated complications. Nothing is gained by the additional bone length in these stumps, as excessively long leg stumps interfere with proper shaping of the ankle portion of the artificial limb and may actually interfere with the ankle mechanism. Amputation at the ideal site.—Amputation through the middle of the leg, or a little below, as recommended in an official publication,13 proved to be the preferable site. The essential points in the technique adopted were: (1) Long anterior and short posterior flaps, the scar line being posteroterminal; (2) circular division of muscles without suture or the use of a thin flap ot muscle and facia sutured over the bone ends to prevent adherence of the skin to bone; (3) divi- sion of the fibula one-half inch higher than the tibia; (4) beveling of the tibial crest* (5) drainage when necessary through a small stab wound in the middle of the posterior flap. The appliance for this amputation is simple, durable, and shapely. If the fitting is proper, disability is scarcely discernible. Stump tolerance to the appli- 734 SURGERY ance is quickly acquired and the functional result is very gratifying to all con- cerned. In amputations oi the leg above this level every effort was made to preserve all bone length possible. When the amount of bone length that can be pre- served with good soft part coverings is 3 inches or less, it is justifiable to sacrifice ideal conditions as regards the soft parts, if bone length may thereby be increased It was generally considered early in the war that it was not justifiable to attempt to amputate below the knee if the amount of bone length possible to be saved was less than 3 inches. Subsequent surgical and prosthetic developments warrant a revision of this opinion. In these cases the leverage may be increased. to the point of utility by removing the fibula, cutting away practically all of the muscular tissue on the back of the stump and severing the inner hamstring. Special study and experimentation in the prosthetic treatment of short stumps carried out at various clinics gave promise of increasing the functional utility of stumps not less than 2 inches in length, so that it seems best to defer ream- putation until surgical attempts to increase bone length or to increase leverage by other methods have failed. Fig. 167.—Transcondylar reamputation. Total end bearer The Thigh If it was not possible to amputate below a point 2 inches from the knee joint (bone length), the next best site proved to be the high transcondylar amputation. This excludes knee-joint amputations, all osteoplastic amputa- tions at or immediately above the knee joint, and low transcondylar amputa- tions. All ot these are too long to allow the use of the standard artificial knee action and require a cumbersome and faulty mechanism outside the clublike stump. Osteoplastic amputation (Stokes-Gritti) offers nothing in function above the high transcondylar to compensate for a rather high percentage of ORTHOPEDIC SURGERY 735 surgical failures (in three seen by the writer at Walter Reed General Hospital all required reamputation) and the prosthetic difficulties already mentioned. In the high transcondylar amputation the bone section is made at the point where the condyles begin to merge with the shaft. It is important to keep within the spongy bone just below the beginning of the medullary cavity proper. A long anterior flap of skin and quadriceps tendon is used. The scar is placed well posteriorly, away from the end-bearing surface. Surgical failures are few. Practically all of them permit total end bearing. Ample space is left to place the standard artificial knee action in the proper place. Above the site for the high transcondylar amputation every effort was made to save all bone length possible to a point 2 inches below the lesser trochanter. All stumps having bone length of from 2 to 4 inches below the lesser trochanter require a pelvic band. This is an objectionable feature, so that a special effort was always made to preserve more than 4 inches, if possible. A stump having bone length of less than 2 inches below the lesser trochanter does not have sufficient leverage to operate the thigh appliance. The only choice, then, is to give a stump suitable for the so-called hip-joint appliance. From a prosthetic and functional viewpoint the classical disarticulation at the hip is not preferable to amputation through the neck, which is much more quickly and easily performed. In the latter the mortality is lower, and the resulting stump is better adapted for the fitting of an appliance. It was not, however, considered justifiable to reamputate a stump too short to operate the usual thigh appliance for prosthetic reasons solely. UPPER EXTREMITY The role of the appliance in the functional utility of stumps of the upper extremity is considerably less important than is the case in stumps of the lower extremity. In fact, it is debatable whether or not appliances in the case of single amputations of the upper extremity are of sufficient value to consti- tute a deciding factor in the selection of site. The young soldier who has lost an arm is eager for his appliance, because he is desirous of masking his disability and because he hopes that it will be functionally useful. To his great disappointment, he soon realizes that it is indeed a poor substitute for either purpose. It has been found that approximately 60 per cent of individ- uals who have suffered the loss of a single arm do not find existing prostheses sufficiently useful to compensate for the inconvenience of wearing them, except occasionally for esthetic reasons. The following conclusions regarding sites are based upon the use and requirements of American prostheses existing at the time our amputation cases were being treated and do not involve a con- sideration of surgical and prosthetic experimental work being carried out in various foreign clinics during and after the World War, as opportunity for exhaustive study and practical applications of these appliances and methods was not possible in the short time offered. The Hand In primary surgery immediately following the trauma nothing more should be done than debridement, trimming the devitalized tissues, and establishing 73(» SURGERY thorough drainage, the question of site being totally disregarded. The pre- vention of contractures of the fingers following infection and of the formation of scar tissue demands special attention from the beginning. In the secondary surgery of the hand radical alteration in the site of amputation is seldom advisable. The usual conditions demanding treatment are, sluggish, unhealed areas associated with localized osteomyelitis, or tender and adherent scars with deforming tendency. The latter condition usually demands special plastic procedures, the aim of which is to displace the scar by freely movable tolerant skin. The distal pedicle transplant gave the best results where it was impor- tant that no bone should be sacrificed. Usually a portion of a phalanx of any of the fingers except the index and thumb can be sacrificed without serious functional damage in order to obtain good soft part covering. The loss of the thumb or any part of it constitutes a serious disability. A badly damaged thumb, with loss of muscular power or ankylosis, or both, is preferable to no thumb at all. Heroic efforts at reconstruction of the thumb are justifiable. One case in which a thumb stump was lengthened one-half inch, with gratifying functional improvement, has been reported.17 Prostheses for amputations of individual or multiple digits are very useful but are usually inferior to even a severely mutilated stump. They are most useful if the thumb is amputated or if all except the thumb are gone, as apposi- tion is made possible by their use. If sufficient of any of the fingers remain to make active apposition possible, prostheses are seldom worn except for esthetic reasons. Transcarpal amputation is preferable to amputation at the wrist even though there may be an adherent terminal scar. The latter can be repaired by distal, pedicle skin transplant. Wrist-joint amputation is distinctly preferable to any higher up, as prona- tion and supination are better preserved, and the fitting of an esthetic hand or a work appliance is facilitated by the more or less club-like end of the stump, which permits the elimination of much attachment apparatus. The Forearm Amputation in the forearm should be done as low down as possible. In the lower third circulation is often poor, but usually not troublesome enough to warrant amputation higher up solely on this account. Primary amputation should seldom be done higher up for this reason, and reamputation should not be considered unless all efforts to improve the circulation have failed. The im- portance of preserving pronation and supination warrants special attention to surgical details; i. e., careful treatment of the periosteum to avoid shredding and consequent overproduction of bone and the interposition of muscle to prevent bony bridging. No matter how short a forearm stump may be, it should not be sacrificed, as in the majority of cases a forearm stump, no matter how short, is more useful without prosthesis than an upper-arm stump either with or without an appliance. They should never be shortened to correct inequality in the length of the bones. Tender scars or scars objectionable for any reason should not be corrected by the ORTHOPEDIC SURGERY 737 sacrifice of bone, but by plastic methods involving the soft parts only. The presence of redundant soft parts in this region constitutes an indication for plastic methods to increase length rather than for their removal. The Upper Arm Transarticular and transcondylar amputations are generally considered objectionable from the standpoint of existing prosthesis, because the fitting is difficult and there is inconvenience to the patient in applying and removing the apparatus. Moreover, the artificial joint must be placed lower than normal. On the other hand, experience shows that in single amputations less than 20 per cent of persons with amputation of the upper arm wear appliances. Of these it is reasonably safe to assume that the majority are wearing a practical (work) appliance rather than the dress-up type. The newer types of the former, are more securely fitted with less "harness" if the bony prominences of the condyles are present, so that before deciding upon the sacrifice of the condyles a careful analysis of the requirements in the individual case is necessary. The trans- condylar is preferable to the transarticular amputation n any case. Above this all bone length possible should be saved. It was found that short arm stumps could be improved as regards leverage by severing or raising the insertions of the pectoralis muscles, the latissimus dorsi and the teres major. The humeral head should always be saved if possi- ble, as the shoulder contour is preserved thereby. In double amputation of the upper extremities the necessity for prosthesis is unquestionable, so that the rules regarding site for amputation as influenced by prosthesis and previously outlined 18 apply more forcibly here. The most successful cases of double amputation seen, however, were those using special, usually self-designed, appliances particularly adapted to their individual requirements. In the latter case the more conservative surgical methods would be most applicable. CINEMATIZATION OF AMPUTATION STUMPS Cinematization of stumps is accomplished by connecting at the end of the stump the antagonistic muscles, or by giving them artificial insertion into the prosthetic apparatus. In July, 1918, the report of a special committee directed to investigate the question of cinematization was available for the information of those engaged in amputation work.19 Briefly the conclusions of this committee were that cinematization was still in the experimental stage and that it could not be recom- mended except as an experimental procedure and that it should not be attempted unless adequate facilities were available for pursuing the experimental prosthetic work necessarily associated with it. No doubt the few who were interested felt that they were not adequately fortified with the requisite knowledge and experi- mental facilities to undertake this work on a really progressive scale. Three cases were done in the base hospitals in the United States and two cinematized stumps were returned from overseas.20 In only one of these cases was the final functional result a distinct improvement over that obtained with the usual methods. Two were failures and required excision of the tunnels. Lack of 73S SURGERY success was due to failure of coordination in the surgical, physiotherapeutic, and prosthetic treatment, which resulted from the frequent transfer of patients and perhaps in a measure to the breaks in follow-up coincident with frequent changes in personnel after the beginning of the armistice. POSTOPERATIVE TREATMENT In all stumps in which there was even moderate tension, traction straps were applied in the operating room. It was found best not to apply weights in undrained cases until the following day, unless tension was marked. In the average case of this type, traction, if applied at once, seemed to favor oozing and the accumulation of clot. In addition to the advantages of traction pre- viously mentioned, there seems to be no doubt that it adds to the comfort of the patient by preventing muscular spasm and that it is instrumental in pro- venting postoperative hemorrhage in the same way. Blood drainage was removed in 48 hours. In case secondary hemorrhage occurred, with ballooning of the flaps, it was found best to remove the sutures, clean out the clot, and reapply traction. Secondary infection was the rule in all cases in which special attention had not been given to the elimination of dead spaces and in those in which secondary hemorrhage occurred. After the wound was healed, massage of the muscles was begun. Adjacent joints were moved passively once daily through the full range of motion. After healing was firm, if the patient was able to be out of bed, he was sent to the shop for his provisional fitting. Daily baking and massage was continued after fitting, in order to remove edema and to generally improve the circula- tion. The stump was bandaged at all times when the appliance was not being used. USE OF PROVISIONAL APPLIANCES IN AMPUTATIONS LOWER EXTREMITY In all stumps of the lower extremity, with the exception of partial ampu- tation of the foot and the Syme amputation, a portion of the stump is called upon to function in a manner entirely new and for which it is poorly adapted, i. e., weight bearing. Radical physiological changes necessarily take place in the weight-bearing portion of the stump, pressure atrophy of the soft parts; increased tolerance of the skin to lateral pressure from the encasing socket of the appliance; development of balance and sense of position; tolerance to pressure on and adjacent to bony prominences. The other important task of the stump leg is propulsion of the limb and its appliance. In spite of the fact that the artificial limb is not as heavy as the amputated part, more power is required in swinging it on account of its comparative inertness. Increased difficulty in balancing undoubtedly adds to the demands made upon the mus- cular power of the proximal part of the stump leg. The preservation of normal muscular power, or better the development of increased muscular power in the proximal part of the stump leg, is of vital importance. Since certain definite physiological changes must take place both in the stump and the proximal part of the leg before a stump can be considered functionally fit for a permanent appliance, it is clearly the duty of the surgeon to use all methods ORTHOPEDIC SURGERY 739 at his disposal to hasten these changes and to obtain a good functional as well as a good surgical stump before a permanent appliance is used. Principles of Fitting Weight bearing in the case of below-knee amputation is distributed as follows: Cone bearing (lateral surface bearing); bony prominence bearing (head of tibia, tuberosity of tibia, fibula below head); partial thigh-surface bearing (thigh cuff); and, in a certain percentage of cases, end bearing. In a finished appliance the stump is incased in a solid shell which is molded or carved to fit the stump in such a way that all the bearing points and surfaces are used to a variable degree. The physiological changes in the stump will depend largely upon the predominating type or types of bearing chosen in a particular case. ('one and bony prominence bearing with slight partial thigh bearing are found to be applicable to most leg stumps except in the Syme amputation. Pressure atrophy is rapid and marked, consequently repeated remolding of the socket is imperative. End bearing diminishes pressure atrophy of the stump. In amputation of the thigh, bony prominence bearing (ischial tuberosity) cone bearing, and, in certain cases, end bearing, are utilized. Bony prominence bearing predominates so that pressure atrophy of the stump is slower and less marked than in leg stumps. End bearing has the same relative advan- tages, but to a lesser degree. Undoubtedly end bearing is possible in a high percentage of stumps; success in obtaining it is largely dependent upon faithfulness and persistence in carrying out the necessary preliminary measures to increase the tolerance of the end of the stump. Experience has proven that a definite distinction must he made between total and partial end bearing, and that in certain instances end bearing may not be desirable, i. e., in long, below-the-knee stumps. Cone and bony prominence bearing have given nearly perfect function. If end bearing is attempted in these stumps it is found that there is a certain lack of adhesion between the appliance and the stump and that the gait is not as good as with cone bearing. In thigh stumps of moderate length total end bearing is not preferable to ischial and cone bearing for the same reasons. There is little doubt that partial end bearing is always an advantage. The following stumps, in addition to partial foot amputations, were found to be especially well adapted for end bearing: (1) The Syme stump; (2) short below-knee stumps, and (3) that resulting from a transcondylar amputation. The bone section in each of these is through spongy bone, which seems to give a more tolerant end bearing surface. Each is clubbed more or less on the end, which favors proximal methods of attachment of the appliance, thus avoiding instability of the appliance mentioned above. An ideal provisional appliance should possess, in the main, similar mechani- cal features to those found in permanent appliances. The socket should be of solid material and should be molded or carved in the same accurate manner, as in a permanent one. Excavations and additions which are customarily made to influence bearing on certain definite points, which are known to be adapted for this function, should be carefully made. A provisional appliance which 740 SUROKRY merelv shrinks the soft tissues of the Fig. 168.—Temporary appliance—plaster socket; stock metal bars; wooden foot. This was the best type of temporary appliance utilize a provisional leg which in all : necessity it was adjustable as regards 1 tump and does not develop the tolerance of the bearing points and surfaces, which will be called upon to func- tion in a proper permanent appli- ance, is not an efficient provisional appliance. The provisional socket must be one which can be remolded frequently and comparatively inex- pensively. In addition to chang- ing shape, in a certain percentage of cases it is not only desirable, but necessary to change the position of the socket so that a complete change of socket rather than a reshaping is sometimes necessary. This feature is important in all cases in which there is more or less malposition of the stump, which is gradually being improved by the use of the appli- ance. Various types of temporary ap- pliances were used in the different centers. In most of them the socket was made of plaster-of-Paris and the framework of wood or metal. In one center a papier mache socket was used and found to be very satis- factory. The soldier with a recent ampu- tation usually is most concerned in removing his physical deficiency as soon as possible from an esthetic rather than from a functional stand- point. Pegs and the cruder types of temporary appliances were stren- uously objected to by a fair number of patients. After the provisional type of appliance was available in quantities, very few pegs were used. There seemed to be no ad- vantage in delaying the fitting of the standard provisional appliance, inasmuch as it was even more versa- tile as regards refitting than pegs and the cruder temporary appli- ances. An attempt was made to .pects looks like a finished leg. Of Lgth, foot position, and socket. The ORTHOPEDIC SURGERY 741 Fig 169 —This and Figure 170 show original models of stock provisional appliances for thigh and leg amputation. An adjustable leather cuff was used to effect refitting "42 SUECKRY socket adjustment was accomplished by supplying a rather large number of stock sizes, and by means of a leather cuff which could be adjusted to the shrinking stump by lacing. Fig. 170 In addition to meeting the esthetic requirements more satisfactorily than the temporary appliance, it offered the advantage of quantity production and quicker fitting. AA hile this type of appliance was not applicable to as high a percentage of cases as anticipated, it was used in all centers except one until supplemented by a more versatile type. ORTHOPEDIC SURGERY 743 In thigh amputations this type of finished provisional leg was entirely satisfactory and in about T per cent of cases where there was sufficient bone length to operate the ordinary thigh leg. Most of the remaining 15 per cent fell into the class of excessively long stumps. It was not possible to fit these on account of interference of the mechanism for the adjustment of length. The greater part of the weight is taken on the tuberosity of the ischium and Fig. 171.—Provisional appliance used at Letterman General Hospital accurate cone bearing is relatively unimportant, consequently the cone fitting does not need to be verv exact. In leg amputations the task of fitting this type of leo- was much more difficult. Bony prominences are more numerous and less tolerant to weight bearing. Consequently, the bony prominence fitting must be more accurate and a greater amount of weight bearing must be allotted to the cone fitting. For this reason the latter must be more precise. 744 SURCERY In order to meet the requirements of the more difficult cases which it was not possible to fit with the original model of the stock appliance, a more versatile type was developed and the stock parts (framework) manufactured Fig. 172.—Letterman General Hospital artificial leg, assembled and unassembled in quantity, in a variety of sizes; the only essential difference from the original model being that, instead of making the necessary refitting, by means of a leather- laced cuff, a plaster-of-Paris refitting was substituted in leg amputations. The plan generally adopted in all amputation centers was to fit the stump with a temporary appliance as soon as healing was complete, but not to hasten the prosthetic treatment at the expense of a good surgical result. The appliance was worn at first to the limit of tolerance, Fig. 173.—The final model of provisional leg with a plaster of Paris inset ORTHOPEDIC SURGERY 745 special care being taken not to damage the soft parts. The part of the appli- ance which incases the terminal part of the stump, commonly called the socket, was changed and refitted as pressure atrophy progressed. Three changes were usually required. Deformities and surgical defects of the stump, i. e., bony spurs, latent infection and tender nerves, will be readily discovered and should be treated during this preliminary prosthetic treatment. Stumps were not fitted with a permanent appliance until they were surgically sound, pressure atrophy of the weight-bearing portion well advanced and the propulsive mus- culature of the proximal part of the leg well developed. The stock provisional appliances used were found to be sufficiently durable to last from eight months to one year. Six months preliminary prosthetic treatment was usually found to be sufficient to prepare stumps for permanent appliance. Partial amputations of the foot, Syme stumps, end-bearing knee-joint amputations, and disarticulations of the hip as a rule were not fitted with pro- visional appliances. During the earlier experimental period a few were fitted in the appliance shops largely for experimental reasons. In these stumps the fitting is difficult and there is so little change in the stump as compared with those in which cone and bony prominence bearing predominates that there seems to be no reason to delay the permanent fitting. UPPER EXTREMITY The use of provisional appliances in amputations of the upper extremity does not seem to be so essentially necessary from the standpoint of fitting as in those of the lower extremity. The physiological changes in the stump from the use of the appliance are not marked enough to necessitate frequent refittings and it is not necessary to have so exact a fitting as in lower extremity stumps. The chief advantages in provisional fitting are that (1) immediate fittings are possible, which would not be the case in the time of war if permanent appli- ances were supplied by the artificial limb industry; (2) an opportunity is given to coordinate the surgical, prosthetic, and physiotherapeutic treatment and to carry out a reeducational program which is often more helpful than the appliance, per se; (3) surgical defects of stumps become apparent while the patient is still under Army control and can be corrected at once; (4) the patient has an opportunity to learn something about appliances which enables him to make a more intelligent choice of a permanent appliance. The first appliances used were of simple design and rather crudely made. The socket was of plaster of Paris. In the end of the socket was incorporated a metal clamp to hold various implements. Later an inexpensive arm with a universal end attachment plate in which a hand, tools, or any type of hook or other useful device could be used interchangeably was adopted. The metal parts were manufactured in quantity and issued to amputation centers. Sockets were made of leather, the work of fitting being done in appliance shops. Xo originality can be claimed for this appliance, as similar types were already being used abroad. Workmanship and exactness of fitting was probably '40 ^UROF.RY Fig. 174.—This and Figures 175 and 176 show the type of provisional arm used, and various attachments for work and play Fig. 175 ORTHOPEDIC SURGERY 747 not equal to that obtainable in the open market, but it is believed that it served the purpose as a provisional appliance as well as could have been expected from any single type of appliance obtainable. Fig.176 REFERENCES (1) The Relation between the Amputation and the Fitting of the Artificial Limb. Military Surgeon, Washington, D. C, February, 1918, xlii, 154. The Temporary Artificial Limb. Ibid., April, 1918, xlii, 490. The Care of the Amputation Stump. Review of War Surgery and Medicine, Washington, D. C., 1919, ii, No. 2, 22. (2) Information on Artificial Limbs and the Care of the Stump. In The Relation between the Amputation and the Fitting of the Artificial Limb. The Military Surgeon, Washington, D. C, February, 1918, xlii, 154. (3) Circular Xo. 90, Surgeon General's Office, February 14, 1919. (4) Letter from the Surgeon General to Major Edgar King, M. C, August22,1917. Sub- ject : Assignment as Chief of Division of Special Hospitals and Physical Reconstruc- tion. On file, Record Room, S. G. O., 11556S (Old Files). Memorandum from S. G. O., May 6, 1918. On file, Record Room, S. G. O., 0.024 (Division of Special Hospitals and Physical Reconstruction). (5) Annual Report of the Surgeon General, U. S. Army, 1919, ii, 1106. (6) Ibid., 191S, 399. (7) Report from Division of Military Orthopedic Surgery to the Surgeon General, July 15, 191S. On file, Record Room, S. G. O. (S) Correspondence. On File, Record Room, S. G. O., 442.3 (Artificial Limbs). Weekly Reports. On file, Record Room, S. G. O. (Weekly Report File). 74S SURGKRY (9) Letter from the Association of Artificial Limb Manufacturers of America, to the Surgeon General, October 19, 1917. Subject: Meeting in Washington. On file, Record Room, S. G. O., 442.3 (Artificial Limbs). (10) Annual Report of the Surgeon General, U. S. Army, 1919, ii, 1105. (11) Amputation Reports. On File, Record Room, S. G. O., 702.2. (12) Based on Sick and Wounded Reports made to the Surgeon General. (13) Relation between the Amputation and the Fitting of the Artificial Limb. The Military Surgeon, Washington, D. C, February, 1918, xlii, 154. (14) The Care of the Amputation Stump. Review of War Surgery and Medicine, Washing- ton, D. C, 1919, ii, No. 2, 22. (15) The Medical and Surgical History of the War of the Rebellion. Government Printing Office, Washington, Surgical Volume, Part III, 357. (16) Huggins, G. M. The Surgery of Amputation Stumps. Lancet, London, April 28, 1917, I, 646. (17) Lyle, H. H. M. The Formation of a New Thumb by Klapp's Method. Annals of Surgery, 1914, lix, No. 5, 767. (IS) " Amputations and Artificial Limbs" from Some Essentials in Military Surgery. Printed for the Surgeon General, United States Army. Press of the American Medical Association, Chicago, n. d., 39. (19) A Report to the Chief Surgeon, A. E. F., by Major Williams S. Baer, M. R. C, and Capt. Philip D. Wilson, M. R. C. Subject: Cinematic Amputation in Italian Hospitals. War Medicine (Published by the American Red Cross), Paris, 1918-1919, ii, No. 1, 218. SECTION III NEUROSURGERY CHAPTER I ORGANIZATION AND ACTIVITIES OF THE NEUROLOGICAL SERVICE AMERICAN EXPEDITIONARY FORCES a In June, 1918. upon the reorganization of the professional services of the American Expeditionary Forces, neurological surgery was made a separate subservice of the genaral surgical services, and a senior consultant was ap- pointed thereto. PROBLEMS OF ORGANIZATION No precedent covering the activities of such a subdepartment of general; surgery existed in either the French or British Armies. Moreover, no figures were available which would serve to give an idea of the probable responsibilities of this service beyond the rough estimate that 25 per cent of all surgical casual- ties presented neurological problems of one sort or another. More or less un- official figures from British and French sources had given the following per- centage of injuries of the nervous system in relation to the wounded: For wounds of the head, including all types, 16 per cent;6 for wounds of the spine, 2 per cent; for wounds of the major peripheral nerves, 20 per cent of all serious injuries of the extremities. The problem, so far as could be seen, divided itself into two main parts: (1) The immediate care in forward hospitals of the more serious cranial cases; (2) the later care at the base hospitals of the residual paralyses of the main peripheral nerves, the neurosurgical aspects of which were not likely to come into prominence until the complete healing of the complicating wounds and fractures. The results of the early operations for penetrating wounds of the skull, so far as figures rendered them available, had been lamentable, the estimated operative mortality from reports in literature varying from 50 to 65 per cent, and of all spinal cases about 80 per cent. So far as the peripheral nerves were concerned, it was known that they had been accumulating during the four years of war in the French and ■» Being the report to the chief surgeon, A. E. F., from the senior consultant in neurological surgery on summary of activities of the department, dated Neufchateau, December 2, 1918. Copy on file, Historical Division, S. G. O. » The exact figures from two mobile hospitals operating in the Argonne in October and taking only seriously wounded were as follows: Out of a total of 1,202 cases, excluding those marked "multiple Q. S. W." there were 135 head cases, giving 11.1 per cent. At this time no figures from a field hospital for seriously wounded were at hand and the proportion of head cases to other wounded, owing to the many early fatalities from wounds of this sort, naturally fell off greatly in the hospitals of the intermediate and base zones. 750 SURGERY British hospitals and that great numbers of them were awaiting neurological study and neuroplastic operation or orthopedic procedures to ameliorate deformities. PLAN OF ORGANIZATION TEAMS FOR HOSPITALS IN THE ZONE OF THE ADVANCE Obviously the most urgent need in June, 1918, was to supply the hospitals in the zone of the advance with surgeons who had had some neurological train- ing and experience with penetrating wounds of the skull. As the available number of such officers was small, it became necessary to select and give per- sonal instruction to one surgeon from each evacuation hospital and to supply the proper surgical equipment. REPRESENTATIVE IN BASE HOSPITALS In the emergency it was regarded of secondary moment to include in this plan the hospitals at the base, though provision was made so far as possible to have a representative surgeon in each base hospital who, even without much neurological experience, could work in conjunction with the neuropsychiatrist of the unit. Later on, some of the commanding officers of the larger hospital centers cooperated in the secondary routing within the particular center of the majority of the organic lesions of the nervous system to one hospital where they could be more satisfactorily supervised. NEUROLOGICAL CENTERS It was planned eventually to establish in certain favorable areas centers devoted exclusively to diseases of the nervous system, corresponding to the French neurological centers, where neurological cases might be assembled and where groups of experts, neurologists, neurosurgeons, and orthopedists with neurological interest, could be gathered and thus bring less strain upon a meager personnel. Such a plan, however, could be realized in a very small way only, largely in view of the fact, as is explained below, that relatively little time intervened between the inception of the subservice of neurological surgery in June, 1918, and the signing of the armistice the following November. ARRANGEMENTS FOR THE CARE OF HEAD WOUNDS SPECIAL SURGICAL INSTRUMENTS For success in this work, special surgical instruments not contained in the Army equipment were essential, and only after some delay the necessary perforators, drills, and rongeurs were secured through French manufacturers. INSTRUCTIONS FOR NEUROLOGICAL SURGEONS In addition to the practical instruction in craniocerebral surgery given to selected surgeons from the various evacuation hospitals, the following directions were prepared by the senior consultant in neurological surgery, American Expeditionary Forces, and were furnished to members of neuro- surgical teams. NEUROSURGERY 751 DIRECTION'S TO NEUROSURGICAL TEAMS CONCERNING CRANIOCEREBRAL WOUNDS It is expecte^ of all neurosurgical teams that they shall primarily be capable of the general surgical work of a forward hospital. This is so, firstly, because multiple wounds are common and a compound fracture of an extremity or any other injury may accompany the head wound; secondly, because neurological cases may not happen to be admitted in sufficient number to occupy the full time of the team, or the situation may be such as to render advisable their early evacuation, untreated, to the nearest base. At best a well- trained team can hardly expect to cover on an average more than S or 10 cases of penetrating craniocerebral type in a working day. It is requested that, on the form shown below, each neurological team send a monthly report of its cases to the senior consultant in neurological surgery, A. P. O. 731: To the Senior Consultant in Neurological Surgery Med. & Surg. Consultant Hq. A. P. O. 731, A. E. F. Report of Neurosurg. Team No.___ hosp. no.....-- for the month of -- Name, rank, and organization Serial No. Diagnosis and classification Operation Date Condition on evacuation Remarks ; i GENERAL REMARKS CONCERNING CRANIOCEREBRAL WOUNDS Every scalp wound, no matter how trifling, is a potential penetrating wound of the skull. Many penetrating wounds are met with even among the walking wounded. Only after an X-ray, after shaving the head, and possibly only after exploration, can one be assured that there is or is not a cranial fracture with or without dural penetration. If a case is operated upon and a penetration found, the operation must be completed, with a primary closure following the special debridement applicable to these injuries. In this respect wounds of the nervous system differ from other wounds which in times of rush should not be subjected to primary wound closure. "All or nothing" is a good rule to apply to craniocerebral injuries—in short, evacuate these cases untreated to the nearest base (except for shaving and the application of a wet antiseptic dressing) rather than do incomplete operations. Patients with craniocerebral injuries stand transportation well before operation; badly during the first few days after operation. This is true of all pri- mary wound closures. Cranial cases in more or less shock need not undergo a period of resuscitation. The operations should be done under local anesthesia combined with morphine. Consequently the patient can be properly warmed and given fluids during the course of the operation through which they will often sleep. Only in exceptional cases, when patients are irrational or uncooperative, is a general anesthetic necessary. Its administration always adds to the difficultv of the operation, and by increasing intracranial pressure causes extrusion of brain and tends to increase the damage already done. The chief source of the high mortality in cranial wounds is infection—infection of the meninges- direct infection of the brain leading to encephalitis; infection of the ventricles. Wounds in which the dura has been penetrated are supposed to give a mortality of from 50 to 60 per cent, due to infection. It, however, has been shown that experienced neurosurgical surgeons can lower this supposedly inevitable mortality to 25 per cent if the operations can be done with reasonable promptitude in a forward area and the cases retained for a reason- able time after operation. These figures are capable of still further improvement. 41*997—27----50 752 SURGERY CLASSIFICATION OF HEAD WOI'XDS On the basis of their severity, gauged by mortality percentage, head wounds may be divided into the following categories: I. Wounds of the seal])___________________________ ____ Mortality circa 5 per cent. II. Cranial fractures without dural penetration____________ Mortality circa 10 per cent. III. Cranial fractures with depression and dural penetra- tion, but without extrusion of brain_________________ Mortality circa 20 per cent. IV. 'Wounds usually of gutter type, with brain extruding and indriven bone fragments____________________________ Mortality circa 30 per cent. V. Wounds usually of penetrating type with indriven bone fragments plus metal_______________________________ Mortality circa 40 per cent. VI. Wounds of Type IV and V with penetration of bone or metal opening ventricles____________________________ Mortality circa 50 per cent. VII. Craniofacial wounds of orbitofrontal or temporopetrosal type in which ethmoid or petrosal sinuses are opened. Primary closure impossible and risk of secondary infection great_____________________________________ Mortality circa 60 per cent. VIII. Perforating or transversing wounds____________________ Mortality circa 70 per cent. IX. Extensive bursting fractures. (Fatality very usually due to trauma rather than infection.) CLINICAL RECORDS A preliminary note with (1) a brief history of case, (2) the patient's general condition, (3) the characteristics of wound, and (4) the positive neurological findings, should be made before the patient becomes drowsy from his morphia, which may well be given an hour before the operation and before the act of shaving. DUPLICATING BOOKS These are timesaving and desirable, for not only is it essential that the surgeon retain a record of his own cases and keep track of his end results, but it is of great importance that a duplicate record be forwarded in the field envelope with the patient, so that subsequent attendants may know something definite as to the patient's condition and the procedure followed in the forward area. INFORMATION POST CARDS Ordinary plain French post cards requesting information as to the outcome of the operating may be inclosed in the field envelope, addressed either to the surgeon himself, or to the senior consultant in neurological surgery, A. P. O. 731, who will forward the report together with such other information as may be pertinent. PREPARATION FOR OPERATION The success of these specialized operations and the celerity with which thev may be done depends entirely on attention to detail and development of team plav. Don't hesistate to do the first case or two slowly and carefully. Time will be saved on succeeding ones As the preliminaries may take almost as long as the operation itself, two tables should be in use, or if not two tables, the patient being prepared should be on a stretcher and trestles alongside the tables on which one operation is being completed. Morphia is well tolerated. A third of a grain should be given and this repeated if necessary. After a thorough soaping, with massage to soften the hair matted bv blood, the entire head should be shaved, an act which requires no inconsiderable skill and on the perfection of which the successful outcome of the operation depends not a little. A shaving brush is essential to a good lather. The hair should not be clipped as this greatly increases the difficulty of shaving. NEUROSURGERY 753 Novocainization of the scalp.—The infiltration should be made in lines of the proposed incisions 15 to 20 minutes before the patient is put on the table for operation. After novo- cainization it will be found that the dirty wound may then be filled with gauze before the final cleaning. This need consist of nothing more than careful wiping of the scalp with alcohol followed by bichloride solution. Avoid the use of iodine, picric acid, etc. Position of the head.—Ordinary pillows and long sandbags are desirable. In order to get a proper elevation of the head so that it can stand free of the surroundings, one or two loosely filled sandbags, measuring about 8 by 8 by 3 inches, covered with rubber sheeting, will be found convenient. A secure arrangement of towels to prevent their slipping in the course of a prolonged operation is essential, and it is well to have some sort of makeshilt wire rack to keep the towels from settling against the patient's face. A head-light is desirable, since the lighting system over most operating tables is central with imperfect illumination of the end of the table. THE OPERATION Its principles are those of wound debridement in general, consisting in the removal of the contaminated margins of the wound and tract, together with soiled fragments of indriven bone, and, if possible, of the foreign body. It is unnecessary to remove more than the merest edge of the contused scalp wound. It is found that the making of "tripod incisions," which radiate from the central wound, permits of the reflection of three flaps, which when undermined can subsequently be drawn together with complete wound closure. Sufficient exposure of the cranial lesion is secured by these reflected flaps. Only in the case of large scalp defects is the switching of flaps necessary for closure and it is questionable if this is ever desirable. The bone defect should be closely encircled b}- three or four perforations with perforator and burr, and these openings connected by linear cutting forceps (Montenovesi preferable, small De Vilbiss can be used). In this way the bone defect can be excised in toto and in the majority of cases the entire block may be tilted up in one piece. Some bone wax should be at hand. Nibbling with rongeurs across the area of the bone defect after preliminary lateral trephining is undesirable, particularly as this is apt to be a soiled area. Leave as small a bone defect as possible—a quarter of an inch margin beyond the defect suffices. Do not enlarge the area of dural laceration. Never open an intact dura unless (1) an underlying clot or area of pulped brain is indubitable; (2) the operation is sufficiently early to antedate infection of the internal wound; (3) you have the experience and materials for an accurate reclosure. Except in very skillful hands a dural incision greatly increases the chances of a fatality from infection. In the British Expeditionary Forces there are strict regulations against it under any circumstances whatsoever. Curved French round-pointed needles with fine black silk sutures are essential for proper reclosure of the dura in case it has been opened during the operation. The debridement of the contused area of the brain and tract can be best carried out with production of the least damage to the brain by gentle suction and irrigation with a soft catheter to which a Carrel syringe with a rubber bulb is attached. The catheter detects indriven bone fragments as well as does the finger, and they can be picked out by delicate esquillectomy forceps. Metallic fragments of small size are surprisingly well tolerated. It is tlierefore much better to give the patient the chance of carrying the missile, which may not have been contaminated, than the certainty of having existent paralysis increased and perpetuated by too energetic attempts to extract it when deeply placed. When at hand, a magnet will be found useful as a means of extracting shell fragments from the bottom o a tract. A craniocerebral wound should never be sponged with dry gauze. Pledgets of cotton wrung out of salt solution will clean the wound infinitely better and will be much less likely to start up bleeding. All sponging, whether by operator or assistant, can be done by such pledgets held by the forceps, thus keeping fingers from the wound. Bleeding points from sinuses or brain should be checked by tissue implantation. "Stamps" of muscle are most efficacious and can usually be obtained from some other opera- tion or by additional incision from the patient himself. 754 SURGERY AR M A M E N T AR IU M In addition to the usual dissecting set with rongeurs, etc., a proper layout of instruments should include: Perforator and burr.—The burr in the official brain, plastic, and oral surgery set is much too small and is therefore somewhat dangerous. Care must be exercised in making an open- ing which will be sufficiently large to introduce the cutting forceps. The cranial cutting forceps in the official sets are of the De Vilbiss pattern with two blades, the smaller of which can, with care, be introduced through the small opening without dam- age to the dura, and the three or four perforations encircling the bone defect can thus be connected. The Carrel syringe utilized for suction is of the common type of glass syringe in general use. The catheter should be very soft and should have a large bore with the eye near the end. Delicate esquillectomy forceps for the removal of bone fragments after they have been detected by the catheter are desirable. Antiseptics.—In an early operation, in which thorough cleansing of contaminated tissue is possible to the depth of the wound, no antiseptic need be employed. In many cranio- cerebral wounds, however, it is often impossible to be sure when, by thorough suction, the pulped and contaminated brain from the depth of the tract has been completely removed, and there is a temptation to lean, therefore, upon the crutch of an antiseptic. Oily solutions are preferable, and Dakin's dichloramine -T in oils, which has a prolonged antiseptic action, is not only harmless to the tissues but appears to be the most suitable antiseptic to bury in these cases. Through the catheter, after the tract has been as thoroughly cleansed as possible, a cubic centimeter or so of dichloramine -T may be introduced as the catheter for the last time is withdrawn. Dressings.—In wounds of the head, particularly if the brain is exposed and the defect can not be closed, gauze should not be placed directly against the wound. The best sub- stance to interpose between the wound and the gauze dressing is gutta-percha tissue which has been practically unobtainable. A fairly good substitute for this is cellulose tissue. This material can be boiled and therefore in the individual cases can be used again for subsequent dressings. It can also be used most advantageously for drains in case they are needed. One difficulty which is met with by those inexperienced in cranial operations lies in the application of a dressing which will remain in place. Many of these patients are restless and pick at their bandages, which become easily dislodged. In most hospitals will be found bandages which have been cut on the bias. With practice these bandages can be adjusted to fit the head snugly, and can be brought around under the chin without annoying the patient too greatly. It is usually necessary to place several safety pins in the areas where the turns of the bandage cross. A neat head dressing is usually a good indication of the quality of the operation which it conceals. APPENDIX Supplies.—Duplicating books and certain other supplies may be obtained from the senior consultant in neurological surgery, A. P. O. 731. From Gentile, 49 Rue St. Andre-des-Arts, Paris, esquillectomy forceps, an excellent perforator and burr, curved French needles, Carrel syringes, and catheters. From Intermediate Medical Supply Depot No. 3, A. P. O. 737, by requisition through any commanding officer, Lurken's sterile bone wax, head lamp, cellulose tissue, and dichlora- mine -T with paraffin and eucalyptus oil. Also Lilly capsules and various novocain prepara- tions. The most convenient are the 1-ounce bottles of powdered novocain of the Saccharin Corporation (Ltd.). To make a 1 per cent solution add 0.3 grams of this powder to 30 c. c. of sterile water. To this 30 c. c. of 1 per cent solution add 15 drops of adrenalin. This will make the scalp incisions comparatively bloodless. The Lilly No. 1 gelatine capsules which come in boxes of 100, hold just 0.3 grams of this powdered novocain. It is a convenience therefore to secure these capsules, as they can be filled without weighing out each separate portion of 0.3 grams. A Luer syringe and satisfactory needles can also be obtained from the medical stores. NEUROSURGERY 755 CARE OF HEAD INJURIES AND INJURIES TO THE SPINE AND PERIPHERAL NERVES IN THE FORWARD HOSPITALS HEAD INJURIES The senior consultant in neurological surgery, A. E. F., had learned from personal experience in British casualty clearing stations and general hospitals that the accepted high mortality of the craniocerebral cases could be reduced fully 50 per cent if these cases were operated upon in forward areas. A series of about 200 patients operated upon in the fall of 1917 at a casualty clearing station of the British Expeditionary Force, which was given over entirely to wounds of the head, gave 28.5 per cent mortality; a similar series operated upon at a later period by members of the same team in an American base hospital attached to the British Expeditionary Force gave a mortality of about 45 per cent. NEUROSURGICAL TEAMS Certain difficulties, never entirely overcome, were met with in the organi- zation of the neurosurgical teams. It was obvious that if surgeons were to be assigned to forward hospitals in charge of teams that they should primarily be good general surgeons, for their presence would be an encumbrance if they could only cover their specialty. This had one unfortunate outcome, for dur- ing the months of June and July eight of these specially equipped officers were soon put in surgical charge of their hospitals and became triage officers, so that their services as neurosurgical experts were lost. Another difficulty lay in the administration opposition to the performance of operations of a time-consuming and detailed character, particularly during periods of rush. As these opera- tions should be done under local anesthesia, they necessarily consume time, and rarely could more than eight serious head wounds be thoroughly done by one team in a working day. Where there was a large number of wounded, the temptation was strong for hospitals to strive for an operative record, and teams were apt to be rated by the commanding officer according to the number of cases they were able to cover in their individual shift. As a result, in many hospitals the neurosurgical teams were restricted to general operations and the more tedious head cases were either passed on to the base or were distributed without selection among the teams on duty, who did incomplete operations.0 During the earlv operations in which some of our forces were engaged in the latter part of June, only two teams had been organized, one at Mobile Hospital No. 2 and another at Mobile Hospital No. 1. A subsequent survey of the head cases which had reached the Paris area and the centers of the inter- mediate zone at Bazoilles and Vittel showed that practically no case of pene- tratino- wound of the head had survived except the 10 or 20 who had gone through the hands of these two teams. Bv July, 1918, it had become possible to apportion to most of the evacua- tion and mobile hospitals of the forward area one team which had had more or less personal instruction and which had been equipped with the proper sur- ' To give an idea of the importance of having men for this special work, the operative mortality in a series of 38 cases of dural penetration of one neurosurgical team working at a mobile hospital was 29.4 per cent, whereas in 26 cases done by 11 different surgeons without equipment or training in the same hospital it was 62 per cent. 75(i SURGERY gical supplies. This was due to the fact that sonic medical officers who had received some neurological instruction in schools established for this purpose at home had arrived recently in France. Also a number of sets of instruments for brain surgery had been sent out and had become available. Each of the neurological teams was furnished with the instructions quoted above. Before the St. Mihiel offensive, September, 1918, more time for preparation was given, and each hospital was supplied with one neurosurgical team which had had some experience. Even though this operation was of brief duration, it became apparent that one team in each hospital was not sufficient to screen out the cases, for though the work was covered in some hospitals, in others the neurosurgical team was either off duty or busy doing general surgical work so that most of the head cases were handled by the general surgical teams rather than have them wait. In consequence, more craniocerebral cases had been operated upon, it was found, by inexperienced than by experienced teams and the hospital mortality was very high—considerably over 50 per cent, exclusive of the cases which subsequently succumbed in base hospitals. In view of this experience and in preparation for the Meuse-Argonne operation, the proposal was made to the representative of the chief surgeon, First Army, that at least two neurosurgical teams be supplied to the hospitals which were on the main avenues of evacuation, viz., at Fleury, at Souilly, and at Villers-Daucourt, with the issuance of orders to field hospitals to route cases direct to one of these points. This plan was met with a counterproposal that we should attempt, as the British had done, to have a special hospital somewhat more in the rear to which all head cases could be forwarded. A hospital at Deuxnouds was selected for this purpose by the representative of the chief surgeon, First Army, and several neurological teams were concentrated there. Between September 29 and October 16, when the hospital was in operation 813 cases were secondarily routed there. The situation presented difficulties. Although it seemed an easy matter to have all wounded men wearing head bandages collected at one point, since this point was farther away than the main hospital centers the cases were almost certain to be dropped at these centers, necessitating a delay of from 10 to 12 hours before they could again be sorted and ambulances secured to forward them to the so-called head center. However, this center was placed in a town far from a railhead, so that the hos- pital became overcrowded and evacuation was difficult. Lastly, the mistake was made which perhaps was unavoidable, of using the personnel and equip- ment of a mobile hospital unit, which was withdrawn after a 10-days' service, leaving no one to carry on the work in the interval until another mobile hospital unit was similarly and temporarily utilized. In spite of these difficulties, however, the hospital did creditable work and under different circumstances could have relieved to a greater degree the pressure on the evacuation hospital a few miles farther forward. In preparation for the later phases of the Meuse-Argonne operation, the earlier proposal to assign neurosurgical teams to the forward hospital was ac- cepted by the general staff, and at Evacuation Hospital No. 7 at Souilly at Hospital No. 114 at Fleury, at A. R. C. Hospital No. 110 at Villers-Daucourt, a sufficient number of teams to operate continuously on craniocerebral injuries NEUROSURGERY 757 were stationed. This implied the setting aside of 50 to 100 beds for the reten- tion of these cases—not a particularly large number of beds, in view of the size ot these hospitals.d The work according to this arrangement was very much more satisfactorily accomplished than at any time previously in spite of the fact that with the advancing line an increasingly long interval elapsed between the time of injury and the time of operation. In summary.—So far as these craniocerebral wounds were concerned, experience may be compared profitably with each of the following plans: (1) Operations on craniocerebral wounds by uninstructed surgeons, unfamiliar with this special kind of work; (2) single neurosurgical teams placed in individual hospitals; (3) a number of teams collected in one special hospital for head wounds, after the principle adopted in the British Army; (4) the placing of two teams in the larger evacuation hospital centers on the main lines of traffic. Of these four plans undoubtedly the third is suitable for a more or less stationary battle front such as existed in Flanders during 1917. Plan 4 was unquestionably the more desirable under such conditions as existed in our Army during the Meuse-Argonne operation. Supplementary to this arrange- ment it would have been ideal to have the convalescent cases sent directly to a neurological center in the base. SPINAL CASES These did very badly throughout, as was anticipated. Most of them were immediately evacuated to base hospitals and fully 80 per cent died in the first few weeks in consequence of infection from bed sores and catheteri- zation. The conditions were such, owing to pressure of work, as to make it almost impossible to give these unfortunate men the care their condition required. No water beds were available, and each case demands the almost undivided attention of a nurse trained in the care of paralytics. Only those oases survived in which the spinal lesion was a partial one. PERIPHERAL NERVE CASES It was impossible, owing to the conditions in the forward hospitals and pressure of the work, to do more than emphasize the necessity of some neuro- logical observations being made before any major operation in the nature of a debridement was carried out for wounds of the extremities. Experience had shown that excision of presumed contaminated tissues in the depth of the wound had not infrequently led to accidental nerve division. It was urged, furthermore, whenever the preliminary examination showed the nerve to be injured, that if possible it should be exposed in the wound, its condition noted, and in case of traumatic division a suture be immediately performed. There can be no question that immediate suture of divided nerves, with primary wound closure, offers the best chance of restored func- tion. However, in view of the regulation against primary wound closure during the active fighting of the summer and fall of 1918, it was practically impossible, except in isolated cases, to attempt the early suture of nerves. d It may be noted that a sine qua non of these operations is a primary wound closure after thorough wound debridement, owing to the cei tainty otherwise of the development of a cerebral fungus. Hence the regulation forbidding primary wound closure in the forward areas was, in cases of this kind, necessarily overridden. It is this fact which made it obligatory that patients thus operated upon should be retained for a period of at least 10 to 14 days. 758 SURGERY CARE OF HEAD INJURIES AND INJURIES OF THE SPINK AND PERIPHERAL NERVES IN BASE HOSPITALS NEUROLOGICAL CENTERS Within hospital centers.—The commanding officers of the various hospital groups were requested to sort at the railhead, as far as possible, and to send to a selected hospital in the area as many of the cranial cases as possible, and subsequently to secondarily transfer to this same hospital the peripheral nerve cases. It was the intention to have a nucleus of well-trained neurolo- gists and neurosurgeons for each of the larger hospital centers, and in some areas notably in the Bazoilles group, and at Vittel and Contrexeville, this plan was put in operation. Likewise Military Hospital No. 1 served as a neurological depository for the Paris group. A special hospital.—Owing to lack of competent personnel and to the difficulties and inconveniences of secondary routing, the project of having one or more actual neurological centers comparable to the French centers, was not put into operation, though after the arrival of Base Hospital No. 115 at Vichy a very promising start was made there in this direction. CHAPTER II ACTIVITIES OF THE AMERICAN FIRST ARMY HOSPITAL AT DEUXNOUDS a On September 26, 1918, Casual Team No. 538 was ordered to proceed to Deuxnouds and to take over the French ambulance in that village, it being the intention of the chief surgeon, First Army, to convert this ambulance into a head hospital. At noon of the 28th the first portion of the equipment of Mobile Hospital No. 6 arrived and continued to do so during the 29th and 30th. Because of the haste in opening, the taking over of the French hospital, and the functioning for the first time of a mobile unit fresh from its assembling point, many im- provisations were necessary, and as complete records as might be desirable were not at all times obtained, especially in the first few days. In the triage all lightly wounded were dressed and such as were non- operative immediately marked for evacuation. Operative cases were undressed, bathed, and placed on stretchers pending operation. About 90 per cent of the neurosurgical work was done during the first two weeks. Inasmuch as no systems of permanent records in evacuation hospitals had been established, it was necessary to improvise some method of keeping track of at least the most important cases received at this hospital. Each team was asked to keep a record in a duplicating book provided for them, of which one copy was placed with the field medical card or its equivalent. When a patient was evacuated, the records were passed through the office of the sur- gical chief, who abstracted the more essential points upon the patient's field medical card and saved the complete record to turn into the consulting sur- geon's office. Lnfortunately, when teams were ordered away, records were left in the hands of men who, although able and willing, had had no experience previously with the system of keeping them. The total number of admissions up to the morning of October 15 was 815. Of these, 403 underwent operation, leaving 412 which were dressed in the triage at once and marked for evacuation. These cases then had passed through, in the majority of instances, triage at the field hospitals and evacua- tion hospitals without their dressings being changed and had come through to Deuxnouds before being recognized as nonoperable and evacuated. Of the 403 operations, 106 were craniotomies. The operative capacity of the Deuxnouds hospital was, roughly, 100 cases per 24 hours, of which, from the experience gained there, one would expect 25 to be craniotomies and 15 dural penetrations. In addition, on the above basis, 100 cases would be passed through the triage with a dressing and for imme- diate evacuation. If, as is generally estimated, 10 per cent of the total casual- <> Based on report on head hospital at Deuxnouds, undated, made by Capt. S. C. Harvey, M. C, to the chief surgeon, A. E. F. Copy on file, Historical Division, S. G. O. 760 SURGERY ties involve the head, face, and neck, then this hospital was caring for its pro- portion of 2,000 casualties in 24 hours. With the equipment the personnel could be expanded at least 50 per cent, and in that case such a unit could handle 200 operations, admit 400 casualties, and handle its proportion of 4,000 in the 24 hours. This would make a total of 28,000 a week or, roughly, 100,000 a month, which perhaps is approximately the casualty rate for the fighting at this time in the First Army; that is to say, one well-developed unit of this type or two smaller ones should be able to handle wounds above the clavicle for one army as at present organized. Frequently it is assumed that the retention of head cases will soon choke the bed capacity of a hospital. The normal intakes of this hospital estimated at 15 dural penetrations per day (these being the only cases retained) would provide at the maximum an accumulation of 100 per week. In two weeks this type of case is evacuated, so that at no time would more than 2,000 beds be occupied. As a matter of experience, during the second week of function of this hospital, the beds occupied reached 290, but this was chiefly because of lack of evacuation, and in spite of this there was no choking of the hospital by re- tention of head cases. CLINICAL DATA Deaths.—In so far as neurosurgical conditions are concerned, the deaths from the opening of the hospital until its evacuation by Mobile Hospital No. 8, that is until about November 8, numbered 67, of which 25 died without opera- tion and 42 following operation. These have been classified according to Cushing's classification, as follows: DEATHS UNOPERATED Cranial: Group I (general shock and sepsis from other wounds)___________________ 1 II (previously operated)_________________________________ 1 IV (previously operated)___________________________ 1 V (all moribund on entrance)______________________ 5 VI (4 meningitis; 3 moribund on entrance)_____________ 7 Wounds of head (no data; moribund on entrance)__________________ 4 Dead on entrance (dural penetration; no further data)_____________ 1 Spinal cord____________________________________ i Total______________________________________ 2l Of these, it may be noted that two (Group II and Group IV, respectively) previously had undergone operation. The records of these are as follows: Case 1.—A. I. J. F., No. 3270146. Wounded October 5, 1918. Field hospital (?). Copy of note: "(1) G. S. W. left arm; compound fracture. (2) G S W head left Com- pound fracture of skull. 36 hours. Operation October 7: Cleaning, partial suture of scalp; no evidence of depression of skull. Amputation left arm after consultation Hold " En- tered Mobile Hospital No. 6, October 12. Amputation left forearm. Suture lacerated scalp wound, left occipital. Neurological examination negative; X rav negative. Dressing One suture removed from scalp. Patient profoundly unconscious; manifestly moribund Died October 13. Autopsy: Depressed fracture of the inner plate, left occipitoparietal, with large extradural hemorrhage; no dural penetration. Brain saved for section. NEUROSURGERY 761 This patient arrived profoundly unconscious, with notes of operation performed elsewhere and revealing no fracture. A negative X-ray and neuro- logical examination of the patient confused the picture still further. In view of the moribund condition of the patient and the negative findings, it was not thought worth while to do an exploration. The surgeon who operated upon him would have been in a better position to judge of his condition and the advisability of further operative action. Consequently this case should not have been evacuated. Case 2.—J. G., No. 1624243. 79th Div. 314th Machine Gun Battery, B Co., admitted to A. R. C. Hospital No. 114 with following note: "X-ray: F. B. 1 cm. right side of head, 4 cm. under skin mark, right temple. Large depressed fracture of skull; left parietal region. 22 hours after injury. Operation: Removal of depressed parts of bone. Brain irrigated and macerated brain tissue removed. F. B. not removed. Hold." Ad- mitted to Mobile Hospital No. 6, October 6, 1918, 11.30 p. m. A. T. S. given. October 7: Unconscious; delirious; tosses about with left arm and hand. Incontinence of feces and urine. Complete right-sided hemiplegia. Right facial palsy. Large postoperative wound, left parietal region; crow-foot incision; sutures infected; spinal fluid oozing out. Three central sutures removed. Skin edges infected; decompressed area size of half dollar in left parietal; there has been considerable brain injury. No rigidity of neck; no Kernig; left Babinski plus. October S, 1918. Considerable foul discharge. Neck rigidity marked. October 9, 1918. Meningitis. Foul discharge from wound; opened more; fragments of inner table which were loose, removed. October 10, 1918. Died 12.40 p. m. No autopsy. It is impossible to convey by notes, especially such as can be placed on a field card, the completeness of an operation and the history of a case such as this. Any dural penetrations should always stay under the care of the man operating until either evacuated to the base or dead. Of the five cases in Group V dying without operation, in three the foreign body had traversed or lodged in the region of the basal ganglia. In the remain- ing two tlie cranial damage was extensive, partly direct laceration of brain tissue and partly extensive "commotion" of the brain, such as is seen in pro- found concussion. They were all moribund on entrance. The following case is typical of this group: Case 3.—W. H., Pvt., No. 542269, 7th Inf., Co. H. Field Hospital No. 27, October 8, 1918. G. S. W. skull. Field Hospital No. 26, October 8, redressed, morphia, external heat, small piece of high explosive taken from right knee. Wound of thigh dressed. Mobile Hospital No. 6, October 8. Patient entered hospital in unconscious condition. No history other than above. Pulse 144; respiration rapid and with apparent beginning edema of lung. Wound: G. S. W. right anterior quadrant skull, about 4 cm. in length. Multiple G. S. W. right leg. X ray; foreign body 1 by 1^ cm. inside skull, 73^ cm. under skin mark Tight anterior frontal region head on left side; 8 cm. under skin mark on middle anterior frontal region; plane passing on the line drawn will meet at a point giving the position of foreign body 1 by 1J^ cm., 6 cm. under skin mark on upper inner surface of thigh, right. Foreign body & by A under skin mark on point of heel, right. October 9, 4.15 a. m. patient died. Autopsy: Penetrating wound right frontoparietal region. Extensive comminution of cerebrum with softening opposite side. Brain saved for section. In Group VI, three patients entered in a moribund condition, the missile having, judging from its course, reached or traversed the ventricle. Four died of meningitis, one having a foreign body traversing the lateral horn of the left ventricle, unconscious on entering and developing infection in 24 hours; a second entering, unconscious, with foreign body localized in such a position 702 SURGERY as to indicate that it had traversed the ventricle, developed signs of meningitis in 24 hours and died on the seventh day after admission; a third had outspoken signs of meningitis; and the fourth, the foreign body had traversed one hemi- sphere from pole to pole, passing through the ventricle, while the man was pro- foundly unconscious and developed meningitis in 24 hours. A typical case is as follows: Case 4.—145th Inf., Co. B, 37th Div. No notes from field hospital. Admitted to Mobile Hospital No. 6, September 30. Unconscious, with diagnosis of G. S. W., left parietal region. Condition good. Entrance wound in front of left ear just above zygoma. X ray: Foreign body J4 by 1 cm. lying below mark on right ear, right side of head to the table. Neurological examination: Complete right hemiplegia. October 1, 4 p. m.: Temperature, 100.6; pulse, 94; deeply unconscious. Fundus examination: Disks blurred; fields distended. Operation not considered advisable. October 3: Symptoms of meningitis. October 4: Semiconscious. October 7: Semiconscious; marked symptoms of meningitis. October S: Died from meningitis. October 9: Autopsy. Penetrating wound left temporal region, entering tip of temporal lobe, entrance measuring 2 cm. in diameter, exuding quantity of pus and disorganized brain. Acute purulent meningitis especially marked over the base. DEATHS OPERATED Operated deaths are as follows: Cranial: Group II__________________________________________________ 1 III__________________________________________________ 2 IV__________________________________________________ 17 V______________________________________ __________ 3 VI________________ ____ _______________ ________ 5 VII___________ _____________________________________ 2 VIII___________ _____________________________________ 2 IX__________________________________________________ 2 Sinus (venous)____________________________________________________________ 1 Total______________________________________________________________ 35 The death in Group II was due to lobar pneumonia, shown at autopsy. There was also a linear fracture of the skull down to the right, but with no evidence of depression. A small and unimportant extradural clot was present. This fracture was not recognized at operation, and the skull consequently was not trephined. The records of the patients in Group III who died are as follows: Case 5.—G. H. P., No. 65331, 103d Inf., Co. H. Admitted to Mobile Hospital No. 8, October 25, 5 p. m. Wounded 7 a. m., October 24. A. T. S. given. Unconscious 15 to 20 minutes after accident, with immediate paralysis left side of body. G. S. W., 12 by 3 cm., right parietal region, dirty and inflamed. G. S. W. right arm and elbow, outer surface, above and below knee, foul-smelling discharge suggesting gas infection. X ray head: Penetrating skull, right parietal. Numerous foreign bodies J^ by % cm. in length in wound in skull. One foreign body 1 cm. long projects from the wound, to inner surface of the skull. No foreign body in brain. Right arm, leg, and thigh negative. Neurological examination: Paralysis left side of face, left arm, and left leg. Loss of sensation to touch and pin prick left arm and hand. Touch sensation in left hand present. Deep reflexes left arm, left leg hyperactive. Left epigastric, left cremasteric absent; right present. Spasticity'left leg and left arm. Left Babinski. Pulse rate 100. October 25, 10.20 p. m.: Blood pressure, systolic 120, diastolic 80. Operation: Excision of scalp. Block removal decompressed skull fracture 3 cm. in diameter; dural penetration. Subdural blood clot and contused brain NEUROSURGERY 763 removed by suction. Dural wound left open. Partial closure of scalp. Local anesthesia, under primary ether. Arm and leg wounds excised for drainage. Pulse 150 and very weak, so that more extensive procedure could not be done. October 26, 8.45 a. m.: Convulsion, Jacksonian type, left side of face, left hand, duration 10 minutes. Dressings changed. Pulse 120. During the next 12 hours, patient had 6 of the localized convulsions. October 30: Continued and increasingly severe convulsions since operation, always involving left arm and left side of face. Left leg paralyzed; leg wound dirty and foul-smelling. General condition never good and became steadily worse. Right leg shows evidence of gas infection. Died at 7.30 p. m. The severe shock and the sepsis resulting from wounds other than that of the skull seemed to preclude as extensive an operative procedure as was advis- able in the first place, and also a secondary exploration to ascertain the cause of the irritative phenomena, which might otherwise have been done. A similar case with Jacksonian attacks, on secondary operation showed a tract in the cortex about 2 cm. deep under considerable pressure and tension. On relief of this, the convulsion subsided. No autopsy. Case 6.—H. P., No. 2257218, 361st Inf., Co. C, Pvt. Admitted to Mobile Hospital No. 6, October 4, 1918. Wounded October 3, 3 p. m. Was not rendered unconscious and was able to walk. X-ray examination: Foreign body 8 by 5 cm., 20 mm. from mark on posterior surface of right thigh. Forehead shows no foreign body. Wound of head 3 cm. above right eyebrow, 1 cm. in diameter. Neurological examination: Right pupil greater than left; pupils react to light, otherwise negative. Operation: October 4, 5.50 p. m. Block excision of block and bone. Internal plate, 2 by 1^_> cm., which had been driven inward and striking into dura, removed. Escape of large amount of clear, cerebrospinal fluid. No con- tusion of underlying brain noted. Dura and scalp closed with silk. October 7: Scalp wound infected; opened. October 8: Kernig positive. Neck stiff; lumbar puncture done, 20 c. c. cloudy fluid removed. October 9: Lumbar puncture, with removal of cloudy fluid. October 10: At midnight patient died of meningitis. Autopsy: Scalp wound only slightly infected. Dura tight. Spreading from this is an acute, purulent meningitis, most marked over the right cerebrum and base. In Group IV, there were 17 deaths, of which 1 had signs of meningitis on admission; 1 died of severe and generalized gas burns; 3 of meningitis; 8 encephalitis; and 4 directly as a result of very extensive intracranial damage, although this in some cases may have been complicated by infection. In other words, 11 out of the 17 cases were amenable to operative treatment. In the cases of meningitis, two showed signs in 24 hours, making it seem possible that the meninges were infected previous to operation, while the third flared up on the fifth day following a very extensive herniation and encephalitis. In the first two, the scalp was closed tightly and not opened at any time. The third was lett open because of the size of the scalp defect. Four of the eight cases classified as dying of encephalitis had such an ex- tensive intracranial damage that their condition was obviously practically hopeless for operation. One of these died of a gas infection of the brain. The following is a typical case: qase 7__m. K., Pvt., No. 1630902, 30th Inf., Co. I. Evacuation Hospital (A. R. C.) No 114 October 11. G. S. W. head. Admitted to Mobile Hospital No. 6, October 12, ATS given. History: G. S. W. head, October 11, 4 p. m. Conscious, no vomiting. Paralysis, left; spastic. Condition fair. Wound 2% by 6 cm., right parietal, parallel with sagittal suture to the right of mid line over parietal region. Ragged, dirty, depressed frag- ment 1 bv ]A cm. Stellate fracture radiating from depression. X-ray examination: No 764 SUROERY foreign body. Fracture of skull through inner table beneath wound. Neurological examina- tion: Spastic left hemiplegia, arm and face; arm less than lower limb. Knee jerks dimin- ished, left. Ankle-clonus, left. Operation: Debridement, two sutures in the dura; closure- with no drainage. October 13: Wound dressed; considerable discharge. Patient stuporous. October 14: Wound shown increasing sanguino-purulent discharge. No rigidity marked. Unconscious. October 15: Condition serious. Much foul discharge from wound. Uncon. scious; no rigidity; Kernig. October 16: Nystagmus to the left. Condition worse. Con- vulsion this morning at 9; this afternoon at 1.30. Died at 5.30 p. m. Autopsy, October, 17: Wound, vertex, of the skull, right parietal region, softened brain substance exuding- Three radiating lines of fracture from bone defect. Opening in the dura measures 3 by 5 cm. Brain is so softened that its removal intact is almost impossible. Right parietal lobe entirely replaced by softened hemorrhagic mass. The remaining four cases represent errors of treatment, and these are re- ported in detail: Case 8.—F. S., Pvt., No. 2965964, 314th F. A., Co. E. Wounded October 7, 1918. French field hospital, October 7, 1918. A. T. S. given. G. S. W. head. Entered Mobile Hospital No. 6, October 7, midnight. History indefinite; patient's statements uncontrolled and unreliable. Given his name, organization, State, etc., but readily forgets and repeats. Recognizes objects and names; knows he is in hospital and has been wounded. Wound: Small penetrating, left posterio-parietal, measuring 2y2 by \x/i cm. X-ray examination negative, for foreign body. Area of increased density size of nickel, suggestive of intracranial hemor- rhage under wound. Operation: Debridement of scalp; fractured bone 6 by 5 cm. had been driven into the dura and brain. Removal of bone fragments, enlarging the opening to the size of a dollar, under local anesthesia. October 10: Visual fields somewhat limited, homo- nomously to the right. October 11: Patient much more alert. Visual fields probably normal. October 17: Sutures removed. Slight amount of sero-purulent material. October 24: Died at 7.15 p. m. Progressive cerebral herniation and signs of encephalitis. The condition of this patient previous to the operation seemed quite favor- able, but for some unknown reason the block operation with wide exposure was not done, consequently thorough debridement was not accomplished. Infec- tion ensued in the presence of inadequate drainage, followed by progressive encephalitis and death. Case 9.—F. D., No. 2557608, 138th Reg. Admitted to Mobile Hospital No. 6 Sep- tember 30, 1918. Unable to talk. Slip with him says wounded in action: Day not known. Marked S. W. of skull. Condition: Unconscious on admission. An hour later could be roused. Could not speak, but some attempts to obey simple orders, such as moving arm and leg. Wound: Severe, penetrating, over left parietal region. Bone fragments driven inwards and down outwards. Neurological examination: Complete right hemiplegia. Right pupil larger than left. Right ankle-clonus. Right knee jerks greater than left. No Babinski. X-ray findings negative. Operation: Debridement; removal of shattered bone. No foreign body. October 2: Dressing, some herniation. October 3: Dressing; herniation increased; slight hemorrhage. October 4: Severe hemorrhage. Herniation of almost entire left lobe. Discharge of bloody spinal fluid on slightest cough. Died at 1.30 p. m., October 4. Case 10.—Pvt, No. 1781329, Co. L, 313th Inf. Wounded, October 1, 1918. G. S. W. head: (1) fronto-parietal; no foreign body or fracture. (2) G. S. W. 5 cm. in length, left Rolandic area; indriven bone. Admitted to Mobile Hospital No. 6 October 2, 1918. Neuro- logical examination: Spastic paralysis right side. Right facial paralysis. Operation: De- bridement. No foreign body found. Subdural clots. Bone fragments removed. Closure incomplete. October 3: Slight hemorrhage from dural vessels; brain hernia. Vessel cauter- ized; actual cautery. October 4: Patient died, 5.45 a. m. In both of these cases, the dressings were carelessly done, with compres- sion and damage to the herniating cerebral tissue, followed by hemorrhage. This was controlled only after further rough usage, resulting in the shutting NEUROSURGERY 765 off of blood supply to considerable areas of herniating cerebrum. Such a con- dition so handled is, of course, always progressive and followed by death. Case 11.—F. C, Sgt. No. 2307026, Co. G, 127th Inf. G. S. W. head. Wounded Octo- ber 4, 4.30 p. m. Hit by piece of high explosive. Unconscious for hour and a half. Vomited directly on regaining consciousness, but not since. At Field Hospital No. 27. A. T. S. given. Entered Mobile Hospital No. 6 October 6, 1918, midnight. Wound: Gutter wound over right median frontal, apparently tangential. Dirty and protruding cranial tissue. General condition good. Pulse 60. Weakness of arm and hand. Positive Babinski, left; cremasteric, left; less than right. No other signs. Operation: Wound in bone removed en bloc. Three bone fragments removed, completing half mosaic. Cortical bleeding started by an attempt to remove bone fragment; controlled by cotton and finally by a small facial slip. Scalp sutured. October 6, 3.10 p. m.: Left lower fascialis weak. Pupils equal and react to light and accommodation. Left arm paralyzed except for very slight movement of forearm. Left leg very weak; no Babinski or Oppenheim. Reflexes: Knee jerks, left greater than right; no clonus. Vomiting. Wound dressed; blood under scalp expressed; seems clean. Pulse rapid. October 7: Neck stiff. Optic neuritis. Unconscious. Pulse 116. Temperature 100.6; respiration 30. October 8: Condition much worse this morning; com- plete left hemiplegia; stuporous. Died at 10.05 a. m. The tearing of the deep cortical vessel, and the consequent hematoma along the tract, destroyed what small chance of recovery this patient had. Ex- amination of wound post mortem showed a gas infection involving the greater part of the right frontal lobe, patient having died of a gas encephalitis. In Group V, three cases died following operation. One of these entered with a foreign body 5 by 3 cm. in left parietal region and a herniation already present measuring 6 by 8 by 4 cm. Patient was unconscious and hemiplegic- An unsuccessful attempt at removal of foreign body was made. Wound was dressed; patient died within 48 hours. The records of the remaining two cases are given in detail. Case 12.—J. E., Pvt, No. 2256961, 361st Inf., Co. A. Wounded October 1, 1918. Entered Mobile Hospital No. 6, October 3, 191S, 10.45 a. m. Penetrating wound right occipital region. X-ray examination: Penetrating wound: Foreign body 1J^ cm. in the brain. Mid line 7 cm. back of external auditory meatus. No localizing neurological signs. Operation: Block removal of fracture area through tripod incision. Foreign body lying about x cm. under the surface removed; several bone fragments also. Scalp closed tightly. October 5: Incontinence of urine; temperature 100° F.; no nausea or headache. Deep re- flexes very sluggish; drowsy. Disorientated for time and place. Knows he was in 361st Inf., does not remember any circumstances of accident. October 7: Temperature ranged to 102° F. Patient vomiting to-day. Fungus formation, with broken-down wound. Scalp resutured, with anterior drain. October 8: Bloody discharge but wound holding. Opistho- tonos; positive Kernig; patient has developed meningitis. October 9: Died at 7.40 a. m. Case 13.—Pvt. No. 1458990, 152d Inf. G. S. W. head. Entered Mobile Hospital No. 61 October 1, 1918, 12.05 a. m. Extensive gutter wound of left side of head from above left orbit upward and outward to left external auditory meatus. No neurological signs except for motor aphasia. Operation: Local anesthesia. Debridement: Removal of bone fragments and pieces of shrapnel from brain. Closed in layers. October 7: Lower end of wound incision opened. Brain irrigated with saline. Fungus cleaned away. Scalp wound sutured tightly. October 10: Wound suppurating; dressed daily and irrigated with sterile salt solution. Draining profusely. Condition fair. October 12: Redressed. Free drainage, with suppuration of wound. Condition improved. October 13: Redressed. Some improvement. Temperature normal. Draining freely. October 14: Redressed. Wound condition same; still draining freely. Temperature 102.6° F. Suspicious Kernig. No opisthotonos. October 16: Died 4.30 p. m. 766 SURGERY These cases are of special interest because once having been sutured and having broken down, they were again closed over the hernia. The conception in the operator's mind of the condition being that it was a purely mechanical thing, it was not appreciated that while cranial herniation is due to increased intracranial pressure, this may be either the result of edema from mechanical disturbances, or, what is more important in war injuries, from infection. If the herniation is due to a purely mechanical cause, under proper dressing it will shortly subside even if the scalp is left open. If, however, it is due to infection, as in any other region of the body, the infected area must be ade- quately drained. Both of these cases, as might have been expected under the treatment used, did badly. Of the five deaths in Group VI, three were instances where the projectiles traversed the entire hemisphere passing through the ventricle in its course. Such injury—according to Cushing's experience, confirmed by this data— results uniformly in death. In time of rush such cases should be marked inoper- able. An instance of this class is the following: Case 14.—E. W., Pvt. No. 1937561, 26th Inf., Co. G. G. S. W. right side of head, severe. Entered Mobile Hospital No. 6 October 11. History of being wounded October 9, 4.55 p. m. States that he was struck by shrapnel. Not unconscious. Helmet broken. Very severe headache, and nauseated. Left hand has been weak since injury. No speech difficulty. Wound: Right frontal region, just back of hair line. Brain substance oozing. X ray shows machine-gun bullet lying near junction of temporal and occipital lobes on the right. Neurological signs: Left facial weakness. Left arm and hand extremely weak; left leg somewhat so. Slight diminution of sensation left. No astereognosis: Complete left homonymous hemianopsia. Reflexes, biceps, more lively right than left. Knee jerks, present right, absent left. Few clonic jerks each side. Operation: Novocaiue and morphia. Com- plete removal of fractured skull. Debridement of scalp and track; through irrigation. Foreign body, machine-gun bullet; removal of right hemisphere, location 4J^ cm. from point just above right external auditory canal and about 9 cm. from the point of entrance in the right frontal lobe. Irrigated with sterile saline. Bone fragments removed; scalp sutured; patient's condition good. October 13: Dressed, wound clean. Temperature 101.4° F.; delirious; stiff neck and double Kernig. Left hemiplegia present. October 14: Died 2.15 a. m. Autopsy: Penetrating wound, deep, right frontal lobe. Brain saved for section. The two remaining cases were instances of indriven bone fragments reach- ing the ventricle, and they died of meningitis. About one in four of such wounds recover and they are, therefore, distinctly operable. In Group VII, two cases died, both having a wound involving the orbital contents, frontal sinus, and frontal lobe. The extensive mortality accompany- ing this type of injury suggests more radical measures, which were not under- taken in this hospital, namely, evisceration of the orbit and establishing wide and thorough drainage. Two cases with traversing wounds of Group VIII died following opera- tion, one of the cerebellum and one of an occipital lobe, the latter dying from a generalized gas infection, apparently arising from the foreign body which lodged deeply in the neck muscles and was not removed. In the former the foreign body traversed the right lobe of the cerebellum, almost completely destroying it, encephalitis of the cerebellum resulting in death in six days. Two deaths are recorded in Group IX, one being the type of basal fracture commonly seen in civil life, and the other a fracture of the petrous portion of the temporal bone, with cerebrospinal fluid from the ear. NEUROSURGERY 767 Of these cases involving a venous sinus, one died. In this case the approach was made with an inadequate exposure resulting in profuse hemorrhage, packing, and death on the fifth day, which, however, was probably due to the effect of the missile ranging forward and inward to the basal ganglia. PATIENTS EVACUATED The following records are of cases that were evacuated in good condition: Cranial—Group I, 69; Group II, 32; Group III, 14; Group IV, 6; Group V, 11; Group VI, 1; Group VII, 1; Group VIII, 2. Sinus (venous): 4. Total: 140. CRANIAL Group I.—The majority of cases in this group were scalp wounds in which the injury had extended to the bone. In a few, however, the pericranium was not lacerated. It would seem, particularly in times of rush, that the patients in whom the laceration did not extend to the bone might be evacuated without operation. It is realized that there might well be a depressed fracture under- neath such a lesion, but with the absence of neurological symptoms and the lack of a tract leading from the external wound to the depressed fracture, there would be few if any cases which would afterward show either neurological signs or infection of the fracture and the underlying cranial structures. In other words, in proper hands, a more conservative position might be taken as regards the operating on scalp wounds. Group II.—Every case of this group should be explored and trephined. Experience with this hospital confirmed what already was well known, that is, that even the simplest linear fracture or even abrasion of the skull may overlie serious intracranial damage. If the pathway from the external wound to the fracture is continuous, then infection will in many cases—even with the simple depressed fracture without dural penetration—lead to a meningitis or an abscess in the contused adjacent cortex. Group III.—The majority of cases reported in this group showed only a small puncture of the dura or slight laceration. An occasional one, however, had a short tract of contused tissue. The question always arises as to whether the best procedure is to close the dura at once with silk sutures, thus hoping to avoid infection of the underlying tissues, or to leave it open, arranging for drainage. From a study of the cases in this hospital, as well as experience elsewhere, it seems that every patient in whom the dura is sutured does badly. There is a tendency to the damming back of the infection in the subdural tissues, leading to meningitis or cortical abscess. Where the dura has been left open, such infected material evacuates itself beneath the scalp, and if the scalp is drained into the dressing no progressive infection arises and the wound heals with little reaction. As a general policy it would seem advisable in cases of this type to leave the dura open and, in addition, to drain the scalp with a small rubber-tissue wick. A case of this type is as follows: Case 15.—S. D. Pvt., No. 552003, 38th Inf., Co. K. Wounded: October 9, 10 a. m. machine-gun bullet, which made two holes in his helmet. Unconscious five minutes after injury. Wound 10 by 2 cm. over the right parietal eminence, the large diameter being 46997—27----51 70S SURGERY anteposterior. X-ray examination showed metallic dust in the wound. Shadow suggesting fracture of the inner table. Admitted, Mobile Hospital No. 6, October .». 6.30 p. in. A. T. S. given. Neurological symptoms: Right pupil larger than the left. Right cremasteric reflex present, more sluggish than left. Left knee jerk more active than right. Left Babin- ski. Pulse 80. Operation: Tripod incision, with wide incision of wound. Scalp wound did not extend down to skull, but upon examining skull a line of fracture extending backward toward the occipital lobe was present, with no depression of the external plate. Upon opening the skull, two pieces of internal plate measuring \y2 cm. in diameter were found pressing deeply against the dura. One of these lay partially through a small tear in the dura. These were removed. The exposed dura pulsated and there seemed to be no undue tension. It was, therefore, not opened further. The scalp was now closed with S. W. G. sutures. Local anesthesia. October 11: Wound dressed. Looks all right. Pupils equal No Babinski. Diminished sensation left hand and left forearm. Perception of pin prick. Loss of muscle sense and astereognosis. October 13: Stitches removed. Wound healed. October 17: Both pupils dilated equally. React to light. No neurological symptoms. Evacuated sitting. This case was evacuated to Base Hospital No. 56-A. His condition upon arrival was good, and from there he left on November 14. Wound healed; no symptoms; recommended for convalescent camp. In some cases, classified as Group III, there was no penetration of dura from the original injury, but there were marked neurological signs, and the appearance of the dura at time of operation indicated hemorrhage and con- tusion in the adjacent cortex. In three such cases the dura was opened and the damaged tissue beneath evacuated by irrigation and by having the patient cough, and the dura subsequently sutured. These cases did very well. It seems that with a relatively clean external wound excised thoroughly with a block removal of the bone, carried out with the necessary technique, a sufficiently clean operation field can be obtained, so that the dura may be safely opened and sutured. In contradistinction to the type of cases referred to above, where the original injury has punctured the dura, the contused cortex beneath the intact dura is sterile and if the technique is good, after the evacuation of this contused tissue, the dura may logically be sutured over what is a sterile field. Drainage may be advisable down to the dura to take care of the oozing and any possible contamination of the scalp incision. A case of this type is as follows: Case 16.—L. F., No. 2255444, 347th Reg. Machine Gun Bat,, Co. D. Wounded: September 29, 4 p. m. Gunshot wound head and left buttocks. A. T. S. given. X-ray examination: Head negative. Admitted to Mobile Hospital No. 6, October 3, 12 p. m. Wound on vertex of skull lying in direction of Rolandic fissure, cm. beneath mark on hair back of left ear. No fiuroscopic evidence of fracture. .Neuro- logical svmptoms: None. Operation: October 1, 2 p. m. Block removal of fractured skull area, Foreign body removed from right occipital lobe. Wound cleaned, lore.gn body was just below the dura; not much cortical laceration; dura left open. Scalp closed tightly Temperature normal. Left forearm had through and through shrapnel wound; fracture of both bones and loss of bone substance. Debridement: Thomas extension splint. October 4: Wound healing per primum. October 6: Wound healing cleanly. Temperature .)Xb. October 8: Wound healed; temperature normal; no headache; reflexes normal; no Babinski; no hemianopsia. Stitches partially removed. October 11: Remaining sutures removed. Xo headache. Reflexes normal; arm doing nicely with daily saline irrigations. October 14: Head dressed; wound clean and healed; now 14 days old; dressing applied. No diplopia or hemianopsia. Knee jerks active and equal. No Babinski; no motor or sensory disturb- ances. Left arm wound clean and granulating. Has had daily saline irrigations. Some movement with thumb and first finger. Evacuated lying. Case 19.—R. L. Sgt. No. f..".sl98, 48th Inf., Co. H. Admitted to Mobile Hospital No. 6, October IS, N.30 p. m., from Neurological Hospital No. 1. History and notes of neuro- logical hospital: Entered hospital October 1; wounded September 27. Age 26 years. Fam- ily history negative. Past history: Graduate, clerical; works at 18 dollars a week. Not interested in sports. Enlisted October, 1917. Arrived France May 23, 191S. In at end of Chateau Thierry operation. Had a severe emotional shock then; saw one of his men hit, went to his assistance, found his head blown off. Nauseated for two days. Carried on in Verdun Sector for two days. At the end of second day, September 27, shell exploded near and he was hit by some of the pieces; received three slight wounds in left arm; one piece of the shell pierced helmet and gave him a slight wound over the parietal region. Blow from this was quite forceful and staggered him, but did not lose consciousness. Believes he bled from the right ear. Was brought back. When first seen wore an anxious expression and was apparently quite confused. October 2: Seen in convulsion, tonic. Mouth was half open; no frothing at the mouth. Physical examination: Deep reflexes exaggerated and exhaustible. Left ankle-clonus, otherwise signs negative. October 17: Later the man gave a clearer account and verified facts above mentioned. In addition, he says there seemed to be about two days he can not account for. Remembers coming to this hospital and that when he was being brought into the hospital he had a convulsion. He noticed that his left arm and leg were beginning to twitch and his throat tightening and remembers no more. He has had same sensation twice since. The past three or four days he has had severe head- ache, but is better to-day. Pulse 48 to 60, remittent. All neurological signs negative except that superficial, epigastric, and cremasteric reflexes are slightly more active. Eye grounds: Disc margins are both indistinct and decidedly hazy; vessels seem normal. Diagnosis: (1) Psychoneurosis; hysterical. (2) Observation for epilepsy; traumatic. First diagnosis was made on first seeing the patient, but was later changed. Summary: Right head injury, September 27. Two or more convulsions since. Now severe headache. Slow pulse and hazy eye grounds. Entered Mobile Hospital No. 6, October IS. Wound: There is a small healed scar in the right parietal region 1 cm. long over the parietal eminence. Neurological examination: Right pupil measures 5 mm. in diameter, left 3 mm. in diam- eter. Right optic disc 1^ mm.; swelling of left lid. There is a small retinal hemorrhage in the right eye. Left facial nerve slightly affected during expression. Left arm and hand movements somewhat ataxic. There is also partial loss of muscle sense in the left hand. X-ray examination: Fracture of skull, anteriorally; right antrum cloudy. Foreign body 2 by 3 mm. under mark right side of head (this was about 3 cm. anterior to the wound). Op- eration: October 18: Straight line incision as for decompression. Small bone defect meas- uring 1 cm. in diameter excised en bloc. Small opening 1 cm. in diameter in the dura through which brain under pressure was protruding. On coughing, patient squeezed out a blood clot size of a large bean. Subcortical collection of old bloody fluid about 15 cc. in amount. This was removed from the region of the track and also small amount of contused brain was NKUROSURGERY 773 removed by suction. Foreign body was not removed, although an attempt was made with the magnet. Dura left open; scalp closed. October 19: Headache very much better. Neurological signs as previously noted. October 25: Edema of optic disks subsiding; head- ache practically disappeared. Neurological signs clearing up. This case was later evacuated in good condition. Group VI.—An example of a favorable case of this group is the following: Case 20.—F. M., Cpl., No. 1N..7372, Machine Gun Co., 325th Inf. Entered Mobile Hospital No. 6. October 12. Wounded October 11, 4 p. m. by shrapnel; unconscious 12 to 15 minutes; nausea and vomiting; weakness left leg immediately. Blurred vision; bright flashes of light. Persistent headache. Wound: Lacerated wound 2 cm. in diameter over left parietooccipital region. X-ray examination: Foreign body ^ by T3o cm., 1 cm. under skin mark just above ear. Neurological examination: Right hand and arm spastic and weak. Loss of sensation of right upper extremity as well as lower; no Babinski. Patella clonus on the right. Knee jerks hyperactive, but equal. Left homonymous hemianopsia. Opera- tion: Small laceration of the scalp. Two by three cm., excised. Bone removed en bloc. Dura punctured and three indriven fragments removed. Foreign body found in scalp. Large masses of blood oozed from cortex, cerebral fluid leaking in small amounts. Irrigation of wound produced severe headaches. It was thought that the fluid entered the ventricle. Scalp closed tightly; dura left open. October 14: Wound clean; temperature normal; no subjective changes. October 16: Fundi normal; wound clean; several sutures removed. October 18: Remaining sutures removed; temperature 98.4. Has had occasional headache, and temperature reached 100 last night. Profuse discharge from scalp wound. October 22: Complains of slight headache; no ocular symptoms or nausea; hemiplegia improving. Sense of position and common sensation absent. Heat and cold preserved. No fever for past three days. Wound draining slightly; condition good. October 24: Redressed. Condition improved. October 25: Dressed. Drainage has stopped. Wound healed. Neurological condition improving. On evacuation, condition good. Group VII.—A case which recovered in this group is as follows: Case 21.—W. D. P., Pvt., No. 573950, 12th Machine Gun Battalion, Co. C. Admitted to Mobile Hospital No. 6, October 2, 1918, at 4.15 p. m. History: Wounded October 2, at 10 a. m., machine-gun bullet, penetrating right upper eyelid. Complete collapse of right eye, bullet apparently having passed posteriorly. X-ray examination: Machine-gun bullet lying in the cranial cavity, 1 inch to the right of median line over roof of the orbit and back of the posterior border of the orbital cavity, directly at the intersection of lines from two skin marks. Neurological examination: No signs. Operation: Enucleation of right eye; removal of contused brain tissue; bone fragments and bullet from a bone defect in supraor- bital plate very deep down in frontal lobe. Plastic closures of structures about the right orbit. October 17: Convalescence uneventful; no neurological signs; evacuated. Group VIII.—Two cases of traversing wounds in this group recovered, and will be given in detail. Case 21.— L. S., Pvt., No. 2661431, 59th Inf., Co. B. Admitted to Mobile Hospital No. 6, September 30. History: Wounded September 29. Point of entrance left frontal; point of exit right frontal about 2 inches above the external orbital process. Lacerated wound at higher point about 2 cm. in diameter, both outside of the hair line. Not uncon- scious- walked in, complaining only of some frontal headache. Neurological examination negative. Operation: Wounds excised and connected, with thorough debridement. Dura penetrated and brain oozing out. Edges cleaned, and toilette of entire wound; drainage at either end and with suture of scalp between. October 11: Neurological note says headaches the whole time and eyes burn; otherwise feels well. He states at this time that he remembers everything from the time he was hit; did not vomit; walked to dressing station; had no pain, but was dazed and his head began to ache soon after. Is perfectly rational at present; relevant and coherent; euphoria; no irritability. October 14: Sutures removed; wound healing. October 17: Convalescence has been uneventful. Evacuated. 774 SURGERY Case 22.—J. G., Pvt., No. 1448900, 37th Inf. Admitted Mobile Hospital No. 6, Sep- tember 30. History: Wounded by machine-gun bullet September 28. Condition stuporous: answers questions slowly; retarded; no aphasia. Wound: Point of entrance left occipito- parietal; point of exit right occipitoparietal, both 2 inches above left occipital protuberance and 3 inches to the right. No foreign body. Neurological examination: No evidence of cranial nerve injury; complains of loss of vision in the right eye; distinguishes light, right eye; recognizes objects with left eye. Operation: Debridement scalp and bone both exit and entrance. Suture. October 4: Pupillary examination, normal. Fundus: Slight but definite hyperemia; no swelling; vision both eyes nil. October 6: Slight convulsion, seizure lasting five minutes. Says he can hear well. October 9: Thinks he can distinguish light. Wound clean. October 13: Vision improving; distinguishes objects both right and left eye. October 17: Wound healed. Vision and memory returned. Cerebration keener. Evac- uated. SINUS (VENOUS) The following case is illustrative of a wound which involved the longi- tudinal sinus: Case 23.—Pvt., No. 220739, 362d Inf., Co. G. Entered Mobile Hospital No. 6, Sep- tember 29. History: Wounded, September 28. Shrapnel passing through helmet; not unconscious; did not vomit. Slight headache. Condition: Walked into the hospital; headache only at present. Wound: Slight lacerated wound over sagittal suture at the occip- itoparietal junction. X-ray examination negative. Neurological examination negative. Operation: Excision of scalp wound, small indentation of external table measuring 2 cm. in diameter; square piece of bone removed en bloc over area 5 cm. in diameter. Depressed fracture inner table; small fragments piercing longitudinal sinus with a linear tear about 1 cm. in length; no clot. Bleeding controlled by cotton and a slip of muscle placed directly over the tear. Scalp sutured tightly. October 2- Wound healing primum; no neurological signs. No headache. Patient evacuated. SUMMARY The following table gives the complete data as regards the cranial injuries handled by this hospital: Cranial: Group I. II. III. IV. V. VI. VII. VIII IX. Sinus__________ Craniotomies____ Dural penetration Mortal- uated Died Total ity, per cent 69 0 69 0 32 1 33 3 14 2 16 12 6 17 23 74 11 3 14 21 1 5 6 83 1 2 3 56 2 2 4 50 0 2 2 100 4 1 5 20 140 35 175 20 71 35 106 33 37 31 68 45 The advantage of such a specialized unit as this may be summarized as follows: 1. Refinement of technique, approximating that really necessary to do even fairly satisfactory work, is possible. 2. Changes in technique, and the adoption of adjuncts, such as X ray are rapidly possible in a group with a cen- tralized control, such as this. 3. The training of surgical teams, and the insistence upon the most fastidious technique can be accomplished readily only in such a hospital. 4. It is possible to get Team play" between the NEUROSURGERY 775 ophthalmologists, maxillofacial surgeons, X-ray department, pathologists, etc., in one hospital; it is exceedingly difficult to do so in all of a dozen or more hospitals. The disadvantages, as they appear in this experience, were principally those of transportation and triage. This hospital was situated at such a distance from the front that during a major portion of the fighting, cases reached it upon an average of 36 hours after injury. In addition, there were too many steps in transportation; that is, all cases would be evacuated through one and sometimes through two hospitals, at which points there would be a delay of sometimes 12 or even 24 hours. These cases did not suffer from length of trans- portation to any great degree, but they did suffer, as shown by data, especially those under Group IV, by the prolonging of the preoperative period, during which infection was uncontrolled. It should always be stated as a corollary to the axiom, "Head cases bear transportation well before operation," that a delay of 24 hours increases the chances of infection and decreases the chances of survival almost as markedly as it does in penetrating wounds of the abdomen. This is shown by the high mortality in Group IV, where the wounds were open, cranial contents extruding, and infection had a wide pathway of entrance, whereas in the other groups in which the point of penetration was smaller, and the path of infection more devious, the mortality was as low, and even lower, than the ideal figure given in "Instructions to the Neurological Surgical Teams." CHAPTER III MANAGEMENT OF GUNSHOT WOUNDS OF THE HEAD AND SPINE IN FORWARD HOSPITALS, A. E. F. CRANIOCEREBRAL SURGERY PRIOR TO OUR ENTRANCE INTO THE WORLD WAR Wounds of the head in the war, 1914-191S, were, generally speaking, of a more serious nature, as was true of all wounds, than was the case in former wars, due principally to the short-range firing of trench warfare, to the employ- ment of intense artillery fire, much of which was high explosive, and to bombing from the air. Thus the relatively great number of head wounds requiring surgical intervention presented a problem seriously demanding a solution. It was evident from the first that the victims of cerebral injury were likely to con- stitute the last residium of the wounded needing hospitalization long after the end of hostilities. There was a lack of unanimity of opinion, with respect to the management of these cases, which persisted throughout the war. This was more marked, however, during the first two years. Toward the latter part of this period (1916) it was considered good practice to transfer head wounds to the rear, in view of the fact that patients with head injuries bore transportation badly following operation. This, of course, meant a delay of 36 to 72 hours and longer. When to operate, which cases to operate, the anesthetic to be used, etc., gave rise to much discussion. De Mart el 1 and Pauchet 2 were among the first to advocate local anes- thesia in operations on the head. This presented several advantages: It did not raise the blood-pressure, either by its action per se, or as the result of the patient's struggling during the induction stage of anesthesia; and it enabled the patient to assist at the operation by coughing, which oftentimes extruded pulped brain substance, debris, and particles of bone, after trepanation of the skull and exposure of the dura. The British surgeons advocated osteoplastic bone flaps with the wound at or near the center of the flap .see figs. 1 to 4). The finger was used in palpat- ing for foreign bodies, but gentleness in the use of the finger was emphasized. This in itself, in experienced hands, was not a serious drawback to the operation, but as many men, with limited experience in this branch of surgery, were called upon to care for these cases, lack of gentleness was very often the cause of much additional damage to cerebral tissue, and there was a high mortality. The French employed trepanation of the skull, and some surgeons habitually re- moved shell fragments and bullets under the fluoroscope. This method had several distinct disadvantages: It was not only necessary to remove the metallic foreign body, but pieces of indriven bone, hair, pulped brain, and filth as well; it served as a temptation to the surgeon simply to get the foreign body itself 77ti NEUROSURGERY 777 and to content himself with a more or less incomplete toilet of the tract. Fur- thermore, seeking the metallic fragment in the brain under the fluoroscope caused needless and. oftentimes, much additional damage to the brain. In Fig. 1.—This and Figures 2 to 1, inclusive, illustrate tlie tech- Fig. 2 niciue of the osteoplastic method with the wound near the center of the flap selected cases, however, after a careful toilet of the tract and when the foreign body could not be located definitely or removed by a powerful magnet, this method was the only solution in removing the shell fragment or bullet. The French insisted also on the importance of removing all foreign bodies at the first operation; if they were at all accessible,>nd the resulting late brain ab- scesses in cases of retained missiles have verified the wisdom of this contention. 77S SURGERY As stated, it had been the custom in the British Army to route all head cases to the base, and large numbers of them had passed through the hands of Colonels Sargent and Holmes at General Hospital Xo. 13, at Boulogne, where it was customary in the case of penetrating wounds to turn down an osteo- plastic flap, including the wounded area, to remove the foreign bodies, and to replace the flap, draining from either or both lower angles. The wound itself was often closed from the inside. With this method the mortality was high and secondary infection was relatively common. During the Paschendale battles in the summer and autumn of 1917 a new program was put into operation whereby the head injuries were routed to one of the casualty clearing stations at Proven and operated upon before being sent A.*1"__"-s Fig. 5.—Sketch illustrating the method of suction of the tract of a penetrating wound while searching for foreign bodies to the base. To this station Cushing 3 and some of his assistants from United States Army Base Hospital No. 5, serving with the British Armv were attached and a new method of.procedure was adopted. In simple terms, it consisted in approaching the tract in the brain through the wound. This was done by excising the scalp wound down to the skull and employing the tripod or the Isle of Man incisions further to expose the skull. A piece of bone around the hole in the skull was then removed en bloc. A soft rubber catheter was passed into the tract m the brain to locate foreign bodies, a syringe being used to pro- duce suction. At the completion of the operation the scalp was tightly closed by two layers of fine interrupted silk sutures. This method lowered the mor- tality, prevented secondary infection, and lessened the possibility of hernia cerebri. This modification of the technique formerlv employed had several very important advantages: It did not produce any more damage to cerebral tissue and it tended to prevent secondary infection from the outside. The wound, if it tended to break down, always opened at the junction of the three triangular flaps. NEUROSURGERY 779 This technique lowered the mortality from between 50 and 60 per cent to 28.5 per cent in one of the early series. It was generally accepted and practiced in the American and the other Allied Armies. Fig. 6.—Grade II; Wounds producing local fractures of variable types, with the dura intact. Type A, without depression of external table; type B with depression of external table CLASSIFICATION OF HEAD INJURIES The classification of head injuries which follows is that adapted by Cushing in his critical study of the cases which had passed through his hands at a British casualty clearing station during three months in 1917.4 Grade I.—This group comprised wounds of the scalp, with both cranium and dura intact, though occasionally complicated ___ l.fjl h. I by an underlying cerebral contusion. Of 22 cases observed, one was fatal, a mortality of 4.5 per cent. Grade II. — Wounds producing local fractures of variable types, with the dura intact, were placed in the second grade. They were subgraded further into Type A, when there was depression of the ex- ternal table (fig. 6). In the 54 wounds graded thus, local contusions of the brain, or extra dural extravasation were fairly common. Among the 54 cases of this grade observed 5 deaths occurred, or a mor- tality of 9.2 per cent. Grade III — Local de- pressed fractures of various types, with the dura punc- tured, were placed in this grade (fig. 7). Among the 18 cases observed, because of the inevitable local contusions, positive neuro- logical signs usually were present. Two deaths occurred, giving a mortality of 11.8 per cent. Grade IV.—In this grade wounds, usually of the gutter type, with de- tached bone fragments driven into the brain, were placed (fig. 8). Twenty- five cases were observed. Local con- tusion was severe, and extrusion of the brain almost inevitable. Fungus cere- bri and encephalitis were common sequels. Six deaths occurred among the cases of this grade, giving a mortality of 24 per cent, Fig. 7.—Grade III: Local depressed fractures of various types, with the dura punctured Fig. 8.—Grade IV: Wounds, usually of gutter type, with detached bone fragments driven into brain 'SO SURGKRY tirade 1*.—This grade comprised wounds of the penetrating type, with lodgement both of projectile and bone fragments (fig. 9). The brain frequently was found extruding, and there was much contusion along the tract. In such wounds, symptoms depended on the size and course of the missile. Common sequels noted were early compression and late abscess. Among the 41 cases of this grade 15 deaths occurred. 36.6 per cent. Grade TV.—Wounds of this grade comprised those in which the ventricles were penetrated (Type A) by bone fragments or (Typo B) by missiles (fig. 10). Cerebral lesions in this grade were the same as in the wounds of the two immediately preceding grades. The escape of cerebrospinal fluid is constant; hemorrhage into, or subsequent infection of, the ventricles is com- mon. In 14 cases in which the ventricles were penetrated or traversed by bone Fig. 9.—Grade V: Wounds of penetrating type, with lodgment both of projectile and bone fragments Fig. 10.—Grade VI: Wounds with ventricles penetrated or traversed (a) by bone fragments, (ft) by projectile Fig. 11.—Grade VII: Wounds of craniocerebral type involving («) orbitonasal, (6) auripetrosal region fragments, 6 deaths occurred (42.8 per cent); in 16 cases in which the pro- jectile penetrated or traversed the ventricles, the mortality was 100 per cent. Grade VII.—Wounds of this grade were of the craniocerebral type involv- ing (A) the orbitonasal, or (B) the auripetrosal region (fig. 11). In these wounds the brain is commonly exposed and extruding; thefrac tures are radiating; nasal or pe- trosal cavities are opened: men- ingitis is common. Among 15 cases observed 11 deaths occur- Fig. 12—Grade Mil: Wounds with craniocerebral perforation i ,_„ „ . v red (.3.3 per cent). Grade VIII--Craniocerebral perforations were placed in this grade (fig. 12). Extensive cranial and cerebral damage is common to such wounds; death usually is due to intracranial hemorrhage and compression. Among 5 of these cases ob- served, 4 deaths took place (80 per cent). Grade IAZ—Craniocerebral injuries, with massive fracture of the skull were placed in this grade (fig. 13). Such injuries in- F_G. i3.-Grade ix: volve widespread cerebral contusion; compression phenomena Craniocerebral inju- are common. Of 10 of these injuries one half died. nes with massive J fracture of skull NEUROSURGERY 781 ROUTINE PRELIMINARY TREATMENT OF HEAD INJURIES AT AN EVACUATION HOSPITAL, A. E. F. Though having received some instruction in neurosurgical diagnosis before being sent overseas the members of the hastily organized neurosurgical teams attached to the evacuation hospitals of the American Expeditionary Forces had had no experience whatsoever with war wounds in general, much less with the complicated and special procedures which the treatment of craniocerebral injuries demanded. Profiting by such instructions as were given by the senior consultant, neurosurgery, the following routine, more or less modified by individual experience, was so far as possible put into operation. Patients admitted to the receiving room were divested of all their clothing, which was deposited in a tent set aside for that purpose. They were covered with blankets and carried into the adjoining room where their field cards were inspected. Their heads were completely shaved and a hypodermic injection of 1,500 units of antitetanic serum was given in the abdominal wall, if not pre- viously administered at the triage hospital. The patients were then sent through the X-ray room where, in each in- stance, an attempt was made to determine the presence, the location, and the depth of the intracranial foreign body. By means of the fluoroscope crosses, at right angles, were made on the scalp with a lunar caustic pencil. Skiagraphs were then taken, laterally and anteroposterior^", and delivered to the operating room, and placed in the diagnostic box for the surgeon's reference. When this was completed, patients wore placed in a room near by the operating room which could accommodate 30 men, awaiting their turns for operation. Operable cases in shock were carried to a special tent where they were given hot black coffee, and morphine hypodermatically. They were covered with blankets, so arranged as to drape over the sides and ends of the bed. A lighted oil stove was then placed under the bed. An enlisted man constantly watched such stoves. From time to time the patient's condition as to pulse, temperature, and blood pressure was noted. Immediately upon recovery from shock they were operated upon. In instances of severe hemorrhage, citrated blood trans- fusion was employed, when possible, in addition to the treatment already described. Inoperable shock cases were placed in another special tent where most of them died. Their treatment was the same as that described for oper- able cases in shock, with the exception of blood transfusion, as the scarcity of blood rendered it impossible. In the operating room the surgeon in charge employed three tables. A hurried but careful examination was made of each patient before operation. usually on the operating table. The patient was then given morphine, three- eighths grain hypodermatically, if no morphine had been previously given within four hours. At the operating table, patient sitting with a roll under the neck, the scalp was washed with green soap and sterile water and wiped off carefully with etlivl alcohol. Patients that required suboccipital exploration, or decompression, were placed face downward on the regulation stretcher. the forehead resting on one of the slings stretched between the two handles, and the stretcher placed on the operating table. Making a mental picture of the style of incision desired, tripod, Isle-of-Man, or flap, and its possible extent 782 SURGERY a block of scalp was injected. A larger needle was then passed down to the pericranium, injecting deeply within the block. Large wounds often required plastic flaps of scalp to cover cranial defects, even though large areas of intact skull were denuded thereby. Thirty cubic centimeters of a 1 per cent novocain solution, to which one-sixty-fourth grain of adrenalin chloride was added, was usually sufficient for one case. TREATMENT OF DIFFERENT GRADES OF HEAD WOUNDS WOUNDS OF THE SCALP All scalp wounds were considered potentially serious, even in the absence of neurological findings, until proved otherwise by operative exploration. The importance from a military standpoint of caring for these cases in the forward area can not be overestimated, as such wounds, if not complicated by fracture and cerebral injury, heal readily, permitting an early return of the soldier to duty. Many slight cases would otherwise be evacuated to the rear. Very slight wounds of the scalp were often found to overlie a penetrating wound of the skull. These cases may prove to be very serious, as the bone may be perforated without apparent fracture. Other cases, with the external table intact or with only small linear fractures apparent from the outside, may have extensive comminution of the internal table, with perforation of the dura and bone fragments in the brain. In the presence of neurological symptoms one should always drill down to the inner table, and if the symptoms are very marked the dura should be investigated. If found tense, even though intact, it should be opened. In cases where the scalp wound is in- fected and the patient presents marked signs of cerebral injury the excised wound should be sterilized as well as possible and a block of bone removed, exposing the dura. If the dura is found to be per- forated, the in-driven bone and pulped brain should be removed by the patient's coughing, by irrigating through a soft-rubber catheter, using sterile decinormal saline solution, suction, and the use of an esquillectomy forceps in removing the bone fragments. When the tract is clean, it is sterilized by injecting a small amount of dichloramine-T, with eucalyptus oil or ethyl alcohol, through the catheter on withdrawal. A lumbar puncture should be done where symptoms of meningitis are present after injury. If the diagnosis is verified by spinal puncture, the case should not be operated upon, as such cases invariably die, operation or no operation. Figures 14, 15, and 16 reveal the findings in a case reported by Cushing, in which the external table was practically intact. Very extensive wounds of the scalp may occur without the slightest injury to the skull or the brain, but the reverse is much more common, namely, an apparently trifling though penetrating scalp wound which conceals an extensive cranio- cerebral injury. Fig. 14.—The in-driven fragments of inner table (natural size) NEUROSURGERY 783 Many small depressed fractures of the outer table were produced by shell fragments of spent velocity; they were usually tangential. On drilling down through such a fracture the in- ner table was often found to be intact. These cases in most in- stances recovered as rapidly as simple scalp wounds and, in the absence of neurological symp- toms, could be returned to their organizations at the front. When fractures of the inner table were disclosed with an in- tact dura, the membrane was not opened unless it proved to be tense or discolored when it was incised and the underlying brain inspected. If the brain proved to be pulped, the devi- talized brain tissue was removed by irrigating gently with sterile decinormal saline solution, us- ing the soft-rubber catheter, syringe, and bulb. If hemor- rhage was present, the blood was evacuated, and any pial vessels found bleeding were ligated with fine silk or pre- ferably caught with silver clips. Naturally, when a torn dura has been dis- closed, the question of advisability of incision or otherwise will not arise. Fractures of both tables, with perforation of dura and with bone fragments in the brain, constitute a type of injury which is often com- plicated by the lodgment of one or more shell fragments or a bullet. The treatment of these cases will be described more fully under " Opera- tions." Figures Nos. 17, 18, 19, and 20 are illustrations of this type of fracture. It is appropriate here to consider briefly "bursting" fractures of tlie skull, as they were sometimes asso- ciated with local fractures. "Burst- ing" fractures were the result of per- forating wounds, violent explosions, or falls, or of being struck by soft bodies. Some of these fractures were so extensive as to involve practically the entire 4(iJ"»Jl7—27------52 Fig. 15.—From a sketch at autopsy after removing calvarium pIi; i6.—Section through the contused area, showing posi- tion of bone fragments 784 SURGERV v ^r^ >"J .5*0 ^>*^ *•$!%■■.- ^V Zv A ' \ 1$S5*v. .' Jv_ 3^r\'■ \ jt^- ' 1 _w ^-."ZZ^K jfjSS^ml-i. '/*, ZJ M? " jf ' 1 1 « .^L-^ '' ' ^ _ _s__if^^ -;-Z ' *$j :v-'- .^,. ■ ^W Jlf ^f ^| 1 JwSPe" -i. "■ ■"•'l -_?___3_B':. ..sima ;;^JT ■ T T P ' «■ *■ ____ \ jST^ I - ""^3_»p. ,'3 I &'• ' ?! ' t / ^_____HP_i \ iff' i i -^^ f;' \ r I^___F ;\HflD __^^K~' ¥ 1 "MBnT_ Jl VlE-T^J-.1 _■ I ^1 WiSkJfs- f V^^N^ B.i 'T ' : J \i J f ''■< ' YVJrrJJ^^ \ ■' TT''" i NT£>■ . / 1/ .,... Jf ¥»^-__ JkTRReS&s*' V ■ ti r vn " / \_ \_f \^- •■'" "■ . 1 '* ' jfnNm ^___Lv i *'-_____l__H 4.^. >JI ' ^ja1spP«5^p*?_'^^ Fig. 17.—Trepanation block, showing behavior of thick skull to tangential wound Fig. 18.—Bone block. Specimen on left shows interparietal suture and fissures radiating from gutter; on the right, a few fragments of internal table attached NEUROSURGERY 785 skull. Numerous linear and radiating fractures occurred at the point of injury, while every fossa might show fractures. Unilateral and bilateral decompres- sions were performed |on some of these cases, but the resulting cerebral edema was so great that recovery was rare. Cases of this type that appeared to be hopeless but did not develop a fatal edema and were not operated upon were in some instances evacuated alive. Fig. 19.—Example of lodged shell fragment in an oblique gutter wound Operation The prepared head, with the field of operation surrounded by sterile towels held in place by skin clips, being ready for operation, the scalp wound was excised down to the skull, and the excised tissue, forceps, and knife were placed in a basin and removed. Fig. 20.—Small gutter fracture in thin skull; complete dislodg- ment of fragments The scalp incision.—The type most generally used was described by Colonel Cushing as a tripod incision. Three straight incisions were made to the excised area in such a manner as to best facilitate the approximation of all edfes. No o-encral rule can be made, as the angles of the formed incisions differed with the location and the general outline of the excised area. Rat- toothed forceps were now placed on the galea, strips of gauze passed through the handles of the forceps attached to each flap, and the flaps undermined. The strips of gauze were then fastened to the sterile sheet, serving as retractors, and the skull inspected. If the skull was intact, the wound was wiped out with 786 SURGERY ethyl alcohol. The galea was then united with interrupted sutures of silk, or No. 0 or No. 1 chromic gut, and the scalp closed with silk sutures. The scalp sutures were removed in two to three days. Figure 21 illustrates the tripod incision. The three-legged or Isle-of-Man incision was the incision used in larger wounds. The technique was the same as that described in the tripod incision, except that each of the three incisions had a knee (fig. 22). Fig. 21.—Tripod incision for small irregular wound of vault. Dotted lines indicate area of reflection of flaps. (Cushing) Flap incisions were employed in wounds of the temporal and suboccipital regions, especially in cases that required drainage. Occasionally straight incisions were used in the temporal region. Large osteoplastic flap incisions were employed in searching for a shell fragment or bullet, intracranial, but opposite to the wound of entrance. The craniotomy.—The instruments required for trepanation of the skull are: A cranial perforator, a half-inch burr, a dural separator, and a pair of Monte- Fig. 22—Three-legged (Isle of Man) incision for larger wound of cranial vault. (Cushing) novesi or De Vilbis linear cutting forceps. The cranial perforator was used to perforate the bone down to the inner table or through the inner table at a small point. This was followed by the burr. The dural separator then was used to elevate fragments of the inner table at the bottom of the opening made by the burr, and rotating it between the thumb and forefinger, the dura was separated well beyond the margins of the opening made by the drill. The linear cutting forceps then followed the burr. NEUROSURGERY 787 Trepanations were trian- gular, quadrangular, or pen- tagonal, drilling 3, 4, or 5 holes. Pentagonal trepanation was performed when by so doing the defect might be smaller. Quadrangular and rectangular trepanations were usually em- ployed in larger injuries. Fig- ure 23 illustrates a quadran- gular trepanation. The osteoplastic flaps used were those common to surgery of civil life. The enlargement of an alread\r existing defect in the occipital and lower frontal regions where the bone is thick and as small a defect as possible is desired, was done by the use of rongeurs. If the injury was over a sinus, trepanation was always done. The intracranial procedure- Fig. 23.—Quadrangular trepanation A-\t-nA™*L^, -The perforation in the dura was not enlarged, unless the opening was very small. Fig. 24—Diagram to show the insertion of a soft rubber catheter in the tract of a penetrating missile to locate foreign bodies Pieces of indriven bone, hair, or felt from the inside of the helmet, if found in the opening, were removed. A soft-rubber catheter was then passed through the opening in the dura and into the track in the brain, and bone fragments located in this manner were removed by the use of an esquillectomy forceps. Pulped brain and small pieces of bone were removed from time to time during the progress of the operation by the patient's coughing, by irrigating gently through the catheter with sterile decinormal saline solution, and by gentle suction, using glass syringe and bulb. As larger pieces were located by the catheter, they were removed. A shell fragment or bullet, when located, was removed by the esquillectomy forceps, and the tract again very gently explored with the catheter, searching for more bone fragments. Figure 24 illustrates the use of the catheter in locating foreign bodies. 788 SURGERY Split shell fragments with separate tracts and fragments at varying depths. (Cushing) Only in cases where more than one tract existed in the brain, with shell fragments at different levels and widely separated one from another, was the finger employed to locate them, and then with the utmost care and gentleness to avoid doing more damage than already existed (figs. 25 and 26). Opinions differed as to whether or not foreign bodies, difficult of access, should be removed. Foreign bodies in the brain should always be removed, if at all possible, as the chances of infection are very much increased, espe- cially if bone fragments and, possibly, hair and filth lie below them. It was rarely found to be necessary to remove a shell fragment or a bullet under the flouroscope. This should never be done, unless the foreign body can not be removed by the usual method and no magnet is at hand, as more or less additional damage always results. In searching for shell fragments where no tract existed from the side of the brain approached in the operation, i. e., in cases where osteoplastic flaps were turned down opposite to the wound of entrance for the removal of a shell fragment or bullet in the opposite hemisphere, a telephone probe was used. A telephone probe is an ordinary silver probe, 8 or 9 inches in length, to which one of the wires of an ordinary telephone receiver is attached. The other wire is attached to an empty brass cartridge shell. Taking care that the metal cartridge shell does not come in contact with any metal fillings, it is placed in the mouth of the patient. The probe is then used to search for the foreign body. When it comes in contact with the steel fragment, a sputtering is heard, as in the presence of overcharged electricity. This proved to be a very useful instrument in searching for shell fragments as already de- scribed, in the cerebellum, the posterior fossa, and the lateral ventricle. Puncture of the lateral ventricle was done where bulging existed after turning down a large osteoplastic flap in the search for larger shell fragments opposite to the wound of entrance. In these cases the original tract was first cleansed as deeply as possible and ethyl alcohol, or dichloramine-T with eucalyptus oil, injected. In cases where the shell fragments entered the brain through the orbit, the destroyed eye was enucleated, the indriven pieces of bony orbit removed, and the pulped brain cleansed from the tract in the brain. The deep bone and shell fragments were removed by the esquillectomy forceps as these fragments were located by the catheter. When the tract was clean, it was injected with Fig. 2(>.— Split shell fragments in temporal lobe (Cushing) NEUROSURGERY 789 dichloramine-T with eucalyptus oil, or ethyl alcohol through the catheter. Occasionally this type of wound was approached through a supraorbital incision, enucleating the eye at the completion of the operation. Cases with a large shell fragment that had passed through the brain from above and embedded itself in the roof of the mouth were treated from above as already described for penetrating wounds of the brain. The embedded shell fragment was then removed through the mouth, using large foreign body forceps. Bullets or larger shell fragments that passed through the anterior portion of the frontal lobe and lay on the basilar process of the occipital bone in front of the spine were removed through the original tract. Shell fragments that penetrated the middle fossa from below were removed by first rendering approach possible. The zygoma was resected and the opening in the skull debrided by using small rongeur forceps. The catheter was then inserted and pieces of bone and the shell fragment were removed when located. Perforating wounds of the skull were sometimes associated with bursting * fractures. The treatment consisted of trepanation of the wounds of entrance and exit, cleansing the tract from both ends of all pulped cerebral tissue and pieces of indriven bone, some of which were found nearer to the wound of exit than to that of entrance. Perforating wounds of the temporal region often were associated with blindness due to a severing of either the optic nerves or the chiasm. BRAIN ABSCESS! Operations on brain abscesses due to war wounds gave a high mortality. Meningitis resulted because the abscess, when opened, was usually opened through the uncontaminated subdural space. When abscesses were opened at a point in the skull directly over the site of the injury, through a relatively small opening, without disturbing the adhesions to the inner table and opening the dura carefully, it was possible, in some cases, to open directly into the abscess. These cases did not develop meningitis, because no connection was established with the uncontaminated subdural space. Brain abscesses that developed under a scalp wound in which the skull was found apparently intact were best treated in this manner. Neglected cases, or cases in which the foreign bodv could not be removed, or was not removed, at the first operation, could not be treated as described for the cases with no fracture, or an undiscovered fracture of the inner table, when the abscess developed at some distance from the original wound. In such instances, it was necessary to turn down a flap in order to locate the abscess. Abscesses of this type were drained through one of the openings in the skull made by the drill, using a soft rubber-tissue or gutta-percha drain. SPINAL INJURIES War wounds of the spine were particularly distressing. These injuries were so frequently associated with chest and abdominal wounds of a serious nature that one scarcely knew where to begin, if to begin at all. In the for- ward hospitals, cases in which a transverse lesion was suspected were not 790 SURGERY operated upon. These, complicated by serious wounds of the chest and abdomen, were considered inoperable. Of the operable cases, those of the bony spine, compression of the cord, and partial lesion of the cord, were the only ones which held out a little hope of benefit from surgical interference. Fractures of one or more spinous processes and laminae were common in wounds entering from the back. Wounds of the spine and cord in which the shell fragment or bullet entered from the front rarely caused fractures of the vertebra, in perforating the bodies, unless the shell fragment was large, when the case was hopeless and inoperable. The most difficult cases to deal with were those of partial lesion of the cord in which the shell fragment or splinter entered from the front, penetrating the cord or perforating it and remaining in situ. Occasionally one end of the shell splinter would be lodged in the body of the vertebra and the other in the cord. At other times the shell fragment might be free in the canal. Injuries in which the shell fragment or bullet struck the transverse process were accompanied by early symptoms ot a transverse lesion following the injury. Some of these cases recovered spontaneously without any interference, while others developed a true transverse myelitis. Shell fragments or bullets which struck the spine and were deflected without producing fracture, caused a local contusion of the cord in some instances. Injuries of this type sometimes recovered spontaneously. The symptoms in the cases which recovered spon- taneously were due to a form of concussion in which all function below the injury was suspended for a time. The finding of a Babinski reflex soon after the injury showed that a complete transverse lesion did not exist. Such a case was classified as a partial lesion. Just what should be done for the bladder in these spinal cases was never a matter for general orders. It remained a difference of opinion whether permanent drainage, intermittent catheterization or abstention from any inter- vention, merely allowing the bladder to fill and overflow by dribbling, was the method most likely to forestall infection. On the whole there was something to be said for each of these procedures, but the "let alone" policy was that in general favor in the evacuation hospitals. The main object, of course, was to avoid infection if possible, for only so were the automatic lower-cord reflexes likely to be restored and thereby an automatic and periodic spontaneous evacuation of the bladder established. For descriptive purposes wounds of the spine may be classified as follows: (1) Wounds of the bony spine without perforation of the dura or injury to the cord; (2) wounds of the bony spine without perforation of the dura, but with injury to the cord; (3) wounds of the bony spine with perforation of the dura and injury to the cord; (4) injuries to the cord without external wounds. Cases of the first and second categories will be jointly considered, as the dura was not opened in these cases. The external wound was excised and loose bone fragments were removed. The wound was then sutured, bringing the muscle together with No. 2 or No. 3 chromic-gut interrupted sutures, and the skin closed with heavy interrupted silk sutures. When compression of the cord existed, the depressed bone or shell fragment lying on the dura, or wedged in the bone over the dura, was removed. Great care was exercised NEUROSURGERY 791 so as not to produce further injury in relieving the compression. Shell frag- ments wedged in the fracture, or between the laminae or spines, if firmly embedded, were approached from either side by performing laminectomy. In infected cases the wounds were left wide open, Carrel-Dakin tubes inserted, and the w-ound packed with sterile gauze saturated with Dakin's solution. No sutures Avere inserted. The treatment of cases falling in the third category will be described under operations. Cases in the fourth category were not operated upon. Collier 5 has described these as spinal concussion. Cases whose spines had been exposed to the shock of violent explosions showed numerous small subpial hemorrhages. The results obtained in operations on wounds of the spine with injury to the cord were very discouraging, on the whole, and the mortality very high. Of 32 injuries of the cord repotted by Cushing,6 7 were cervical, 2 were thoracic, S were lumbar, and 15 were not specified. Eight were inoperable and there were 23 deaths, or a mortality of 71.8 per cent; 24 were operated upon with 15 deaths, or an operative mortality of 62.5 per cent. These cases were all cared for in the forward area. In considering records of work done in tne forward area, it must be borne in mind that the surgeons were forced to labor under trying conditions, finding it very difficult at times to properly care for the wounded. It was at such times of great activity that the records were more or less incomplete. Because spine cases were usually evacuated early, if at all transportable, any following up of these cases in the forward area was thus impossible. Many of these cases undoubtedly died soon after their evacuation to the rear. It was rather common to have men with spinal cord injuries arrive dead or dying. Injuries of the spine, perhaps, formed a much larger group than those computed from hospital records would lead one to think, as the serious wounds involving the chest and abdomen in which death occurred at the front, were undoubtedly in many instances, complicated by spinal injuries. Operation The utmost gentleness and most extreme care should be taken in the handling of the cord. It should never be sponged or pressed upon. For the removal of foreign bodies delicate forceps should be used. Cord debris and blood should be removed by gentle irrigation with sterile decinormal saline solution. All one can expect to do is to remove foreign bodies and pulped cord substance that is free in the spinal canal, and in this manner to remove infected material and prevent infection. If this is done, one has accomplished all that is possible. Suture of the cord is a vain and harmful procedure, as the added handling produces more injury. An injured cord can be cleansed, but not restored. Removal of Foreign Bodies The external wound was excised down to the bony spine and loose frag- ments of bone removed. If the wound was directly over the spine, the exci- sion was enlarged at either end and laminectomy performed. When the wound was on either side of the spine, the skin incision was made directly over 792 SURCERY the spine. In separating the muscular, semitendinous, and fascial attach- ments from the spines and laminae, a large periosteal elevator was used. Retractors were then placed in the wound, thoroughly exposing the bony spines. The spines were removed by large bone-cutting forceps and the laminae carefully rongeured away. The spine and laminae of two or three vertebrae were removed in this manner. The dura was first opened in the following manner: Two delicate sdk sutures were placed in the dura on either side of the median line. Pulling up on these sutures, the dura was carefully incised with a scalpel. The opening was enlarged by using a pair of straight and slender-bladed scissors. As the opening was gradually enlarged, other sutures were inserted as before and used as retractors. On inspecting the cord, if only a contusion existed, cord debris was removed as much as possible by irri- gating gently with sterile decinormal saline solution without bringing the syringe in contact with the cord. In practice when bone fragments were found, the cord was first irrigated as already described, and bone fragments remaining in the cord were carefully removed by an esquillectomy or other delicate forceps, always in direct line with that of entry. Small shell fragments embedded in the cord were removed in the same manner. Such fragments, if buried in the cord, were approached by first making an incision carefully in the long axis of the cord, preferably on its lateral aspect, severing one of its posterior nerve roots and using it as a retractor and removing the frag- ment from the front of the cord. This was important, as often the end of the fragment presenting itself on the anterior aspect of the cord was larger than the portion deeply buried in the cord or extruding posteriorly. In this manner further damage to the cord was avoided. Missiles of this type that penetrated the cord, but remained embedded in the body of the vertebra, presented the greatest problem for the operator. In order to free the cord from the foreign body it was necessary to sever several anterior and posterior nerve roots on one side, or on both sides, to permit lifting the cord entirely free from the firmly embedded splinter that penetrated or transfixed it. A firm hold on Fig. 27.—Method of opening dura NEUROSURGERY 793 the shell splinter embedded in the body of the vertebra could then be secured rffiUS.ng Sma11 curved rongeilr forceps and extracting. If extraction was difficult several methods were found to be useful. Lifting the cord by its posterior roots, the shell-splinter was firmly grasped bv the rongeur and an attempt made to deflect to one side and extract. This was not difficult unless the portion embedded in the body of the vertebra was larger than appeared apparent from the portion exposed. When found to be firmly fixed rotation on its long axis was done, having the effect of a drill, and attempting from time Fig. 28.—Exposing cord for removal of embedded shell fragment Fig. 29.—Exposing cord for removal of embedded shell frag- ment, using nerve root as tractor to time to rock it back and forth. Great care was necessary in order not to break it, leaving a portion of it projecting into the canal. When such splinters broke off, leaving the bony canal free, they were disregarded. By perseverance and firm but gentle force the removal of such bodies was possible in most instances when it often seemed impossible. Another danger was the possibility of the rongeur slipping and striking the anterior and lateral portions of the cord, resulting in contusion. Operations on the spinal cord required greater care than the usual operations for cerebral injuries. 7<)4 SURGERY REFERENCES (1) Pauchet, Victor: L'Ancsthesie regionale. O. Doin et tils, Paris, 1914. (2) de Martel, T.: La chirurgie cranienne sous anesthesie locale. Bulletins et memoires de la societe de chirurgie de Paris, July 24, 191S, xliv, 1364. (3) Cushing, Harvey: Notes on Penetrating Wounds of the Brain. British Medical Journal, London, February 23, 191S, xliv, 1364. (4) Cushing, Harvey: A Study of a Scries of Wounds Involving the Brain and its Enveloping Structures. British Journal of Surgery, Bristol, 1918, v, No. 20, 558. (,5) Collier, James: Discussion on Gunshot Wrounds of the Spine. British Medical Journal, London, March 25, 1916, i, 451. (6) Hanson, Adolph _\L: A Report of Wounds Involving the Head and Spine Cared for at Evacuation Hospital No. 8, A. E. F. The Military Surgeon, 1920, xlvi, No. 4, 414. CHAPTER IV NEUROLOGICAL ASPECTS OF THE EFFECTS OF GUNSHOT WOUNDS OF THE HEADa The subject matter of this chapter is based on some general observations made in a series of 200 cases of wounds of the head, after their return to the United States, in practically all of which there were symptoms of injury to the brain. The 200 patients referred to represent practically all of the cases of this type under observation at General Hospital No. 11, Cape May, N. J.. from October, 1918, to June, 1919. Of these parents, 163 suffered from wounds associated with demonstrable defects, and 13 with fractures of the cranial bones; 24 presented brain symptoms without demonstrable cranial injuries. It may be seen that the greater majority of these patients presented cranial defects, which, with a few exceptions, were the results of gunshot wounds of the head, treated almost universally by early operation. The associated brain injuries varied greatly, some being severe. In 68 patients the cerebral symptoms were slight or could not be demonstrated when the patients were admitted to the hospital. In 12 per cent of the cases there was no definite history or evidence of cranial injury, but either general or focal symptoms of cerebral origin following traumatisms of the head seem to justify their inclusion in this series. SYMPTOMATOLOGY For present purposes the manifestations of disturbed action of the nervous system have been classified into general and focal symptoms, in much the same sense that the symptoms caused by brain tumors are so classified; focal symptoms representing lesions of definite areas of the brain, and general symp- toms those resulting from the effects of diffuse forces, such as concussion or pressure. EARLY GENERAL SYMPTOMS Among the early general symptoms of importance, according to the clinical records, and to the histories as given by the patients themselves, were disturbances of consciousness, amnesia, delirium and confusion, choked disc, slow pulse, headache, and vertigo. While obviously incomplete, these his- tories, considered collectively, have a certain value. Disturbances of Consciousness Data concerning the state of consciousness immediately following the injury were available in 132 cases. In 22 there was no loss, while in the « This chapter is from "A Review of the Effects of Gunshot Wounds of the Head, Based on the Observation of Two Hundred Cases at U. S. General Hospital No. 11, Cape May, N. J.," by Lieut. Col. Charles H. Frazier, M. C, and Capt. Samuel D. Ingham, M. C. Archives of Neurology and Psychiatry, Chicago, 1920, iii, No. 1, 17. 795 796 SURGERY reim.ining 110 there resulted from the injury immediate unconsciousness which lasted from a few minutes to several weeks. The period^ of uncon- sciousness, by number of cases, was as follows: Less than 1 hour, ol: 1 to 24 hours, 21: 1 to (» days, 22: 6 days, 16. Since there was'such a wide variation in the manifestation of this symptom it is of interest to consider the factors active in its production. These factors include the degree of concussion, or sudden force transmitted to the brain by the blow; the'amount of brain tissue traumatized, and the secondary effects of the injury, including hemorrhage, edema, and infection. To facilitate the analysis the patients as a whole may be divided into three groups: (1) Those in whom there was no loss of consciousness, (2) those unconscious from a few minutes to 24 hours, and (3) those in whom this symp- tom was prolonged. Group 1 included 22 patients with cranial defects who were not rendered unconscious by their wounds. Many of these had severe injuries, and i:> exhibited permanent focal brain symptoms. It is well known that a blow- on any part of the head may produce unconsciousness by concussion, but it is apparent that this factor was insufficient to cause this symptom in the patients of this group. In explanation it may be suggested that the force of the injury was apparently exerted over a small area, and even when the cranial bones were fractured and the brain itself traumatized locally, the diffuse con- cussion must have been relatively slight. An illustration of this principle is furnished by the manner in which an egg may be broken—a quick, sharp blow producing a local fracture, while a slower but heavier blow results in extensive cracks in the shell. In the latter case the diffusion of the force is evidently greater than in the former. Group 2 included 72 patients who were unconscious from a few minutes to 24 hours. It mav fairly be assumed that cerebral concussion was the imme- diate cause of unconsciousness in this group, and that other factors were relatively unimportant in their effect on consciousness. Early surgical opera- tions in many cases effected decompression, removed blood clots, pulped tissue, foreign bodies and bone fragments, and controlled infection. It is probable that the character of the wounds themselves, in some instances, had the effect of automatic decompression, thus preventing prolonged uncon- sciousness. Group 3 included 38 patients who were unconscious for more than 24 hours. In many of these patients the effects of trauma (hemorrhage, edema, infection) were important factors. Several of this group, with residual focal symptoms indicating severe brain injury, had had early operations in which the dura was not opened, hence decompression was not effected. Some had deeply penetrating foreign bodies, and others severe wound infections and hernia cerebri. In this class were also included 10 patients with cranial fractures, not decompressed. Even from the fragmentary records available, the large pro- portion of injuries not relieved by decompression was striking in this group, injuries which must have produced severe secondary effects and high intra- cranial pressure. In none of the cases was there evidence that prolonged unconsciousness resulted from concussion alone. While it is at times difficult NEUROSURGERY 797 to differentiate cases of uncomplicated concussion from those in which intra- cranial hemorrhage and edema are also present, it is apparent that prolonged unconsciousness resulting from simple concussion is rare. On the other hand, conditions producing increased intracranial pressure, such as hemorrhage and edema not Relieved by decompression, must be considered as important factors in prolonging the unconsciousness primarily induced by concussion in head injuries. Incomplete loss of consciousness, dazed and stuporous states, delirium, and mental confusion were common in the early histories, one or more of these conditions frequently following the period of unconsciousness or replacing it as the immediate effect of the trauma. These symptoms were regarded as results of the same factors that caused unconsciousness, concussion standing in relation to the earlier and the secondary effects of trauma to many of the more prolonged manifestations. In this connection it should be stated that definite symptoms apparently resulting from simple concussion occasionally persisted for several montlis. Amnesia • Amnesia was present in practically all of the patients exhibiting the symp- toms mentioned, and the memory blank frequently antedated the injury. In two instances patients who were injured in France had no memory of having been out of the United States. Those who were dazed or delirious for a long time often retained a fragmentary or dream-like memory of isolated occur- rences, or of their subjective mental processes at times fantastic and curiously related to actualities. _-_K._I.AOHE, YERTIGO, ChOKED DlSC, AND Sl.OW Pl'LSE These symptoms were1 recorded with varying frequency, and were all more or less closely related to the secondary effects of injuries. LATE GENERAL SYMPTOMS When coming under observation in General Hospital No. 11, two months or more after receiving their head wounds, many patients still manifested cerebral symptoms of a general character. These included loss of memory, slow cerebration, indifference, mild depression, inability to concentrate, fatiga- bility, nervous irritability, vasomotor and cardiac instability, general convul- sions, fine tremors, irritable reflexes, headache, vertigo, and restricted visual fields, but their manifestations varied in different patients as regards grouping, intensity, and persistence. Some of them were present in most of the cases of severe head wounds, many of them were present in some of the cases, and, exceptionally, a combination of these late general symptoms constituted the principal disability of the patient. Almost without exception these symptoms diminished gradually, and ulti- mate recovery, apparently complete, occurred in from three to nine months after injury, where gross damage to the brain was absent. The tendency to recover from the symptoms both general and focal resulting from brain injuries of all degrees of severity deserves special emphasis. Since it is fairly well 798 SURGERY established that regeneration does not occur in the central nervous system, it is evident that any nervous tissue may be affected to the extent of suspended function without suffering permanent damage, and recovery from the symp- toms of brain lesions signifies returning function in injured but not devitalized neurons. FACTORS CAUSING RESIDUAL GENERAL CEREBRAL SYMPTOMS So far as could be determined the following factors were operative in causing the late general symptoms in the series of cases under discussion: (1) Loss of cerebral tissue; (2) injury to the brain without destruction of tissue; (3) cranial defects; (4) cicatrices; (5) psychoneurosis. Loss of Cerebral Tissue Symptoms resulting from the loss of cerebral tissue should properly be classified as focal, but these symptoms at times included intellectual impair- ment, or dementia, of which we have no definite knowledge in cerebral localiza- tion. Reference will be made, under the discussion of focal symptoms, to several instances in which the dementia apparently bore some relation to the location of the cerebral lesion. Injuries to the Brain Without Destruction op Tissue These injuries include the effects of concussion and pressure, and also those of disturbed cerebral circulation and nutrition. .VIthough, from the standpoint of pathology, changes of this nature are but imperfectly understood, it should be emphasized that they are common and important. Most of the late general symptoms of head wounds are best explained on the basis of such disturbances. These symptoms include memory loss, slow cerebration, indifference, incapa- city for sustained effort, and vasomotor and cardiac instability. Cranial Defects Cranial defects, particularly those large enough to permit fluctuation and pulsation, are commonly accompanied by vertigo, throbbing in the head, and a feeling of insecurity, all of which are accentuated by active exercises and bending movements of the body. Headache, on the contrary, was noticeably unusual in the patients writh cranial defects. Cicatrices These sometimes act as irritating foci, causing nervous and reflex irrita- bility, at times apparently precipitating general or focal convulsions. Head- aches often were traced to pericranial and dural adhesions. Psychoneurosis As an element in the symptomatology of this series this condition was comparatively unimportant. With three or four exceptions, anxiety and neurasthenic symptoms were present only to a degree commensurate with the nature of the injury. Conversion hysteria was not encountered in any of the cases. NEUROSURGERY 799 Summarizing briefly the general cerebral symptoms resulting from wounds in relation to the etiologie factors, they may be divided into four groups: Those due to (1) the immediate effects of the trauma; (2) the secondary effects of the trauma; (3) nondestructive injuries to cerebral tissue; (4) destructive injuries to cerebral tissue. The first two of these groups of symptoms appear early, the latter two coming into prominence as the earlier symptoms subside. The immediate manifestations consist mainly in disturbances of con- sciousness and in dazed, delirious, and stuporous states, the principle causative factor being concussion. The secondary effects of trauma (hemorrhage, edema, infection) add the symptoms of pressure to those of concussion. Injuries to the brain tissue, not destructive in character, complicate all sorts of lesions and cause symptoms which last for weeks or months but which tend toward complete recovery. The syndrome of cerebral concussion (early disturbances of consciousness and prolonged mental symptoms including loss of memory, indifference, incapacity for sustained effort, and mental slowness) probably has its pathologic basis in changes of this character. FOCAL SYMPTOMS Transient Focal Symptoms Although the records were incomplete, they indicated that a considerable proportion of the patients suffered from focal symptoms of a transitory char- acter, which disappeared completely or almost completely within one or two months following the injuries. Symptoms of this nature are to be explained by local injuries to the brain of a degree insufficient to cause tissue destruction. Twenty-four patients gave a history of early hemiplegia which later disap- peared entirely or left an insignificant remnant. In contrast, there were 60 patients with definite residual cerebral paralysis. Fourteen gave a history of aphasic disorders of a transitory character, while in 16 some degree of aphasia persisted as a residual symptom. Four patients described symptoms evidently due to cerebellar disturbance, all of which recovered entirely. In no case was there evidence of a destructive wound of the cerebellum, a fact to be accounted for by the highly fatal nature of wounds involving the posterior cranial fossa. Data concerning early sensory symptoms were for the most part unreliable, as patients usually fail to note any but perceptual losses and are even liable to confuse motor paralysis with anesthesia. In 10 instances, however, there was a fairly consistent history of superficial anesthesia of unilateral distribution and of temporary duration. Residual Focal Symptoms Under this heading are considered the focal symptoms which persisted while the patients were under observation, in most cases six months or more after the injury. Motor Symptoms Of the entire series of 200, 60, or 30 per cent, of the patients suffered per- manent motor symptoms of cerebral origin. Of these, 43 were hemiplegic, 46997—27---53 800 SURGERY 9 were monoplegic, and S were paraplegic. The paralysis was of a severe degree in 10 hemiplegics and 3 paraplegics, while in the remaining 47 the residual motor disability was comparatively slight when the patients were last examined. A striking feature of these cases was the marked degree of recovery which invariably occurred. Probably without exception the patients, immediately following the injury, were completely paralyzed in the limbs affected. Twenty of them were admitted to General Hospital Xo. 11 as litter patients; but when last examined they were all ambulatory and many of them had a very fair amount of function in the paralyzed limbs. Notwithstanding this improve- ment, there remained, in patients having destructive lesions in the motor areas. an irreducible minimum of paralysis. The residual motor disabilities consisted of disturbances of voluntary motion of the arms and legs, and to a slight degree of the face. Complete paralysis of a limb was never permanent. The functions of motility most disturbed were those of highly specialized and intricate character. Individual finger movements were uniformly most affected; finger flexion invariably returned in some measure, but extension was weaker and in two cases failed to reappear at all. All movements involving bilateral groups of muscles were normal or showed insignificant disturbances. Exaggeration of the tendon reflexes and hypertonicity of the muscles of the affected limbs was the invariable rule, although there was considerable variation in the degree of these conditions. Articular relaxation or increased range of movements in the joints as compared to the normal side was occasionally noted, and was demonstrable by the greater latitude of movement on passive manipulation after overcoming the hypertonicity of the muscles. Incoordination constituted a factor in the disability of many of the para- lytics, especially those showing a large measure of improvement though actual muscular strength was very fair. Residual Sensory Symptoms Permanent impairmant of cutaneous sensory perceptions of touch, pain, and temperature was found in only eight cases, and in none was it present as a complete hemianesthesia. On the other hand, 30 patients showed impairment of ability to localize sensory stimuli accurately, to recognize dual contacts, and to appreciate passive movement and position in the extremities. In the same patients there was disturbance of the stereognostic sense. The constant association of impaired sensory discrimination with astereognosis indicates that the latter condition may be considered as a manifestation of the former. Sensory and motor symptoms frequently were associated in the same case, and those having sensory symptoms almost invariably had motor impairment. The converse was not true. Only 50 per cent of the motor cases had demon- strable sensory symptoms. This relationship of motor and sensory symptoms may in part be explained by the dependence of normal movement, especially its coordination, on the discriminatory element of sensation. NEUROSURGERY 801 Residual Aphasia In 16 patients disturbances in the use of language remained six months or more after the wounds were received. Of these, 10 were of the motor or dvsar- thric type, 3 of the sensory type with alexia as the most prominent symptom, and 3 were of the mixed type, manifesting disturbances both in the depression and in the interpretation of language. In none of the patients were the residual asphasic symptoms of severe degree, and all were able to carry on simple con- versations fairly well. The patients with alexia were ultimately able to recog- nize letters and many words, but did not regain the ability to read under- standingly to any practical extent. Residual Visual Symptoms Cerebral wounds were associated with defects in the visual fields in 18 cases, 12 of wliich were more or less complete homonymous hemianopsia, 3 were quadrant anopsias, 2 were symmetrical paracentral scotomas, and 1 was almost completely blind. Comparatively slight improvement was noted in the vision of these cases during the period of observation. Mental Symptoms The occurrence of mental disturbance has been mentioned in connection with the general symptoms of cerebral injuries. Aside from the mental symp- ; toms of cerebral concussion and the mild dementias of indeterminate type associated with many brain injuries, a few of the patients showed late psychic symptoms which evidently resulted from cerebral wounds, and apparently bore some relation to the injured areas of the brain. This was true in four cases in which penetrating wounds involved both hemispheres. In three of these both frontal lobes were affected, and in the fourth a foreign bo'dy entered the right frontal region, penetrating to the left posterior parietal region near the cortex. Mental symptoms were pronounced in all of these patients and consisted of disorientation, loss of memory, emotional indifference and disregard of environment and personal appearance. In some measure they resembled the simple dementia of general paresis. Of the many patients with unilateral frontal lesions, some of them extensive, none showed characteristic psychic symptoms. These circumstances indicate the seriousness of bilateral brain lesions, and suggest the theory that either cerebral hemisphere may functionate in a way to minimize the effect of a lesion in the other. Convulsions Convulsions occurred in 28 patients, either before admission or while under observation at General Hospital No. 11. In 4 of these the attacks were focal without general involvement, 11 had local spasms initiating general attacks, and in 13 the convulsions were general so far as observations were recorded, although it is probable that some of these were preceded by unobserved focal symptoms. Attacks were observed in patients having lesions in the motor area and hemiplegia in which focal signs were definitely absent. In 3 of the cases of this group it was found that attacks had occurred prior to military service, leaving 2o in which there was evidently a close relationship between the war wounds and the convulsions. In 22 of these the wounds 802 SURGERY involved the parietal region, and in 21 there was motor paralysis. In the remaining 3 cases the wounds were in the frontal, occipital, and temporal regions. It is thus apparent that not only focal but general convulsions were associated with motor areas of the brain in the great majority of the cases, and that irritation of these areas is more productive of general convulsions than of other parts of the cerebrum. Eighteen of the twenty-five patients were free of attacks for several months prior to the cessation of the period of observation; three others had but a single attack each. Four had repeated convulsions over a prolonged period, thus evincing a tendency to chronic epilepsy; these were all hemiplegic, and the attacks were the type which begin as focal convulsions, then become general with loss of consciousness. The most frequent period for the occurrence of the attacks was soon after the wound had been received or after some operation on the head. About one-half of this group of patients had isolated convulsions at such times without later recurrences. It should be stated that, as a routine measure, bromides were given in 10-grain doses three time a day to all patients having convulsions and to all those subjected to operations on the head, a measure which no doubt reduced the incidence of the attacks while the patients were under observation. PATHOLOGY The degree of injury to the brain varied from insignificant lesions to ex- tensive losses of cerebral tissue. In 23 cases intracranial foreign bodies were demonstrated by the Roentgen ray, some of them having almost traversed the cranial cavity. Small, indriven fragments of bone were common and were usually located in the vicinity of the cranial defect. In 26 cases the wounds were unhealed on admission, most of these having sinuses extending beneath the dura to fragments of dead bone or foreign bodies. One patient, who died four days after admission, had a large temperoparietal abscess and hernia cerebri. This patient was one of the two fatalities in the entire series of head wounds at General Hospital No. 11. The second fatality resulted from a complicating pneumonia and internal hydrocephalus, occurring after the wound had healed and the patient wras convalescent. During cranioplastic operations evidences of cerebral injury were at times noted. In such operations the dura was not usually opened, but occasionally it was necessary and several times in this way cystlike cavities filled with cerebrospinal fluid were exposed. In one notable case of this kind the operating surgeon opened such a cavity in the occipital lobe which communicated with the posterior horn of the lateral ventricle. In estimating the area and extent of the cerebral lesions resulting from war wounds it may be stated as a rule that, in the absence of penetrating foreign bodies, the area of destruction of brain tissue conforms quite closely to the cranial defect, and extends but a few centimeters beneath the cortex. Foreign bodies may penetrate to almost any part of the cerebrum, even traversing the ventricles without causing death. The course of foreign bodies can be estimated by careful Roentgen-ray studies, comparing their location with the wound of entrance. NEUROSURGERY 803 TREATMENT Besides the surgical treatment, special courses of treatment w-ere given to practically all of the patients with the object of increasing their general efficiency, and of reducing to a minimum the effect of the disabilities from which they suffered. School, occupational, and workshop courses were prescribed, according to conditions. Patients with hemiplegia and paraplegia received daily treatments con- sisting of special massage, passive movements, and electricity, also active exercises, employing the affected limbs to a maximum extent on gymnasium apparatus, and in recreational exercises in which handballs and footballs were found to be especially valuable. The results of this treatment were evident in reducing the spasticity and preventing contractures in paralyzed muscles and in procuring a maximum return of function. The training of the unaffected muscles to compensate as far as possible for those of impaired function gave the patients greater freedom of action, and the general poise, self-confidence, and morale were noticeably improved. Aphasics constituted another group that received special attention. Trained teachers gave the members of this group daily individual instruction and exercise in conversation, reading, and writing adapted to the needs of the patient and the character of his language disturbance. Although no evidence of the development of new language centers on the normal side of the brain was seen, improvement was marked in every patient of this group, the aphasic symptoms of some of whom had previously remained stationary for several months. CHAPTER V LATE TREATMENT OF GUNSHOT WOUNDS OF THE HEAD The surgery of gunshot wounds of the head in the secondary stage of treat- ment followed, for the most part, lines which had been determined prior to the outbreak of the World War. It is true that a greater zeal was shown during the late reconstruction period in the restoration of portions of the skull than was apparent in the management of cranial defects in civil life, but with this exception, the late treatment of head wounds offered a limited field for surgical procedures. Destructive brain injuries and late pathological conditions resulting from intracranial hemorrhage and from contusion of brain tissue, while presenting neurological problems of great interest to the surgeon, rarely required operation. A review of the late surgical treatment of head wounds deals almost entirely with the following conditions: Cranial defects, brain abscesses, retained foreign bodies, and epilepsy. CRANIAL DEFECTS Prior to the World War there was considerable discussion as to the bene- fits to be expected from the repair of cranial defects. Symptoms which during the secondary period of treatment were attributed to a loss of portions of the cranial bone, previously had been regarded by many authoritative observers as arising from the associated damage to the brain tissues. The study of a large number of cases of cranial defects led to the rather general belief that the loss of bony protection of part of the brain may be accompanied by disturbances due to the opening itself and that the disability of a patient with serious brain damage associated with cranial defect may be reduced by a restoration of the bony loss. The repair of cranial defects was the most frequent surgical procedure in the treatment of head wounds during the reconstruction period of the World War injured; in fact, with the exception of relatively few operations for ab- scesses and for retained foreign bodies, cranioplasty was practically the only operation performed upon the skull. Some idea of the frequency of cranial defects may be obtained from a series of 200 head cases at General Hospital No. 11, Cape .May, N. J., reported by Frazier and Ingham.1 In this series. 163 patients had cranial defects. Projectile wounds of the skull present a rather characteristic appearance Usually, an area of the scalp as well as bone has been lost and in many cases a long-continued infection has added to the extent and density of the 'resulting scar. These scars are subject to trophic disturbances, often with ulceration and mild infection many months after apparent healing. As a rule the bony opening is irregularly quadrangular, although triangular, circular, and narrow 804 NEUROSURGERY S05 Fig. 30.—Conspicuous craniofacial defect with dense scar Fig. 31.—Large right parietal defect. Photograph shows model and location of defect. Repair by autogenous cranial trans- plant after Frazier's method Fig. 32.—Characteristic defect in the parietal region Fig. 33.- Characteristic defect in the frontal region 806 SURGERY linear defects caused by tangential wounds are seen. In defects of moderate or large size without intracranial tension, when the patient's head is higher than the body, the skin overlying the defects recedes sometimes to considerable depth. On the other hand, the skin overlying the defect becomes level with the surrounding scalp or protrudes when the patient lies down or stoops. It is this fluctuation of the defect which seems to be mainly responsible for the patient's symptoms. The usual complaints are of throbbing and pul- sation about the defect, vertigo upon exertion, a feeling of insecurity and particularly a dread of injury to the unprotected brain. Any sudden change of position such as stooping, a sudden movement of the head, or coughing, may be followed by one or more of the symptoms. The patients are fairly comfortable when quiet, though sleep is sometimes dis- turbed because of the throbbing or Fig.34—Skiagraph of an irregular defect in the parietal region . , _ . , , , ^ vertigo when lying m bed; they suffer from the exaggeration of symptoms upon exertion. Tenderness of the scar and over the rim of the defect is frequently complained of. Fluctuation of the defect is thought by some to produce tension on the adhesions con- necting the overlying scalp with the brain and with this fluctuation there Fig. 35.-Skiagraph of a characteristic oval defect in the Fig. 36.—Skiagraph of a rectangular defect, in the parieto- frontal region occipital region, resulting from removal en bloc of area of skull in debridement may be sudden changes in the blood supply of the brain adjacent to the defect. Often defects are very conspicuous deformities, in which case an operation is required not only for its protective value but also for cosmetic reasons; NEUROSURGERY 807 i ___r' -_-_-&' -<____ 8_rSIBwf "''■• V _________ ___nKK'r,r'el?'v_^IB^';' _^fl __■ SK?*^^ ^___id BL. ________ Fig. 37.—Large parietal defect. Roentgenogram before cranioplasty Fig. 38.—Roentgenogram of head shown in Figure 37, after repair. The bone graft is clearly outlined SOS SURGERY Fig. 39.—Posterium parietal defect. Roentgenogram before cranioplasty Fig. 40.—Roentgenogram of head shown in Figure 39, after autogenous cranial transplant NEUROSURGERY 809 V ''// -/. \ however, in the zeal for the restoration of lost bone certain contraindications to a cranioplasty should not be overlooked. The operation should not be done for war injuries until there is a reasonable certainty that infection has been removed from the tissues. This removal of infection requires from three to six months after all gross evi- dences of infection have disap- peared. Any associated intra- cranial process accompanied by an increase in tension, the presence of large intracerebral foreign bod- ies, and sometimes epilepsy, make an operation inadvisable. Medical literature pertaining to the period of the World War abounds in descriptions of the technique of cranioplasty and much surgical ingenuity was dis- played in its performance. Of the materials which had been used to replace lost bone, metal, rubber, and celluloid plates, ani- mal transplants, homotransplants, and autogenous grafts from the skull, tibia, scapula, and ribs, were recommended; however, with the exception of autogenous grafts and celluloid plates, these mate- rials, to a large extent, have been abandoned. Autogenous grafts came to be the material of choice in most of the hospitals, with the occasional use of celluloid plates for large defects. Wegeforth, by animal experiments at the Army Neurosurgical Laboratory, Johns Hopkins Medical School,- showed that the cranial transplant pos- sessed great advantages in repair of defects of the skull. It was also demonstrated clinically that the autogenous cranial transplant possessed similar advantages, and that a oraft of any desired shape /&/ ~tY' !)!>7—27-----54 KKi ;URGERY Fig. 47.—Cranial abscess, a, Bone fragments at center of abscess; 6, fibrous tissue abscess wall and site of section shown in Figure 4S Fig. 48.—Section of wall from 6 in Figure 47. a to a', inner layer of abscess wall, showing young fibrous tissue elements; b to b', outer layer of abscess wall, showing adult fibrous tissue. X85 NEUROSURGERY Fig. 49.—Pedunculated dural abscess, a, Abscess stalk, point of attachment to dura; b, layer of cere- bral ti.ssue adherent to abscess; c, fibrous tissue wall of abscess; x, site of section shown in Figure 50; y, site of section shown in Figure 53 §35? Fig. 50.—Sect ion at i of wall of abscess shown in Figure 49. a, Abscess cavity; b, necrotic tissue covering inner surface of abscess wall; c abscess wall, shown also in Figure 51; d, brain tissue, the site of active glial proliferation. XI5 818 SURGERY A _ _. _• k. <_ H Vfc**/ Pr. li t;^ = x >K_«-P'' I *>"n &T ^ T;»' "v V1R.n_ ■ '*>-* Fig. 53.—Section at 2/ of wall of abscess shown in Figure 49. o, Abscess cavity; b, necrotic substance covering inner surface of wall; c, young fibrous tissue elements; d, adult fibrous tissue; e, site of section shown in Figure 54. X15 Fig. 54.—Higher magnification of section at e in Figure 53, show- ing firm fibrous tissue strands. X300 00 I—' CO S20 SURGERY the wall of the abscess, for a few strands were sufficient to protect the abscess against rupture. The quality of these strands is shown in Figure 51. ^ Beyond tlie fibrous tissue wall there was neuroglial proliferation, as shown in Figure 52. This latter reaction of cerebral tissue, of little importance in this case, is the main protective reaction in the wall of the abscess designated as Type III herein. It is evident that the method of infection and the propinquity of meso- blastic tissue to the site of infection influence greatly the above-described formation of an abscess wall. Fairly Firm Wall Coxtuxixg Somi. Fibers Proliferated From Neighboring Mkso- blastic Tissue (Type II) The typo of abscess wall shown in Figure 56, while not the most valuable, represents the usual form of reaction when the infection occurs deeper than the fibrous tissue coverings. The chief reaction takes place in the glia. but this is augmented by proliferation from the mesoblastic elements of the blood vessels. In addition to the availability of the mesoblastic tissue, the quality of the resulting Fig. 55.—Frontal section of a brain with left temporal lobe ab- scess, a, Abscess cavity; b, abscess wall and site of section shown in Figure 56; c, site of section shown in Figure 57 wall is likely to improve somewhat with the duration of the process. In speci- mens under consideration all of which were of less than a year's duration, the fibrous tissue proliferation reached a stage in no sense approximating the density of the wall shown under the heading of Type I. In Figure 58 the small band of fibrous tissue represented the most advanced stage of the fibrous tissue proliferation of an abscess wall which had existed as long as the wall shown in Figure 47. Hassin,7 however, described a wall of eight years' duration in which the outer layer of the abscess wall was made up of adult fibrous tissue strands. The question of time necessary for the proliferation of an abscess wall is an important one. It is certainly unusual for an abscess to exist for a period longer than a few months and walls of this type may be formed with great rapidity. the history of the abscess shown in Figure 50 indicating that the wall was formed within a period of three or four weeks. The hemorrhages shown in Figure 57 were no doubt due to the very active vascular proliferation in the soft cerebral tissue. XEUROSURGERY 821 "3-|fZ^v..-_z.T;_ "•<_S*-:i" -Se-' '';■•*'/•' z^TTT£ —■ ° ~ T " = ■- ■S "= =3 " X tJD rt ^? ^ j- "S "5 c — ^ "ss y ° S i_ ? _ - ^ - c ^ -.j -_; t_ *> c x 5 O yi O £ 2 Fig. 58.—Section from an abscess wall similar in type to that shown in Figure 56 but of longer duration, o, Small band of adult fibrous tissue. X325 Fig. 59.—Frontal view of brain, with large abscess in right frontal lobe, o, Adherent dura of frontal lobe reflected toward mid line; b, perforation of dura; c, perforation in frontal lobe, which was continuous with b and formed the abscess stalk Fir.. 60.—L. F. A section from the wall of the abscess sliovvn in Figure 59. o, Abscess cavity; 6, disorganized tissue of inner abscess wall and site of section seen in Figure 61; c, abscess wall; d, brain tissue adjacent to the abscess wall. X6 00 to to NEUROSURGERY 823 Walls of Varying Thickness, the Results of Glial Proliferation (Type III) Walls formed almost entirely of glial fibrils may be very heavy, but because of the delicate character of the fibrils the wall is not so resistant as one in w-hich there is fibrous tissue. In Figure 60 the wall visible microscopically and in this picture of low magnification has the appearance of a thick, limiting mem- brane, but the delicate quality of the tissue is shown in Figure 61. The relative value of this type and of the firm fibrous tissue wall is perhaps best showm in Fig. 61.—L. F. A higher magnification of wall of abscess seen in Figure 60, showing the membrane to consist of delicate fibrils. X325 Figure 50, in which there is a firm fibrous tissue wall at c and at d, the adjacent cerebral tissue with glial proliferation. A photomicrograph of d, given in Figure 52, is similar to the abscess wall shown microscopically in Figure 61. The neuroglial fibrils are again well shown in Figure 62. which was taken from the innermost part of the abscess wall. A large part of the cellular element has fallen out because of the necrosis, leaving the fibrils in plain view. Walls Showing No Evidence of a Protective Reaction (Type IV) Figure 04 shows an abscess which was the result of a virulent streptococcus planted deep in the substance of the cerebellar hemisphere. There is no evidence of'a protective reaction and the lesion marks an intermediate stage between S24 SURGERY Fig. 62.—L. F. Section of the innermost portion of abscess wall in Figure 60. Because of the necrosis the cellular elements have fallen out, leaving the delicate fibers in plain view. X85 Fig. 63.—Cpper surface of cerebellum, with abscess in left hemi- sphere underlying 6. A cross section of the abscess is shown in Figure 64. a, Point of spontaneous evacuation of abscess into posterior fossa Fig. 64.—Cross section of cerebellum seen in Figure 63. a, Abscess cavity; 6, area of hemorrhagic ex- travasation, the result of thrombosis; c, site of sec- tion shown in Figure 65; d, sire of section seen in Figure 66 NEUROSURGERY 825 an encephalitis and the usual abscess formation, for though suppuration occurred there was no true barrier between the pus and the brain tissue. At b in Figure 64 there is an area of hemorrhagic extravasation, the result of thrombosis, which is also wrell showm in Figure 65, the destructive process entirely replacing the usual proliferative reaction. The merely necrotic end-result of the destruc- tive process is shown in Figure 66. Abscesses of this type also occur as secondary lesions to firm wall ab- scesses. In Figure 67 the primary abscess has a thick wall, the building of which, no doubt, required several weeks, but the extension from this abscess was doubtless more recent, due to escape of pus into the substance of the Fig. 65. -Section from c in Figure 64. Xote the large and small areas of thrombosis. xxr> occipital lobe, an invasion altogether too sudden to allow the slowly proliferat- ing glial tissue to form a protecting membrane. D. F., ago 29. Gunshot wound left hemisphere, July 14, 191S. Constant drainage of pus from the wound. Drainage of abscess, June 22, 1919. Death, June 30. The architecture of the wall of the primary abscess is similar to that described under Group II. The firmness of the wall and heavy consistency of its content indicate a long duration. At b, however, is a larger abscess cavity with soft necrotic walls evidently due to a more recent extension from the original abscess. Figure OS shows an abscess, also the result of extension from the firm- wall abscess, as seen in Figure 55. There was evidently leakage of pus into the occipital pole of the ventricle which was shut off anteriorly from the remain- ing part of the ventricle so that the occipital pole was converted into an abscess cavitv. Extending from the ventricle to the inferior surface of the brain, an 826 SURGERY g S Q B" » (3 l> &;**y. - r- "-.'." " V>" •** *• ill ■S 4> ® 2 a 5 ^. » « x a '? ,5 NEUROSURGERY 827 Fig. 68.—P. V. Transverse section through the occipital pole of the brain shown in Figure 55. a, Occipital pole of the lateral ventricle converted into abscess cavity with necrotic wall; b, area of encephalitis, tract of evacuation of pus from the ventricle cavity to the subarachnoid space; c, thickened pia-arachnoid; d, site of section shown in Figure 69 f7 ^^ 3tl -$v„-.- ^•^«^v^v_r^ ^T-T/ ''"'" '!,#;- : .VV^'irH* >KTT"T:. "T: >\ .•"T> '•"'*■'.•.-: . ■;' ,z..z.j ■-■..i.,,..'. '• V.;^^T«T _^> - >/■ ■■* ' ' -* '**,;flie?***.'" ;>-.:-r..-vz-,, *«£%.., . •■'* '■> . -v • '!'■_■ v TT^ ** ■ " -v _:■ • ;••< '. - SJMSSKB-W W*Z'. '• sz'zjT^^- . TtTv t - z z . . . ~?m&< ,v TTT-T-* ^ • TZV -^ .'-■?.-':":.'^"..iplf'&iZ: "'*-."-;- .T Z5^%T#-jr\ = - -*.'><. .TT''-/ "*•'• ?V .►.•■ ,.&i*?~" '■':-/■ Z-/'.■■'■■'?'■''-«'•>. .'s» TZv*; . V'.';V:-;'. T •^,: "fit •Z-' ;"j, T" - ';'.",'-.:'" .-•'?> "T ^\D§!J& fgy.'OZ. •: --;'Z-:rV. •'■tT •'-■"'"-" C• '■"'''■■'''■' iT' -*■ V?^P« 1%1^'V. '.:V-Z.-.TVi;'- *V" • -' •'• * '■ • '■'"■ *- - ■■ »*■■ &iB8 1^^>l5^^1ei^-V,i-:. ■'••. -- . -. .- --.-.- Fig. 69.—P. V. Section of the abscess wall at _ in Figure 68. o, Abscess cavity; 6 to 6', necrotic brain tissue surrounding pus; c to c', brain tissue beyond the necrotic zone. X*.' S2S SIRGKKY inflammatory tract marks the site of the escape of pus into the subarachnoid space. Figure 69 is a section from the ventricle wall of the specimen shown in Figure 6S, illustrating the poor quality of the abscess wall, which consists only of necrotic brain tissue entirely incapable of acting as a barrier to the pus content in the cavity. The escape of pus from the abscess into the ventricle is a very common method of termination of neglected abscesses, but the conversion of a portion of the ventricle into an abscess cavity as shown in Figure 66 is certainly an uncommon reaction. The formation of secondary abscesses may be due to the ineffectiveness of an abscess wall as a barrier to constantly accumulating pus, or to organisms, so that such extension is dependent upon the duration of the abscess and the virulence of the organism producing it. The follow-ing case reported by Frazier1 illustrates the difficulties in the management of a tubular abscess of the left frontal and parietal regions, result- ing from a penetrating gunshot wound, with retained bone fragments and metallic foreign bodies. Private _\I, admitted to U. S. Army General Hospital No. 11, November 10, 191S, as an ambulatory case. He was unable to give history of his disability. He received a gunshot wound of the right frontal region near the midline, date unknown. There was a circular cranial defect in the right frontal region about 2 by 2J^ cm., without hernia. The Roentgen-ray examination showed several bone fragments near the defect and a foreign body 0.5 by 4 cm. in the parietal cortex above and behind the left ear. There were no definite motor, sensory, or other focal symptoms present. He appeared to understand what he heard but refused to speak at first. About two weeks after admission he spoke more freely. The sudden development of a hernia at the site of the frontal defect, accompanied with other signs of compression was the indication for an exploratory operation. The site of the hernia in the frontal region was explored for abscess, with negative results. The patient subse- quently died. The autopsy revealed a chronic meningitis and an abscess cavity along the tract of the missile. Death was attributed to chronic meningitis and hydrocephalus rather than to the abscess. REPORT OF NECROPSY Dura.—There was an oval opening to the right of the midline in the frontal portion, through which the brain herniated. Beneath the dura, covering the anterior part of the left hemisphere, there was evidence of a hemorrhagic pachymeningitis. Hernia.—Beginning at a point 3.5 cm. above the base of the brain, anteriorly and just to the right of the midline, there was an irregularly rounded mass measuring x by 3.5 cm. beyond the frontal lobe. Ventricles.—Both ventricles were dilated. The right showed 11.5 by 6.4 cm. in its greatest dimensions. At one point the left wall of the right ventricle projected 1.4 cm. to the left of the midline. The ependyma showed irregular areas of grayish white thickening. The choroid plexus of the posterior was thickened and firmly attached to the right lateral wall. The left lateral ventricle appeared to be less dilated than the right. Abscess cavity.—Beginning just to the left of the falx and extending outward and back- ward to the surface in the anterior central gyrus there was a pale orange-yellow granular zone measuring 6 cm. in length, 1.2 to 2.5 cm. in width and 3.9 cm. in diameter. The cen- tral portion of this zone was occupied by a cavity filled with gelatinous and gray amorphous material. The autopsy findings in this case show no rupture of the abscess and no acute meningitis. The general ventricular dilation indicates a chronic infec- tion of the ventricles with possible obstruction of their exits. It should be XEUROSURGERY 829 noted that the abscess cavity did not extend to the metal foreign body but probably originated from the bone fragments near the defect, The intracranial pressure in the case was probably due to chronic inflam- matory obstruction of the exits from the ventricles. 'This pressure, however, was offset to some extent, after the abscess began to form, by the cranial delect in the frontal region. Effective drainage of such an abscess would have been accomplished with great difficulty. Fig. 70.—Patient with hernia at the site of the frontal defect. Fig. 71.—Brain showing (a) enlargement of left hemisphere Xote.—This photograph refers to autopsy specimen (fig. 71) and hernia cerebri at site of cerebral defect; (6) horn of dilated ventricle in relation with tubular abscess cavity filled with inspissated pus; (c) bullet just be- neath the cortex. Note relation of abscess cavity to trajectory between site of hernia and location of bullet Figure 72 shows an abscess following a penetrating gunshot wound in which the bullet entered the skull near the coronal suture of the left side and passed backward through the motor area, lodging in the cortex of the left occipital lobe. The wound was received three months before an operation was undertaken for the removal of the bullet. The patient was recovering from aphasia and a right motor paralysis, but there was a residual hemianopsia. At the operation, which was done under local anesthesia, the bullet was found embedded in the cortex and was definitely encapsulated by a small cyst, which lay in an an""le between the longitudinal and left lateral sinus. A cerebral abscess was not searched for, there being no symptoms suggesting a progressive intracranial distrubance. The bullet was removed without difficulty and a rub- 830 SURGERY ber tissue drain inserted into the small cyst cavity. The culture of the bullet proved negative, but 12 hours later the patient showed signs of meningitis and died within :^(. hours. Streptococci were grown from the spinal fluid. In this case hemianopsia caused by the original injury combined with a residual disturbance of speech function and intelligence, due to a destructive lesion, had masked any possible signs of focal disturbance arising from the abscess itself. An exploration which approached within 1 cm. of the abscess wall led to no information that an abscess was present. In the manipulation necessary to remove the bullet either a latent infection about the abscess wall was brought into activity or else the wall was weakened and rupture took Fig. 72—Abscess from penetrating gunshot wound of left parietal and occipital lobes. There were no retained bone fragments. Note collapsed cyst cavity from which sterile bullet was removed. This is well separated from abscess, which was not discovered at operation place. The case further illustrates the possibility of removing a sterile missile which in its course had deposited infection which led to an abscess some dis- tance from the projectile. The symptoms of brain abscess in which there is a cranial defect or a discharg- ing sinus may not include such marked evidence of intracranial pressure as is frequently seen in cases with abscess following infection from the accessory sinuses. If there is a cranial defect the tension is offset to some extent by protrusion of the tissues through the bony opening, much in the same way as subtemporal decompression offsets intracranial pressure from other causes. In some cases the discharging sinus from a foreign body which has become the seat of an abscess may delay or prevent the accumulation of pus whereas in NEUROSURGERY 831 others the escape of pus through the sinus is inadequate to prevent the forma- tion of an abscess of considerable size. The presence of a retained foreign body associated with a progression of symptoms or the accession of new symp- toms indicating cerebral impairment should obviously arouse the suspicion of abscess formation. As was mentioned at the beginning of the consideration of this subject, the mortality of brain abscess from war wounds is very high. Bagley," in his pathological study of abscesses, referred to above, reports four cases following war wounds of the head. Tw-o of the patients recovered and two died. In one case which recovered there were no symptoms of neurological disturbance and the operation was undertaken for the removal of a machine-gun bullet from the right cerebellar hemisphere. Abscess was unexpectedly encountered. In a second case with recovery, the w-ound of entrance continued to drain until a temporal lobe abscess was evacuated. This patient also had metallic foreign body in the middle cranial fossa. Both of the fatal cases had retained bone fragments and in both of these cases the wound remained unhealed. A number of factors must be taken into consideration in attempting to give a fair estimate of the mortality of the operation in brain abscess. The type and stage of infection, presence or absence of capsule, location of the abscess, and the method of drainage has each a direct influence upon the operative mortality. In view of the high mortality any method of operation should be carefully scrutinized to exclude all technical errors, which may not only prevent the eradication of a localized suppuration but may actually spread the infection to uninvolved regions of the brain. The principles utilized in the successful treatment of abscess in other regions of the body must be modified in operations for brain abscess. The best results in the treatment of brain abscess have been obtained in the drainage of single abscesses with capsules. Multiple abscesses are practically always fatal and recovery from brain abscess without a capsule is extremely rare1. If an encapsulated abscess is connected with the meninges by adhesions and the evacuation of the pus is properly conducted through the adherent cortex, the mortality rate of cerebral abscess in general should be very much reduced. Much has been written about the importance of early diagnosis and drain- age of brain abscess. The primary stage of abscess formation is one of septic encephalitis for which surgical procedures will give no relief. To recognize the stage of encephalitis is highly desirable but it is equally as important to have in mind the limitations of surgery at this period in the evolution of infection. The ideal time of operation is after the formation of the capsule and it has not been shown that deferred operations for abscess, provided rupture has not taken place, has appreciably raised the mortality rate. It is sometimes difficult to determine just how drainage of pus should be accomplished or whether simple aspiration with a needle should be made. It is highly probable that in many fatal cases the drainage tube does not enter the abscess cavity but lies in the brain tissue about the abscess, traumatizing the brain and producing a septic encephalitis. 4(.!l!)7—27------">■! S32 SURG K1U In deep-seated small abscesses it is almost impossible to reenter the abscess cavity with a drainage tube after the withdrawal of the instrument used for exploration. For this reason exploration should be done with some form of instrument which may be left in position when a deep subcortical abscess is entered. Graduated drainage of abscesses has been advocated to prevent con- tamination of the meningeal spaces.8 By this method the abscess is first located and the distance from the cortex carefully measured. A small amount of pus is aspirated to relieve tension and a narrow strip of rubber tissue placed down to but not into the abscess. A few days later the eye end of a soft catheter is inserted through the opening made for the rubber tissue. The advocates of this method believe that meningitis is less likely to result because of the formation of adhesions about the opening in the dura before free drainage is instituted. Such a procedure would be unnecessary in gunshot wounds if the abscess can be reached through the original defect where adhe- sions of the cortex to the tissues of the scalp have already formed. It is not know-n whether septic encephalitis, due to fumbling with the primary drainage or meningitis from overflow of pus on to the cortex, is the most frequent cause of death after the operation. If the intracranial pressure is high before the ab- scess is drained it is not likely that the cortex will recede from the dura during the evacuation of the pus. Moreover, it is difficult to control the escape of pus from abscesses with high tension situated within one centimeter of the cortex. A consideration of all the facts justifies the conclusion that the most favorable time for accurately placing a drainage tube in an abscess cavity is when the pus is first discovered. It is often possible to empty the abscess completely at this time and there may be very little subsequent discharge. If metallic foreign bodies or bone fragments are in the abscess cavity or about the capsule every effort should be made to remove them. If, however, the abscess has developed some distance from a retained foreign body, inspection of the abscess cavity is probably unnecessary and adds to the risks of the operation. In cases of large cerebral abscess the expansion of the abscess has been at the expense of the space- normally occupied by the lateral ventricle. Liberation of the pus is followed by reaccumulation of fluid in the ventricle which has been compressed by the abscess and this expansion of the ventricle after the evacuation of the pus serves to maintain the contact of the cortex with the dura. Procedures for the drainage of abscesses vary in magnitude, all the way from the osteoplastic flap to a simple trephine opening. Bone flap operations are of considerable magnitude in very ill patients and appear to be justified only on the ground that often the operation is exploratory in character and that the exposure of a wide area of cortex gives a better opportunity for search- ing for a collection of pus which might be overlooked when a small opening is used. As far as the treatment of subcortical abscess is concerned, the bone flap offers no advantages. The advocates of both the simple exploration through a small perforation and the osteopathic flap finally drain a subcortical abscess through a short dural incision so that the extensive procedure of rais- ing the flap is entirely unnecessary in the actual evacuation of this tvpc of abscess. One great advantage of the drainage of an abscess through a small NEUROSURGERY 833 cranial opening is that the method is simple and can be employed without the use of general anesthesia. Troublesome osteomyelitis of the'skull as a late complication js aiso tlVoided by this method. The importance of utilizing the force of gravity in evacuation of brain abscess is generally recognized. The satisfactory results of operation of encap- sulated temporal lobe abscess when the abscess cavity is entered at its lowest level illustrates this point. On the other hand, the evacuation of the deep frontal abscess through the vertex is usually accompanied bv considerable interference with drainage. In some cases there is very little drainage after primary evacuation, in others drainage continues for many weeks and there may be during this period temporary cessation of the discharge accompanied by an increase of existing symptoms, or an accession of new symptoms. The drainage tube should be carefully fixed to the seal]) and should not be removed until drainage is discontinued. In some cases, particularly those m which the evacuation is primarily complete, the tubes may be extruded in 10 days or 2 weeks. Healing may then proceed rapidly and the patient is entirely relieved of the symptoms. In other cases the tube can not be kept in satisfactorily oven from the beginning and the patient shows signs of an exten- sion of the infection. It is likely that most of these latter patients have a spreading encephalitis about the abscess and the increase of intracranial pres- sure forces the tube out of the cranial cavity. The question of just how long drainage should be continued is difficult to answer. Some have recommended that the tube be kept in position for several months. In this connection it- must be borne in mind that there Avill be some drainage from the reparative efforts of the tissues as long as the tube is kept in position. Such being the case, if the patient appears to be doing wrell and the drainage is scanty, it w-ould seem safe to begin the shortening of the tube after two or three weeks and remove about one-eighth of an inch of the tube every second day until it is finally withdrawn. FUNGUS CEREBRI One of the most frequent complications of the drainage of brain abscess is a fungus of the brain; however, this complication w-as rarely present among head injury patients returned from overseas. The mortality of the condition w-hich produces fungus is high. An uncovered protrusion commonly develops after compound fracture of the skull with laceration and infection of brain tissues. The principle of complete removal of debris with excision of contaminated tissues and tight closure of the w-ound at the primary operation not only prevents fatal early infection but serves to eliminate the formation of cerebral fungus. The condition responsible for fungus following brain injury is an expanding lesion due to infection. The pathology of this lesion may be undrained abscess, with or without obstructive hydrocephalus (fig. 73). A more frequent cause is probably encephalitis (fig. 74). The com- plication of brain abscess by fungus, even when a fatal result is avoided, greatly prolongs the patient's convalescence and adds generally to the post- operative difficulties. The treatment of the condition itself is, as a rule, unsatisfactory. It is important to drain any accumulation of pus, if this is S34 SURGERY possible, but the recognition of tlie refilling of part of the abscess cavity or the diagno- sis of new abscess in or about the fungus is beset with many difficulties. The exploration of the fungus with a ventric- ular needle may carry infec- tion into the ventricle, the horn of which may extend well into the protrusion. If the cause of the fungus can not be located and removed the ex- posed portion of the brain should be protected by rubber tissue and a firm ring of gauze. The pad should be sufficiently thick to protect the fungus from further injury by the bandage. If the intracranial pressure is raised, and fungus does not often exist unless it is, daily spinal punctures are Fig. 73.—Fungus following a subtempora .'exploration for multiple right nelpiUl. I he patient SIlOUul frontal abscesses. Two abscesses were evacuated through a small per- snend a nart of each dav sit— foration in the frontal bone, which shows a small fungus in the . . , . .. , „ photograph. One abscess was overlooked. Autopsy showed wide- ting Up in Deu ll tPe IUIlgUS IS spread encephalitis near the vertex, so as to re- duce the intracranial pressure about the protrusion. A subtemporal de- compression may sometimes be of benefit in the treatment of fungus, but it is of no value if there is an ob- structive hydrocephalus. The com- plete eradication of infection through a small dural incision is the best protection against the development of fungus following abscess. If the abscess cavity is not well drained an extrusion of brain tissue of consider- able size may take place through a very short dural incision and a fungus developed under such conditions tends to increase in size from mechan- ical interference writh the blood sup- ply of the extruded brain. Fig. 74.—Fungus complicating the drainage scess of the right frontal lobe. Incomplete with encephalitis was probably responsible Complete recovery followed the protection by a doughnut pad, and spinal punctures of a large ab- early drainage for the fungus. of the fungus NEUROSURGERY 835 RETAINED FOREIGN BODIES The relatively small number of retained foreign bodies discovered in head- injury patients following their return to the United States is striking proof of the efficiency which characterized primary operation for penetrating wounds of the brain. In two series aggregating 392 head-injury patients, at General Hospitals Xos. 2 and 11, 29 had intracranial foreign bodies which were either pieces of metal or bone fragments. It is not unusual to find small metallic bodies associated with bone fragments in the same patient. A foreign body, even of considerable size, rarely produces symptoms unless infection develops either in the tract of the missile or about the foreign body itself. It is not rare for foreign bodies to remain quiescent in the brain for a year or more and then become the seat of an abscess. There is usually a limited zone of sclerosis of the tissues about the foreign body, but it is doubtful if this often results in progressive impairment. In view of the fact that a foreign body often deposits infection in the brain and that this infection may be present even when the clinical condition of the patient indicates that the foreign body is quiescent, the question of extraction of the foreign body should always receive consideration. If the abscess which forms in cases with retained foreign body always develops in the location of the foreign body, the argument is much stronger for its removal either to prevent infection or to eradicate a latent infection. It often happens, however, that an unsuspected abscess may lie some distance from the foreign body the removal of which does not affect the abscess itself. In some cases the missile projects into or is inclosed by the abscess wall as in the following case reported by Bagley:4 Pvt. P. L.—Right occipital penetration by machine-gun bullet which lodged in the right cerebellar hemisphere; extraction of bullet and drainage of abscess; recovery. The patient was wounded September 27, 1918, and admitted to a front line hospital in good condition. There was no attempt made at that time to remove the bullet. When brought under observation at General Hospital No. 2, Fort McHenry, Md., in April, 1919, the Rcentgen-ray findings were the only clinical evidence of the presence of the bullet. Removal of the missile was advised because of its large size and the fact that the pro- cedure seemed to offer no difficulties. Operation, May 19, 1919. A uni- lateral cerebellar exposure was made. After deflecting the right flap a small portion of bone was removed and a transverse incision made in the dura. Fjg y5 _case i: a, Point of entrance; 6, machine-gun bullet in There were a few delicate adhesions be- right cerebellar hemisphere tween the dura and the pia-arachnoid. An exploring needle passed 0.5 cm. into the hemisphere encountered the bullet. Division of the cortex resulted in a free flow of pus. Further examination revealed a small abscess cavity in the right cerebellar hemisphere which contained about 3 cubic centimeters of pus. Into the S3(3 SURGERY abscess cavity the distal two-thirds of the bullet projected while the approximate one-third was firmly encapsulated in the right wall of the abscess. The bullet was removed and imme- diately placed in culture media, examination of which later showed a growth of staphylococci Folded rubber tissue drains were placed in the abscess cavity and brought to tlie surface at the outer extremity of the transverse incision. Forty-eight hours after operation there was Fi.i.Tfi.-A -shower" of metallic fragments partly intracerebral and partly extra- cerebral some headache and elevation of temperature. Drainage continued until November 1 1919 when there was complete healing. At no time during this period was there evidence of dis- turbance of the cerebellum. In a series of nine patients with retained missiles treated by Barley seven were operated upon. Of the operated eases, four had an abscess, with NEUROSURGERY 837 a positive culture. In three cases there appeared to be no signs of brain dis- turbance from the foreign bodies, and in these the cultures were negative. In the patients who showed no infection from the missile there was prompt recovery, and they are perhaps free from the menace of infection in the future. It is generally recognized that bone fragments or organic debris are more likely to produce late abscess formation than a metallic foreign body, and in some cases with retained metal and bone fragments the metal had passed well beyond the location of the abscess about the bone fragments and appeared to he giving no trouble. Fig. 77.—Large single metallic fragment, intrahemispheric Frazier 1 is of the opinion that the indications for the extraction of foreign bodies are as follows: Foreign bodies causing encephalitis or epileptic seizures should be extracted; those apparently latent should be left alone. The following case, reported by Frazier and Ingham, was operated upon because of Jacksonian epilepsy, which was correlated with the region of the brain having a retained missile. The patient, who was struck by a high-explosive shell in the frontal region just above the e\ ebrow received first aid at once. He was operated on at the field hospital. Fragments of bone were removed and the wound closed with tube drainage. September 27, 1918, the wound 838 SURGERY Fig. 78.—Three metallic fragments at a distance from the defect; two bone fragments within the margin of the defect Fig. 79—One minute bone fragment and three silver clips applied at operation overseas for control of hemorrhage NEUROSURGERY 839 had healed. He was operated on June 9, 1919, at General Hospital No. 11. Craniotomy was performed for removal of a foreign body which was localized by measurements and identified by its relation to the bifurcation of the anterior middle meningeal artery, grooves of which could be seen in the skiagraph. The foreign body was located with a needle and extracted with a magnet. It appeared to be covered with soil. The sinus from which it was extracted was dinsinfected with dichloramin-T and the wound closed. Just before leaving the operating table the patient had a short convulsive seizure involving the left face, left arm, and left leg. The foreign body was readily localized and its close proximity to the precentral con- volution justified the belief that it might have been the exciting factor in the epileptic seizures. At all events this possible relationship, the fact that there had been but two seizures, that the foreign body could be removed without risk to life or harmful damage to the brain, justified its removal. While it is difficult to give definite rules for the extraction of apparently quiescent foreign bodies in the brain, it may be said that all easily accessible foreign bodies, except minute fragments, should be removed. Foreign bodies deeply embedded in the brain without giving symptoms, should be left alone. A precise Roentgen-ray localization is necessary before operation. After the localization has been made, a small incision through the brain tissues and the removal with alligator forceps is perhaps the most satisfactory method of extracting the foreign body. An osteoplastic flap is rarely necessary, and the operation may be done under local anesthesia. The magnet extraction of foreign bodies after healing is complete is less easily carried out than at the primary operation. The fibrous tissue encapsulation and the entanglement of the missile in the scar make removal by a magnet difficult and increase the trauma of the brain tissues. Bagley's4 suggestion that a rubber tissue drain be kept in the cavity from which the foreign body is removed until the culture proves negative is important. Generally the presence of a foreign body is considered a contraindication to cranioplasty and patients would often urge the removal of them so that a cranial defect could be repaired. EPILEPSY Convulsions were of frequent occurrence following gunshot wounds of the head, quite commonly appearing after the primary operation and often upon evacuation of the patient to another hospital. The early attacks were some- times Jacksonian in type, but patients who had these early convulsions did not appear to be more liable to the development of epilepsy later on. There is a great variance in the statistics as to the incidence of epileptic seizures following head wounds. In the series of 200 head cases at General Hospital No. 11 there were 25 patients with convulsions, or 12.5 per cent, while Villandre 9 reported operations on 70 per cent of a series of 450 cranial wounds in which the main indication was the development of epileptic seizures. The type and location of the wound appear to be factors in the production of epilepsy. Patients with infected wounds and dense scars, particularly those of the motor cortex, seem to be more liable to late convulsions, but no head wounds are exempt from this complication. In view of the many procedures w-hich had been proposed for the relief of epilepsy it is surprising that surgery for the relief of this condition received S40 surgkuy no accessions from the management of patients during tlie late treatment period. Some patients with cranial defects of the parietal region which were covered by dense scar appeared to be benefited by cranioplasty and there was rather general support of the operation for the repair of defects in such cases. It is difficult to make deductions as to the effects of cranioplasty upon epilepsy in patients with large cranial defects. It is certainly true that many of them were relieved of a train of discomforts and that the convulsions appeared to be less frequent after the excision of dense scars and a repair of the defect. Retained foreign bodies in the motor area of patients w-ith Jacksonian attacks furnish a clear indication for operation and the removal of the foreign body. Apart from the relatively few cases in which there were troublesome cranial defects or intracranial foreign bodies, surgical procedures were rarely used in the treatment of traumatic epilepsy. REFERENCES (1) Frazier, Charles H., Lieut. Col., M. C, and Ingham, Samuel D., Capt., M. C: A Review of the 1 .fleets of Gunshot Wounds of the Head Based on the Observation of 200 Cases at U. S. Army General Hospital No. 11, Cape May. N. J. Trans- actions American Neurological Association, June 17-IS, 1919. (2) Wegeforth, Paul, Capt., M. C: A Note on Experimental Cranioplasty. Annals of Surgery, Philadelphia, 1919, lxix, No. 4, 3X4. (3) Coleman, C. ('., M. D., F. A. C. S.: Repair of Cranial Defects by Autogenous Cranial Transplants. Surgery, Gynecology, and Obstetrics, Chicago, 1920, xxxi, No. 1, 40. (,_> Bagley, Charles, Jr., M. D., F. A. (.. S.: Gunshot Wounds of the Brain with Retained Missiles. Surgery, (lynecology, and Obstetrics, Chicago, 1920, xxxi, No. 5, 44S. (5) Based on sick and wounded reports made to the Surgeon General. ((>) Bagley, Charles, Jr., M. C, F. A. C. S.: Brain Abscess with Pathological Observations. Surgery, Gynecology, and Obstetrics, Chicago, January, 1924, 1. (7) Hassin, C. B.: Histopathologic^ Studies on Brain Abscess. Medical Reeetrd, New York, 191S, xciii, 91. (S) Dowman, Charles E.: The treatment of Brain Abscess by the Induction of Protective Adhesions between the Brain Cortex and the Dura before the Establishment of Drainage. Archives of Surgery, Chicago, 1923, vi, No. 3, 747. (9) Yillandre, C, M. D.: Healing of Skull Wounds. Archives de medecine et de pharmacie militaires. Paris, October, 1917, lxviii, 54(5. ADDITIONAL REFERENCES Coleman, C. C, M. D., F. A. C. S.: Some Observations on the Drainage of Subcortical Brain Abscess. Archives of Surgery, Chicago, January, 1925, x, 212. Eaglet on, W. P.: Brain Abscess. Macmillan Company, New York, 1922. CHAPTER VI A STATISTICAL ANALYSIS OF GUNSHOT WOUNDS OF THE HEAD General statistics concerning gunshot wounds of the head are included in the tables on the various kinds of battle injuries sustained by members of the American Expeditionary Forces, in Chapter III of Section I of this volume. The data referred to show that of the 174,21)0 battle injuries, 10,452 were gunshot wounds of the head, a percentage of 5.99. Eleven hundred and forty-six of these head injuries (10.SO per cent) resulted fatally. For purposes of a more detailed statistical study of these gunshot wounds of the head, about 1,100 clinical records, pertaining to such injuries, were selected and studied. Tabulations were made therefrom according to the legions involved, the symptoms presented, the operations, complications, per- sistent symptoms, dispositions, and causes of death. At this point it might be well to add that some of the clinical histories were remarkably complete and accurate; others were lacking in detail. However, considering the adverse" conditions under which the original entries often were made, the preponderance of good case records is surprising. The material thus made available, repre- senting approximately one-tenth of the whole, and being about 75 per cent adequate for the purpose, gives a fairly accurate cross section of all the cases. In the analysis of these clinical records the grouping of Cushing is used. Since this grouping is given in detail in other chapters of this volume no further explanation of it is deemed advisable here. CLASSIFICATION OF WOUNDS Table 1 records the cases as to regions of the head involved according to the depth of the injury or severity. It will be noted that bursting fractures of the skull, listed in Class IX are relatively rare, the number of cases recorded being too small to be of value. Penetration of the ventricular system was also only occasionally noted. The largest total is in the frontal region, the smallest in the suboccipital. Probably the great majority of such injuries succumbed before admission to a field or evacuation hospital. When admitted alive and dying shortly after, they were probably recorded as fractures of the skull with- out further qualification. Therefore the largest group is that of Class II, simple fracture of the skull. S41 842 SURGKI.y Table 1.—Classification of gunshot wounds of the head, according to depth of injury, or its severity ° Regions Eye________ Frontal_____ Temporal___ Parietal____ Vertex_____ Occipital___ Suboccipital. Mastoid____ Total. ABSOLUTE NUMBERS Classification I II III IV V 2 1 25 ' 15 24 2 1 21 , 1 4 1. VI 1 1 2 VII VTII IX Total 4 31 33 58 3 48 6 99 63 93 10 51 1 30 46 68 28 3 58 33 21 42 2 15 1 3 35 22 50 4 25 1 3 6 6 1 4 3 3 1 3 1 1 301 192 279 23 2 3 172 6 21 15 77 199 353 117 140 94 6 163 24 12 1,108 PERCENTAGES Eye_______ 2.01 15.57 16.59 29.14 1.51 24.12 .50 10. 55 1.70 28.05 17.85 26.35 2. S3 14.45 .28 8.50 2.13 26.59 15.95 25.53 2.13 22.34 1.06 4.26 16.67 16.67 33. 33 28. 22 41.72 17.17 1.84 "~25."C~6~ 25.00 29.17 4.17 16.67 "25.66" 25.00 8.33 25.00 8.33 8.33 5. 24 Frontal... 28.21 17.95 35.90 1.71 12.81 .85 2.56 24. 99 15.72 35.71 2.86 17.86 .71 2.14 27.17 Temporal______ 17.33 Parietal___ 25.18 Vertex. .. 2.08 Occipital. _____ 33.33 1.84 15.52 Suboccipital.. .54 Mastoid.. 9.20 6.95 Total________ 100.00 100. 00 100. 00 100.00 100.00 100.00 100.00 100.00 100.00 1C0.00 ; Source of information, sick and wounded reports made to the Surgeon General. SYMPTOMS In Table 2 are the symptoms presented by the cases. The discrepancies are many—no doubt from lack of opportunity carefully to examine and record the findings. This is evidenced by the preponderance of records of outstanding symptoms such as blindness (85 cases) over such symptoms as amnesia, which was certainly more common than these records show (18 cases). Thus there are eight cases of extraocular paralysis recorded, but only two of diplopia, Again it is surprising to find that there were only 13 cases with hemianopsia, while we see in Table I 99 cases of occipital injury with definite cerebral injury- NEUROSURGERY 843 Table 2.—Symptoms b ABSOLUTE NUMBERS PERCENTAGES III 13 Classification I II IV 20 V i _ VI VII VIII IX Total 4 26 Received dead.._ .. ________ 4 _______ SS 1 1 Paralysis....... _ _____ 4 1 1 2 7 1 41 17 3 21 25 ____ 24 14 4 6 15 38 24 3 11 12 1 1 1 14 9 1 1 3 2 Hemiplegia_______________ 1 lit Paraplegia________________ 1 _______ 12 Monoplegia. _ _______ 5 3 1 27 Cranial nerve palsies........__ Olfactory________________ Optic. ... . ______ 1 1 2 3 1 13 3 1 2 1 1 6 Ocular motor__________ Trochlear _. ........ 1 3 3 9 3 55 Trigeminal.....__________ 2 2 1 Abducens_________ _____ Facial_____ . 5 1 7 3 18 3 1 Auditory_______________ Glosso-pharyngeal.. _______ 1 Vagus____......_________ Spinal accessory___________ 1 .... 1 Hypoglossal____ ________ 1 11 6 4 1 3 3 Sight.....__________ 5 4 1 12 9 1 2 11 5 6 59 58 I 101 85 Blindness._______ Hemianopsia________________ Diplopia___________________ Strabismus_________________ 1 11 4 7 23 12 6 1 Hearing_____ _________________ Partial___.. ___________ Deafness........ __________ Cerebral symptoms______________ Aphasia____________________ s 6 2 6 2 3 22 8 14 14 7 1 14 5 9 13 4 2 4 1 3 18 7 5 ---- 18 6 12 2 2 1 1 4 2 1 1 79 31 48 81 3.1 Amnesia___ ___________ ---- 1 1 18 Apraxia____________________ Agraphia___________________ 1 1 5 1 Epilepsy___________________ 1 6 4 2 1 3 1 13 Convulsions. _____________ 2 Delirium___________________ 1 10 2.23 8.78 13.40 17.54 18.75 50.00 3. 88 26.67 5.88 5.88 9.72 . 11 2.24 .56 .56 1.12 3.91 .56 13.84 5.74 1.01 7. 09 8. 45 24.74 14. 43 4.12 6.19 15.46 33.62 21. 04 2. 63 9. 65 10. .ri3 .88 . 88 .88 . ss 17.50 25.00 2.91 11. 25 | 25. 00 1. 94 6.25 _______ .97 3.75 _______l 26.21 6.67 14.04 7.52 6.67 5.88 1.33 5.19 20.00 .. 10. 17 .22 .34 .34 . 68 1.01 .34 4.39 1.01 .34 2.06 ...... Tir 2.06 8. 25 1.03 .97 6.67 .66 .22 --- ________ .97 .33 2.91 .99 .33 2.79 .56 6. 14 3.75 17.48 2. 91 6.67 6. OS .88 .11 .97 6.67 ___ 20. 00 |_______ 20.00 :_. .11 .88 9.65 5.26 3.51 .22 Sight _______________ 2.79 2.24 .56 4.05 3.05 .34 .68 13.75 6.25 7.50 ---- 57. 28 56.31 .97 11.16 9.39 1.43 .22 .88 9.65 3.51 6.14 20. 18 10. 53 5. 26 .88 .11 4.47 3.35 1.12 3.35 1.12 1.68 7.43 2.70 4.74 4.73 2.37 .34 14.43 5.15 9.27 13.40 4. 12 2.06 5.00 1.25 3.75 22.50 8.75 6.25 17.48 5.83 11.65 1.94 13.33 6.67 6.67 26.67 13.33 5.88 5. 88 8.73 3.43 5.30 8.95 3.87 .97 .97 1.99 .22 .34 1.69 .11 .56 1. 03 6.19 3.51 2.50 1.25 3.75 6.67 1.44 .22 6.67 1.11 b Source of information, sick and wounded reports made to the Surgeon General. 844 SURGERY PRIMARY OPERATIONS Table 3 shows the primary operations performed. Since 1.05(1 are recorded, it is evident that many of those who were w-ounded had more than one primary operation. The zeal of the surgeon in noting what he did is in marked contrast to Table 2 of the symptoms his patients presented. It is interesting to note that 102 cases were treated by primary closure. In 195 the foreign body was removed at this time and only 33 were cleaned and dressed. Table 3.—Primary operations performed e ABSOLUTE NCMBERS Classification IX 2 4 1 I Primary operations I 3 48 25 30 1 14 | II 137 68 23 57 III IV V ' VI VII i 38 22 10 5 33 2 VIII 4 3 1 5 Total Decompression________________ Debridement______ ---------- Removal of foreign body___________ Drainage___________________ ---- Closure. ____ . .. ---- Enucleation of eye. ______ ... .. Cleaned and dressed_______ ------ 26 54 9 20 11 90 21 17 33 9 44 28 14 8 3 3 2 i 121 425 195 83 162 34 10 2 1 1 2 1 1 2 1 1 33 0 ■ 1 ! PERCENTAGES Decompression_______ Debridement________ Removal of foreign body. Drainage______________ Closure________________ Enucleation of eye______ Cleaned and dressed____ Cranioplasty___________ Mastoidotomy_________ 1.68 26.81 13.97 3.91 16. 76 19.93 46.29 22.97 7.77 19. 26 3. 38 .68 .34 26.81 55.67 25.77 9. 28 20. 62 9.65 78.97 18.42 14.91 28.95 11.25 55. 00 35.00 17.50 10.00 75.00 75.00 50.00 25.00 3.88 36.89 21.36 9.71 4.85 32.04 1.94 26.67 46.67 20.00 6.67 33.33 11. 76 23.53 5.88 11.76 17.65 2.06 .88 2.50 6.67 5.88 13.37 46.96 21.55 9.17 17.90 3.76 3.65 .22 .11 Note.—More than one primary operation was, of course, performed on many cases, hence the apparent discrepancy. c Source of information, sick and wounded reports made to the Surgeon General. SECONDARY OPERATIONS Table 4 records the secondary operations performed. Bone fragments and foreign bodies had to be removed in 50 cases only, while drainage had to be established in only 32. Abscess occurred 15 times. This is an excellent indica- tion of the thoroughness and success of the primary operations. In this table the record of 4 Source of information, sick and wounded reports made to the Surgeon General. S4(i SURGERY DISPOSITION OF CASES The disposition of the cases of head injuries is shown in Table 6. Only 23 per cent died; 43 per cent were returned to duty; 26 per cent were judged to be unfit for further military duty; 5 per cent were sent to convalescent camps. Table 6.—-Disposition of head injury cases ! ABSOLUTE NUMBERS Classification Disposition II ! Ill VI VII VIII IX Total Dutv_________ S. C. D______ Died________ Transferred to (' Not stated____ Remaining..... 131 175 22 21 23 75 35 39 6 30 31 50 13 12 6 3 1 . 3 3 2 1 Total. 394 235 207 50 3 11 900 PERCENTAGES Dutv_________ _______________ S. ('. D_______________________ Died . _________________ 74.02 12.99 3.39 7.34 .57 1.69 59. 33 25.42 10.17 4.07 22.92 36.46 32.29 6.25 18.42 34.21 43. 86 2.63 13.58 18.52 56. 79 9. 88 1.23 75.00 27. 45 43. 14 21.57 6.86 14.29 21.43 57. 14 7. 14 5. 88 5. S,8 82. 35 5.88 43.78 26. 11 23 00 Transferred to C. (Z . __________ 5 56 33 1.02 2.08 .88 25.00 .98 1 22 Total ___________________ 100.00 100.00 100.00 100. 00 100.00 100.00 100. 00 100. 00 100. 00 100. 00 / Source of information, sick and wounded reports made to the Surgeon General. PERSISTING SYMPTOMS Table 7 shows the persisting symptoms. This table is interesting when compared with Table 2. Of 127 cases that presented some form of paralysis as a primary symptom, in only 66 did this paralysis persist, without consider- ing the 23 per cent mortality that must have affected these figures. There are other discrepancies: Though 55 cases of facial palsy w-ere recorded in Table 2, only 1 case of facial paralysis persisted or survived. Other cerebral symptoms were recorded as more careful studies were made, such as astereognosis and nystagmus. Table 7.—Persisting symptoms ° ABSOLUTE NUMBERS Symptoms persisting Paralysis--------------------- Deafness, complete or partial----- Blindness_____________________ Partial____________________ C omplete__________________ Aphasia______________________ Ataxia________________________ Amnesia______________________ Apraxia______________________ Epilepsy______________________ Hemianopsia----______________ Vertigo_______________________. Hemiplegia____________________ Holmes-Sargent Syndrome_______ Slight nystagmus and right facial paralysis_____________________ Adiadokocinesis________________ Astereognosis__________________ Cerebrospinal fistula____________ III Classification VI VII « Source of information, sick and wounded reports made to the Surgeon General. VIII IX Total NEUROSURGERY 847 Table 7.—Persisting symptoms—Continued PERCENTAGES Symptoms persisting Classification I II III IV V VI VII VIII IX Total Paralysis__________ 2.79 1.12 3.35 1.68 1.68 1.12 6.08 7.43 3.71 3.38 .34 1.35 9.28 7.22 1.03 1.03 8.77 9.65 .88 .88 13.59 13. 59 68.93 48.54 20.39 13.33 6.67 6.67 5.88 Deafness, complete or partial Blindness_________ __ 7.50 _____ 5.00 _______ 3.75 _______ 7.29 7.07 Partial_____________ _______ 1U. 5U Complete.__ _ ... 2.87 1.55 Aphasia__________ _______ _ 3.09 3.51 1.25 1.25 2.50 1.25 2.50 5.00 Ataxia___________________________ .56 1.03 .88 .97 .97 Apraxia....._____________________ .22 1.11 Epilepsy ________________________ 1.35 .34 .68 1.69 1.03 3.09 1.03 2.63 4.39 .88 .88 6.67 6.67 Hemianopsia........ .56 .97 .97 Vertigo_________________________ . .44 .99 .11 .11 .22 .22 .11 Hemiplegia.________________... Holmes-Sargent Syndrome________ Slight nystagmus and right facial paralysis______________________ .88 1.75 .88 Adiadokocinesis__________________ Astereognosis______ __________ ... 1.25 Cerebrospinal fistula____ _ l CAUSES OF DEATH Table 8 shows the causes of death as recorded. If " Not associated" and "Not stated" are disregarded, the preponderance of septic complications, accounting for 72 per cent of the deaths, is very striking. Of these meningitis was much the most common. Table 8.—Causes of deathh ABSOLUTE NUMBERS Causes of death Classification VIII IX I II III IV V VI VII Total 3 2 4 2 7 33 1 2 1 10 1 24 1 1 1 2 2 10 1 2 9 Shock _____________ 8 1 6 18 1 2 6 Meningitis. _____________________ 2 4 2 1 23 1 2 35 39 6 6 92 Encephalitis......_______________ 1 2 Total_______________________ 6 29 30 46 39 2 22 8 10 192 PI _RCEN TAGES 10.34 6.67 8.70 4.35 15.22 71,74 2.56 5.13 2.56 25.64 2.56 61.54 50.00 50.00 4.55 9.09 31.82 9.09 45.46 ....-- 12.50 12.50 75.00 20.00 20.00 60.00 4.69 Shock _____________'_______ 4.17 3.33 20.00 60.00 3.33 6.67 3.13 33.33 66.67 6.90 3.45 79.31 18.23 20.31 47.92 .52 1.04 100. 00 100.00 100.00 100.00 100.00 100. 00 100.00 100.00 100. 00 100. 00 » Source of information, sick and wounded reports made to the Surgeon General. 4C.0O7—27----56 CHAPTER VII EXPERIMENTAL STUDY OF PROBLEMS OF INFECTION OF THE CEN- TRAL NERVOUS SYSTEM AND THE TREATMENT THEREFOR a During the existence of the Army Neurosurgical Laboratory the original plan of investigation was developed and extended. In some lines of activity progress was achieved, while in other phases no definite advances were made. The work of the laboratory is summarized in this chapter. HYDROCEPHALUS' One of the most frequent of the soquehe of meningitis (particularly of the chronic type) is the development of an internal hydrocephalus. The experimental production of the condition was found to be possible in both adult cats and kittens. Previous investigators had been able to reproduce the condition by blocking the intraventricular passages of the cerebrospinal fluid; in this laboratory the experimental obstruction to the normal escape of the fluid was caused by a lesion in the meninges and not by blockage in the ven- tricular system. The method used for this purpose was the injection into the subarachnoid space of a 5 to 10 per cent solution of lampblack in Ringer's solution. The carbon particles thus introduced either mechanically blocked the meningeal passages of the cerebrospinal fluid or occasioned a sterile menin- gitis which, in turn, accomplished a similar obstruction.2 Such subarachnoid injections of suitable amounts of lampblack in adult animals caused an almost immediate lethargy and sleepiness; the more acute cases remained in this condition for several days. In the milder cases the animals were a little more quiet than normal, with the progressive develop- ment of a lethargy. The lesion at autopsy in such adult cats was a typical hydrocephalic enlargement of the lateral ventricles. The younger animals (kittens), in which the ossification of the skull was not yet complete, showed even more striking abnormalities after such injections of lampblack. Not only did the ventricles enlarge enormously at the expense of cerebral cortex, but the whole head became bulging and relatively enor- mous. The fontanelles opened widely; in some animals in which the cranial bones were already united by bony union, the fontanelles were re-formed. The clinical and pathological pictures were typically those of an infant with an internal hydrocephalus. As soon as it was found possible to reproduce this pathological condition invariably, therapeutic measures aiming at its relief were undertaken. A certain degree of amelioration follow-ed the creation of an artificial connection between the subarachnoid space and the superior sagittal sinus. a Report of Investigations conducted at the Army Neurosurgical Laboratory, Baltimore, Md. Bv Cant I .wis II Weed, M. C S4S NEUROSURGERY S49 CISTERN PUNCTURE 3 Difficulty in obtaining cerebrospinal fluid by lumbar puncture in labo- ratory animals led to the adoption of puncture through the occipitoatlantoid ligament as a convenient method (Dixon and Halliburton). The technique for performing this puncture proved to be quite simple, and with a little practice the needle may be inserted into the fluid reservoir, lying just beneath the ligament, without injury to the structures of the medulla. The use of this operation greatly facilitates the obtaining of spinal fluid from the cadaver. It should prove of value in man when there is a block in the spinal subarachnoid space due to meningitic adhesions; it should be serviceable likewise in irriga- tions of the spinal subarachnoid space for the removal of the pus and debris due to infection. With the increase in experience in the use of this puncture the route may prove of value for the introduction of serum in early cases of epidemic meningitis. It was found that a much better spread in the basilar cisterns and over the convexity of the brain was obtained when a suspension of india ink was injected by the occipitoatlantoid route than when it was introduced in the lumbar region. EFFECT OF INTRAVENOUS INJECTIONS OF SOLUTIONS OF VARIOUS CONCEN- TRATIONS UPON CEREBROSPINAL FLUID PRESSURE4 Research in the Army Neurosurgical Laboratory demonstrated that the intravenous injection of hypertonic solutions exerted a marked effect on the pressure of the cerebrospinal fluid. Hypotonic solutions, when injected intra- venously into an etherized animal, caused an enduring rise in the pressure of the fluid as determined in a manometer connected with the subarachnoid space. On the other hand, the intravenous injection of a strongly hypertonic solution brought about an initial rise in the pressure of the cerebrospinal fluid followed quickly by a marked fall, often to negative values. The employment of a solution isotonic with the blood occasioned no lasting change in the pres- sure of the cerebrospinal fluid. The logical explanation of the alterations in the pressure of the cerebrospinal fluid following the intravenous injection of hypotonic and hypertonic solutions, seems naturally to be related to the ex- perimental change in the osmotic value of the blood. Data regarding the abso- lute or relative osmotic values of the body fluids were not obtained, but it appeared that the alteration in the salt-content of the blood produced experi- mentally could only be compensated by fluid readjustments within the tissues. ALTERATION OF BRAIN VOLUMES Investigations on cats showed that the intravenous injection of a strongly hypertonic solution (30 per cent NaCl or saturated NaHCO,) was followed bv a marked decrease in the size of the brain. This change in cerebral volume occurred in the unopened skull; but if the skull was trephined and the dura opened, the brain after such injection could be seen to fall away several milli- meters from the inner surface of the skull. Intravenous injection of a hypo- tonic solution (water) caused a marked swelling of the brain. Such increase in brain bulk was noted in the intact cranium; if the skull was opened, tense hernia1 of the cerebral substance, protruding several millimeters, invariably 850 SURGERY resulted from the experimental procedure. Animals subjected to these experi- mental procedures promptly became normal on recovery from the anesthetic. These changes in brain bulk were independent of the volume of the fluid injected, as w-as demonstrated by control injections of Ringer's solution, which did not alter the size of the brain. The age of the animal was found to play a noticeable part in this phenomenon, the brains of old cats failing to respond readily to such intravenous injections, especially of hypotonic solutions. No histological changes were demonstrated in the brains of animals subjected to experimental alteration of brain bulk but with opened skulls (removal of restric- tions to change in volume). In those animals which were not trephined, inter- nal changes, recognizable microscopically, were found quite constantly. The clinical application of this phenomenon of volume-change of the brain should be of value in cases of increased intracranial tension, cerebral herniation, cere- bral edema in acute infections or injuries. BRAIN ABSCESS « The methods by w-hich brain injuries and local infections were produced in experimental animals varied much in detail, but the investigation was pri- marily related to the study of the general principles underlying the spread of infection and the possibility of the experimental control of the process. In every instance the dura was perforated; in some of the experiments, parts of the cortex w-ere removed; in others, perforations communicating with the lateral ventricles were made, while in others only the most superficial layers of the brain were injured. Foreign bodies of bone or metal were some- times introduced into the wound; while at other times the skull was fractured, with puncture of the central nervous system. In a word, attempts were directed tow-ard reproduction of cerebral wounds similar to those occurring at the battle front. It was early discovered that an abscess in the brain of a eat developed only with great uncertainty unless a massive dose of bacteria was introduced into the wound. Simple puncture wounds were found to heal per primam although no efforts were made to sterilize the instruments or tract. The ani- mal's resistance to infection even after puncture of the dura seemed quite re- markable. Gross examination of such infected brains showed principally great swelling, with necrosis of the tissue and protrusions through the wound opening. In about one-half of the cases recorded a generalized meningitis was present at death, either from direct or indirect infection of the lateral ventricles in the region of the wound and subsequent spread to the meninges through the foramina of Magendie and Luschka. A complete restoration of the destroyed nervous tissue was never attained, although function might have been taken over by other cells; and m some instances a normal individual, to all intents and purposes, was preserved. An attempt was made by the tissue to combat the process of destruction instituted by the infecting organism; this defense as well as the removal of the debris by large phagocytic cells, could be seen micro- scopically. The tendency of the infective process to invade the subarachnoid space from the point of injury was not marked, but in a third of the animals the infection entered the subdural space, forming there a subdural abscess ' XEUROSURGERY 851 These acute traumatic lesions were very different from the more slowly growing abscesses, extending from the cranial air sinuses. The latter, occurring frequently in man, may be differentiated by the relatively slight swelling and dislocation of the cerebral substance, and by the development of a definite connective tissue capsule between the infective focus and the sound parenchyma. The traumatic abscess in the experimental animal extended rapidly along the fiber tracts. No encapsulation could be demonstrated in any of the observa- tions. Healing took place by the ingrowth of connective tissue. ACTION OF ANTISEPTICS UPON THE CENTRAL NERVOUS SYSTEM i The toxicity of certain antiseptics upon the central nervous system was tested by direct injections into, or irrigation of, the subarachnoid space. Prac- tically all of the chemical bodies employed possessed definite intraspinous toxicity, so that, unless given in suitable dilution and amount, immediate death of the animal ensued. With chloramine and flavine on subarachnoid injection, in addition to the initial toxicity, death in five to ten days was brought about in consequence of the direct injury to the central nervous system. With injec- tion of small amounts of a suitable dilution the animals remained apparently normal but all showed at autopsy pathological changes in the meninges. The lesions consisted of a more or less complete obliteration of the meningeal (sub- dural and subarachnoid) spaces with serofibrinous exudate; in the more severe cases the nervous system became involved in a process of destruction by direct continuity from the meninges. The blocking-off of the subarachnoid space by this exudate was complete in one case, as demonstrated by the subsequent injection of india ink; it was not, however, sufficient for the localization of an infection. The subarachnoid injection of lysol and potassium permanganate, in the presence of an otherwise fatal meningeal infection, did not prolong the life of the animal. SUBARACHNOID IRRIGATIONS 8 In the earlier experiments the irrigation was limited to the spinal canal, and for this operation the first puncture needle was inserted into the subarach- noid space through the occipitoatlantoid ligament, and the second in the lumbar region. Between these needles fluid could be passed through the spinal subarachnoid space in either direction, although the descending route (from cervical to lumbar) w-as, as a rule, selected. Later, in order to include the cerebral meninges in the irrigation, needles were introduced into the sub- arachnoid space in the vertex area; from there the flow could be conducted either to an occipitoatlantoid or to a lumbar needle. Irrigations of the spinal and cerebral subarachnoid spaces wore well toler- ated by cats if the irrigating fluid was composed of sodium chloride, potassium chloride, and calcium chloride in proper proportions (modified Ringer's solu- tion). If, however, the irrigations w-ere made with isotonic solutions of sodium chloride alone, various toxic effects became very apparent. Many of these animals died during or immediately after the irrigation; if this immediate toxicity was survived, convulsive seizures and acute mania were almost invari- able. Recovery from such attacks was frequent. Single irrigation of infected S52 SURGERY meningeal spaces with modified Ringer's solution prolonged the life of the animals as compared w-ith the controls. The period of survival in many cases was doubled as a result of this washing out of the infected meninges. Multiple irrigations were not attempted. EPIDURAL COMPRESSION OF THE SPINAL CORD9 The method employed to produce compression of the cord was the injection of paraffin into the epidural space; subsequently the spinal fluid above and below the area of compression was examined. As a result of such epidural compression of the spinal cord a partial transverse myelitis, manifested chiefly as incomplete paraplegia, resulted. In these cats the spinal fluid obtained from below the area of compression usually differed greatly from that above; the former showed almost constantly a greater protein-content, was usually scanty in amount, and frequently of a yellow color, and at times clotted rapidly and completely. The fluid taken from above was uniformly normal. As in man, the fluids which clotted and contained the greatest amount of protein were found in the animals showing greatest symptoms of pressure upon the spinal cord. The protein associated with the mild aseptic meningitis present in these cases was relatively insignificant as demonstrated by the fact that the fluid, obtained from the cisterna magna, often contained white cells equal in number to those from the lumbar region, but showed only slight increase in protein. In some cases a well-marked vascular engorgement of the pial vessels below the area of compression was demonstrated as was also an abnormal amount of serum in the subarachnoid space at the level of compression. Transudation into the lumbar sac was apparently the pathological process operative in the formation of these fluids so rich in protein. EXPERIMENTAL CRANIOPLASTY "> Experiments were undertaken to determine the relative value of various kinds of bone for bridging experimental defects in the skull, the protection of the underlying structures, and the return of the contour of the head to its normal convexity. The problems of cranioplasty could not be met entirely by the experience obtained from osteoplastic work on long bones. The logical material for use in cranioplasty consisted of plates of cranial bones as the requirements of protection for the brain and restoration of the shape of the head could be immediately accomplished and the format ion of exostoses was avoided. Animal experimentation (on cats) indicated that either living or dead grafts could be used effectively in the head. In the case of dead grafts, the bone might be re- moved during routine autopsies, sterilized by boiling or in the autoclave, and kept until needed for the operation. In man living grafts were recommended: but if they were not available, plates of sterilized cranial bone wore preferred to any other tissue. LETHARGIC ENCEPHALITIS11 The initial investigation of an outbreak of lethargic encephalitis in ('amp Lee, Ya.. was intrusted to the staff of this laboratory. Nine cases of this disease were examined, with complete pathological studies of four. The onset of NEUROSURGERY 853 symptoms was always insidious -headache, malaise, weakness, and vertigo being commonly complained of. Early symptoms of probably greater signifi- cance were sore throat, diplopia, and invariable fever. It was unusual to find signs of organic nerve disease in the first week of illness, but by the second week- sometimes later still—a widespread organic neurological disorder became evident, when cerebral symptoms appeared. Drowsiness occurred in almost every case, frequently developing into coma, and at times alternating with a state of irritability or anxiety. In spite, however, of an apparently clouded mental condition, orientation and cerebration w-ere usually unaffected, until just before death. Long projection fiber tracts to arms and legs showed pro- found disturbance in seven oases as indicated by ataxia, spasticity, and clonus. The only symptoms and signs of a focal character were referable to the brain stem, and these were present in all. Diplopia was complained of in seven of the nine cases, although oculomotor palsy was seldom seen, doubtless because1 of its transitory nature. The second most frequent disorder was weakness of the facial muscles, usually one-sided, a condition seen in five cases. Macroscopically, all the brains examined appeared alike. A great degree of engorgement of all vessels was conspicuous, and free blood was present in the meninges as evidenced by a pink tint to the pia. The chief seats of the lesions were the brain stem and basal ganglia. The essential pathologic processes wore found to be a perivascular exudation and a diffuse infiltration of parenchyma. While both types of lesion varied greatly in intensity, extent, and symmetn-, they occurred especially in the gray matter about the canal, fourth ventricle, and aqueduct, though deeper tissues w-ere also affected and the white matter was not spared. The cells concerned in both types of lesion were all mononuclear; a small mononuclear cell and a large mononuclear cell, frequently phagocytic, together with the lymphocytes and plasma cells, were recognized. Poly- morphonuclear leucocytes were absent even in the cases of short duration. That the diffuse infiltrating exudate was not necessarily related to a destructive process was borne out by the normal or only slightly changed appearance of nerve cells in its midst; however, when the exudate was excessive, marked nerve cell changes, including neuronophagia, resulted. Hemorrhages were few in num- ber and verv small. Blood vessel changes were of two types. There was almost constant evidence of proliferation of the intima in vessels in areas of exudation, those in unaffected territory usually showing no abnormality. The second type of lesion noted was infiltration of the vessel walls (especially intra- adventitial), with mononuclear cells, chiefly lymphocytes and plasma cells. The cord and organs in cases examined appeared essentially normal. Lesions in the cerebral cortex were in all cases either nonexistent or negligible. No organisms were seen and cultures from the cerebrospinal fluid and from the nervous system post mortem were negative. EXPERIMENTAL MENINGITIS Ono of the chief problems presented for investigation in the Army neuro- surgical laboratory was that of meningitis. In general it was not proposed to deal with the meningococcic infections but rather to ascertain whether the pyogenic, nonmeningococci forms of meningitis could be treated successfully Sf)4 SURGERY by measures other than serum therapy. The first need in such an investiga- tion was that of standardization of the infection; i. e., the experimental produc- tion of a uniformly fatal meningitis. It was hoped that an organism capable of bringing about meningeal infections in the laboratory animals in numbers analogous to those causing infection in man could be found. Previous work on meningitis in animals had, almost without exception, dealt with the sub- arachnoid injection of very large doses of organisms (one-half to four agar slants). The infections under such circumstances were hardly uniform, even in the monkey. The search in this laboratory for an organism highly virulent within the meninges of experimental animals wras successful. The investigation necessi- tated the testing of many strains of bacteria within the meninges and the later accentuation of the pathogenicity of those which possessed " natural virulence." Later the major portion of the work became centered about the study of the factors which favored the invasion of the meninges from the blood stream; the production of such hematogenous meningitides was investigated from many angles. The results of the subarachnoid injection of the various organisms will be detailed first and the study of infections of the meninges by organisms circulating within the blood stream will be given later. MENINGITIS PRODUCED BY SUBARACHNOID INOCULATION12 Practically all of the experiments dealing with the direct subarachnoid injection of organisms were done on cats, the inoculations being made into the meninges through the occipitoatlantoid and lumbosacral ligaments. Organ- isms, possessing no natural virulence within the meninges of the cat, were discarded after a few- trials. If the organism seemed to possess some patho- genicity, but too large a number, on initial injection, was required to produce a fatal meningitis, the virulence was raised by passage through the meninges of a series of animals. The reaction caused by the growth of an organism in the meninges was determined by the clinical manifestations of the animal, characteristic changes in the cerebrospinal fluid, and the pathological lesions of the central nervous system at necropsy. Although the clinical manifestations varied somewhat, the more acute cases were characterized by general weakness, convulsions, extensor rigidities of the muscles, accompanied by frequent spontaneous out- cries. These signs of cortical irritation appeared in paroxysms, so that, were the animal observed during a quiescent period, little could be noted unless the reactions were elicited by appropriate stimuli. Chronic meningitis exhibited signs of neuromuscular disturbance^-ataxia, variations in gait (spasticity), weakness and paralysis of certain muscle groups—which were probably the result of permanent destructive lesions in the central nervous system. The microorganisms which generally cause a fatal meningitis in man (meningococcus, pneumococcus, streptococcus, staphylococcus, influenza, etc.) were found to possess but slight natural pathogenicity for the meninges of a cat, This animal also proved to be comparatively insusceptible to these organisms on intravenous inoculation, especially if they were of human origin. Another group of organisms (miscellaneous bacilli) was found to be capable XEUROSURGERY 855 of the production of a fatal meningitis upon the injection of massive doses into the subarachnoid space, but their virulence could not be raised markedly. A third group of organisms was found to possess great virulence within the meninges of the laboratory animals used. Of this group (B. pi/oci/aueus, B. coll, B. paratyphosus-B., and the mucosus capsulatus group) a strain of B. lactis aerogenes possessed the greatest natural virulence for the meninges. The chief disadvantages of this organism were related to its extreme virulence, the difficulty experienced in producing an immune serum, and its relative infrequency as a meningeal invader in man; these characteristics made it dif- ficult of use in the investigation of certain other phases of the study of experi- mental meningitis, although for the purpose of this laboratory it was invalu- able. This strain of B. lactis aerogenes was virulent within the meninges of all the common laboratory mammals; in cats, the subarachnoid injection of as few as 20 organisms (as determined by plating) produced a meningitis causing death within 24 hours. The organism was originally obtained at autopsy from the heart's blood and lungs of a man dying of bronchopneumonia. The routine culturing at necropsy of the heart's blood of animals dying of experimental meningitis revealed certain interesting facts in regard to the transfer of infection between the meninges and the blood stream. In all cases of meningitis caused by the injection of organisms into the subarachnoid space, cultures of heart's blood showed the presence of the same bacteria with w-hich the animal had been inoculated intraspinously. THE PATHOLOGY OF EXPERIMENTAL MENINGITIS" The study of the meningeal reaction produced by subarachnoid inocula- tion of a large number of organisms, was made largely upon formalin-hardened material. The meningitis resulting from such subarachnoid inoculation could be grouped into three pathological types. The first, a focal subacute menin- gitis, showed small accumulations of exudate in isolated foci, especially in the deeper layers of the pia. Organisms were usually absent from the meninges and the blood, both culturally and on microscopic examination. The second, an acute, low-grade, exudative meningitis, was characterized by a scanty or a considerable exudate, of polymorphonuclear or lymphocytic cells. Organisms, if present, were but few in number and were considered to possess only mild subarachnoid virulence. The third group consisted of those cases of massive acute meningitis, in wliich there w-as evidence of extreme virulence and prolifera- tion of the organism. In this type alone was death considered to be due pri- marily to the meningitis. In the cases of acute fulminating meningitis the exudate soon passed beyond the subarachnoid space into the ventricles, and a little more tardily invaded the substance of the brain and spinal cord. In 24 hours approximately one-half of the specimens showed such involvement of the central nervous system; this invasion usually occurred by direct extension from the ventricles and canal. The exudate also spread outward with the nerve roots, and a patchy or diffuse epidural infection then resulted. The dura itself became infiltrated at areas of root "perforation." The blood stream was early infected in such acute 856 SURGERY meningitis, as seen on section and on culture, and it is likely that this septicemia played an important role in the death of the animal. In the less acute forms of meningitis, the arachnoid membrane more or less effectively limited the spread of infection from without and from within. FORMATION OF MACROPHAGES BY THE CELLS LINING THE SUBARACHNOID CAVITY " In the course of the study of the processes involved in the localization of an infection w-ithin a focus in the nervous system, certain physiological reac- tions of the cells lining the subarachnoid space were noted. When active or inert particles of matter were injected into the subarachnoid cavity of a living animal, the cells lining the space hypertrophied, lost their normal attachments, and engaged in removing the debris. The importance of such a formation of free cells from fixed elements in any process involving destruction and repair in the meninges (infection, hemorrhage, etc.), seemed great. The reaction of the cellular membrane to such particulate matter was a slow one and appeared to be well under way only after the first 24 hours; dead bacteria might be taken up and removed by the leucocytes before the arachnoid cells showed any signs of activity. The most striking results occurred after subarachnoid injec- tion of laked blood, due probably to the fact that it had no toxic effect on the cells and could be utilized by them. This reaction of the cells lining the subarachnoid space apparently plays a part in the defensive process against infection. Many of the earliest cases of meningitis (six hours) showed a marked proliferation of these cells; the exudate frequently was largely mononuclear. In other cases roughly half of the cells were mononuclear while the remainder were polymorphonuclear. On section, the cell borders of the arachnoidea (particularly the trabecule) seemed to be high and proliferating; the origin of at least a considerable portion of the mononuclear elements in the exudate seemed certain. The proper control of such a defensive cellular reaction will ultimately accomplish much in the therapy of infectious processes. THE CEREBROSPINAL FLUID IN MENINGITIS" In meningeal infections there is always a cellular and protein exudate in the cerebrospinal fluid. With different bacteria and etiological factors, such pathological conditions within the meninges cause also variations in the con- centrations of glucose, of sodium chloride, and of urea, and perhaps other changes both in organic and inorganic constituents. The increased cellular and protein constituents of the cerebrospinal fluid must, however, be considered as giving greatest indication of a reaction caused by the injection of a know-n micro- organism into the subarachnoid space. The number of cellular elements in the normal cerebrospinal fluid of the experimental animals was found to be rather variable; in a series of routine examinations the counts of the white cells ranged from 0 to 10 per c mm No erythrocytes were demonstrated in the cerebrospinal fluid from normal cats in a large number of examinations. The protein content varied from 0 l'to 0.5 grams per liter, 0.25 grams being a low normal and 0.5 grams a hi^h border XEUROSURGERY 857 ing on a pathological fluid. The colloidal gold reaction of a number of normal fluids gave a similar curve to that obtained by normal fluids from man. In acute meningitis the cerebrospinal fluid of the cat was found to contain from 200 to 22,400 white blood cells, 2 to 17 grams of protein to a liter, and to give a reaction in any of the three zones in the gold sol test. The cerebrospinal fluid of chronic meningitis in a cat proved to be practically normal, with exception of the gold sol reaction, in which a change to the paretic or luetic zones was recorded. In some of the chronic cases there w-as a slight increase in the number of white blood corpuscles and in the content of protein. The colloidal gold reaction was of service in demonstrating a pathological cerebrospinal fluid but showed no specific zone reaction, except to a slight extent in the cerebro- spinal fluids from animals with chronic meningitis. There was indeed a great similarity in the Lange test as applied to the cerebrospinal fluids from cases of experimental chronic meningitis and those of general paresis in human pa- tients. It w-as suggested that reaction in the paretic or even the luetic zone denotes the presence of a small amount of protein, as in a chronic lesion of the central nervous system. INTRAMENINGEAL VIRULENCE OF MICROORGANISMS1" In determining the natural virulence of 102 strains of 24 groups of micro- organisms, it was found that certain bacteria or groups of bacteria were more capable than others of producing a fatal infection when injected directly into the meningeal spaces. The term "natural" virulence has been used to denote the pathogenicity of recently isolated strains of microorganisms, before increase in virulence by animal passage. It was found necessary to enhance the natural intrameningeal virulence of strains of B. mucosus capsulatus, hemolytic strep- tococcus, meningococcus and B. paratyphosus, as after being kept for some time on the ordinary laboratory media their virulence so far decreased as to render them of little value for experimental work. Failure to increase the intramen- ingeal virulence (though the intravenous pathogenicity was raised considerably) bv successive intravenous injections of the culture in cats caused the trial of " animal passage" by means of inoculation directly into the meninges. It was found possible by this method of direct subarachnoid inoculation to increase the virulence of four strains of microorganisms, representing as many groups, to the degree indicated: B. lactis aerogenes, 0.000,000,000,01 c. c. of a 24-hour broth culture killing in 24 hours (cats); B. paratyphosus-B., 0.0001 c. c. (cats).; hemolytic streptococcus (cats), 0.001 c. c., and (rabbits), 0.0005 c. c; menin- gococcus (rabbits), 0.001 c. c. By such passage, the intravenous virulence was hardlv increased; the intrameningeal and intraperitoneal virulence increased to the same degree. By combined intraperitoneal and intrameningeal methods, approximately the same degree of pathogenicity was developed with strepto- coccus in rabbits. The intrameningeal virulence became at least 500 times "■roator than the intravenous. The ratio of the intrameningeal and intravenous pathogenicity of B. lactis aerogenes. of B. paratyphosus-B., of streptococcus on cats and on rabbits, and of meningococcus became, respectively, 10,000,000 to 1; 10 000 to 1; 1,000 to 1; 500 to 1, when the intrameningeal method of animal passage was employed. 858 SURGERY HEMATOGENOUS MENINGITIS" The marked virulence of the B. lactis aerogenes within the meninges of the eat led to its use in other laboratory mammals. For all of these (guinea pig, white rat, rabbit, monkey) the same intraspinal pathogenicity held. Later, experiments leading to another end were undertaken. These concerned the intravenous injection of this organism in doses of from 0.5 to 1 c. c. of a 24-hour broth culture. None of these cats developed meningitis, but remained normal throughout the period of observation. In one case, shortly after such experi- mental injection into the blood stream, cerebrospinal fluid was removed by puncture. The next day the animal showed signs of meningeal irritation, and a second puncture, with withdrawal of cerebrospinal fluid, was made. This fluid was definitely turbid, contained 5,800 white blood cells, and yielded a positive culture of B. lactis aerogenes. In the film preparation from this fluid many bacilli were present. The animal died in 28 hours, and at necropsy a typical exudative meningitis was found. Experiments on cats w-ere immediately devised to test out the possible relationship of this withdrawal of cerebrospinal fluid during an artificial bac- teremia to the later production of a meningitis.18 The series were so arranged that the control animals were given double the intravenous dose of B. lactis aerogenes (usually 0.5 c. c. of a 24-hour meat infusion broth culture). These control cats remained normal and showed no signs of meningeal infection, and were usually killed at the end of a month for histologic control. The other cats in the series were given the unit dose of organisms intravenously (usually 0.25 c. c. of the same culture), and two minutes afterward, cerebrospinal fluid was withdrawn. In the routine experiment, from 1 to 2 c. c. of fluid was per- mitted to escape, and the animal then allowed to recover from the anesthetic. As contrasted the next day with the control cat, wdiich, though receiving double the intravenous dose, was normal and active, the punctured cat would exhibit signs of meningeal infection. Customarily within 24 hours, the typical signs of such meningeal involvement were present; the animal was somewhat hyper- sensitive, ill, and cautious, and moved only on urgent necessity. The tendency toward convulsions became more outspoken as time elapsed, and spontaneous seizures were noted. During such a spasm death often occurred, or the animal went into a coma and died without further signs of meningeal irritation. Path- ologically, an acute exudative leptomeningitis was invariably found. The experimental procedure outlined above was repeated in scores of animals; the production of meningitis by intravenous inoculation followed by release of cerebrospinal fluid was so certain and so regular that it became the chief method for the experimental production of the infection. The work w-as controlled in many ways, in addition to the routine method of giving one animal in the series an intravenous injection of double the amount of the culture but without puncture. The release of cerebrospinal fluid w-as brought about by either lumbar or occipitoatlantoid puncture. Approximately the same amount of fluid was withdrawn by either method; the end result was identical. Release of fluid by both procedures, with proper dosage of the organism within the blood stream, resulted invariably in infection of the meninges. NEUROSURGERY 859 That this phenomenon of an acute meningitis following intravenous inoculation with release of cerebrospinal fluid was not peculiar to cats was demonstrated by a series of experiments on rabbits, guinea pigs, whi^e rats, and monkeys. In each of these species, the control was given the same or double the intravenous dose as the animal from which the cerebrospinal fluid was removed at the height of the artificial bacteremia. In every case, the control remained well and normal until killed, while the animals from w-hich spinal fluid was removed promptly developed a typical meningitis with death in 96 hours or less. In the two monkeys at our disposal, the same procedure was carried out; the control (receiving only the intravenous injection) re- mained normal for seven months, while the monkey receiving the intravenous injection, followed by release of cerebrospinal fluid, died in 54 hours with typical signs of meningitis. The two monkeys were subjected to cistern puncture 48 hours after the initial injection; in the control, the cerebrospinal fluid contained no white cells and the culture was negative, while the fluid of the other had 14,000 white blood cells and gave a positive culture. The time relations between the withdrawal of cerebrospinal fluid and the intravenous injection of organisms were found to be of importance. In no case did meningitis develop when the cerebrospinal fluid was released 30 or more minutes before the intravenous inoculation. If the puncture were done, however, only a few minutes before the inoculation into the blood stream, infection of the meninges occurred as in other observations in which routine withdrawal of fluid was accomplished immediately after the intravenous injections of organisms. During the height of a suitable artificial bacteremia, the release of spinal fluid invariably caused a meningitis. In one series of experiments, the punctures were delayed for various periods after the intravenous injection. Animals from which cerebrospinal fluid was removed within three hours after the intravenous injection developed meningitis. But also animals receiving somewhat larger intravenous doses could not be punctured five hours afterwards without devel- oping infection of the meninges. Hence a striking time relation between the degree of the artificial bacteremia and the withdrawal of cerebrospinal fluid seemed established. It must be assumed that following the intravenous injec- tions of B. lactis aerogenes the number of bacteria in the circulating blood was constantly diminishing so that in practically all cases of simple intravenous injection the blood was sterile in 24 hours. Consequently delay in removing cerebrospinal fluid became comparable to the initial administration of a smaller intravenous dose of organisms. Apparently the number of organisms circulat- ing in the blood stream at the time of puncture is one of the crucial factors in determining the infection of the meninges. Other observations were made to determine how- soon the infection of the meninges occurred after the release of cerebrospinal fluid during the height of the bacteremia with B. lactis aerogenes. In these typical experiments the animals were killed in one hour, two hours, four hours, and six hours after the injection and puncture. The membranes of the central nervous system were then examined in the fresh by means of smears taken from the subarachnoid space, and the findings later controlled by histologic sections. In the one-hour 860 SURGERY case, after repeated search one or two large bacilli, morphologically identical with B. lactis aerogenes, were found in the cerebral leptomeninges but not else- where within the meninges. The two-hour specimen yielded bacteria only in the cranial portion of the pia-arachnoid, but in considerable numbers. Prac- tically no cellular exudate was found. Many polymorphonuclear and mono- nuclear cells were present in the four and six hour animals; the infection seemed to be largely within the cerebral meninges, but apparently to a lesser degree the spinal portion of the subarachnoid space was involved. These findings indicated that the infection of the meninges occurred almost immediately after the release of cerebrospinal fluid during the bacteremia. Pathologically, the meningitis produced by this means was comparable to infection of the meninges in man. In a great majority of cases (particularly those under 4S hours' duration) the gross distribution of the exudate was almost entirely cerebral; but in a small percentage of the early cases, the exudate was wholly confined to the spinal meninges. In the more prolonged infections, the involvement of the subarachnoid space was customarily universal. Micro- scopically the exudate consisted of polymorphonuclear leucocytes, large mono- nuclear cells, a few phagocytes, and the infecting organisms. It was essential to determine whether the meningitis produced by intra- venous inoculation and release of cerebrospinal fluid was the result of infection due to a possible leakage of blood along the track of the needle into the sub- arachnoid space. The evidence was strongly in favor of the idea that the determining factor in the infection was the reduction of the pressure of the cerebrospinal fluid, with associated vascular changes. With such results following the intravenous injection of B. Lactis aerogenes with release of cerebrospinal fluid, experiments were undertaken to ascertain if the same procedure, but with other organisms, would produce meningitis. The difficulty here was that with the ordinary cultures in a laboratory, the intravenous toxicity was high in comparison to the intraspinal. However, it was possible to repeat these experiments and confirm the finding on the cat with two other organisms, B. pyocyaueiis and B. paratyphosus-B. On rabbits a similar result has been obtained with strains of meningococci and of strepto- cocci, procured from an Army camp. The facilitation of infection of the meninges from the blood stream by the release of cerebrospinal fluid seemed established as a biological factor by the production, in this laboratory, of a typical meningitis with five different organ- isms. The conditions for the successful production of such an experimental meningitis concerned two factors, both apparently of determining importance. In the first place, it was demonstrated that the organism used must possess relatively great virulence within the meninges and be capable of multiplication there, even w-hen in small numbers. The strain of B. lactis aerogenes best fulfilled this requirement when introduced into the subarachnoid space of the common laboratory mammals; its virulence in these animals was comparable to that of organisms causing meningitis in man. The other important con- dition dealt with the number of organisms circulating in the blood stream at the time of release of the cerebrospinal fluid; if this was not great enough, no infection took place. XEUROSURGERY 861 It must not be assumed from the statements made that a meningitis could not be produced by B. lactis aerogenes after simple intravenous injection. Such a meningitis was caused by the introduction within the blood stream of massive doses of the organism. The amount necessary to produce such a meningitis was many times the customary intravenous injection; such animals were killed usually by the septicemia and not by the meningitis. Many of these animals died from the overwhelming intravenous injection without development, as shown by later necropsy, of any meningeal infection at all. Practically all of the data indicated that the infection of the meninges by organisms circulating in the blood stream, following removal of cerebrospinal fluid, was due to alteration in the pressure of the cerebrospinal fluid and the associated vascular changes within the cranium. It was assumed that the withdrawal of the spinal fluid was partially compensated by an immediate vascular dilatation, particularly on the venous side. This vascular readjust- ment really involved a slowing of the blood flow through the cerebral vessels; it was thought possible that this slowing of the flow might facilitate ingrowth of organisms from the blood stream into the meninges. Experiments to test this hypothesis were carried out.19 In the first group, the retardation of cerebral blood flow was brought about by digital compres- sion of the jugular veins and adjacent tissues of the neck for two minutes; in the second series, the heart was completely stopped for 30 seconds by ex- cessive administration of ether. Both series were subjected to the necessary controls; every animal was given a suitable intravenous injection of organisms before the secondary facilitating procedure was carried out. In the two series, a fatal meningitis occurred in 50 per cent of the animals; the clinical manifestations of the disease were typical. These experiments seemed to indicate strongly that the infection of the meninges from the blood was closely associated with cerebral vascular changes. That only one-half of the animals developed a fatal meningitis could well be accounted for by the necessary variability of the experimental procedures employed. It did appear, however, that the removal of the cerebrospinal fluid was more certain than these other procedures as a facilitating factor. At this time, experiments dealing with the effect of intravenous injections of solutions of different concentrations upon the pressure of the cerebrospinal fluid were being conducted in this laboratory. It was found, as recorded in a foregoing paragraph, that the intravenous injection of a strongly hypertonic solution markedly lowered the pressure of the cerebrospinal fluid, often to negative values. Such intravenous injections were immediately combined with suitable intravenous injections of organisms, virulent within the meninges; a fatal meningitis invariably occurred as in the experiments in which the pressure of the cerebrospinal fluid was reduced by withdrawal of fluid. The relation of the low- pressure of the cerebrospinal fluid and its associated vascular changes was thereby demonstrated. Further observations were made to determine the effect of preliminary subarachnoid injections of protein (autologous, homologous, and heterologous) upon the intrameningeal lodgment of organisms circulating within the blood stream. Flexner and Amoss had earlier demonstrated that poliomyelitis S62 SURGERY could be experimentally produced by intravenous injection of the virus, pro- vided that the permeability of the meninges had previously been altered by intraspinous injection of serum, salt solution, etc. Subsequently Austrian applied this same procedure to experimental meningococcic meningitis in rabbits. Austrian recorded the production of a fatal meningitis in three out of twenty rabbits given intravenous injections of meningococci after preliminary intraspinous injections of serum. In this laboratory preliminary injections of serum into the subarachnoid space were given and later suitable intravenous injection of B. lactis aerogenes was made. In 6 out of 39 cats, a typical fatal meningitis was produced; the other animals remained normal in every way. As a facilitating mechanism the preliminary subarachnoid injection of serum has been found to be by no means as effective as the reduction in the pressure of the cerebrospinal fluid and the associated vascular changes. The interpretation of these many and varied experiments is necessarily related to the mechanism of facilitation of the infection of the meninges from the blood stream. The intravenous injection of suitable dosage of an organism virulent within the meninges did not of itself produce meningitis; such an injection had to be combined with an experimental procedure which facilitated invasion of the subarachnoid space by bacteria. Of these various procedures, withdrawal of cerebrospinal fluid by puncture or reduction of its pressure by intravenous injection of strongly hypertonic solutions w-as most efficacious. Measures slowing the intracranial blood flow- (cerebral venous congestion or stoppage of the heart) caused infection of the meninges in only half of the cases. Preliminary subarachnoid injections of serum resulted in infection of the meninges in but G out of 39 experiments. Pathology of Hematogenous Meningitis17 In this acute hematogenous meningitis, there occurred a more or less wide- spread distribution of purulent matter throughout the subarachnoid space, obliterating all characteristic markings and obscuring contours. With the discoloration due to pus and hemorrhage, there was associated a fairly constant swelling of the nervous system itself, rendering tense the dura of both brain and spinal cord. In a great majority of cases (particularly those under 48 hours' duration) the gross distribution of the exudate was almost entirely cerebral; but in a small percentage of the early cases, the exudate was wholly confined to the spinal meninges. Evidence favored the view that the cortical meninges were the site of earliest infection, with rapid spread to other portions of the subarachnoid space and to the cerebral ventricles. The invasion of the ventricles occurred early in all fatal cases. Infection of the ventricles and canal led to involvement of the substance of the brain and cord. The exudate which accompanied all the meningeal infections was polymorphonuclear or mononu- clear in character and its distribution followed closely that of the organisms. In the earlier cases, the exudate w-as often slight, but in those of longer duration it became massive, imparting to the entire meninges a discolored appearance. Extension outward from the subarachnoid space occurred in many cases and two methods of the accomplishment of this process have been observed. One was through apparent adhesions of arachnoid and dura with infiltration by XEUROSURGERY 863 leucocytes and sw-elling at this point. A more common site of extension was in the area where the dura is "pierced" by the nerve roots, the exudate fre- quently accompanied both the anterior and posterior roots outward for a short distance, invading the dura and sometimes passing through it to its external surface. With the strains of B. lactis aerogenes, meningococcus, and strepto- coccus employed, there w-as produced an acute hemorrhagic-purulent menin- gitis, in which the bacteria appeared to be rapidly increasing in number. With B. pyocyaneus and B. paratyphosus-B., a mild acute meningitis resulted, with very few organisms to be seen. Control animals receiving inoculations alone showed no pathological lesion of the central nervous system or merely a mild "febrile reaction," recognizable only microscopically. PRODUCTION OF PANOPHTHALMIA BY INFECTION FROM THE BLOOD STREAM.™ The microorganism, B. lactis aerogenes, which proved so extremely virulent in the central nervous system, exhibited a similar pathogenicity for the eye. The release of fluid from the anterior chamber of the eye, and the congestion of the cerebral circulation during an experimental bacteremia, resulted in the pro- duction of a purulent panophthalmia. It is interesting, however, that in the course of several hundred experiments on meningitis in which this bacterium w-as inoculated into the blood stream of cats, an ophthalmia was produced only once. When procedures analogous to the withdrawal of spinal fluid w-ere carried out on the eye, the infection was limited to the one organ operated upon, the opposite eye and the central nervous system being unaffected. The close cor- respondence between the anatomical and physiological processes in the eye and central nervous system was emphasized by this production of panophthalmia by intravenous inoculation followed by facilitating measures. LUMBAR PUNCTURE AS A FACTOR IN THE CAUSATION OF MENINGITIS21 A series of cases was observed in the base hospital at Camp Jackson by members of the staff of this laboratory for the purpose of determining the relationship, if any, of diagnostic lumbar puncture, in the presence of a septi- cemia, to the subsequent occurrence of meningitis. To this end, blood cultures were taken at the time of the lumbar puncture and the cases were followed sub- sequently with reference to the development of meningitis. In a number of cases in which a septicemia was present, the first diagnostic lumbar puncture yielded a clear and normal cerebrospinal fluid in which no organisms could be demonstrated; later fluids from these cases were turbid and contained the organism isolated from the blood culture. Two cases of pneumococcus septi- cemia developed a meningitis, subsequent to diagnostic lumbar punctures yield- ing normal fluids. In one of,meningococcic septicemia, a negative spinal fluid at the time when the blood culture was positive, was obtained; the presence of an early meningitis w-as observed at autopsy. The case suggested a possible relationship between the release of cerebrospinal fluid during the septicemia and the subsequent meningitis. Three other patients with meningococcic septicemia were observed; lumbar puncture in all three yielded initial negative 40007—27-----•">" S04 SURG 14. Y fluids. Within 4S hours two of the three had developed a definite meningitis. Interpreted from the standpoint of the experimental work in this laboratory, the relationship of the withdrawal of cerebrospinal fluid during a septicemia to the development of a meningitis was indicated. To prevent the possible accidental production of a meningitis as the result of diagnostic lumbar puncture, it was recommended that careful consideration be given the bacteriological study of the blood before such punctures were attempted; and that in acute diseases, in the absence of definite signs of irrita- tion of the central nervous system, lumbar puncture should be avoided unless it was first conclusively shown that the blood stream was free of infection. REFERENCES (1) AYeed, Lewis H., Capt., M. C: The Experimental Production of an Internal Hydro- cephalus. Carnegie Institution of Washington (Publication No. 272), 1920, 425. (2) Wcgeforth, P., Aver, J. B., and Essick, C. R.. Captains, M. C: The Method of Ob- taining Cerebrospinal Fluid by Puncture of the Cisterna Magna (Cistern Puncture). The American Journal of the Medical Sciences, Philadelphia, 1919, clvii, No. 6, 789. (3) Weed, L. H., Capt,, M. C, and McKibben, P. S., 1st Lieut., S. C: The Effect of Intra- venous Injections of Yarious Concentrations upon the Central Nervous System. The Anatomical Record, Philadelphia, 1919, xvi, No. 3, 167. (4) Weed, Lewis H., Capt., M. C, and McKibben, P. S., 1st Lieut., S. C: Pressure Changes in the Cerebrospinal Fluid following Intravenous Injection of Solutions of Yarious Concentrations. The American Journal of Physiology, Baltimore, Md., 1919, xlviii, No. 4, 512. (5) Weed, Lewis H., Capt,, M. C, and McKibben, P. S., 1st Lieut., S. C: Experimental Alteration of Brain Bulk. The American Journal of Physiology, Baltimore, Md., 1919, xlviii, No. 4, 531. (G) Essick, C. R., Capt., M. C: Pathology of Experimental Traumatic Abscess of the Brain. Archives of Xcurology and Psychiatry, Chicago, 1919, i, No. 6, 673. (7; Wegeforth, P., and Essick, C. R., Captains, M. C: The Effect of Subarachnoid Injec- tions of Antiseptics upon the Central Nervous System. The Journal of Pharma- cology and Experimental Therapeutics, Baltimore, Md., 1919, xiii, No. 4, 335. (S) Weed, L. H., and Wegeforth, P., Capts., M. C: Experimental Irrigation of the Sub- arachnoid Space. The Journal of Pharmacology and Experimental Therapeutics, Baltimore, Md., 1919, xiii, No. 4, 317. (9) Aver, J. B., Capt., M. C: Cerebrospinal Fluid in Experimental Compression of the Spinal Cord. Arcliives of Neurology and Psychiatry, Chicago, 1919, ii, No. 2. 158. (10) Wegeforth, P., Capt,, M. C: Note on Experimental Cranioplasty. Annals of Surgery, Philadelphia, 1919, lxix, No. 4, 3S4. (11) Wegeforth, P., and Aver, J. B., Capts., M. C: Encephalitis Lethargica. The Journal of the American Medical Association, Chicago, July 5, 1919, lxxiii, 5. (12) Felton, L. D., Contract Surgeon, and Wegeforth, P., Capt., M. C: The Production of Experimental Meningitis by Direct Inoculation into the Subarachnoid Space. Monographs Rockefeller Institute Medical Research, New York, 1920, No. 12, 5. (13) Aver, J. B., Capt., M. C: A Pathological Study of Experimental Meningitis from Subarachnoid Inosulation. Monographs Rockefeller Institute Medical Research, New York, 1920, No. 12, 26. (14) Essick, C. R., Capt., M. C: The Formation of Macrophages by the Cells Lining the Subarachnoid Cavity in Response to the Stimulus of Particulate Matter. Carnegie Institution of Washington (Publication No. 272), 1920, 377. U5) Felton, L. D., Contract Surgeon: Analyses of Cerebrospinal Fluid of Cats with Menin- geal [Infections. Johns Hopkins Hospital Bulletin, Baltimore, Md., 1919, xxx, XEUROSURGERY $()0 (16) Felton, L. D., Contract Surgeon: The Intrameningeal Yirulence of Microorganisms. Monographs Rockefeller Institute Medical Research, New York, 1920, No. 12, 45. (17) Weed, L. H., Wegeforth, P., Ayer, J. B., Capts., M. C. and Felton, L. D., Contract Surgeon: The Production of Meningitis by Release of Cerebrospinal Fluid during an Experimental Septicemia. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 3, 190. (IS) Weed, L. H., Wegeforth, P., Ayer, J. B., Capts.. M. C. and Felton, L. D., Contract Surgeon: The Influence of Certain Experimental Procedures upon the Production of Experimental Meningitis by Intravenous Inoculation. Monographs Rockefeller Institute Medical Research, New York, 1920, No. 12, 57. (19) Weed, L. H., Capt., M. C: Sur l'infection experimentale des meninges par des germes, contenus clans le sang circulant. Archives medicates beiges, Bruxelles, 1920, lxiii, No. 1, 1. 20) Ayer, J. B., Capt., M. C: Experimental Acute Hematogenous Meningitis—A Patho- logical Study. Monographs Rockefeller Institute Medical Research, New York, 1920, No. 12, 113. .21) Wegeforth, P., Capt., M. C: Experimental Production of Panophthalmia by Infection from the Blood Stream. Archives of Ophthalmology, New York, 1919, xlviii, No. 3, 276. 22) Wegeforth, P., Capt., M. C, and Latham, Jos. R., 1st Lieut,, M. C: Lumbar Puncture as a Factor in the Causation of Meningitis. American Journal of the Medical Sci- ences, Philadelphia, 1919, clviii, No. 2, is:.. CHAPTER VIII MOTOR DISTURBANCES IN PERIPHERAL NERVE LESIONS One of the functions of a peripheral nerve is the transmission of motor impulses. When a peripheral nerve is injured or severed its function is diminished or destroyed, thus resulting in a loss of motion. If the loss of motion is complete, it is defined as paralysis, if incomplete as paresis. The state of the function of motion is determined by an examination of a muscle at the moment of voluntary or willed movement, Inasmuch as many muscles are deep- seated and others seem to contract when synergistic muscles are shortened, it is impossible, in many instances, to determine paralysis by an examination of the muscle itself; consequently, the preservation of the function of muscles is largely deteimined by the examination of movement of segments about the joints. Loss of motion may be the result of conditions other than paralysis of a muscle or muscles. Among these causes may be included local shock, pain, swelling, fractures, dislocations, adhesions, or ankylosis of joints, contracture of opposing uninjured muscles, spasm, sclerosed fibrous tissue, as in ischemic paralysis, tendon and muscle section or loss, and hysteria. EXAMINATION OF MOTOR FUNCTION POSTURE Loss of function of any peripheral nerve produces a position and deformity which is characteristic, such as wrist-drop of musculospiral nerve paralysis, frequently associated with a "tumor of the wrist" due to the distention of the ligaments of the wrist, producing a protrusion of the proximal metacarpal bone. Other deformities include the talipes equinovarus or foot-drop of external popliteal nerve paralysis, the talipes equinus of sciatic nerve paralysis, the ape hand of ulnar and median nerve paralysis, the characteristic position of the thumb in a plane w-ith the palm, in median nerve paralysis, the sagging shoulder of a spinal accessory nerve paralysis, the winged scapula of aTong thoracic nerve paralysis. RANGE OF MOVEMENT The degree of motility of segments about a joint should be determined by examination of both active and passive motion. In examining for passive motility due consideration must be given to the pain elicited. The range of movement may be determined by a goniometer and measured in degrees of a circle, or by tracings obtained from molds made with a flexible lead tape, - The subject matter treated herein is general in nature; that is to say, much of it was known prior to the World w.r however, its inclusion is believed to be essential to a clear understanding of how nerve lesions were treated durine the period of the war.—Ed. ulumB ll,K S.66 NEUROSURGERY 867 first obtaining a tracing of the movements of the segment in one direction (flexion) then in the other direction (extension). It is important to note the position of segments of joints adjacent to the ones being examined, for example, in musculospiral paralysis with wrist-drop there may be some interphalangeal joint fibrosis. If the range of flexion of the fingers be obtained with the wrist ''dropped" it will be far less than with the wrist in a position between extension and flexion. Similarly in median and ulnar nerve paralysis the range of extension of the finger will be less w-ith the wrist extended than when the wrist is flexed. In popliteal nerve paralysis the dorsal flexion of the foot will be less w-ith the leg extended than when it is flexed. Fig. 80.—Lead tape and tracings ACTIVE MOTION Because of the many factors entering into the movement of segments about the joints, but particularly because of the frequency with which more than one muscle may produce similar movements about the segments of the joints, the necessity for great care in the analysis of all muscle movements is stressed. The segments about the joints in the body may normally be moved in certain directions to certain degrees, flexion, extension, abduction, adduction, rotation, circumduction, etc. The failure of such movements indicates a loss of function which with certain precautions may be attributed to the motor paralysis. 868 SORCERY Having eliminated such causes as pain, swelling, contracture, spasm. fibrosis, ankylosis of joint, fracture, etc., one begins to study the loss of function by observation of range of motility in various directions. Here certain pre- cautions are necessary. Each joint must be studied separately. The part of the extremity proximal to the joint tested should be passively immobilized; for example, in testing for extension of the wrist, the forearm should be immobilized. Just as in examining for passive motility so here the muscles moving the segment should be placed in a position which is neutral, so that their function can best be motivated. In a musculospiral paralysis, although the flexors of the fingers are uninjured, the degree and force of motility is diminished unless the hand is passively extended on the wrist. The influence of gravity must be properly evaluated and its forces nulli- fied by proper position. Paretic muscles may be capable of contraction and be too enfeebled to move a part or whole of any extremity against gravity. A deltoid muscle may be enfeebled to such a degree that abduction of the arm to a right angle is impossible when the patient is standing, but with the patient in a supine position, abduction of the arm may be possible. At times under this condition it is advisable further to facilitate movement and diminish the force of gravity by placing the paretic extremity on a board which has been powdered with talc In a musculospiral lesion, extension at the wrist may be impossible with the forearm unsupported and in a pronated position, yet feeble extension may be produced with the forearm in a position midway between pronation and supination and supported on a powdered board. Similarly flexion of the fore- arm may be impossible against gravity, but possible if the upper extremity is supported in a position of abduction at a right angle. Extension of a paretic quadriceps femoris may be impossible in an erect position with the thigh flexed and quite possible when the lower extremity is supported on its inner or outer surface while the patient lies on his side. Such precautions must be taken as wrell in examining the hamstrings, the dorsal and plantar flexors of the feet, in short, of all the muscles of the body. At times the force of gravity works in the opposite direction and, as will be pointed out under supplementary movements, it often produces a movement which is misinterpreted as muscle function. When the triceps is paralyzed, if the arm be abducted, the forearm flexed and then externally rotated, gravity may produce extension at the elbow. Similarly when the quadriceps femoris is paralyzed and the thighs passively flexed on the abdomen and the legs on the thigh while the patient is in a supine position, gravity may extend the leg. At times a muscle may be so enfeebled that it can not change the position of the segments about a joint but its contraction can be ascertained by palpa- tion. Frequently such examination leads to erroneous conclusions, as in ulnar nerve paralysis the tendon of the flexor carpi ulnaris may seem to contract when the wrist is flexed by the flexor carpi radialis and palmaris longus. Sometimes if the paretic segment be passively moved in the direction of the action of the paretic muscle the patient may actively increase this move- ment. For example, in an external popliteal nerve paresis, if the foot be NEUROSURGERY 869 passively dorsi-flexed to a degree, the patient may then be able to actively increase the degree of dorsi-flexion of the foot. Frequently, although the patient may not be able to produce a movement of a segment in a certain position, he may be able to retain this position when it is passively produced, as in a paresis of the extensors of the wrist, when the wrist is passively extended, he may for a brief interval hold it in that position. The degree of motor deficiency may be measured relatively by the ob- servation of the degree of capability of producing change in position of segment in (a) neutral position, (?>) against gravity, and 0) against interposed resist- ance. In estimating the amount of interposed resistance one may compute it in degrees of one's own strength or as compared with the uninjured corre- Fir,. 81.—Spring scales dynamometer sponding segment of the patient, In a paresis of the extensors of the wrist, one may compare the strength of the paretic to the normal side by resisting with one's own hands the extension at the wrist. The degree of motor defi- ciency may then be described as paralyzed, very weak, moderately weak, weak, or moderately strong, and so recorded. The necessity for accuracy in the examination of motor function can not be overemphasized. Careful measurements and precise records are necessary not only for the purpose of diagnosis and prognosis, but also for the determina- tion of the progress of a case. Accurate measurement of motor function is possible only bv a dynamometric examination. A simple and accurate method may be employed by the interposition of a sprino- scale between the examiner's hand and a segment to be examined. One S70 SURGKHV may employ several such scales, some measuring to 500 grams and others as high as oO pounds. To determine the strength of flexion of the distal phalanx of the thumb the hook of the scale is fastened to the distal phalanx and, hold- ing the scale in one hand, the remaining portion of the thumb is fixed or im- mobilized with the other hand. The patient is then requested to flex t he thumb and the degree of motor function is read in terms of grams or pounds. It is essential that influence of movement of adjacent segments be avoided by passive fixation. When dealing with more complicated movements, such as pronation, or supination, or rotation, a flat piece of wrood at one end of which a hole has been drilled may be employed. The hook of the scale is inserted into the hole and the patient grasps the flat piece of wood and, turning it either by pronation or Fie. 82.—Measuring pronation by spring scales supination, the results may be read upon the scale. At times it may be neces- sary to bind the hook of the scale or the piece of wood to a segment about the joint being examined. The results so obtained may be recorded opposite the name of muscles supposed to move the segment in the direction measured, or, and this is far more accurate, upon a diagrammatic representation of the segment For ex- ample, m examining the movements of the hand and fingers, each result is noted upon the palm or dorsal surface of the part of the hand recorded Sche- matic representation of abduction of the fingers, flexion of the proximal phalanges, adduction, opposition and short abduction of the thumb mav be denoted as in the following illustration (fig. S3). NEUROSURGERY 871 Fig s:-i -Ulnar nerve lesions: A, Anatomical section verified at operation, complete sensory loss; B, severe lesion not anatomical section, complete sensory loss; C, compression of ulnar nerve, verified at operation, partial sensory loss; D partial and recovering lesion not verified by operation, complete sensory loss; E, cases similar to D with some sensory regeneration. Only four cases showed sensory regeneration in the absence of motor recovery S72 Sl'ltGKRV In lesions of the ulnar and median nerve this type of examination and recording has led to the observation of many phenomena of great diagnostic and prognostic value which have not heretofore been described. These are dealt with under injuries of the several nerves. SUPPLEMENTARY MUSCLE MOVEMENT Supplementary muscle movement, supplementary motility, or supple- mentary motion or trick movement, is frequently responsible for misinterpre- tations in the examination of cases of peripheral nerve lesions. The preservation of certain movements, the loss of which is supposed to follow- particular nerve lesions, has been observed for many years. Sherren ' called attention to the fact that Swan,2 in 1S24, w-as astonished at how much a rabbit could move its leg after experimental section of the sciatic nerve. Later Letievant ;i studied this phenomenon and termed it supplementary mo- tility. Since that time numerous investigators have observed its presence in peripheral nerve lesions, notably Duchenne ' and Bcevor,5 to whom may he credited much of the present knowledge of these movements. Head and Sherren,6 (Maude,7 and Athanassio-Benisty 8 are among the recent observers who noted its presence. American workers, Coleman,9 Woods,10 and Pollock,11 among others, have been particularly interested in those movements and have contributed considerable information as to their occurrence. These movements may be caused by a number of factors, among which may be included the anastomotic supply of muscles from adjacent nerves, and one must recall the not uncommon existence of an atypical nerve supply—total supply of the flexor brevis pollicis by the ulnar nerve, and the supply of the first dorsal interosseous by the median. Supplementary muscle movements may likewise be produced by muscles other than for primary movements— the flexion of the wrist w-hich is produced by contraction of the abductor longus pollicis and the extensor ossis metacarpi pollicis; by movement occurring as the result of mechanical factors producing a change of direction of leverage by the shortening and lengthening of tendons and muscles passing over several joints—in a lesion of the musculospiral nerve with paralysis of the extensors of the wrist, when the wrist-drop does not exceed an angle of 120°, complete flexion of the fingers produces extension at the wrist; by slight movement resulting from the recoil of elastic tissue following a movement in a direction opposite to the one desired—in median nerve paralysis flexion of the distal phalanx of the thumb may be imitated by the recoil occurring following strong extension of the distal phalanx of the thumb; by utilizing the force of gravity— in paralysis of the median nerve pronation may be produced first by stretch- ing the long wrist and finger extensors and then the forearm resting on the knee the remaining portion of pronation is produced by allowing the force of gravity to carry the forearm through the subsequent action. RECOVERY OF VOLUNTARY MOTILITY The order in which movement is restored to muscles paralyzed as the result of peripheral nerve lesions has a sufficient constancy to attribute to each nerve a clinical individuality.12 Generally speaking, with severe lesions of XEUROSURGERY 873 the nerve, a certain degree of muscular tonicity returns before any reappear- ance of voluntary motion. At first, voluntary movements are awkward and uncertain and frequently the reaction time of a movement is considerably lengthened. One must bear in mind what has been called by Andre-Thomas ™ "an error in the switching" of the motor fibers which have not taken the proper direction and have not encountered each time the sheaths intended for their reception, as when a patient suffering from an injury to the musculospiral nerve wishes to extend his wrist the supinator longus contracts powerfully and often in excess of the radial muscle. At times it has been noted that preceding the ability to produce voluntary motion the patient experiences a feeling of being able to produce such motion when he w-ills it. Thus, in a musculospiral lesion before recovery has taken place, the patient may not have been able to sense the feeling of extension, whereas when recovery is taking place he begins to feel the sense of extending the wrist, although such extension may not be produced. FURTHER CONSIDERATION OF CERTAIN FACTORS PRODUCING DEFECT IN MOTION Some of the factors producing defect in motion deserve additional description. SHOCK Loss of motion following injuries of war may occur as the result of local shock and not as a result of direct injury to the peripheral nerve. Immedi- ately following the reception of a gunshot w-ound there may be a complete paralysis of an extremity. This paralysis more or less rapidly disappears and if a peripheral nerve is injured, may leave paralysis of the muscle supplied by that nerve. Return of motor function occurs in from a few hours to a number of days, depending upon the amount of shock and the degree of injurv of the soft parts and blood vessels. This loss of motion is far more common in injuries which are the result of shrapnel and high-explosive shells than of bullets. It is a constant accompaniment of wounds associated with fractures of long bones. It is not necessarily an accompaniment of loss of consciousness or surgical shock. This loss of motion rarely is accompanied by loss of sensation and it is notable that, oven when a nerve is injured by local concussion or at times by contusion, frequently motor function is lost whereas sensation is preserved. S. Weir Mitchell u observed this during the Civil War. JOINT HANCES S. Weir Mitchell called attention likewise to the common affection of joints in lesions of the peripheral nerves and, as in the Civil War so in the World War these changes produced immobility at times of greater importance than paralysis of muscles themselves. These joint changes may be of a number of varieties and their causes not easily determined. Of the known causes one may enumerate fractures in the joints, dislocations, suppuration of joints, prolonged suppuration of nearby parts, prolonged immobilization, ischemic 874 SURGERY contractures resulting in retraction of muscle tendons, and certain nervous lesions the character of which is unknown. Although it is supposed generally that prolonged immobilization is the pri- mary cause of most of the joint changes there are many cases in which this is not so. Occasionally one may see an early arthritic involvement consisting of a painful swelling of the joint, which differs from the early inflammatory swelling of the wound itself. This may last for weeks, and be followed Im- partial ankylosis. At other times a gradual retraction of muscular tendons and hardening of a joint capsule occurs, sometimes associated with prolonged and particularly improper immobilization, at times associated with prolonged suppuration. Very frequently one sees changes in painful and partial nerve lesions, characteristically present in painful lesions of the internal popliteal and median nerves, perhaps as a part of the picture of causalgia. These partial and painful lesions must consist of more than only a direct injury of part of a nerve because there is no more reason why an injury to a part of a nerve should be follow-ed by joint changes or ankylosis than an injury of a whole nerve where, in the absence of a suppurative lesion, no immobilization or joint changes may be present. They are probably associated with a definite low-grade infec- tion w-hich follows the lymphatics of the nerve to the joint. Injuries of certain nerves produce changes in certain joints peculiar to themselves. For example, injuries to the musculospiral nerves in the middle of the arm arc associated with ankylosis of the elbow. When this ankylosis occurs early it is associated with a spasm of the biceps, when late it is the result of prolonged suppuration or fracture of the humerus. In painful lesions of the median nerve the joint changes are notable, widespread, and of severe character; the interphalangeal and metacarpophalangeal joints of all the fingers are affected. At times a partial ankylosis of the metacarpophalangeal joints of the thumb occurs wherein only abduction and adduction are possible, and as a result attempts at extension produce abduction at right angles to the plane of the palm. The wrrist joint and at times the elbow- joint may be involved. What is true of the painful partial lesions of the median nerve is likewise true of the ulnar to a far lesser degree. The interphalangeal joints of the foot may be involved in a partial painful lesion of the internal popliteal and limitation of abduction of the foot is often seen in external popliteal lesions. Shortening of opposing muscles is not so frequently observed since the necessity of proper splinting has been recognized. Occasionally it occurs and offers retardation to recovery of function. Such shortening is seen commonly when deformities occur as the consequence of the force of gravity in addition to overaction of unopposed muscles, as in musculospiral paralysis affecting the flexors of the wrist, in paralysis of the external popliteal affecting the tendo Achillis, and to a lesser degree in circumflex nerve paralysis, affecting the pectoral muscles. Such shortening may occur even w-hen gravity does not contribute to the deformity, as in overaction of the extensor communis digi- torum in ulnar nerve paralysis, shortening of the abductor pollicis and the extensor ossis metacarpi pollicis in median nerve paralysis, of the lumbricales in radial nerve paralysis, of the extensor communis digitorum in internal popliteal nerve paralysis, of the tibialis posticus in external popliteal nerve paralysis. NEUROSURGERY 875 MUSCLE SHORTENING RESULTING FROM SPASM Muscle shortening may at times result from a different cause, namely, spasm. This condition is usually observed in partial lesions of the peripheral nerves; m muscles the nerve supply of which may not have been primarily mjured. These partial lesions are the result of some irritative agent acting, perhaps, reflexly. Often they are associated with some vascular lesion. At times they occur as an accompaniment of a painful lesion of an adjacent joint or bursa—in arthritis of the shoulder, or in subacromial bursitis, a spasm of the pectoralis major frequently is observed. Such spasms are to be clearly differentiated from the so-called physiopathic reflex nervous disturbances which occur w-ithout any lesion of a peripheral nerve and from lesions at a dis- tance from the site of loss of function. Similarly, they must be differentiated from the fibrous shortening of ischemic or Volkmann's paralysis. ISCHEMIC PARALYSIS In addition to the compression produced by bony callus, that which is produced by sclerosing fibrous tissue must be considered. In such cases there may be no symptoms suggestive of nerve injury immediately following the trauma, but a few weeks later particularly after the removal of a dressing such as a splint or a plaster-of-Paris cast, symptoms of compression manifesting themselves by partial or complete paralysis will be found. In this group the largest number of cases consists of those due to the formation of sclerosing fibrous tissue. This sclerosing results from the organization of diffused blood or of the products of inflammation. The symptoms, particularly the motor symptoms, are frequently confusing in so far as the diagnosis of a possible peripheral nerve injury is concerned. Characteristically, however, such a lesion is never limited to the distribution of the muscular supply of any one or more peripheral nerves; all muscles in an extremity may be involved to a greater or lesser degree. The sensory changes are not definite and when they occur they too are not limited to the anatomical sensory distribution of the peripheral nerves or a combination of such nerves. The electrical reactions do not show the changes consistent with a pure peripheral-nerve lesion. One may find that certain parts of muscles supplied by an individual nerve may react to faradism whereas other parts do not. In general, it may be found that, commensurate with the degree of fibrosis, the muscles have a disappearance of both faradic and galvanic response. Inter- phalangeal fibrosis, with partial or complete ankylosis, is very common. Cold- ness of the extremity and the cyanosis are characteristic signs. TONE When a peripheral nerve is severed the spinal reflex is interrupted in the motor arc and loss of tone results. If one could measure loss of tone accu- rately and if the degree of hypotonicity were an accurate indication of the severity of peripheral nerve lesions, it would be important that this function be carefully examined. Unfortunately, loss of tone occurs in partial lesions as well as in complete lesions of peripheral nerves. It is measurable only in the 876 SURGERY early stages following a wound to a peripheral nerve, inasmuch as later it may he complicated by other factors such as swelling, fibrosis, and contracture, as the result of changes consequent to fracture, joint changes, suppuration, and vascular changes. Frequently, after the secondary changes have disappeared. a fibrosis or hardening results w-hich prevents an accurate determination of the tone of an extremity. The position of an extremity is not always an indication of the hypotonicity of the muscles, inasmuch as secondary shortening may pre- vent wrist-drop or foot-drop. Tone may be measured by some objective method, as the employment of a tonometer which may be rather simply made, as showm in Figure S4. Fig. M—Tonometer When measured in this manner it is found that soon after an injury of a peripheral nerve, in the absence of any changes, such as swelling and inflamma- tion, there is a marked hypotonia which may be measured in the amount of millimeters of mercury necessary to push the plunger a certain distance into a muscle mass. Whereas, in a normal muscle a pressure of 160 to ISO milli- meters of mercury may be required, in a paralyzed muscle a pressure of but 40 to 60 millimeters of mercury is sufficient to plunge the indicator 10 millimeters into the mass. Some time after injury this type of examination proved to be quite useless, because the subsequent atrophy frequently vitiated the result XEUHOSUR..KRY 87 of the examination. Although one may find frequent references to the return of tone a< an indication of the return of function of a muscle, it has been found that the secondary changes prevent the observation of the return of this function. When observed, of course, it is a valuable sign, and if in a given case of musculo- spiral paralysis with a certain degree of wrist-drop as the result of hypoton- icity the wrist is seen to assume an attitude in which it drops to a lesser degree, this may be accepted as a hopeful sign in the absence of secondary shortening. ATROPHY What has been said of tone is true also of atrophy. For some time it has been accepted that when a peripheral nerve is severed trophic disturbances occur in the muscles and these disturbances are follow-ed by atrophy of the affected mus- cles. It has been supposed that this atrophy is commen- surate with the degree of in- jury of the peripheral nerve. Although this is true, one is unable to measure the degree of atrophy so accurately as to make it a valuable sign in differentiating complete from incomplete lesions, and exten- sive atrophy of a paralyzed muscle may be interpreted, with a numberof reservations, as meaning a severe lesion. Ulnar nerve lesions, as a rule, show extensive atrophy vh ether they are severe or not. As a sign, atrophy is of service in denoting the sever- ity of a lesion only when seen soon after injury; the amount of atrophy observed some months after an injury is not commensurate with the severity of the lesion. Painful lesions of the median nerve and of the ulnar nerve are very frequently associated with rapid and marked atrophy. When observed some months after injury absence of demonstrable atrophy is not an indication of a reparable lesion. Frequently replacement of muscle mass by other tissues is responsible for the seeming lack of atrophy, and no method of examination permits us to determine how- much atrophy has been present. Inasmuch as peripheral nerve lesions are associated w-ith destruction of other tissues such as fracture and lacerations of muscles and soft parts w-ith blood vessel lesions, it is apparent that seeming atrophy of long muscles or muscle masses may frequently be the result of disuse and factors other than trophic changes in the nerve supplying that muscle. Fir,. 85.—Can with spout for measuring volume of extremity by water displacement S78 SURGERY If, for example, one measures the amount of water displaced by an atro- phied extremity as compared w-ith the amount displaced by the opposite normal one, some interesting facts are discovered (fig. So). As compared with the unaffected extremity, the affected one shows in an irrecoverable ulnar nerve lesion an atrophy of 4.5 per cent of the total mass: in recovering lesions 4.2 per cent; in radial nerve lesions there is an atrophy of 4.3 per cent in recover- ing lesions, 5 per cent irrecoverable ones. In lesions of the median nerve those recovering showed 11.2 per cent and irrecoverable 50 per cent atrophy; in sciatic nerve lesions recovering lesions showed 9.7 per cent and those irrecoverable 10 per cent; the external popliteal showed in the recovering lesions 6 per cent and in the irrecoverable 7.2 per cent. Although the percentage of loss of muscle mass was slightly greater in the severe irrecoverable lesions, the difference was not sufficient to be of diagnostic or prognostic value. In addition to this, some irrecoverable sciatic nerve lesions showed but 1 per cent loss when a recovering one showed a 17 per cent loss. In a recovering external popliteal nerve lesion 16 per cent loss was found and in an irrecoverable one only 1 per cent loss. This immediately indicates that the demonstration of atrophy is not an accurate guide to the severity of the lesion, and the absence of atrophy does not indicate a recoverable one. Although some of the discrepancies are probably due to the replacement of muscle fibers by other tissues, it would seem in some instances that those cases wherein exercise and massage, electrical stimulation, and passive movement of the extremity were given that the degree of atrophy seemed less. Though ulnar nerve lesions show predominantly the greatest degree of atrophy rapidly occurring, radial nerve lesions show the least atrophy. Graphic methods of recording signs and symptoms in many instances have a greater value than descriptive methods. Frequently it is impossible to have photographic records of the hands and feet in cases of peripheral nerve lesions; under this condition it is found serviceable to record the contour of the palm and sole by making impressions of the hand and foot. The degree of atrophy and resulting deformity of the hand and foot indicate clearly the type of peripheral-nerve lesions with which we are dealing. Not only is the position of the hand determined but the atrophy and the contracture of the muscles are showm as well. Only five of the peripheral nerves showed distinctive changes in a sufficiently large percentage to make it profitable to study lesions by this method. These nerves are the ulnar, median, radial, internal popliteal, and sciatic. The picture produced by a combined lesion of the ulnar and median is likewise distinctive. The imprint of the hand in the case of a lesion of the ulnar nerve shows the following characteristics: The clawing of the inner two fingers is w-ell demonstrated by the absence from the imprint of any part of these fingers except the tip. The hypothenar muscles are seen to be atrophied by the presence ot a notch on what normally consists of a rounded contour made by these muscles (fig. 86). Between the mounds of the ring and middle finger is seen another notch, and when the atrophy is very severe a notch appears between the ring and little fingers as well (fig. 86-c). The fingers can not be spread apart, and the first phalanx of the thumb is in a position of extension. The atrophy of the ad- ___k mk IF* 9 * \ .'#>: 5*. / % • v .-<£►? ^Vk_v^ "■ "r'* "'■ \ * V Mc. 86— Imprint in a case of ulnar nerve lesion: a, Affected; 6, affected; c, affected; d, normal; e, affected;/, affected. A, Notch indicating atrophy of hypothenar muscle; B, notch between the mounds of ring and middle finger indicating atrophy; C, break in line along the radial border of the base of the index finger indicating atrophy of the adductor pollicis 00 CO sso SURGERY ductor pollicis is seen by a break in the line along the radial border of the base of the index finger (fig. Slid). Median nerve lesions show very clearly the disturbance of whorl formation on the tips of the index and middle finger (fig. S7-a). When severe clawing is present in these two fingers, it is marked by the imprint of the very tip, frequently including the nail. The atrophy of the thenar eminence is usually well marked, and is showm by the prominence of the base of the thumb and a considerable notch in the normally rounded contour of the radial border of the thenar eminence (fig. 87-b). The distal phalanx of the thumb is in exten- sion. When severe clawing is present, it is made evident by the absence ot any imprint of the central portion of the palm. Xot only is the atrophy of the thenar eminence noted by the notches proximal to the base of the thumb, but also in many instances loss of tissue is demonstated along the radial border of the first phalanx of the thumb (fig. S7-b). Failure of desquamation and the presence of many new lines is demonstrated over the thenar eminence dig. S7-c). Radial nerve lesions are characterized by the cramped appearance of the finger which results from inability to place the palm flatly on the paper because of the flexed position. The most characteristic feature of this imprint is the position of the thumb, which is adducted, the distal phalanx falling within or on the border ot the outline of the index finger. The thumb is rotated about its axis inwardly so that the radial border of the distal phalanx is straight and not rounded. The distal phalanx of the thumb is usually flexed. Absence of the signs of atrophy in the thenar and hypothenar eminences is an additional feature of this form of lesion. In combined lesions of the ulnar and median nerve signs of atrophy of both the thenar and hypothenar eminences are demonstrable by these notches found along their borders (fig. SI)-a). Clawing is present in all four fingers: the mounds are often separated (fig. 89-b). The center of the palm shows a larger area in which no imprint is seen. When, in addition to partial lesions of the ulnar and median, the radial nerve is involved, the thumb shows at times the same rotation as was observed in the radial lesions. Frequently in lesions of the external popliteal nerve there is a flattening of the toes, so that the plantar surface oi the entire length of the toe will produce an imprint. Lesions of the sciatic nerve show, in addition, a slight pes cavus, and in some cases a clawing of the toes, indicated by the absence of their imprint on the paper. MUSCULOSPIRAL XERVE The position of the hand in musculospiral paralysis is characterized bv a very marked drop of the hand and fingers: the wrist and first phalanges are flexed; the thumb is abducted and falls within the line ot the outer border of the index finger (fig. 90). The best method of testing the function ot the triceps is to allow the patient's arm to hang over the back of a chair, the arm being horizontal, the forearm hanging loosely at right angles to it. The patient is asked to straighten his arm. The muscle may then be both inspected and palpated during the attempt, ('are must be exercised not to misinterpret that extension of the ! w I r* 0 ,\ *< t % A JB i '4 I'm .*** Fio. ST.—Imprint in case of median nerve lesion: n, Affected; b, affected; c, normal; (!, affected; e, normal; f, affected; g, normal. A, Disturbance of whorl formation at tips of index and middle fingers; H, prominence of base of thumb and notch in contour of radial bordei of thenar eminence indicating atrophy of thenar eminence; C, loss of tissue along radial border of first phalanx of thumb; I), failure of desquamation and presence of many new lines over thenar eminence <:k'» '■-._ #t - • ^ I . V D 0 m .7 |r> % 3 c ■?* ''"if.' V Fio. 88-Imprint in rase of radial nerve losioir A, Affected; Ii, affected; C, normal; D, normal; E, affected, paralyzed abductor pollicis F, normal; G, affected OO OO to ■_J* < i # ** 1 / D ** * ^ •r- X" i N ^0Z^1 ;.'if. * T. Fig. 89.—Imprint in combined lesions of ulnar and median nerves: a. Atrophy of thenar and hypothenare minences; 6, separation of mounds SS4 SUKCKRY forearm which occurs from a flexed position as the result of gravity controlled by the flexors. For this reason it is important to have the patient raise his elbow high enough so that it becomes impossible for him to extend the bended forearm by reason of the weight alone. Another way to test the paralysis oi the triceps is to extend the elbow;, then to ask the patient to resist any attempt to flex the forearm on the arm. Because the long head of the triceps receives its motor supply immediately after the nerve leaves the tendon of tlie teres major, complete loss .of extension of the forearm is infrequent in musculospiral paralysis. The supinator longus is brought into action when flexion of the forearm is attempted with the forearm seinipronated. With the extremity in this posi- tion the patient is asked to resist extension at the elbow, under which condi- tion an unparalyzed supinator longus will stand out prominently. Contrary to generally accepted statements that the biceps can not aid in supination Fig. 90.—Musculospiral palsy unless the elbow is partly flexed, at times the biceps supinates the forearm even when it is completely extended. Weakness of the extensors of the wrist is observed when the patient attempts to raise the hand against the action of gravity. In eliciting this sign care should be taken to keep the elbow and forearm of the patient motionless and resting on a table with the hand loosely suspended and pronated. When the extensors of the wrist are paralyzed no contraction is felt during the attempt at extension; on the contrary, there is energetic contraction of the flexors of the hands and fingers. Inversely, an attempt at flexion of the fingers does not produce a synergistic extension at the wrist, and it will be found that the patient can neither close his fist nor flex all the phalanges completely: the third phalanx will flex badly or not at all (fig. 91). To verify lateral movements at the wrist. the possibility of error arising from the movement of the elbow should be elimi- XKUP.OSU-.U1.I.Y S85 nated by resting the forearm on a table but the hand should be raised almost to the horizontal instead of being allowed to drop. A certain amount of abduc- tion is possible in paralysis of the extensor through the action of the flexor ulnaris. The abduction, lunvever, is incomplete and faulty, and is accompanied by ulnar deviation. In a lesion of the musculospiral nerve below- the elbow paralysis of the extensors of the fingers may occur without involvement of the extensors of the wrist. liider these conditions the patient can not extend the wrist if, at the same time, he attempts to extend the fingers, but if he flexes the fingers the extension of the wrist may then be accomplished. To explain this we must recall the laws governing the action of the muscles going over several joints. Beevor 3 states that ''when a muscle by passing over two or more joints has two or more different actions, then, if only one of these actions be required, Fig. 91.—Attempted flexion of fingers in musculospiral palsy other muscles are brought into the movement whose actions are antagonistic to those of the muscles not required." These synergic muscles place the prime movers (in this instance the extensors of the w-rist) in the greatest elon- gation so as to augment their dynamic power and fix the joint so that the move- ment mav be performed from a secure basis. Still another factor must be considered. Beevor 5 found that if the movement of extending the wrist be performed with the fingers actively and fully extended, the extensors of the finders have to do all the work themselves and against the contraction of flexors of the wrist until the amount of work is equivalent to 4 or 5 pounds before the extensors of the wrist will join in and help them. In the cited instance of paral- ysis of the extensors of the fingers with preservation of the extensors of the wrist, the extensors of the fingers can not possibly reach the amount of pull which is necessary before the extensors of the wrist can be made to contract. SN() SURGERY SCPPI.EMENTAHY MOTILITY In a lesion of the musculospiral nerve, with paralysis of the extensors of the wrist, dorsal flexion of the hand may be produced by the action of muscles not innervated by this nerve, as in the energetic contraction of the flexors of the fingers (fig. 92). This occurs under certain conditions and is noted fre- quently. When the wrist-drop does not exceed an angle of 120° complete flexion of the fingers produces extension at the wrist. In this condition the extensors of the wrist are shortened by contracture and fibrosis so that the angle between the hand and forearm is such that passive dorsiflexion or dorsal dislocation of the hand occurs. Without this provision the fingers could not be completely closed because of the shortened extensor tendons. The mechanism may be illustrated by using the wrist as a hinge, the hand as the weight, the flexors as the power transmitted through a pulley at the metacarpophalangeal joint to a fixed point at the origin of the extensors of the wrist. Fig. 92—Extension of wrist by supplementary movement of flexion of fingers In some cases strong contraction of the pronator radii teres will produce extension of the hand on the forearm. During this movement the head of the radius is strongly depressed toward the palm, the styloid process at the ulna is pulled dorsally and the hand is deviated to the ulnar side. One may demon- strate readily that the hand can be flexed to a greater degree when the forearm is supinated than pronated, and if flexed to its fullest degree when the forearm is supinated, the hand will be seen to extend when strong pronation is instituted. The extension at the wrist is probably due to two factors: Lengthening of the tensor tendons and muscles; a leverage exerted on the scaphoid by the head of the radius. At times, in addition to the contraction of the pronator, there is seen strong abduction and apposition of the thumb against the proximal phalanx of the index finger. At the same time resistance to this action is made by the contraction of the lumbrical muscle and the hand is extended on the forearm to a notable degree. During this action the middle, ring, and little finger show flexion at the proximal phalanges and extension of the two distal phalanges !»!>7—27----W 89(i iURCKRY Fig. 105.—Ulnar nerve lesion XEUROSURGERY 897 the fourth and fifth fingers and sometimes of the middle linger. The reason for this is clear, inasmuch as the first two lumbricales which are supplied by the median are unparalyzed. Extension of the distal phalanges of the fingers is very feeble in the index and middle and practically impossible without sup- plementary motility in the ring and little fingers. Aside from supplementary movement, the lateral movements of adduction and abduction are lost in the middle and ring fingers and often in the little finger. They are much dimin- ished in the index finger. Paralysis of the adductor pollicis and of the inner head of the flexor brevis pollicis produces defects in prehensile movements, attention to wliich has been drawn by Duchenne 4 and recently by J. FromcntT If the patient is asked to grasp any object betw-een his thumb and index finger, such as a folded newspaper, and told to hold it tightly he vigorously flexes the second phalanx of the thumb and presses the tip awkwardly against the outer margin of the first phalanx of the index finger. This is Froment's sign of the newspaper. Fig. 106.—Ulnar "paper sign" Partial Lesions Lesions of partial, incomplete, or dissociated paralysis of the ulnar nerve are very frequent. The commonest type, according to Benisty, is paralysis of the interosseii and hypothenar muscles, with simple paresis of the flexor pro- fundus and flexor carpi ulnaris. In our World War cases it was observed that whether we were dealing with a lesion in the arm or the forearm the same order of frequency of paralyzed or weak muscles existed. Those muscles paralyzed most frequently were, as noted by Benisty, the hypothenar group and the inter- ossei oroup. The order of frequency of involvement was as follows: (1) All muscles weak; (2) hypothenar interossei paralyzed; (3) all muscles paralyzed; (4) abductor pollicis paralyzed. When the long flexors were involved all the muscles were weak. Careful dynamometric examination showed that physi- ologic interruption could not be distinguished from anatomic section by strength of movements of the phalanges in the fingers. In partial lesions relatively greater strength in the phalanges was observed, but at times was an inaccurate guide to the severity of the lesions. Relatively greater strength in the first dorsal interosseus or in the abductor of the little finger proved to be an accurate Painful Lesions As was noted above under the median nerve, so in the sciatic nerve some injuries result in a painful tvpc of paralysis. It has been found that only such injuries are painful as show an involvement of the fibers of the internal popliteal nerve. During the first week after injury complete paralysis is often present. Then motor recovery begins, most often in the region of the internal popliteal. In some cases, however, wiiere the external popliteal branch is less severely injured, movements controlled by this nerve are the first to recover. As with the median nerve, involuntary movements are sometimes observed, consisting of abduction and adduction of the foot or flexion of the toes. EXTERNAL POPLITEAL NERVE Somewhat analogous to the musculospiral nerve, the external popliteal nerve, when injured, produces immediate and extensive paralysis of all the muscles supplied by it. As the result of this injury a de- formity characterized by foot- drop is observed. In addition to the foot-drop a slight drop of the first phalanx of all the toes may be seen. At times a dorsal tumor of the tarsus is observed. This is usually due to the more or less pronounced projection of the heads of the astragulus and scaphoid bones and to the thickening of the sheaths of the extensor tendons. When examining volun- tary motion it is necessary to immobilize the knee of the patient and to be alert lest twitchings of the aponeurosis of the leg caused by contrac- tion of the muscles of the thigh be mistaken for contrac- tion of muscles supplied by the external popliteal nerve. When carefully observed, no active movement of dorsal flexion of the foot is possible. Abduction of the foot is executed by the tibialis posticus. Extension or dorsal flexion of the proximal phalanges of the toes is impossible. The distal phalanges may be extended by the contraction of the interosseus tendon which in the foot as in the hand extends the last two phalanges. Abduction of the foot can not be performed. Fig. 121.—External popliteal nerve palsy NEUROSURGERY 911 Supplementary Movement Supplementary movements of the ankle joint are fairly frequent. Strong flexion of the toe occasionally results in inversion and slight dorsal flexion of the foot, due to a mechanism similar to that observed in which strong flexion of the fingers produces passive extension of the hand in musculospiral lesions. Movements of the toes are sometimes confusing when the contraction of the antagonists of the paralyzed muscle is follow-ed by a rebound simulating the normal action of the muscles under investigation. If the dorsal flexors of the toes are paralyzed and the patient attempts to contract the paralyzed muscle, plantar flexion of the toes may be the initial movement followed by a rebound of the toes to the original position. Partial Lesions Cases of incomplete and dissociated paralysis are met with infrequently. They generally occur following wounds in the leg in which either the musculo- cutaneous or the anterior tibial nerve alone has been injured. Dissociated paralysis may occur, however, in lesions above the bifurcation of the nerve. Under this condition we may have a paralysis of the tibialis anticus alone, or of the peronei muscle alone, the extensors of the toes being spared. Occa- sionally the extensors of the toes may be paralyzed and the other muscles not at all or very slightly involved. Recovery The order of recovery is given by Benisty 15 as tibialis anticus, peronei, extensor longus digitorum, and extensor proprius hallucis. Stopford 22 agrees with this, whereas the records of the Military Orthopedic Hospital put the extensor longus digitorum first. Among 29 American cases spontaneously recovering, the tibialis anticus recovered in 22 cases, the peronei in 7, the extensor longus digitorum in 3, and the other muscles in 3. In 6 cases showing recovery out of 27 cases sutured, the order w-as tibialis anticus, extensor longus digitorum, and the peronei. INTERNAL POPLITEAL XERVE In lesions above the popliteal space complete isolated injury to the internal popliteal nerve is rare. More frequently, as noted above under lesions of the sciatic nerve, partial or dissociated paralysis of the nerve, accompanied by more or less complete paralysis of the external popliteal nerve occurs. In lesions helow the popliteal space the internal popliteal ma}- be completely severed. Motor disturbances which result are paralysis of plantar flexion of the foot. Frank adduction of the foot is impossible; it is ahvays accompanied bv elevation of the foot and is then due to contraction of the tibialis anticus. Flexion and separation of the toes are abolished and no muscle or tendon in the sole can move. POSTERIOR TIBIAL XERVE Paralysis of this nerve frequently occurs as the result of injury in the calf and produces a paralysis of all the muscles of the sole. This is very frequently a painful paralysis of a causalgic nature. 4G!)i)7—27----60 Fie. 122.—Anterior crural palsy XEUROSURGERY 913 ANTERIOR CRURAL XERVE All the muscles supplied by the anterior crural nerve are paralyzed as the result of injury striking the actual trunk of the anterior crural at the highest part of the thigh below Poupart's ligament. Usually some of these muscles are pre- served and the most frequent nerves to be involved are the nerves to the quad- riceps and the internal saphenous nerve. A lesion of the nerve to the quadriceps produces paralysis of this muscle with inability to extend the leg on the thigh. Some extension of the leg on the thigh has been noted by contraction of the tensor fascia femoris, supplied by the superior gluteal nerve. LUMBOSACRAL PLEXUS The lumbosacral plexus is very rarely injured except in its root in con- sequence of a projectile having injured the cauda equina in its intraspinal course inside or outside of the dura mater. CRANIAL NERVES TRIGEM1XAL NERVE Lesions of the trigeminal nerve are not uncommon. Usually the lesion involves but one of the branches. Occasionally a paralysis of the masseter or of the pterygoid, or both mus- cles may be observed. When this occurs, upon clenching the two jaws together the para- lyzed masseter does not con- tract ; upon opening the mouth the jaw deviates to the par- alyzed side. The same obser- vation holds true in attempt- ing to protrude the lower jaw- in front of the upper. FACIAL NERVE The facial nerve is fairly frequently injured in wounds of the parotid region and of the neck. Moreover, wounds of the cranium, particularly in the temporofrontal region are verv often accompanied by paralvsis of the motor fila- ments of the orbicularis pal- pebrarum, or the frontalis. Most frequently some of the branches of the seventh nerve are injured alone. Complete paralysis of the seventh nerve is not uncommon and a dissociated paralysis of the seventh nerve from a lesion of the trunk likewise frequently occurs. Paralysis of Fig. 123.—Facial palsy 914 SURGERY the trunk of the seventh nerve is characterized by complete absence of movements of expression on the paralyzed side, with inability to wrinkle the forehead upw-ard or to close the eye, and attempts at closing the eye are asso- ciated with movement of the eyeball upw-ard, or Bell's phenomenon. In addition to this, the patient is unable to pucker the lips or to smile or show the teeth on the paralyzed side. The expression of the face is characteristic, the paralyzed side being "washed out" and expressionless, and because of atony the angle of the mouth droops, the nasolabial fold is obliterated, and there is an effacement of wrinkles on the forehead. Frequently because of inability to hold the lips closely together there is drooling. All of the signs are exaggerated during attempted movement of the face or during involuntary movement, as in laughing. Fig. 124.—Paralysis of trapezius GLOSSOPHARYNGEAL NERVE This nerve is rarely injured alone but when injured produces paralysis of the superior constrictor of the pharynx. This is manifested by difficulty in swallowing solids so that the patient is obliged to facilitate this deglutition bv he ingestion of fluids. At the same time the soft palate may be involved so hat the unparalyzed part of the palate produces deviation to the sound side. When this occurs nasal regurgitation of fluids may be present. When the tongue is held protruded by the examiner, phonation of the broad "a" produces a movement of the posterior wall of the pharynx toward the unaffected side. ' • PXEUMOGASTRIC XERVE This is rarely affected alone, but w-hen paralyzed produces a paralysis of the adductor of the vocal cords. NEUROSURGERY 915 SPINAL ACCESSORY XERVE When injured alone, usually the external branch only, intended for the innervation of the trapezius and the sternocleidomastoid, is involved. The internal'branch, which joins the pneumogastric soon after its exit from the cranium, supplies the muscles of the larynx and those of the soft palate. Ac- cording to some authors, it is this nerve wiiich, running along with the pneu- mogastric. produces the motor disturbances due to the injuries of the vagus, this nerve itself being purely sensory. When the external branch is paralyzed there ensues a paralysis of the sternocleidomastoid and the trapezius. On turning the head to the]side the paralyzed sternocleidomastoid muscle does not become prominent. The shoulder of the affected side droops, the inner angle of the scapula deviates outward, the outer angle droops, and the lower angle approximates the midline and is projected under the skin. The intraspinous portion of the trapezius receives its innervation from the fourth cervical nerve. Frequently this must course with the branches of the external branch of the spinal accessory, inasmuch as wiien we deal with lesions of the spinal accessory high in the neck the intraspinous portion of the trapezius is involved as well as the supraspinous portion, and under this condition abduction of the arm is impossible because of absence of fixation of the shoulder. Lesions low in the neck produce only a weakness in the supraspinous portion of the trapezius, and ab- duction of the arm may often be adequately performed, inas- much as the intraspinous portion of the trapezius serves to ade- quately fix the shoulder blade during the first stage of abduc- tion of tllC arm. Fig. 125.—Hypoglossal nerve palsy HPYOGLOSSAL XERVE The hypoglossal nerve supplying the muscles of the tongue, the geniohyoid muscle and the subhyoid muscle, is rather frequently injured in the supra- hyoid region and more frequently in the lateral pharyngeal space. This lesion is shown bv a hemiparesis of the tongue, the corresponding half of the tongue is atrophied and shriveled, and within the mouth it is drawn to the unparalyzed side. When protruded, it points to the paralyzed side. 91(i SUHGERY UMULTANEOUS INJURIES OF CRANIAL XEUVES Simultaneous lesions of the ninth, tenth, and eleventh cranial nerves have frequently been observed as the result of war injuries and often injury of one or more additional nerves has been present, most frequently the twelfth, occa- sionally the cervical sympathetic, and rarely the seventh nerve. Vernet26 has described a syndrome due to a combined lesion of the glosso- pharyngeal, pneumogastric, and spinal accessory nerves, called by him the syndrome of the posterior lacerated forearm. Collet27 described a combina- tion of symptoms due to a complete lesion of the ninth, tenth, eleventh, and twelfth cranial nerves under the name of glosso-laryngo-scapulo-pharyngeal hemiplegia. The same condition was described by Sicard 28 as the syndrome of condylo-posterior lacerated forearm. Vil- laret29 described the syndrome of the posterior retroparotid space, w-hich is characterized by the addition of a lesion of the sympathetic nerve to the syndrome of the last four cranial nerves, producing thereby enophthalmos, nar- rowing of the palpebral fissure and myosis. One of the notable features of all the cases is that whatever other nerves might be affected, the ninth, tenth, and eleventh are rather con- sistently injured together. Such lesions are produced by wounds in the uppermost part of the latero - pharyngeal space. Simulta- neous injury of these nerves usually occurs as the result of a missile passing obliquely from the mastoid region on one side to the malar bone on the other, injuring the three nerves and missing both the carotid and jugular vessels. The symptomatology of a combined lesion of the ninth, tenth, and eleventh cranial nerves is constant and easily recognized. As a char- acteristic triad of symptoms indicative of a complete lesion of these three nerves. Vernet proposes nasal regurgitation of fluid, dysphagia of solids, and hoarse- representing, respectively, paralysis of the palate, pharynx, and larynx. REFERENCES (1) Sherren, James: The Distribution and Recovery of Peripheral Nerves. Studies from Instances of Division in Man. Lancet, London, March 17, 1906, i, 727. Swan, Joseph: A Treatise on Diseases and Injuries of the Nerves'. Longmans (and others), London, 1824. Letievant, E.: Traite des sections nerveuses. J. B. Bailliere et fits, Paris, 1873, 142. Duchenne, G. B.: Physiologie des mouvements. J. B. Balliere et fits, Paris, 1867. (5) Beevor, Charles E.: The Croonian Lectures on Muscular Movements and their Rep- resentation in the Central Nervous System. Adlard and Son, London, 1904. Fig. 126.—Syndrome ol the posterior retroparotid space, showing paralysis and atrophy of tongue, narrowing of palpebral fissure, myosis, and en- ophthalmos ne .2) (3. (4- XEUROSURGERY 917 (6) Head, Henry, and Sherren, James: The Consequences of Injury to the Peripheral Nerves in Man. Brain, London, 1905, xxviii, November, pt. 2, 116. (7) Claude, Henri: Blessures des nerfs. Revue neurologigue, Paris, 1916, Nos. 4-5, 492. iS) Athanassio-Benisty, Mme.: The Treatment and Repair of Nerve Lesions, Military Medical Manuals, University of London Press, Ltd., London, 1918. (.9.) Coleman, C. C: The Interpretation of Muscle Function in its Relation to Injuries of the Peripheral Nerves. Surgery, Gynecology and Obstetrics, Chicago. 1920, xxxi, No. 2, 246. (10) Woods, A. H.: Misleading Motor Symptoms in the Diagnosis of Nerve Wounds. Ar- chives of Neurology and Psychiatry, Chicago, 1919, ii, No. 5, 532. (11) Pollock, Lewis J.: Supplementary Muscle Movements in Peripheral Nerve Lesions. Ibid., 518. (121 Marie, Pierre and Athanassio-Benisty, Mme.: Du retour de la contratilite faradique avant le rctablissement de la motilite dans les muscles paralyses a la suite des lesions des nerfs peripheriques. Revue neurologigue, Paris, April 15, 1915, xxvii, 494. (13) Andre-Thomas: Hypertonic musculaire dans la paralysie radiale en voie d'amclioration. Sensations cutanees dans le domaine du nerf radial provoquces par la pression de muscles qui recoivent leur innervation du meme nerf. Seance du 29 Juillet, 1915, Societe de neurologic Revue neurologigue, Paris, 1915, xxvii, Nos. 20-21, 771. (14) Mitchell, S. Weir, Morehouse, George R., and Keen, Wm. W.: Gunshot Wounds and other Injuries of Peripheral Nerves. J. B. Lippincott & Co., Philadelphia, 1864. (15) Athanassio-Benisty, Mine.: Formes cliniques des lesions des nerfs. Masson et Cie., Paris, 1916. (10) Mackenzie, Wm. C: The Action of Muscles. H. K. Lewis and Co., Ltd., London, 191S, 112. (17) S toff el: Deformitaten nach Xervenverletzungen und ihre Behandlung. V erhandl ungen der deutsehen orthopddischen Ge.sell.schaft, Stuttgart, May 2S, 1920, xv, 196. (IS) Marie, Pierre, Meige, Henry et Gosset, A.: Les localisations motrices dans les nerfs peripheriques. Bulletin de I'academie de medecine, Paris, 1915, lxxiv, 3d. s., No. 52, 798. (19) Dejerine, Mme., and Mouzon, J.; Les lesions des gros troncs nerveaux des membres par projectiles de guerre. Presse medicate, Paris, 1915, xxiii, No. 40, 321. (20) Dustin, A. P.: Le service de neurologie a l'ambulance "Ocean." Travaux de l'ambu- lance "Ocean," Masson et Cie., Paris, 1917. (21) Pitres, A.: La valeur des signes cliniques permettant de reconnaitre dans les blessures des nerfs peripheriques. Revue neurologigue, Paris, 1916, xxix, Nos. 4-5, 477. (22) The British Medical Research Council, Special Report Series No. 54. The Diagnosis and Treatment of Peripheral Nerve Injuries. His Majesty's Stationery Office, London, 1920, 37. (23) Froment, J.: La prehension dans les paralysies du nerf cubital et le signe du pouce. Presse medicate, Paris, 1915, xxiii, No. 50, 409. (24) The British Medical Research Council, Special Report Series No. 54. The Diagnosis and Treatment of Peripheral Nerve Injuries. His Majesty's Stationery Office, London, 1920. (25) Bunts, F. E.: Nerve Injuries about the Shoulder-Joint. Transactions of the American Surgical Association, Philadelphia, 1903, xxi, 520. (26) Vernet, M.: Syndrome du trou dechire posterieur. Revue neurologigue, Paris, 191S, xxv, Nos. 11-12, 117. (27) Collet et Petzetakis: Le reflex oculocardiaque dans les lesions traumatiques des pneu- mogastriques. Comptes rendus des seances de la societe de biologie, Paris, 1916, lxxix, 1147. (2.xi Sicard, J. A. et Roger, H.: Paralysie des quatres derniers nerfs craniens. Marseille medicale. 191X, lv, No. 21, 88... (29) Yillaret, M.: Le syndrome de l'espace retro-parotidien posterieur. Paris medicale, 1917, xxii, Xo. 2, 246. Chapter IN SENSORY DISTURBANCES IN PERIPHERAL NERVE LESIONS« For manv years it has been noted that total loss of sensation after com- plete division of a peripheral nerve is limited to a much smaller area than one would expect from its anatomic distribution. Likewise, it has been observed that following injury of a peripheral nerve sensory symptoms may rapidly diminish and at times loss of sensation to pin prick be entirely absent. That severe, widespread anesthesia results only from trauma of several nerve trunks of a plexus, has generally been accepted. Lesions of single nerves result in partial anesthesia, or, if a severe anesthesia be present, the area of complete loss of sensation rapidly shrinks. Many attempts have been made to explain these phenomena. Some of the older theories were to the effect: (1) That nerve fibers grow from healthy surroundings into the insensitive parts;1 (2) that after section of a nerve, stimulation of the severed part may pass through an accessory branch into an adjacent nerve and reach the major branch of the injured nerve above the lesion, through a second lateral branch (collateral innervation); 2 (3) that numerous anastomoses connect the peripheral ramifications of sensory nerves, many cutaneous areas receiving their innervation from different nerves.3 All these opinions have undergone important changes since the investigations of Head and his coworkers. The results of their studies led Head and Sherren s to conclude that the sensory mechanism in the peripheral nerves consists of the following three systems: (1) Deep sensibility, capable of answering to pressure and to movement of parts and even capable of producing pain under the influence of excessive pressure, or when the joint is injured. The fibers, subserving this form of sensation, run mainly with the motor nerves, and are not destroyed by division of all the sensory nerves to the skin. (2) Protopathic sen- sibility, capable of responding to painful cutaneous stimuli, and to extremes of heat and cold. This is the great reflex system, producing a rapid, widely diffused response, unac- companied by any definite appreciation of the locality of the spot stimulated. (3) Epicritic sensibility, by which we gain the power of cutaneous localization, of discrimination of two points, and of the finer grades of temperature, called cool and warm. Head and Sherren 4 state that in complete division of a mixed nerve, as the median or ulnar, the area it supplied does not become uniformly insensi- tive. Whereas previous observers have stated that sensation is diminished over the full area usually assigned to the injured nerve and lost completely over a small portion only, they have shown that this diminution of sensation is ° The statements ol lact appearing herein are based on "Overlap of So-Called Protopathic Sensibility as Seen in Peripheral Nerve Lesions," by Maj. Lewis J. Pollock, M. C, Archives of Neurology and Psychiatry, 1919, ii, No. 6, 667. 91S XEUROSURGERY 919 in reality a total loss of sensibility to stimulation with cotton wool, to the compass test, to the painless interrupted current, and to temperatures between 22° C. and 40° C. In this area are felt only the stimuli affecting the proto- pathic sensibility, such as the prick of a pin and temperatures below 20° C. and above 40° C. The area rendered insensitive to light touch by division of the median or of the ulnar nerve varies little in extent. In sharp contrast to this slight variation is the extreme difference in surface extent of the loss of sensation to a pin prick which follows division of cither of these nerves. " The consequence of both division and irritation of these nerves shows that as far as protopathic sensibility is concerned they overlap to an enormous extent."5 It is evident, therefore, that the complete sensory distribution of a peri- pheral nerve consists of its exclusive supply, or that area in which loss of sen- sation is produced by its division, and in addition its overlap or the area determined by the limits of skin sensitive to stimuli when all the adjacent nerves have been severed. Head and Sherren, employing the method of residual sensibility, were able to determine the complete sensory distribution of some of the nerves. These areas were part of the distribution of the median, the internal saphenous, part of the external popliteal, the external saphenous and part of the posterior tibial nerves. The purpose of the present chapter is: First, to record the smallest area of loss to prick pain which follows interruption of the various peripheral nerves; second, to point out the relative smallness of this area as compared to the area of loss to touch; third, to show that the preservation or early return of prick pain as compared to tactile sense is due to the assumption of function of adja- cent nerves, and not to nerve regeneration, as interpreted by Head; and, fourth, to outline the total sensory distribution of some of the peripheral nerves by residual sensibility. MATERIAL Observations were made on 500 patients with peripheral-nerve lesions seen early in base hospitals in France, and 520 patients with peripheral-nerve lesions studied later at United States Army General Hospital No. 28, Fort Sheridan, 111. The observations of early peripheral-nerve lesions were in most instances uncontrolled by operative procedures. The major portion of the lesions were partial and frequently complicated by injuries to adjacent small sensory branches. But these observations served a useful purpose. They showed: (1) That in many cases for the first two or three weeks only a very small area within the border of the part insensitive to cotton wool was sensitive to pin prick; (2) that in a few a larger zone sensitive to pin prick appeared within 15 days- and (3) that the return of sensitiveness to pin prick in a larger zone, corresponding to the area which was later determined as overlap, usually was found at times variable from 30 to 100 days. The cases showing return to pin prick over a large area in less than 30 days were predominantly cases of radial and musculospiral lesions. The material of peripheral-nerve lesions studied later may be divided into two groups: The first, a group of 391 cases uncontrolled by operation, and in 920 SURGERY the majority of instances recovering spontaneously; the second, a group of 12!) cases controlled by operation, wliich may be tabulated as follows: Nerve lesions Number Ulnar____________________________________________ ___ - - - 20 Radial___________________________________________ --- 31 Median_____________________________________ _____ ---- - 9 Ulnar and median________________________ --------- 15 Median and radial________________________ ___ _____ ----— 2 Musculocutaneous, ulnar, and median__________ _ ___ ----- 2 Brachial plexus__________________________ 2 Great sciatic________________________ _ ___ ___ 20 External popliteal____________________________ ____ 2.. Anterior tibial__________________________ _ _______ ____ ______ 2 Ulnar, median, and internal cutaneous_______ ____________ ___ 1 Total______ _____ _____________ ______________________ 129 General impressions relative to the sensory changes in peripheral-nerve lesions were derived from the whole material. The areas of total nerve supply and of overlap were obtained only from cases certified by operation. The eases which have been used in the study of regeneration of nerves likewise were certified by operation. Therefore, although the whole 1,020 cases contributed to the general conclusions concerning these problems, only one group, consisting of the cases coming to operation, was employed in obtaining the data which serve as the basis for the special conclusions contained herein. METHODS OF INVESTIGATION The problems under investigation were not studied from a psychological standpoint. The areas of overlap were found in the course of clinical examina- tions of a large group of cases. The methods of examination, therefore, were those ordinarily used clinically. The sense of touch was tested by a wisp of cotton. The sensation of pain in response to the prick of a pin was ascertained by using a weighed needle sliding within a bit of glass tubing so that with differ- ent weighed needles a pressure of from 5 to 35 grams could be applied. Although in this chapter temperature sense will not be referred to because of the difficulty of standardizing methods and the impossibility of employing the finer methods clinically, it may be stated that for the rough examination of sense of cold, a pledget of cotton twisted to a point and saturated with ether was used. This method permits a less diffuse type of stimulation and has the advantage of ease and simplicity. For physiologic research this method is, of course, inapplicable. Light touch with a wisp of cotton to determine sense of touch may be accepted if the exact threshold of sensation is not under in- vestigation, and if exact borders of loss of sense of touch be not insisted on. For the purposes of this investigation, the exact borders of loss of sense of touch need not be insisted on. Only one factor must be considered in this method of examination, namely, return of so-called hair sensibility must not be confused with touch; hence, in testing for touch where an accurate border was to be determined, the parts were closely shaven. The degree of pressure which it is' permissible to employ in determining prick pain without jeopardizing the results by confusion with pressure pain NEUROSURGERY 921 remains to be discussed. Although, as pointed out by Head and Sherren,6 deep sensibility may be evoked when testing for touch with a stiff roll of wool, this objection is not valid for determining prick pain within certain limits. .V sharp needle was used by Head and Sherren in their early clinical investi- gation, care being taken to differentiate between sense of deep pressure and true pain. Boring 7 says: "In determining the pain threshold it was especially necessary not to exceed pressures of 6 gm. Although at high intensities of stim- ulus the introspective difficulty of abstracting from pressure was less with pain than with cutaneous pressure, the greater intensities frequently drew blood and therefore were abandoned." As in Boring's work it was necessary to ex- amine a small area of skin repeatedly and at very short intervals for all forms of sensation, his objection is valid. On the other hand, with the World ^Yar cases under consideration, it was necessary only to examine sense of prick pain in areas of overlap and not to confuse this pain with pressure pain. In these cases pain was never found to result from 35 gm. of pressure with a blunt object, and since care was taken to obtain from the patient responses only to pain from prick of a sharp point, it is believed that pressure of even 35 gm. is permissible to map out the overlap of sense of prick pain. Xo exact measure- ments of threshold to prick pain were made and in the majority of cases pressure did not exceed 30 gm. EXCLUSIVE NERVE SUPPLY Recognizing that, following section of a mixed nerve, the loss to prick pain occupies an area much smaller than the loss to touch, it first was necessary to ascertain the smallest area which is insensitive to pin prick following section of various nerves. This would indicate the limits of any possible overlap. Although only a small portion of the area insensitive to touch is quite insensitive to pin prick, diminution of pain sense is present in a large part of the area insensitive to touch, and if graduated degrees of pressure be employed, concentric rings of analgesia are demonstrated. However, we are concerned not with the question of whether any hypalgesia is present, but whether any portion of the skin is at all sensitive to pain, provided this pain be due to superficial sensibility. If a part of the skin is sensitive to pain, when a nerve is divided, this sensation must be derived from some source other than this nerve. To delineate the area exclusively supplied with pain sense by a given nerve one of two conditions must be present: First, the presence of pain sense hav- ing been demonstrated within the area of a nerve's supposed anastomic supply, that nerve is found at operation to be divided, and the ends separated. Second, the nerve having been seen to be divided, presence of pain sense is demonstrated in its distribution within the length of time given for the return of protopathic sensibility (Head, Kivers, and Sherren, 43 days). In the cases under the second condition 2S days was the limit, with the exception of the radial nerve, in which the limit was 37 days. The relatively small number of cases studied does not warrant an attempt to outline the exclusive supply of peripheral nerves to both epicritic and prog- nathic sensibilities. Suffice it to say that the results as to the nerves in the 922 SURGERY hand are in general accord with Stopford.* who found in the ulnar nerve some variation from the accepted area of epicritic sense in 20 per cent of the cases and in the median nerve in 38 per cent. In three cases of median nerve section anesthesia was present over the dorsal surface of the distal phalanx of the thumb. Fig. 127.—Sensory changes In ulnar nerve lesions: Diagonal lines, anesthetic to touch; black lines, loss of prick pain and touch sense; continuous line, borders of loss of temperature sense. The same scheme of charting is followed in all of the diagrams. Where duplication of letters occurs, the first is preoperative and the second postoperative sensory chart In ulnar-nerve lesions superimposing the outlines of complete analgesia, in the cases shown in Figure 127, the smallest area of analgesia was found to occupy the palmar and dorsal surfaces of the little finger, extending over the dorsal surface of the hand in a triangular area over the fifth metacarpal bone to one-third of its length (fig. 128). The area included between the borders NEUROSURGERY 923 of the accepted supply of the ulnar nerve and the borders of this analgesia represents the possibly supply of overlapping nerves to pain sense. The inner border of the smallest area of exclusive supply to pain of the median nerve was obtained in the same way from cases in which the median nerve was subsequently found to be divided (fig. 129, g, h, i, j). The outer border was obtained from these cases and in addition from cases of combined ulnar and median lesions which at operation were likewise found to be anatomic divisions, with the ends separated (fig. 129, a, b, c, d, e,f, ~k). The exclusive supply of the median nerve to pain sense was found to occupy the dorsal and palmar surfaces of the distal phalanges of the index and middle fingers, the ulnar half of the palmar surface of the second phalanx of the index finger, part of the ulnar portion of the distal half of the second phalanx of the middle finger and the dorsal surface of less than half of the second phalanges of the index and middle fingers. Despite the fact that this small area of total analgesia in median Fig. 128.—Smallest composite area of analgesia in ulnar nerve lesions nerve lesions has been recognized,9 it is necessary at this point to call special attention to this observation as from the study of this nerve much evidence relative to overlap was obtained (fig. 130). The cases of radial nerve lesions, certified at operation or examined less than 37 days after resection and suture, showed a wide variety of areas of analgesia and in one case no analgesia at all. (Fig. 131, a to m.) Although not infrequently recorded, no case of radial nerve lesion was observed which did not show loss of sensation to touch. Of all the peripheral nerves the radial shows the greatest variation in the areas of loss of sensation to both epicritic and protopathic sensation. This is due to the fact that six nerves are concerned with the sensory supply of the dorsum of the hand; the median, radial, antibrachii, posterior branch of the musculospiral.. musculo- cutaneous, and ulnar. Stopford 8 emphasizes, as do Head and Sherren,4 the importance of the musculocutaneous nerve in the supply of the dorsum of the hand, and states 1)24 sUKOKRY Fh;. 129—Sensory changes in median nerve lesions: G, II, J, radial and median; I, ulnar and median; B, E, ulnar, median, and internal cutaneous; A, C, D, E, ulnar median, and musculocutaneous, K Fig. 130.—Smallest composite area of analgesia in median nerve lesions NEUROSURGERY 925 that its terminal branches may extend on to the dorsum of the metacaipus, and "it appears that the extent of its distribution varies inycrselv with that of the radial." Although this may be true, it must not be forgotten that the median nerve must be considered in the supply of sensation to the dorsal area over the distal portion of the metacarpus and the distal portion of the thumb. Fig. 131.—Sensory changes in radial nerve lesions One of the reasons for varying reports relative to the sensory loss in radial nerve lesions is the hairy nature of the area of skin under investigation. The early return of hair sensibility frequently is confused with the presence of sense of touch. The skin must be closely shaved in all cases where examination of touch sense is contemplated. Xo area of skin is exclusively supplied by the radial nerve for prick pain. 926 SURGERY Fig. 132.—Sensory changes in external popliteal lesions The area of exclusive supply of pain of the external popliteal nerve was obtained from certified cases of division and cases examined less than 37 days following resection and suture (fig. 132, a to h). The area consists of a narrow band extending from a point a little above the junction of the lower and mid- dle one-third of the outer surface of the leg, diagonally across the dorsum of the foot to a point over the middle of the metatarsal bone of the great toe. It is interrupted at the junction of its lower and middle one-third by an area which is sensitive to pin prick. The area is due to the overlap on one side of the internal saphenous nerve and, on the other side, the internal popliteal nerve. Although a number of cases showing such an interruption in the band of anal- gesia have been observed, they have not fulfilled the requirements demanded in estimating exclusive supply. One case. Figure 132, e, showed this type of interruption of the band of analgesia 27 days after resection and suture. F,°" '^T^^S™ "^" ~ NEUROSURGERY 927 Another case which was examined 53 days after resection and suture is shown in Figure 132, d, but was not used in estimating the isolated supply. The external popliteal nerve has a surprisingly small exclusive area of pain sense (fig. 133). ' P The area of the sciatic nerve was obtained from cases certified to be anatomic divisions, Figure 134, a to /. This area is illustrated in Figure 135 and need not be described. Inasmuch as the results above illustrated represent the smallest area of exclusive supply of various nerves for pain, it is necessary to define to what Fig. 134.—Sensory changes in sciatic nerve lesions extent they may be used in formulating our ideas relative to nerve overlap. It is recognized that in some instances such small areas may be present only when we are dealing with the group of 25 per cent of cases showing unusual distribution of sensory nerves. These areas are used, therefore, only in estab- lishing a certain limit beyond which it is not permitted to go in interpreting return of sensation to pain as a sign of nerve regeneration. Any return of sense of pain in regions without these borders may be due to unusual nerve distribution or sensory overlap, and represents possible areas of overlap. It will be found that the areas of overlap, described below, are not as extensive as these areas would permit us to assume were we to use exclusive pain sensi- bility as an indication of the borders of overlap. 4(5097—27----«1 928 SURGERY XERVE OVERLAP The return of sensibility to pin j>rick, which takes place before the return of sensibility to touch, occurs in regions which occupy the areas of nerve overlap, and this return of sensibility to pin prick can not be interpreted as a sign of nerve regeneration. This view is supported by the facts that no return of sensibility to pain was found when sensibility to touch had not returned, except in an area of overlap; that when a nerve is divided and at the same time one or more adjacent nerves are divided sensation to pin prick does not return in the area of the overlap of these nerves even many months following the injury; that when a nerve adjacent to one which is severed and which supplies an area of overlap to that nerve is sectioned, the preexisting sensibility to pin prick in the overlap area is lost; that when sensibility to pin prick is present within the anatomic sensory distribu- tion of a severed nerve resection and sature has no effect on the general outline of this area of sensibility. Within two weeks after the oc- currence of a peripheral-nerve lesion the area of analgesia usually nearly coincides with the area of anesthesia. Some cases showed an intermediate zone or a shrinkage of the analgesic area within 15 days. In from 30 to 100 days the majority of cases showed the presence of a shrinkage to an extent which was later identified with overlap. It is probable that the cases would have shown the same -Smallest composite area of analgesia in sciatic nerve extent of shrinkage in less than 100 lesions days, but conditions were such that in these cases the first record available was obtained 100 days after the injury. Certainly the majority of cases showed the shrinkage to be well established under 50 days. Some months after the injury had been received the shrinkage was present and the remaining area of analgesia has been described above as the exclusive sensory supply for pain sense in various peripheral nerves. The shrinkage of the analgesic area can be due to but two conditions: Xerve regeneration, or the assumption of function by adjacent nerves. If any overlapping of peripheral nerves is possible, it becomes necessary to define the extent of this overlap before any return of sensation can be inter- preted as a sign of nerve regeneration. So far as it can be ascertained, no evidence has ever been adduced to show that overlapping nerves functionate Fig. 135. XEUROSURGERY 929 immediately following the injury of an adjacent nerve. Neither have the laws of dual innervation been clearly denned. Until this is accomplished, it is illogical to infer that return of sensation in the area of an overlapping nerve is a sign of nerve regeneration and is not caused by the functioning of this over- lapping nerve. If the shrinkage of the area insensitive to pin prick responsible for the increase in size of the intermediate zone be a sign of nerve regeneration and not a result of overlap, it should occur whether the adjacent nerves be intact or not. This, however, is not the case, as will be shown. In other words, if certain areas of skin become sensitive to pain or are found sensitive to pain following section of a given nerve, and the condition is due to nerve regeneration, then section of the adjacent nerve would have no effect on the appearance of this sensibility. Fig 136.—Sensory changes in combined lesions of the ulnar, median, and internal cutaneous nerves SECTION OF NERVES Section of Adjacent Nerves Although in isolated lesions of the ulnar nerve sensibility to pain is fre- quently seen on the ulnar half of the ring finger, this is never observed when the median nerve is divided at the same time (fig. 136, a, f). Although isolated lesions of the ulnar and of the internal cutaneous nerves always show that the distal end of the analgesia resulting from a lesion of the internal cutaneous and the proximal end of the analgesia resulting from a lesion of the ulnar, do not 930 SURGERY meet, no instance is found in combined lesions of the ulnar, median, and internal cutaneous nerves where an area between the borders of the analgesia of the internal cutaneous and ulnar nerves is sensitive to pain (fig. 130, b, c, d, e, h,i, j). When the ulnar, radial, and median nerves are divided, a year may follow their division and no shrinkage of analgesia be found on the palmar or dorsal surface of the hand except on the proximal portion of the analgesia where the musculocutaneous and the antibrachii posterior areas adjoin the analgesic area (fig. 137, a, b, d). When a radial lesion is combined with a median, analgesia is always present on the radial part of the palm. When a median lesion or a radial lesion alone is present, this part of the palm is usually sensitive to pin prick (fig. 137, d, e,f, g). Fig. 137.-Sensory changes in combined lesions of the ulnar, radial, and median nerves, A, B, C, and of the median and radial, D, E, F, G Isolated lesions of the external popliteal nerve (which corresponds closely to the fifth lumbar root) may show only a small area of analgesia, but when the internal popliteal as well as the external popliteal is severed, there is never found any shrinkage of analgesia or reappearance of sensibility to prick pain in the zone where the supply of the external popliteal meets that of the internal popliteal (fig. 138, a to gr). It can be definitely stated that when nerves supplying adjoining areas are severed sensation to pain is at no time present in the border areas where it is uniformly observed when either nerve is divided alone. Inasmuch as a large number of the cases observed had resections and sutures performed at least three months prior to the last examination, it mav be stated likewise that no NEUROSURGERY 931 sensation to pain returns in such areas in the time given for the beginning of regeneration of protopathic sensibility. Effect of Section of an Overlapping Nerve When return to sensibility to pain or presence of sensibility to pain is found in the area of overlap of an adjacent nerve, analgesia will result if this nerve is severed. This is well illustrated in the case shown in Figure 129, g, page 024. This patient had a partial ulnar lesion combined with a complete section of the median. Prick pain was preserved in the radial portion of the Fig. 138.—Sensory changes in combined lesions of internal and external popliteal portions of sciatic nerve palm and the index finger. When at operation the superficial radial nerve was resected for use as a cable transplant, this part of the palm became analgesic (fig. 137, e). Effects of Resection and Suture on Existing Overlap Following resection and suture when sensibility to pain is present in an area of overlap, although some change in the outline of this area occurs, in General the area remains the same. At times the borders show some increase m analgesia; much more frequently they show a shrinkage of the analgesia. Sli.rbt chano-es in the borders of an area of analgesia can not be used in arriving 932 SURGERY at a hard and fast conclusion. Frequently these borders change in an astonish- ing manner for pain produced by higher degrees of pressure by a sharp point not sufficient to produce pressure pain. The laws governing dual innervation have not been clearly ascertained. What effect, if an v. the handling of nerves or freshening of their ends may have on inhibition is unknown. Another fact in support of the statement that return of sensation in an area of possible overlap can not be ascribed to the regeneration of a nerve is that this area is not generally changed by resection and suture of a severed nerve. Fig. 139.—Sensory changes before and after resection and suture of the ulnar, median and ulnar, and median nerves The conditions necessary to study profitably the effect of resection and suture of nerves on return of sensibility to pain are: First, that the nerve ends be separated, and, second, that the examination subsequent to the operation be made within the period of time ascribed to the return of protopathic sense. Some difficulty is encountered in meeting the second condition inasmuch as frequently the wide separation of the ends of the nerves makes it necessary to place the extremity in a position which will permit approximation, and to fix it in such a position by means of a case. This often prevents an examination before six weeks have elapsed. None of the cases under consideration were examined later than 50 days after operation, one in less than 15 days. Although some objection may be made to the cases examined over 45 days after operation on the grounds of beginning return of protopathic sense due to regeneration, XEUROSURGERY 933 the similarity of the areas unaffected by operation in cases examined under 45 days and those between 45 and 50, coupled with the facts that the ends of the nerves were separated in all of these cases, makes it reasonable to admit them into the group. To describe again the areas sensitive to pin prick in the lesions examined, or to attempt by description to show the sensory changes following operation, is needless. They are clearly indicated by Figures 139 and 140. It is sufficient to state that the following nerves were studied: Ulnar, examined 42 days after operation (fig. 139 a); median, 8 days after operation (fig. 139/); ulnar and median, 45, 36, 40, 40, 48, and 14 days after operation (fig. 139, b, c, d, e, g, h); external popliteal, 48, 36, 20, and 26 days after operation (fig. 140 a, b, c, d); sciatic, 50 and 36 days after operation (fig. 140/, h). RESIDUAL SENSIBILITY If we assume the relatively early return of sensibility to pin prick to be due to overlap it becomes possible by the method of residual sensibility to outline the borders of overlap of the various peripheral nerves. The method of residual sensibility is based on the assumption that following section of a given nerve, the area of skin, in its anatomic distribution in which sensation remains, is subserved by the intact adjoining nerves distributed to that area. For example, four nerves supply the palmar surface of the hand: The ulnar, median, musculocutaneous, and radial. If two—the ulnar and 934 SURGERY median—are severed, what sensibility remains is subserved by the musculocuta- neous and radial. If then the borders of the musculocutaneous be determined, that which remains is radial. In employing this method certain precautions must be observed. For example, we can not take the outer border of the analgesia on the dorsal surface of the hand in an ulnar section to be any part of the border of the overlap of the median unless we may observe the effect of a combined ulnar and musculo- spiral so that the overlap of the latter nerve be not included. Similarly, we can not outline the border of the overlap of tlie median on to the radial unless radial, combined radial and mediL nerves H J M I ? wv. ^ °f the U,nar and interaal cutaneous. was obtained 6S' H' J' M' from whlch the r<*idual sensibility of the median nerve verv few. As a result the ar. »- nfZ . mailable for conclusions to a than the real overlap tZZ he ml o. °Utl'ined ^^ Vm Sm*r prove that it is mthL such an ^ftha S™ ^2*™^ *> soon after injury of peripheral nerves. sensibility to pin prick occurs NEUROSURGERY 935 It is hardly necessary to state that the cases studied must have nerves recently resected or be examined prior to an operation which reveals the ends of the nerves separated. In illustrating the areas of overlap the space bewteen the borders of the overlapping to adjacent nerves has been blocked out with black. The black area therefore represents the total supply to pain of the various nerves studied. The area of actual overlap would be that part of the total sensory supply to pain which extends beyond the accepted sensory limit of the adja- cent nerves. The restrictions of the methods necessary to obtain these areas are responsible for an indicated area of total supply, which in some instances is smaller than is actually present, as may be seen in the case of the outer border of the ulnar on the dorsal surface of the hand and the inner border of the externa] popliteal on the back of the leg (figs. 143, p. 936, and 147, p. 938). Fig. 142.—Residual sensibility to prick pain of the ulnar nerve The area of total supply to pain of the ulnar nerve was obtained by the method of residual sensibility from a median lesion, an internal cutaneous lesion, and a combined median and radial (fig. 141, 6, g, m). It occupies the ulnar portion of the palm to a line which is a continuation of the ulnar border of the abducted index finger, the palmar surface of the fingers except the ter- minal phalanx and one-third of the ulnar part of the second phalanx of the middle finger. On the dorsal surface it occupies the ring, little, and more than the ulnar half of the proximal, one and a half phalanges of the middle finger, and the dorsum of the hand to the radial border of the fourth metacarpal bone, ending proximally 1 inch above the wrist (fig. 142). The area of the median nerve was obtained from an ulnar and internal cutaneous lesion, a radial, a combined radial and median lesion, and cases of combined radial and ulnar lesions (fig. 141, h, j, m). The inner border on the palmar surface was obtained by the method of residual sensibility from an ulnar and internal cutaneous lesion. As to the dorsal surface it was necessary to employ another method, as the cases of combined ulnar and radial lesions were too recent to have had return of prick pain due to overlap. The border 936 SURGERY of overlap of the musculocutaneous to the radial was obtained by means of residual sensibility in a ease of combined radial and median lesion. Inasmuch as the radial has no isolated supply to prick pain, this border separates the muscu- locutaneous from the median overlap. Therefore, this border was used as the proximal border of the median overlap to the radial nerve, especially m such cases as showed an area of analgesia between the areas of overlap of the median and musculocutaneous nerves (fig. 141). Part of the inner border of the over- lap on the dorsum of the hand is hypothetical and shown as a rough border (fig- 143). . • ., f The total supply of the musculospiral nerve was obtained Irom cases ot com- bined ulnar and median nerve lesions, a case of combined ulnar, median, and musculocutaneous lesions and a case of combined ulnar and internal cutaneous lesions (fig. 141, a, d, e, f, h, i, I, I, m, n). An overlap onto the palm was found to an extent heretofore undeseribed. In median nerve lesions the sensibility Fig. 143.—Residual sensibility to prick pain of the median nerve to pain in the palm has frequently been ascribed to ulnar overlap. But Atha- nassio-Benisty 9 recognized the importance of the musculospiral and the muscu- locutaneous nerves in this condition. The area of overlap on the palm of the musculospiral nerve extends over the radial part of one and a half phalanges of the index finger, the radial part of the proximal phalanx of the middle finger, and the web between the middle and ring fingers, all of that part of the hand external to a line continuous with the radial border of the middle finger. Internally, it extends from the middle of this line to the middle of the base of the first phalanx of the ring finger and proximally to the middle of the outer surface of the wrist, from which point the border extends in a line to a point 1 inch proximal to the base of the metacarpal bone of the thumb on the radial border of the wrist. This area occupies the entire dorsal surface of the hand with the exception of a strip one- half the width of the little finger on the ulnar border, the little finger, the distal two phalanges of the ring finger, most of the distal two phalanges of the middle NEUROSURGERY 937 finger and a little more than the distal phalanx of the index finger. The area on the forearm need not be described (fig. 144). The inner border of the pain area of the musculocutaneous nerve on the anterior surface of the forearm was obtained from the residual sensibility fol- lowing seetion of the internal cutaneous nerve; the inner border on the dorsal surface of the forearm, from a musculospiral division. The distal border on the palm was obtained from radial lesions, a combined radial and median lesion, and from lines obtained in combined ulnar and median lesions where an area of analgesia existed between the areas of overlap of the musculospiral and the musculocutaneous (fig. 141, e,f, /.). On the dorsal surface of the hand combined sections of ulnar, radial, and median and a case of combined radial and median the musculospiral nerve the musculocutaneous nerve were employed (fig. 137, a,b,e, f; fig. 141, m. h, j). The area of total sensory supply to pain of this nerve can be better appreciated by viewing the illustration than by description (fig. 145). The proximal limits of both the musculocutaneous and musculospiral nerves are hypothetical. Fortunately two cases were obtained from wliich the overlap of the internal and external popliteal nerves could be observed according to the method of residual sensation. One was the case in which the internal saphenous and internal popliteal nerves were injected with alcohol for causalgia, producing anesthesia, the residual sensibility about which permitted the outlining of the total supply for pain of the external popliteal nerve (fig. 146, /). The upper border of this area is hypothetical and merges on the outer surface with the external cutaneous, on the posterior surface with the small sciatic, and on the inner side with the obturator nerve. 938 SURGERY The overlap on the sole seen in Figure 147, b, is probably smaller than that which actually exists, as may be seen from the presence of sensibility to pain in the blank area of the sole in a case of complete interruption of the internal Fig. 146.—Sensory changes of combined lesions of internal saphenous and internal popliteal nerves, F; small sciatic, external popliteal and internal saphenous and sciatic nerve lesions from which the residual sensibility of the external and internal popliteal nerves was obtained Fig. 147—Residual sensibility to prick pain of external popliteal nerve, B; sensory changes in an uncertified case of complete interruption of the internal popliteal, A popliteal nerve, a case which, because it was not certified by operation, is not included in the present series (fig. 147, a). NEUROSURGERY 939 The area of total supply for pain of the internal popliteal nerve was ob- tained from the residual sensibility in a case of a combined lesion of the small sciatic, the internal saphenous, and the external popliteal nerves, and a case of Fig. 148.—Residual sensibility to prick pain of the internal popliteal nerve external popliteal section (fig. 146, d, e). The upper border of this area is hypo- thetical and merges with the borders of the small sciatic and obturator nerves (fig. 148). Fig. 149.—Residual sensibility to prick pain of internal saphenous nerve The area of total pain supply of the internal saphenous nerve was obtained from the residual sensibility of a combined lesion of the small and great sciatic and cases of sciatic section (fig. 146, a, b, d). The upper border here is likewise hypothetical, merging with the borders of the anterior crural, the external cutaneous, and the obturator nerves (fig. 149). 940 SURGERY CONCLUSIONS 1. The area of prick pain supplied exclusively by an indhidual nerve is far less than the accepted sensory distribution of that nerve. 2. The area between the border of exclusive supply of prick pain of an individual nerve and the border of its accepted sensory supply constitutes the area of algesic nerve overlap. 3. When nerves serving adjacent areas are severed, sensibility to prick pain between these areas is not present after injury, nor does it return before the sense of touch. 4. When a region in the area of sensory distribution of a severed peripheral nerve is sensitive to prick pain, and this region is adjacent to another nerve area, if this second nerve be severed, complete analgesia results in the previous sensitive region. 5. When sensibility to prick pain is present or returns in the area of possible overlap on to the sensory distribution of a severed nerve, subsequent resection and suture of this nerve does not change the general extent of this sensitive area, although the borders may at times be slightly enlarged or diminished; that is, the pain sense returned or present before the operation was not due to partial regeneration. 6. The laws governing the assumption of function by nerves adjacent to a severed nerve are unknown. 7. Handling and resection and suture of previously divided nerves changes the condition governing the function of overlapping nerves, often initiating greater function. S. Evidence of the assumption of function by nerves adjacent to a severed nerve is not present immediately following the nerve injury, but gradually shows itself at a later date. 9. The early return of sense of prick pain before the return of sense of touch is not due to temporal dissociation of epicritic and protopathic sensi- bilities, but is due to the assumption of function by adjacent overlapping nerves. 10. The areas of overlap may be determined with fair accuracy and the early return of sense of prick pain in those areas can not be interpreted as a sign of regeneration of the divided nerve. 11. The changes in prick pain following division of a single nerve are not a safe basis for conclusions regarding regeneration of that nerve. 12. Only when a group of nerves is divided at the same time can the studies of sensation be used in the interpretation of regeneration of these nerves Under these conditions only that part of the analgesic area may profitably be studied which is removed from the effect of overlap from adjacent nerves. On the other hand, if return to sensibility to prick pain occurs on the border of an uninjured adjacent nerve, this return to sensibility does not indicate re- generation ol a nerve. 13. Return of sensibility to prick pain can be used clinically for the deter- mination of nerve regeneration only when it is accompanied by return of tactile sense or when it occurs outside the area of possible overlap of adjacent nerves. J XEUROSURGERY 941 REFERENCES (1) Oppenheim, Hermann: Text-book of Nervous Diseases. Translated by Alexander Bruce. Edinburgh, Otto Schulze and Company, 1911, i, 5th Edition, 408. (2) Leti6vant, E.: Traits des sections nerveuses. J. B. Bailliere et fils, Paris, 1S73, 41. (3) Head, Henry, Rivers, W. H. R., and Sherren, James: The Afferent Nervous System from a New Aspect. Brain, London, 1905, xxviii, part 2, 99. 14) Head, Henry, and Sherren, James: The Consequences of Injury to the Peripheral Nerves in Man. Brain, London, 1905, xxviii, part 2, 117. (5) Ibid., 295. (li) Ibid., 120. (7) Boring, Edwin G.: Cutaneous Sensation after Nerve-Division. Quarterly Journal of Experimental Physiology, London, 1916, x, No. 1, 1. (8) Stopford, John S. B.: The Variation in Distribution of the Cutaneous Nerves of the Hands and Digits. Journal of Anatomy, Cambridge, October, 191S, liii, part 1, 14. .0 Athanassio-Benisty, Mme.: Treatment and Repair of Nerve Lesions. University of London Press, Ltd., London, 1918, 32: 117. Also: Head and Sherren, Brain, London, 1905, xxviii, 135. CHAPTER X ELECTRICAL EXAMINATIONS IN THE DIAGNOSIS OF PERIPHERAL NERVE INJURIES The importance of making a pathological as well as a clinical diagnosis of injuries to the peripheral nerves as a guide to surgical treatment was recognized early in the war, and consequently neurophysiologists concentrated their attention on this field in an effort to discover a means of accomplishing this purpose. Neurologists had been more or less content with determining what nerve was injured, and the site of the lesion. With the tremendous number of nerve injuries due to war wounds, it became imperative to attempt to decide in addition how much the nerve was damaged, as the treatment differed with the degree of injury sustained. Roughly one could separate nerve injuries pathologically into five groups: Contusion of nerve caused by missile passing through tissue near it without striking it; compression by scar tissue in infected wounds with secondary healing; hemorrhage into nerve without cutting fibers but with central neuroma; partial division with formation of lateral neuroma; complete division with formation of neuroma on the proximal end of severed nerve. A corresponding clinical differentiation was sought on the basis of care- ful motor, sensory, and electrical examinations. Physiologists familiar with the principles and application of electrical currents in diagnosis agreed that by this means such exact pathological information could not as yet be obtained, but felt that it was by developing this method of investigation more than any other that progress might be made. A considerable mass of experimental and clinical data to serve as a basis for further study was available as a result of the patient work of physiologists and clinicians of the nineteenth century. Galvani,1 in 1791, by his accidental dis- covery of the effect of an electrical current on a muscle-nerve preparation, laid the foundation for all the investigation that followed it. DuBois-Reymond,2 applying the principle of induced currents discovered by Faraday, devised the faradic induction battery, an apparatus which is used to-day practically un- changed. In 184S he made the important observation that it was not the passage of the galvanic current but the changes in its intensity which caused muscular contraction. In 1S49 Duchenne,3 of Boulogne, introduced electrodiagnosis with the faradic current, and defined the principles which guide its use to-day. Pfluger4 established the laws which govern the differences in effect of the opening and closing contractions of the galvanic current. Remak,5 in 1865, stated "in some cases of completely paralyzed muscle and nerve, the strongest induction shocks do not excite muscular contractions, whilst a stronger effect than the norm accompanies the opening and closing of a constant galvanic current." The most outstanding addition to the practical value of electrodiagnosis was made by Erb,6 physiologist and clinician, who, in 1883, described the reaction 942 NEUROSURGERY 943 of degeneration (De R) following complete nerve section. In his book are set forth clearly and completely the practical details of electrical examination and in it will be found many of the suggestions and facts rediscovered by later writers. D'Arsonval,7 near the end of the century, added to the therapeutics of electrical treatment the proper utilization of the heat generated by the galvanic current passing through tissues. Further contributions to our understanding of the principles underlying electrical degeneration were made preceding and during the years of the war by Sherrington,8 Lucas,9 Adrian,10 Forbes,11 Lapicque,12 and numerous others. A large part of this work has as yet no practical application to the clinical problem, but its value is unquestionable. Thus recent work has resulted in establishing the "all or none" principle of nerve response to stimulation; has demonstrated the return of a nerve impulse to its full intensity after passing diminished through an area of decrement produced by localized narcosis; has advanced the conception of the nerve impulse as deriving its energy from the nerve itself, similar to the burning of a fuse once it has been ignited; and has made a tentative separation of the nerve impulse to the muscle into an element maintaining position (static) and a part controlling motion (kinetic). Facts of normal nerve physiology such as these are the background upon which abnormalities can be judged and are therefore of great importance; but it must be confessed that practically they have not brought us measurably nearer to the possibility of making a diagnosis of the pathological condition of an injured nerve. There have been a few additions to our knowledge of a more practical nature which may safely be attributed to the interest aroused in this subject by the problems of the war. That the cathodal response is always greater than the anodal in stimulating normal nerves and is usually reversed in degenerated nerves has been known for a long time, but the explanation of this phenomenon has only recently been found. The experimental work of Cardot and Laugier13 and of Bourguignon14 has shown that the negative pole is always the active one on making the current, and that the electrical current invariably flows from the cathode to the anode. It is clear, therefore, that when the small stimulating electrode is placed in close proximity to the nerve, a greater response from the concentrated stimulus results, while, when the large, distant electrode is the origin of the current, a diffused and weakened stimulus reaches the nerve from it or from the secondary negative pole, which it causes to appear deep in the tissues. Furthermore, if the nerve is degenerated, the concentration of the current from the small active electrode upon it has little effect, while the relatively more greatly diffused current when the opposite polarity is used, due to its diffusion, stimulates the muscle over a wider area, thus accounting for the apparently greater reaction with the positive pole. Another important point which has recently received more attention is the increased irritability of the paralyzed muscle to direct galvanic stimulation, the quantity of current necessary for contraction being less than for the normal muscle. This statement requires qualification, for it holds true only for a few weeks after the nerve has been injured, and the response is obtained only by 4..097—27----62 944 SURGERY direct stimulation of the muscle at its tendon insertion and not through its nerve. The increase in galvanic irritability is coincident with increased mechanical irritability, or increased ideomuscular reflex, demonstrated by tapping the muscle. It is worth noting in this connection the interesting observations made by Langley15 that immediately following section of the nerve the paralyzed muscle is in a state of constant fibrillary twitching, during the time when rapid atrophy is taking place. The association of increased electrical and mechanical irritability, the constant fibrillary activity, and the rapid atrophy when the nervous control of the muscle is removed are instructive as illustrating the loss of inhibition brought about by severing the connection between the anterior horn cell and the muscle. Practically it is possible to utilize this increase in irritability in examination and treatment. The use of strong currents causes contraction of healthy muscles, wliich may be misinterpreted as the contraction of paralyzed muscles or may make it difficult to determine if the muscles wdiich are being tested are responding. The use of the weakest current which will cause contraction in paralyzed muscles will help to eliminate this difficulty, as this intensity of current does not contract healthy muscles. Finally the importance of the duration of the application of a current necessary to produce a contraction in a normal muscle has been recognized, and the attempt to apply this knowledge to diagnosis has resulted in the addi- tion to the instruments used for electrical examination of the condenser. It has been found that under fixed conditions for every muscle with a normal nerve supply a definite duration of stimulus is necessary for contraction with a minimal current. The slightest injury to the nerve causes an increase in the time required to produce a contraction with this minimal current, and the degree of injury is reflected in the relative increase in time. Adrian10 has shown that the normal nerve has a "quick mechanism," responding to a very short stimulus, while the muscle deprived of its nerve requires a stimulus much longer, at least one-hundredth of a second. Expressed in figures it may be stated that a normal muscle will respond to electrical stimulus of 100 volts potential applied to its nerve for about one twenty-four-thousandths of a second. After injury to the nerve has taken place, the duration of the stimulus must be increased to from one five-hundredths to one one-hundredth of a second. The average faradic impulse lasts approximately one one-thousandth of a second, and this current therefore soon becomes ineffective as the nerve degenerates. To provide an instrument which will readily indicate the time necessary to produce a contraction, the condenser as adapted by Sir Lewis Jones,16 or some modification of it, has been brought into wide use. By using the dis- charge through a constant resistance of condensers of different capacity charged at the same voltage, a numerical value could be obtained of the duration^ current necessary to produce contraction, and this recorded figure was then available as a basis for comparison on subsequent examinations. The value of this addition to our investigating instruments has been differentlv stated by various users, and widely different opinions have been expressed. It is agreed that it furnishes confirmatory evidence of nerve injury bv showino- the increased time necessary to produce a muscular response. It has been claimed that it has value in showing in which direction the injury to the nerve is pro- XEUROSURGERY 945 grossing, a gradual increase in time necessary to produce a response indicating a lesion which is increasing in severity and therefore requiring operation, and a shortening of the time, a tendency to spontaneous cure, contraindicating operative interference. It would thus have its greatest value as a measure of the progress toward recovery in cases of nerve injury where operation was postponed because a degree of function remained. An effort was made to gain further information about the condition of the nerve by noting the effects of stimulation of nerves exposed at the time of operation. This was accomplished by using specially constructed electrodes of two wires separated by beads and surrounded by glass tubing. Such an electrode can readily be sterilized. By the use of a weak faradic current the exposed nerve was stimulated directly, and if any response was obtained a partial lesion could be recognized and the surgical treatment modified accord- ingly. The large number of nerves which were exposed by war injuries gave an unusual opportunity to study the internal geography of the nerve by elec- trical stimulation, and it is regrettable that advantage was not more fully- taken of the opportunity, as the knowledge gained is of inestimable value in the intelligent surgery of the peripheral nerves. However, a considerable number of observations were made, and these have supplemented the careful anatomical studies made by A. Stoffel,17 who was the first to show the great practical value of a knowledge of the internal topography of nerves. The methods of examination as actually carried out in Army hospitals devoted to treatment of cases of peripheral nerve injuries may have value as a matter of record. The apparatus used was chiefly the Wappler galvanic- faradic plate equipped with a sliding induction coil of the DuBois-Revmond type, milliamperemeter, rheostat, and pole changer, and the modified Lewis Jones condenser. These instruments were connected with the lighting current. Whenever possible patients were examined on return from the physiotherapy department, as the massage of the paralyzed muscles made their response to electrical tests more satisfactory. The room was kept warm enough to prevent chillino- of the skin and the electrodes were covered with wet cotton or chamois skin so as to diminish skin resistance as much as possible. When testing with the o-alvanic, the current was allowed to pass for a while through the muscle before being broken, as suggested by Erb, a better response being thereby obtained. The bipolar method was used practically exclusively, the large indifferent electrode being placed on the sternum or spine and held by the patient, and the small one being manipulated by the examiner. The small electrode was equipped with a spring on the handle to facilitate making and breaking the current. To determine the polarity of the stimulating electrode in case of uncertainty, the ends of the connecting cords were placed in a glass of water the negative pole being indicated by the ebullition of bubbles. The amount of current necessary to produce contraction was determined on the corresponding muscle of the opposite extremity. The examinations were recorded in terms of the individual observations, rather than in terms of the conclusions to be drawn from them. Where all the muscles supplied by a single nerve were paralyzed, this was recorded as a group; when only part of them were affected, the individual muscles were specified. Observations were 946 SURGERY recorded of the following facts: The presence of sensibility to faradic currents in the skin supplied by the nerve to be tested; the response of the muscle to stimulation with the faradic current at the motor point and directly over the body of the musele; the response to stimulation of the nerve with the galvanic current; the character of the response of the muscle to stimulation directly at its tendon insertion as to speed and strength of response and the relative effectiveness of opposite poles. In some of the clinics the condenser examina- tion was part of the routine. Examinations were made at about monthly intervals and the results charted on a specially devised blank outline. The conclusions drawn may be here briefly summarized. Loss of skin sensibility to the faradic current in the most distal area of distribution of a nerve, usually associated with a corresponding loss of deep pressure, vibratory, and joint sensibility, was almost regularly found to indicate complete inter- ruption of the nerve. In the few cases observed which seemed to invalidate this conclusion two explanations were considered possible. Lnless careful microscopic sections were made of the fibrous tissue which invariably was found in the gap of a severed nerve, one could not be certain that some aberrant fibers carrying sensation were not contained in it. The other possibility, and one which has a correct anatomical basis, is that anastamosis may occur below the site of the lesion between the injured nerve and one running parallel to it. The return of faradic sensibility to the skin was usually the first certain evi- dence of returning function. Loss of response to stimulation of the nerve or muscle with faradic current was invariably found with any degree of traumatic injury to the nerve sufficient to cause motor or sensory disturbances. Immediately following injury the motor and sensory loss was usually over a greater area than could be accounted for by the nerve involved. This condition might rapidly disappear or persist. In the latter case the faradic response readily disclosed which muscles were actually deprived of their nerve connections and which were functionally paralyzed. A normal response in all muscles to faradic stimulation, therefore, was considered to eliminate the possibility of peripheral nerve injury, the paralysis being in such case either hysterical or due to involvement of the central rather than the peripheral nervous system. The phenomenon described by Erb, in wliich faradic stimulation above the site of the lesion gives no response but stimulation of the nerve below or of the muscle produces con- traction, must be guarded against. This condition is interpreted as indicating either a functional blocking of the nerve due to compression or an injury so recent that secondary degeneration is not complete. Kraus18 has called atten- tion to a similar phenomenon on stimulation of the exposed nerve. Return of voluntary motion invariably preceded the return of response to the faradic current. Stimulation of the injured nerve with the ordinary galvanic current also failed to give a response no matter how mild the lesion, and this method of examination, therefore, tells us nothing about the pathological condition of the nerve. It is m this part of the electrical examination that the condenser was expected to yield information of value, for by increasing the duration of the current a reaction could be obtained when the nerve was not completely NEUROSURGERY 947 interrupted. The modified Jones condensers used in the Army hospitals were graded to give a discharge at 100-volt potential from 0.01 microfarad to 2 micro- farads. Normal muscle gave a response to the shortest of these discharges. Follow-ing injury the duration had to be progressively increased as degener- ation of the nerve took place. Of course, when division was complete and followed by secondary degeneration, no length of condenser current gave a contraction. The changes observed by direct stimulation of the paralyzed muscle with the galvanic current were of the greatest value. Uniformly the muscle failed to respond when stimulated over its motor point, but responded with increased rritability when the electrode was applied over the insertion of its tendon, giving the so-called "longitudinal reaction." The response was delayed, wave- like, or creeping in character, and in general the degree of slowness was an indication of the severity of the lesion. Thus the contraction immediately after injury was still quick, but became slower as the nerve degenerated, and the reverse process took place as the nerve gradually regenerated. When muscles remained without treatment for a prolonged period, such fibrosis might take place that very slight or no contraction could be obtained. This condition warranted a poor prognosis. Occasionally stimulation with the gal- vanic current gave a tetanic contraction. This phenomenon has been recog- nized for a long time in the literature of the subject, but no explanation is given for it. Since it occurred with all degrees of nerve injury, its occurrence could not be used as a diagnostic criterion. Finally a reversal of polarity was commonly found associated with a com- pletely interrupted nerve; that is, the contraction obtained with the anodal closing current was greater than the cathodal closing current. While this phenomenon was occasionally observed in normal muscles, no confusion resulted, as other signs of injury to the nerve were always essential to make a diagnosis of nerve injury. It has been stated by some observers that massage will change the polarity of a muscle. It was assumed, then, that when the application of the faradic current over the sensorv distribution of a nerve was not perceived, and the muscles failed to respond to stimulation with this current, when galvanic and condenser current failed to cause contraction, and muscle stimulation with the galvanic current over its tendon insertion showed an increased contraction of a wave- like, creeping character, with reversal of polarity, a diagnosis of complete interruption could almost safely be made. Partial interruption or compression would be indicated correspondingly by fewer of these signs. In summarizing the wTork on electrical examinations, the question that naturally arises is, does this method of investigation give sufficiently accurate and valuable data to the surgeon to repay him for the time spent in carrying it out. Conservative opinion seems to be agreed that this question can be answered in the affirmative. Its greatest value, surely, is in the period which follow-s shortly after the injury, when with complete motor and sensory paraly- sis a reaction of degeneration would influence the surgeon to early operative interference. It must be confessed that w-hen such a condition remains sta- tionary for six months or longer, an electrical examination is no longer needed to determine the advisability of operation. 94N SURGERY REFERENCES (1) Galvani, Aloysius: De viribus elcctricitatis in motu musculari comnientarius cum Joannis Aldini dissertatione et notis. Mutinae, apud socictatem typographicam, 1792. (2) Du Bois-Reymond, Emil: Untersuchungen iiber thierische Elektricitiit. Ci. Reiiner Berlin, v. 1, 1X48, 258: 447. (3) Duchenne (de Boulogne): Exposition d'une nouvelle methode de galvanisation, dite galvanisation localiscc. Archives generates de medecine, Paris, 1850, xxiii, 257: 420. (4), Pfliiger, Eduard: Ueber die tetanisirende Wirkung des constanten Stromes und das allgemeine Gesetz der Reizung. Yirchow's Archiv fur pathologische Anatomic und Physiologie und fur klinische Medicin, Berlin, 1858, xiii, Nos. 4-5, 437. (5) Remak, Robert: Application du courant constant au traitement des ncvroses. Germer Bailliere, Paris, 1865. Oi.) Erb, Wilhelm: Handbook of Electrotherapeutics; translated by L. Putzel. William Wood & Co., New York, 1S83, 74. (7) d'Arsonval, A.: Production des courants de haute frequence et de grande intensite; leurs effets physiologiques. Comptes rendus hebdomadaires des seances et memoires de la societe de biologie, Paris, February 4, 1893, 9 s., v, 122. Also Nouveaux modes d'application de 1'energie electrique: La voltaisation sinusoidale; Les grandes fre- quences et les hauts potentiels. Bulletin de I'academie de medecine, Paris, March 22 1892, 3 s., xxvii, 424. (8) Sherrington, C. S.: Break-shock Reflexes and "Supramaximal" Contraction-response of Mammalian Nerve-muscle to Single Shock Stimuli. Proceedings of the Royal Society of London, Series B, London, 1921, xcii, No. B 246, 245. (<)) Lucas, Keith: The Conduction of the Nervous Impulse. Longmans, Green and Com- pany, London, 1917. (10) Adrian, E. D.: The Electrical Reactions of Muscles before and after Nerve Injury. Brain, New York, 1916, xxxix, Pts. 1 and 2, 1. See also Adrian, E. D. and Forbes, A.: The All-or-nothing Response of Sensory Nerve Fibers. Journal of Physiology, Cambridge, 1922, lvi, No. 5, 301. (11) Forbes, A., Ray, L. H., and Griffith, F. R.: The Nature of the Delay in the Response to the Second of Two Stimuli in Nerve and in the Nerve-Muscle Preparation. American Journal of Physiology, Baltimore, Md., 1923, lxvi, No. 3, 553. (12) Lapicque, Louis: Sur l'interpretation des electromyogrammes. Journal de radiologic et d'electrologie, Paris, 1923, No. 6, 249. (13) Cardot, H.. and Laugier, H.: Localisation des excitations de fermeture dans la methode unipolarie. Comptes rendus hebdomadaires des seances de I'academie des sciences, Paris, Feb. 5, 1912, cliv, 375. (14) Bourguignon, G.: La forme de la contraction a, l'etat normal et pathologique. Journal de radiologic et d'electrologie, Paris, 1914-1915, i, No. 5, 261. (15) Langley, J. N.: Remarks on the Cause and Nature of the Changes which Occur in Muscle after Nerve Section. Lancet, London, July 1, 1916, ii, 6. (16) Jones, H. Lewis: The Use of Condenser Discharges in Electrical Testing. Archives of the Roentgen Ray, London, 1913, xvii, No. 12, 452. (17) Stoffel, A.: Zum Bau und zur Chirurgie der peripheren Nerven. Verhandlungen der deutschen Gesellschaft fur orthopddische Chirurgie, Stuttgart, 1912, xi, 177. (18) Kraus, Walter M., and Ingham, Samuel D.: Peripheral Nerve Topography Seventy- seven Observations of Electrical Stimulation of Normal and Diseased Peripheral Nerves. Archives of Neurology and Psychiatry, Chicago, 1920, iv, No. 3, 259. CHAPTER XI TECHNIQUE OF NERVE SURGERY INTRODUCTION In presenting a system of technique on the operative treatment of periph- eral nerve lesions, it is assumed that the reader is familiar w-ith the histo- pathology and pathologic physiology of peripheral nerve tissue when visited with disease or subjected to injury; it is only on the basis of a thorough under- standing of the histologic and physiologic principles involved that a rational operative treatment may be founded. Fortunately, these principles, placed upon a sound footing more than two decades ago, have been amply verified by subsequent experimentation and consistently upheld by the innumerable clinical observations afforded by the vast amount of material supplied by the casualties of the World War. The conclusions arrived at by Howell and Huber in 1891, in their many experimental studies of peripheral nerve physi- ology, degeneration, and regeneration may still serve as a general text for a rational system of procedure in the operative treatment of peripheral nerve lesions. Probably in no other type of surgery will the end results so emphatically demonstrate the necessity of subserving physiologic principles. It has been generally known that the fibers of one nerve trunk, when anastomosed to the distal segment of another nerve, will regenerate satisfactorily through the adopted nerve; this fact was utilized in hypoglosso-facial anastomosis for the correction of facial paralysis, though the principle governing this procedure was not based upon a complete physiologic appreciation of all the factors in- volved. This operation demonstrates the principle of anatomic surgery, in which fibers are supplied to the denervated muscles of the tongue by the anas- tomosing of one nerve into another. The physiologic principle ignored in this type of anastomosis is manifest in the end results, namely, the paralyzed facial muscles, though having regained some motor power, still remain immobile to emotional facial expression, contracting synchronously with lingual movements durin^ mastication or deglutition. While the paralyzed facial muscles were re-innervated, the innervation from a physiologic standpoint was doomed to failure, because the new fibers innervating the facial musculature are hypoglossal fibers, capable of subserving hypoglossal function only—motor function to the tongue__wliich is in no way correlated to the emotional reactions expressed through the facial musculature. This represents but one type of physiologic transgression in the surgery of nerves. Most peripheral nerves are both motor and sensory in functions; the motor portion of the nerve trunk, derived through a neuraxon outgrowth from the motor cells in the anterior horns of the spinal cord, carry efferent motor im- pulses; the sensory portion of the nerve trunk is composed of fibers which carry 949 950 SURGERY sensory or afferent impulses through the posterior horns of the cord. Those motor and sensory fibers, though anatomically incorporated within a single nerve trunk, are from a physiologic standpoint totally unrelated; this well- known physiologic fact, wThen given due consideration, immediately elevates the operation of nerve suture from the domain of anatomic to that of physiologic surgery. The anatomic principle of simply obtaining a satisfactory end-to-end approximation of a divided peripheral nerve, adequate to permit the passage of regenerating fibers, does not suffice in nerve surgery, for it may, from a physio- logic standpoint, be very imperfect, in that the motor fibers in regenerating may enter sensory channels leading to sensory terminations, and these motor fibers, not being able to subserve sensory function, would be physiologically lost. A study of the end results following nerve suture has amply demonstrated that perfect anatomic sutures are frequently attended by only a partial restora- tion of function, and occasionally by its total absence. At best, the unqualified anatomic principle of nerve suture, without regard to the physiologic differen- tiation of fibers, can be nothing more than a hit-or-miss method of procedure. If in the approximation of the ends of the divided nerve the surgeon is fortunate enough to approximate motor fibers to the motor channels in the distal segment and sensory fibers to their respective channels, the ultimate results—if regenera- tion is unimpeded in both nerve and muscle—should be a complete restoration of function. The possibility of a physiologic approximation, if left wholly to chance as in an ungoverned anatomic suture, can be seldom expected, though in the majority of instances some motor fibers will probably (by chance) reach motor channels and regenerate to a motor termination; no doubt many will be lost, and our experience seems to indicate that the regenerating motor and sensory fibers are incapable of selecting their respective physiologic channels. The principle of physiologic approximation resolves itself almost entirely into the prevention of torsion of the nerve trunk during suture; the most important factor involved in the technique of nerve surgery depends upon our ability to prevent or correct this unfortunate incident. While end-to-end approxima- tion is absolutely essential to neuraxon regeneration, physiologic approximation is indispensable to the restoration of function. An adequate conception of physiologic principles will immediately enable the surgeon to disregard many of the older operative procedures of nerve anastomosis, more or less brilliant from a purely anatomic standpoint, but absolutely futile wiien considered in the light of our present knowledge. An appreciation of the fact that each fiber within a nerve trunk has to a greater or lesser degree some functional individuality should lead the surgeon to a realization that, though it is within his power to change the anatomic course of these fibers, their physiologic attributes remain unchanged; at best, his most painstaking and careful operative manipulation, however ingenious from an anatomic standpoint, loses in functional value in direct proportion to the perversion of the original physiologic pattern. Satisfactory end results in nerve surgery depend primarily upon a full appreciation of physiologic function and our ability to conserve the anatomic characteristics compatible with the normal expression of that function. NEUROSURGERY 951 THE GENERAL TECHNIQUE ANATOMIC REQUIREMENTS Primarily it is essential that the operator have that practical working knowledge of peripheral nerve anatomy which is acquired and maintained only by frequent recourse to the dissecting room. It is particularly impor- tant that he be familiar not only with the general course and relationship of nerve trunks, but also the origin and distribution of the various branches as they arise; it is not only essential that these branches be preserved in dis- section, but they must also be exposed and accurately identified in order to determine, by their intraneural position, the intraneural topography of the nerve trunk. While no dogmatic rule may be laid down regarding the point of separation—superficial origin—of branches from the parent trunk, their intraneural course, as a rule, is sufficient!}- constant to permit a fair degree of accuracy in topographical identification. It is usually necessary that the particular branch under consideration be liberated for a short distance up the nerve trunk, in order that its exact intraneural position be accurately deter- mined. Occasionally a motor branch may have its superficial origin from the sensory side of the nerve trunk, but its deep intraneural position will usually be found to be in that sector of the nerve trunk which contains the motor bundles. The exposure and identification of motor and sensory branches, arising from a peripheral nerve, is of exceedingly great value in topographical localization, as their intraneural localization will nearly always indicate that portion of the nerve trunk which subserves their respective function, either motor or sensory. PREPARATION OF AN EXTREMITY FOR OPERATION It is important in nerve operations that the skin of the entire extremity be sterilized from a point some distance above the proposed incision. The necessity of sterilizing the peripheral portion of the extremity is due to the fact that manipulation of the entire limb is frequently necessary during an operation; the observation of the entire limb during electrical stimulation of the nerve is essential to determine the action of individual muscles. This is particularly important in the hand. Occasionally a sterile rubber glove may be used to cover the hand of the patient, when adequate sterilization is doubt- ful. The glove usually will permit observation of muscle action. The drap- ing of an extremity should always be arranged in such a manner as will facilitate observation and manipulation without contamination; the surgeon should personally direct the placing of protective sheets and towels with this object in view. Position The position of an extremity, for operation upon one of its principal nerves, should be planned with as much forethought as might be given to any other step of the operation; the surgeon should endeavor, by the effective placing of sand bags, to maintain the extremity in a position conducive to the comfort of the patient as well as to his own convenience. A third assistant, or a sterile nurse with specific instructions, should be retained to maintain the extremity in the desired position of flexion, when flexion-relaxation is utilized in the correction of continuity defects. 952 SURGERY ANESTHESIA Local anesthesia, in the writer's experience, has supplanted all other types of anesthesia for peripheral nerve work. Its proper use is attended with complete analgesia, with the retention of motor function. It permits the use of the electro-anatomic method of funicular identification; it greatly diminishes the oozing encountered in scar tissue dissections; and avoids the disagreeable complications attending inhalation anesthesia. The following technique is used in producing local anesthesia: A 1 per cent solution of novocaine or procaine is used, to each ounce of which 15 minims of a fresh 1:1,000 adrenalin chloride solution has been added. The line of pro- posed skin incision is carefully infiltrated, producing a continuous line of intra- dermal wheals. The needle is now passed into the subcutaneous tissue for a depth of \y2 cm., where 1 c.c. of the solution is injected; the needle is then directed deeper and a second injection is made. Without withdrawing the needle, which should be sufficiently long to reach the nerve, these injections are made at an increasing depth until the tissues surrounding the nerve have been reached. These subcutaneous injections are made about 2 or 2*-^ cm. apart, along the entire line of the proposed incision. At each injection, in deep infiltration, particularly in the region of a large vessel, the piston of the syringe should be slightly withdrawn before any of the solution is injected, to determine the possibility of an intravascular penetration; if blood is aspirated the needle should be redirected. It is usually neither necessary nor desirable to inject the nerve until it is ready for section, unless pain is experienced. After the field has been thoroughly infiltrated, pressure is used for a few minutes to promote the diffusion of the solution through the surrounding tissues. If it be necessary to carry a dissection to the surface of a bone, its periosteum should be infiltrated. When the incision and surgical manipulations are confined to the infiltrated areas, they are absolutely painless and frequently bloodless; and, as most peripheral nerve operations are attended with much scar tissue dissection, this bloodless field is highly desirable. EXPOSURE OF THE NERVE The importance of long incisions and adequate exposures can not be too greatly emphasized in the surgery of peripheral nerves. It has usually been our experience that a seemingly adequate incision will require lengthening before the operative procedure is completed. This possibility should always be borne in mind during the preparation of the skin and draping of the extremity, for by so doing the surgeon will avoid the risk which attends invasion of parts not adequately prepared. One of the greatest mistakes a surgeon can make is to attempt the exposure of a nerve in a scar-invaded region; for safety's sake alone, without a considera- tion of other advantages, the surgeon should make it his invariable rule to expose the nerve above and below the lesion, when the location of the lesion will permit. The nerve, having been exposed in a region where normal anatomic relationships prevail, may then be followed through the scar-invaded area where these anatomic guides have been distorted or lost. NEUROSURGERY 953 The prevention of scar tissue following nerve operations is of paramount importance; and while it can not be wholly obviated, there is no doubt but that it may be greatly mitigated by a careful operative technique. Scar tissue fol- lowing surgical intervention is usually the result of tissue trauma, inadequate hemostasis, and infection. Tissue trauma may be reduced to a minimum by careful, clean-cut dissections, confined when possible to normal lines of cleavage. A common source of tissue trauma lies in the use of artery forceps and the liga- tion of vessels. When it is necessary to clamp a vessel, no more tissue than is absolutely necessary should be crushed to secure the vessel. The habit of crushing and ligating the entire area around a vessel is greatly to be deplored, as it is accompanied by considerable tissue strangulation and subsequent necrosis, inviting infection and scar formation. Blunt and finger dissection, which is so frequently associated with tissue tearing and extensive trauma has no place in the surgery of peripheral nerves. The use of antiseptics, such as iodine, within the wound is to be condemned. It is desirable to cover the skin edges with clamped towels, as complete skin sterilization is often questionable. Parts of the incision which are not receiving immediate attention may be prevented from drying and protected from contamination by cotton pads saturated w-ith warm saline. Scar tissue dissections, w-hich under general anesthesia would be associated with constant oozing, are often rendered blood- less by infiltration anesthesia, and by the time the constricting action of the adrenalin has disappeared clotting has occurred in those oozing points which so often defy ligation. A time-saving procedure in the dissection of neuro- vascular bundles is preliminary control of the circulation by isolation of the veins below the lesion and the artery above, which structures may be tem- porarily constrict ed by tape to control hemorrhage following vascular accidents. Nothing is more deplorable than to see a surgeon blindly attempting to grasp an unseen bleeder in a pool of blood; in nerve surgery such a procedure is fraught with so great a degree of danger to nerve trunks and branches that it is inexcusable, in that it may usually be obviated by using sufficient precaution for vascular control. DEFECTS IN NERVE CONTINUITY When a nerve is divided its ends tend to retract in the surrounding loose connective tissue, where they become fixed with the process of healing and the formation of scar tissue, making a defect in nerve continuity. In certain instances a portion of the nerve trunk may be completely destroyed or trauma- tized to such an extent as to obliterate its recognizable anatomic continuity; more frequently, however, the nerve so suffers from the devastating effect of infection and subsequent scar-tissue proliferation that large sections must be sacrificed before normal-appearing nerve bundles are found in its ends. Various procedures have been recommended for the correction or filling of nerve defects, many of wliich have little, if any, physiologic grounds for support. Mechanically, some of the procedures recommended for the filling of defects, such as the interposition of tubes and various other foreign materials, may appear to be verv ingeniously conceived, but from a physiologic standpoint they were often so defective that the probability of recovery was actually 954 SURGERY minimized by the procedure. To permit nerve regeneration, direct anatomic approximation of the nerve ends must be attained. In certain instances when this is found to be impossible, the use of the autogenous cable graft is justified for filling defects, but at best it seems to promise but a very moderate degree of functional restoration. The interposition of heterogenous nerve grafts has been so universally unsuccessful in clinical experience that their use is to be dis- couraged. Various procedures, such as nerve implantation into neighboring nerves and the neurotization of paralyzed muscles, have so little to recommend them from a practical standpoint at the present time that they may be dismissed from the category of effective clinical procedures. The following methods of correcting continuity defects in peripheral nerves are the only ones whose functional end results, in our experience, justify usage: (1) Primary nerve stretching; (2) flexion-relaxation; (3) nerve transposition; (4) stretching with secondary suture (two-stage operation); (5) autogenous cable grafts; (6) viable neuroplastic transplants; (7) bone shortening. PRIMARY STRETCHIXG Primary stretching will overcome many of the lesser defects. It consists of freeing the nerve trunk beyond the area of scar tissue fixation and drawing its ends together by gentle traction. Extensive mobilization of a nerve trunk permits a proportionately greater stretching. It is particularly necessary to freely mobilize the nerve beyond the region of extraneural adhesions, but in doing this, great care should be exercised in avoiding injury to branches. FLEXION-RELAXATION The majority of nerve defects may be corrected by taking advantage of the relaxing effect upon a nerve trunk, by flexion of governing joints. The approximation of the nerve ends is made possible, after the nerve is prepared for suture, by flexing the governing joint, in which position it is maintained, after the nerve is approximated, by suitable splints until the wound is healed; after which the mobilizing splints are occasionally changed to permit a gradual extension of the flexed extremity. In our study of end results of nerves under tension or those stretched by the foregoing method, we have not found that this stretching seriously interferes with regeneration; in fact, some of our best end results have been observed in cases where approximation was attainable only under considerable tension. In our early experience, when flexion-relaxation was used in overcoming large defects, we maintained the limb in the position of primary flexion for a period of six weeks; later, however, this period of fixed flexion was reduced to two weeks, after which the gradual extension of the extremity was permitted at the rate of approximately ten degrees every second day. NERVE TRANSPOSITION The course of certain nerves in the arm may be made more direct and thereby shortened by transferring them from a dorsal to a more ventral plane. This procedure is commonly used to great advantage in overcoming the more extensive defects. NEUROSURGERY 955 The ulnar nerve in its normal position behind the internal condyle is not relaxed by flexion of the elbow until it has been transposed to a position anterior to the internal humeral condyle. This procedure not only somewhat shortens its course but also renders it susceptible to flexion-relaxation. The musculospiral nerve is occasionally transposed, being directed from its posterior humeral course to one anterior to the humerus. Large defects in the median often require for their correction a transposition of the nerve from its deep position below the superficial head of the pronator teres to one ventral to this muscle." In the transposition of nerves it is essential that the operator be familiar with the various branches given off from that portion of the nerve trunk requiring mobilization; these branches must be freed some distance up the nerve trunk by an intraneural dissection to permit mobilization without their avulsion. It is also essential to place topographical markings on both proximal and distal segments of the nerve by means of well placed identification sutures, before the position of these segments has been disturbed and anatomic relationships lost, in mobilization. STRETCH1XG, WITH SECONDARY SUTURE (TWO-STAGE OPERATION) After a divided nerve has been exposed and found to present a defect, the surgeon should determine means of correcting this defect before the neuroma and scar tissue have been excised from the ends of the nerve. If it be found that the defect will not lend itself to correction by one of the foregoing methods, the operator must then resort to the two-stage operation. This consists in extensive mobilization of the nerve trunk after it has been marked with topo- graphical identification sutures, and all possible relaxation has been attained by transposition and flexion-relaxation. The unsectioned nerve ends are drawn together by one or two strong chromic catgut traction sutures, using sufficient tension to permit, if possible, an overlapping of the nerve ends to a point approximating that which will correct the defect, after the scar tissue has been resected; or at least, to obtain as much overapproximation as pos- sible. The w-ound is now- closed, and after one week the extension of the extremity begun, the object being a gradual stretching of the nerve trunk. When this has been accomplished by complete extension of the extremity and the wround is entirely healed so that it is safe for a secondary aseptic invasion, the nerve is again exposed; the neuroma and scar tissue are resected and the freshened ends approximated by again utilizing the assistance of flexion-relaxa- tion. The extremity is splinted in this position for a period of two weeks, after which extension is gradually encouraged. Many of the defects encountered in extensive lesions of nerves have been corrected by a two-stage operation, and only when the nerve defect is of such magnitude as not to be corrected bv the above method are we justified in resorting to grafting. NERVE GRAFTS From an experimental standpoint, nerve grafting has attracted considerable interest and much has been expected from this procedure; from a clinical stand- a The technique of transposing the above nerves is considered in detail under the surgery of special nerves. 956 SURGERY point, however, the end results have been very disappointing. A review of end results in so far as functional restoration is concerned, in 15 cases in which the operations were done by different operators, shows that functional restoration was nil, with the exception of one instance in which there was some return of sen- sation in a low- median graft. (This restoration consisted, after four years, in simply the restoration of a nondiscriminative sensation in the index and middle fingers. All sensation, including touch, pin prick, heat, and cold, were inter- preted as tingling—differentiation not being possible.) In the writer's experi- ence, a number of homogenous refrigerator grafts were tried out; in each instance the condition of the wound was favorable and remained so through- out the healing process, though in no case was there any clinical evidence of regeneration. These grafts when subsequently removed showed a total absence, histologically, of nerve fiber regeneration, and the proximal end of the nerve trunk exhibited a secondary neuroma. In most of the above instances it was later found possible to obtain satisfactory end-to-end approximation by the above-described two-stage operation. With increasing experience in dealing with large defects, we found that in most instances it was possible to repair the defect by a two-stage operation, thereby almost entirely eliminating the necessity for grafts. Occasionally, however, defects are found of such magni- tude that the only possibility of nerve repair lies in grafting, but as a rule such cases, by virtue of their severit}-, the extent of tissue destruction and scar tissue formation, promise but little in the way of satisfactory functional restoration. It must be remembered that the experimental work of nerve grafting which has been attended with such satisfactory results has been done in relatively small defects under extremely favorable conditions from a surgical standpoint. Such satisfactory conditions are rarely encountered clinically because of the severity of the original lesion which makes nerve grafting necessary. Autogenous Cable Grafts Autogenous cable grafting consists in exposing the ends of both proximal and distal segments of the divided nerve and preparing them for suture. The length of the defect between the nerve ends is measured and the grafts to be inserted are selected from convenient sensory nerves. In the arm the following nerves may be utilized: Radial (sensory portion of the musculospiral), sensory portion of the musculocutaneous, internal cutaneous. In the leg: Sensory por- tion of the musculocutaneous, tibial, and peroneal recurrent, the sural branches of the peroneal nerve. One or several segments from one or more of the sensory nerves, of sufficient length to fill the defect, are removed and trans- planted to fill the gap betw-een the ends of the damaged nerve. These sensory branches are usually so small that several are required in making a cable which will approximate in size the nerve trunk. After a cable graft of sufficient size and length is obtained, it is carefully anastomosed to the ends of the nerve trunk and in this way made to bridge the defect. It is essential to obtain accurate end-to-end approximation between both ends of the nerve trunk and graft. If a defect in a small nerve is being bridged, it may be possible to obtain a sensory graft of approximate size, thereby eliminating "the necessity of using NEUROSURGERY 957 several grafts as a cable. It is particularly important that a favorable bed be found to protect the grafted nerve. The writer, in the removal of a number of unsuccessful grafts, has found them converted into strands of fibrous tissue; in a few instances some regenerating neuraxons were found to have penetrated the proximal end of the implant. -J :£__. hut in none had they succeeded in completely traversing the graft. VIABLE NEUROPLASTIC TRANSPLANTS 111 irreparable defects of combined nerve lesions, such as the median and ulnar or the tibial and peroneal portions of the sciatic trunk, the writer, by sacrificing the nerve of lesser importance, devised a method of filling the defect in the more important nerve with a viable transplant. In this procedure. for example, in a combined median and ulnar irreparable defect, the median considered to be the nerve of greater im- portance, the end of its proximal segment is anastomosed by end- to-end suture to the proximal end of the ulnar nerve—the nerve of lesser importance— permitting the median fibers to regenerate around the loop so formed by the anastomosis and up the ulnar trunk. The ulnar nerve is divided the required distance (length of median defect) above its anastomosis to permit the degeneration of its fibers in that portion of the trunk which subsequently is to be used as a transplant, thereby preparing it to receive the regenerating fibers of the median nerve. The trunk of the sacri- ficed ulnar nerve remains undisturbed in its original position, to conserve its nutrition during the migration of median fibers through its entire length. Before the transplant is utilized, it is allowed one month for each inch of its length plus one month's grace, to assure regeneration through its entirety. The upper end of the adopted trunk may be placed subcutaneously if desired, where it can be readily palpated and percussed to determine the growth of nerve fibers to its extremity—the presence of regenerated fibers may be readily demon- strated bv Thiol's sign, thus assuring the surgeon of the viability of the trans- plant before it is turned down at the second stage of the operation. The advantage of the viable neuroplastic transplant is that its nutrition is maintained during neiiraxon regeneration, and at the time of use it has, to Fig. 150.—Bundle or "cable" graft, using an autosensory nerve for repair of the defect. (Xey. Annals of Surgery, 1921) 957—27---65 992 SURGERY SITROKRY AXILLARY KXl'OSCRK Exposure of the circumflex nerve is obtained, as in low lesions of the brachial plexus, with the arm in outward rotation and marked abduction. The incision is made over the course of the neurovascular bundle from the middle of the clavicle to a few centimeters below the tendon of the pectoralis major. The deltoid is separated from the pectoralis major and the cleft between these muscles deepened to expose the deep pectoral fascia. (See figs. Kio, 166, 167.) The pectoralis major is divided near its insertion into the humerus and reflected. The deep pectoral fascia is now divided to expose the neuro- vascular bundle. The median nerve and the axillary artery are identified and retracted medially, exposing the musculospiral nerve passing over the latissimus dorsi tendon. The musculospiral nerve is now followed upward to a point near the insertion of the pectoralis minor, where the circumflex will be found joining its lateral side to form the posterior cord of the brachial plexus. When thus identified the circumflex nerve may be followed around the medial side of the neck of the humerus to where it leaves the axilla by passing through the quadrilateral space to the dorsum of the arm. DORSAL OR LATERAL EXPOSURE Occasionally the circumflex nerve is injured after it has left the axilla in its passage around the surgical neck of the humerus. To approach lesions in this region a dorsal or lateral exposure is needed. The patient lies on his side with the arm acutely flexed across the chest, giving access to the posterior deltoid region. A longitudinal incision is now made approximating closely the dorsal border of the deltoid. This musele is elevated and retracted forward. Retraction may be facilitated by elevation of the arm, relaxing the deltoid. Occasionally it will be found advisable to divide some of the posterior deltoid fibers. The circumflex nerve will be found hugging the neck of the humerus, as it emerges from the quadrilateral space, accompanied by the posterior cir- cumflex artery and it^ verne comites. Isolated lesions of the circumflex nerve are comparatively rare, though deltoid paralysis is frequently associated with brachial plexus lesions,'particu- larly those involving the upper trunk. Fortunately, the muscle's of the shoulder girdle are supplied by branches given off from the brachial plexus at various points, so that a total paralysis of the shoulder is seldom encountered except in complete brachial plexus lesions. Individual nerves supplying the muscles of the shoulder and shoulder girdle run a relatively short course before breaking up into terminal branches to supply their respective muscles so that their repair is as a rule exceedingly difficult; in fact their short course usually eliminates the possibility of effecting end-to-end approximation where a defect is present. Practically the only recourse the surgeon has when confronted with a serious defect m a nerve of short course is to resort to nerve grafting or viable transplants. This is particularly true in regard to isolated lesions of th. circumflex nerve. XEUROSURGERY 993 In irreparable lesions of the circumflex nerve and in those instances in which partial brachial plexus lesions are associated with deltoid paralysis and the loss of humeral abduction, arthrodesis of the shoulder joint gives perhaps more satisfactory results than any form of tendon transplantation if the scapular muscles have been preserved. The usefulness of this operation, however, depends entirely upon the preservation of scapular rotation/ THE MUSCULOCUTANEOUS NERVE GENERAL ANATOMY The musculocutaneous nerve receives its fibers from the outer cord of the brachial plexus, in common with the outer head of the median below the clavicle. In the region of the neck of the humerus it leaves the neurovascular bundle and passes laterally between the two heads of the coracobrachialis to the under surface of the biceps, where it divides into a number of branches supplying this muscle and the brachiahs anticus. Its sensory portion continues down the arm, and, emerging from between the biceps and the brachiahs anticus, penetrates the deep fascia and pursues a subcutaneous course down the lateral side of the forearm, supplying the integument. As the musculocutaneous nerve enters its canal between the heads of the coracobrachialis. it gives off a branch to this muscle, which, though running directly with the musculo- cutaneous nerve and usually incorporated within its sheath, derives its fibers from the seventh cervical and is, to all intents and purposes, a special nerve as the musculocutaneous is derived solely from the fifth and sixth cervical. Anatomic irregularities of the musculocutaneous nerve are too varied to be considered in detail; they consist principally of various communications with the median nerve. Occasionally a portion of the median nerve may follow the course of the musculocutaneous, and after this nerve gives off branches to the biceps and brachialis anticus the divergent fibers will again join the medial trunk; in other instances the branches to the biceps and brachialis anticus may spring directly from the median trunk. It is not uncommon to find various anomalous communications between the musculocutaneous and median nerves in various degrees. A consideration of these abnormalities will assist in explaining certain types of combined lesions which are at times inclined to be rather perplexing. The possibility of anatomic irregularities should always be considered when the clinical findings point to a combined partial musculo- cutaneous and median lesion. SURGERY Lesions of the musculocutaneous nerve may occur in any part of its course; in the upper portion of the arm, or in the axilla, it may be associated with concomitant lesions of the neurovascular bundle, though isolated lesions are « The writer has recently observed a case of infantile paralysis in which the deltoid was completely paralyzed, though fairly elTeetive abduction of the humerus by the short head of the biceps was possible. The possibility was immediately suggested of changing the point of origin of the short head of this muscle to a more lateral position by inserting it into the acromion process under the deltoid; this might also be reinforced by transplanting the long head of the triceps into this same position. Experimental work on the cadaver demonstrates the possibility of this procedure from an anatomic standpoint Traction on these transposed muscles in a line corresponding to what would be their action after transposition results in forcible abduction of the arm. He has not had occasion to attempt this transplant clinically, but believes that it offers a possible means of humeral abduction in deltoid paralysis when bicipital and tricipital function is preserved. 994 SURGERY bv no means rare. If the nerve is injured in the lower third of the arm the motor fibers usually escape injury, its sensory portion alone being involved. EXPOSURE The exposure of the musculocutaneous nerve in the upper portion of the arm may be made as in lower plexus lesions. A long incision follows the medial border of the coracobrachialis. beginning a few centimeters below the clavicle and extending downward to the middle of the arm. The superficial fascia is divided, exposing the coracobrachialis. The line of cleavage between the pectoralis major and deltoid is deepened and the deep pectoral fascia exposed, care being taken to preserve the cephalic vein, which runs in the cleft between these muscles. It is usually necessary to divide the tendon of insertion of the pectoralis major to obtain access to the origin of the nerve. (See figs. 165,166,167.) The pectoralis major is retracted medially and the pectoral fascia covering the neurovascular bundle in the axilla divided, exposing the median nerve, which may be identified by electrical stimulation, though this is rarely necessary. If the nerve be followed upward, it will be found to divide into an inner and outer head, between which lies the axillary artery. Springing from the lateral side of the outer head will be found the musculocutaneous nerve, which abruptly leaves the neurovascular bundle and enters its canal between the two heads of the coracobrachialis. When the lesion is below the branch to the coracobrachialis, the musculo- cutaneous nerve may be exposed without invading the axilla. A longitudinal incision is made over the upper portion of the biceps, and the line of cleavage between its two heads found and deepened. In the recess, the musculocuta- neous nerve will be found lying upon the coracobrachialis. The nerve may now be followed along the under surface of the biceps by extending the line of cleavage between the long and short head downward through the substance of the muscle. In this way the motor branches may be adequately exposed. The motor branches spiing from the lateral portion of the nerve trunk; the sensory from its medial side. A recognition of this fact will serve to facilitate physio- logic approximation. DEFECTS Defects in the musculocutaneous nerve may be overcome to some extent by the relaxation obtained in flexing and adducting the arm over the chest. Defects not correctable in this manner, nor by stretching, will require grafting or a viable transplant. In closing the incision, if the tendon of the pectoralis major has been divided it should be carefully sutured with 20-day chromicized gut, and the arm maintained in flexion and adduction by strapping the hand to the opposite shoulder. EXPOSURE OF THE SENSORY PORTION Lesions involving the musculocutaneous nerve in the lower third of the arm are not accompanied by motor disability—in this region the nerve is entirely sensory. Occasionally, however, certain irritative lesions necessitate its exposure, when it may be sectioned or subjected to alcoholic injection. The NEUROSURGERY 995 sensory portion of the nerve is occasionally utilized as material for autogenous grafts. Its exposure is made through an incision along the lateral surface of the arm corresponding to the medial border of the brachioradialis. The nerve will be found emerging from beneath the lateral border of the biceps, after which it pierces the deep fascia to become subcutaneous in the forearm. The biceps may be retracted medially, and the nerve followed upward beneath this muscle to the junction of the middle and lower third of the humerus, where it may be sectioned without injury to motor branches. IRREPARABLE DEFECTS Paralysis of the muscles supplied by the musculocutaneous nerve is not particularly disabling, as their function consists almost entirely in forearm flexion, which may be very satisfactorily accomplished in biceps paralysis by the brachioradialis, which muscle is supplied by the musculospiral nerve, though flexion by this muscle is usually associated with some degree of supination, wliich is corrected by action of the pronator radii teres, also capable of some forearm flexion. If an irreparable musculocutaneous lesion is combined with a permanent paralysis of the brachioradialis, pronator teres flexion of the elbow alone will be of little practical assistance, as its flexor power is weak and always associated with marked pronation. Under such conditions, apparently the only recourse is in arthrodesis of the elbow joint, immobilizing it in a position of flexion compatible with the needs of the individual. MUSCULOSPIRAL NERVE GENERAL ANATOMY The musculospiral nerve is a continuation of the posterior cord of the brachial plexus, which in turn is formed by the posterior trunks of the anterior primary divisions of the fifth, sixth, seventh, and eighth cervical nerves. In the early part of its course it occupies a position dorsal to the axillary artory in the neurovascular bundle and pursues a somewhat spiral course posteriorly around the humeral shaft, and gains the lateral surface of the arm by pene- trating the external intermuscular septum. In the lower part of the arm, it passes from a lateral to a ventral position at the elbow and there divides into two terminal branches, the radial and posterior interosseous nerves. 1.RAXCIIES In the axilla and on the inner side of the arm, which constitutes its medial portion, the musculospiral nerve gives off three branches: The internal cutane- ous- a muscular branch to the long head of the triceps; and a muscular branch to the medial head of the triceps, sometimes called the ulnar collateral. In its posterior or intratricipital portion it gives off two external cutaneous branches, and muscular branches to the lateral and medial heads of the triceps. On the external surface of the arm, lateral port ion, branches are given off to the brach- ioradialis, the extensor carpi radialis longior, and occasionally a small branch to the brachialis anticus. ()<)(') SURGERY Terminal branches. — The radial nerve passes down the radial side of the forearm, under cover of the brachioradialis muscle, to the dorsum of the band; it is purely sensory and supplies sensation to the dorsum of the lower third of the forearm, hand, and fingers. The posterior interosseous nerve carries chiefly motor fibers; passing under the brachioradialis muscle it pierces the supinator brevis. and in its passage through this muscle winds around the shaft of the radius to appear on the dorsum of the forearm. Before entering the supinator canal it gives off branches to the extensor carpi radialis brevior and the supinator brevis. Shortly after it emerges from the lower border of the supinator it fans out into a number of branches which supply the extensor communis digitorum, ex- tensor carpi ulnaris, and extensor minimi digiti. A little lower in the forearm other branches are given off to the extensor ossis metacarpi pollicis, extensor longus and brevis pollicis, and extensor indicis. SURGERY From a standpoint of surgical accessibility, we shall consider the muscu- lospiral nerve as having medial, dorsal, and lateroventral portions, with two terminal branches, the posterior interosseous and radial nerves. MEDIAL PORTION The medial portion of the musculospiral constitutes that part of the nerve trunk which lies medial to the humerus, extending from its origin in the axilla to where it crosses the long head of the triceps. In the upper part of its medial course the musculospiral nerve lies posterior to the axillary artery; in the lower part of the axilla it leaves the neurovascular bundle and, passing over the tendons of the teres major and latissimus dorsi, it begins its dorsal or intratricipital course by passing anterior to the long head of the triceps. From the medial portion of the musculospiral three branches are given off from the medial side of the nerve trunk—an internal cutaneous branch and two motor branches, one of which supplies the long head of the triceps, the other, known as the ulnar collateral, supplies the medial head of the tri- ceps. These branches may be followed some distance up the nerve trunk, where they will be found to unite with two distinct bundles. The internal cutaneous branch unites with the bundle which in the dorsal portion of the nerve's course forms the external cutaneous. In other words, the sensory fibers contained in the internal and external cutaneous branches spring from a common bundle and separate from the parent trunk either combined or as separate branches. The identification of one sensory branch, if followed intra- neurally. will serve to identify the other by their intraneural union. They may be identified distally by a careful dissection which will demonstrate their cutaneous termination. The two motor branches may be given off from the musculospiral trunk individually or, as occasionally happens, all the motor branches to the triceps will be found leaving the nerve trunk as a single large branch, later subdividing and forming the individual branches to its respective heads. More often the tricipital branches are loosely incorporated within the XEUROSUKGERV 997 musculospiral sheath, though they are distinctly individual and may possess a well-developed sheath of their own. The bundle containing the tricipital branches occupies a very definite position upon the medial side of the nerve. ventral to the cutaneous sensory bundle. The larger or lateral bundle con- stitutes that portion of the nerve which gives off branches to the supinator and extensors, ultimately terminating in the radial and posterior interosseous nerves. Lesions of the musculospiral nerve in its medial portion are often Fir,, ins.—Exposure of medial portion of musculospiral nerve in the axilla and upper portion of the arm. Tendon of pectoralis major divided. Median and ulnar nerves with brachial artery, retracted medially, exposing musculo- spiral nerve and superior profunda artery, as they cross the tendon of the latissimus dorsi and long head of the triceps, entering their posterior humeral course. The branches of the medial portion of the musculospiral are shown springing from the medial aspect of the musculospiral trunk. A, Median nerve, outer and inner head; B musculospiral nerve: C, axillary artery; D, pectoralis major, reflected; E, musculospiral medial branches; K, superior profunda artery; (!, brachial artery; II, latissimus dorsi tendon; I, coracobrachialis; J, deltoid; K, Pec- toralis minor tendon combined lesions, corresponding to terminal plexus types, and frequently are associated with vascular injury. The method of exposure of the musculospiral nerve in its upper medial portion within the axilla is the same as that used in infraclavicular plexus lesions. Its lower medial portion is exposed through a straight incision, extending from the base of the axilla to the middle of the humerus, in a line corresponding to the medial edge of the coracobrachialis. The deep fascia is divided, exposing the neurovascular bundle; by ligating a few branches of the brachial artery and their accompanying veins, the contents of the neurovascular 998 SURGERY bundle may be retracted medially, and the musculospiral nerve located as it crosses the latissimus dorsi tendon, accompanied by the superior profunda artery: or it may be located before it leaves the neurovascular bundle, where it lies behind the brachial artery. Its cutaneous and motor branches should now be identified as they leave the nerve trunk from its medial surface. The motor branches are identified readily by following them to a muscle termina- tion, while the internal cutaneous branch will be found to penetrate the deep Fig 169-Exposure of median portion and internal part of posterior portion of musculospiral trunk through medial incision Contents of neurovascular bundle retracted medially; superior profunda artery ligated; compfete expo Zk rCt0irB oiee1^ acneural dfct>io,'.showing their °rigin from mediai side °f the r^oSi trunk. A, Deltoid B, b ceps, C, coracobrachialis; D, superior profunda artery, ligated- E pectoralis minor s^r.^.^ b^r10^1—h>——'. -- ««= fascia to assume a cutaneous position. Retraction of the long head of the triceps will permit very satisfactory exposure of the nerve on the medial side of its intratricipital course, where it will be found passing lateral to the medial head of the triceps as it enters the musculospiral groove on the posterior surface of the humerus Division of a few of the internal fibers of the medial head of the triceps will permit adequate exposure of the nerve through most of its posterior course. This medial incision is also frequently required to gain access to the nerve in its dorsal position. S NEUROSURGERY 999 DORSAL PORTION The dorsal or intratricipital portion of the musculospiral is that part of the nerve which lies posterior to the humerus and is covered by the triceps. The nerve enters the posterior surface of the arm by passing anterior to the long head of the triceps shortly after it has left the neurovascular bundle. In its dorsal course it first lies on the ventral surface of the long head of the triceps; then occupying a position in direct contact with the humerus it passes through the musculospiral groove, just above the origin of the medial head of the triceps and below the origin of the lateral head of the triceps, which latter covers the nerve. Having pursued a somewhat spiral course around the humeral shaft, the nerve emerges from its dorsal position by penetrating the external intermuscular septum to appear on the lateral aspect of the arm. In its dorsal course, the nerve is accompanied by the superior profunda artery and its accompanying vein, which lie lateral to the nerve. The superior profunda artery, upon reaching the external intermuscular septum, divides into two branches, the smaller of which penetrates the intermuscular septum and accompanies the musculospiral nerve; the larger branch follows along the posterior surface of the intermuscular septum to the elbow. In its dorsal portion the musculospiral nerve gives off branches to the lateral and medial heads of the triceps. These branches almost invariably lie on the medial side of the nerve, and may be followed up the nerve trunk as individual branches or as a single bundle into the axilla. The external cutaneous nerve, though given off with the internal cutaneous from the medial side of the musculospiral nerve, crosses the parent trunk and follows its lateral surface with the pro- funda artery where it divides into a superior and an inferior cutaneous branch. These cutaneous branches do not penetrate the external intermuscular septum, though the inferior branch passes over it and becomes cutaneous near the elbow. The nerve in this region, occupying a position in direct contact with the humerus, is frequently injured in fractures of the middle third. It may be completely crushed by the trauma producing the fracture, though probably it is more often traumatized and stretched by the bone fragments at the time of injury or during efforts at fracture reduction. Occasionally it is found compressed or completely buried in the callus of an old fracture. Exposure of the musculospiral nerve in its dorsal position may be accom- plished by several methods: A. Dorsal longitudinal incision.— An incision beginning about 7 centi- meters below the acromial process is carried down the middle of the posterior surface of the arm to the junction of its lower and middle thirds, in line with the olecranon. The deep fascia is incised; and the cleavage between the long and lateral heads of the triceps found and deepened until the aponeurosis of their ventral surface is encountered. This aponeurosis is then carefully divided to prevent injury to the musculospiral nerve and its branches, which lie directly on its ventral surface. In separating the long and lateral heads of the triceps upward, the posterior fibers of the deltoid are retracted laterally, some of which may require division. Retraction of the tricipital heads will give a satisfactory though rather limited exposure of the musculospiral groove 1000 SURGERY and .ts contents. When extensive scar tissue is present, the dorsal ineuion should be supplemented bv a lateral incision, exposing the nerve as it emerges on the lateral surface of the arm, after penetrating the external intermuscular The nerve is identified at this point and the lateral head of the tn- soparated from its attachment to the septum and retracted dorsally, xpoMno- the lateral portion of the musculospiral groove. Occasionally it septum CO] P 1 will bo found necessary to divide the lateral head of the triceps and in such instance* the division should be made as high as possible to avoid injury to its nerve supply. A piece of tape passed under the lateral head of the triceps between these two incisions will often permit sufficient retraction of the muscle from the humerus to expose the nerve throughout its course in the musculo- spiral groove. In attempting retraction or division of the lateral head of the triceps through the combined dorso- lateral incisions, the greatest care should be used to prevent injury to the tricipital branches, which at first should be iden- tified and isolated in the upper portion of their course. The operator fre- quently experiences difficulty in this dissection, due to injury of the superior profunda artery and veins. It is ex- pedient, therefore, early in the exposure, to secure primary ligation of the artery in the upper part of the wound and ligation of the veins dorsal to the ex- ternal intermuscular septum. B. Exposal re of the dorsal portion of tlie musculospiral by a combined medial and lateral incision.—The medial portion of the musculospiral groove may be readily approached through the low incision described for exposure of the musculospiral in the lower part of its medial portion, by retracting medially the neurovascular bundle, and dorsally the long head of the triceps. This ap- proach will also facilitate control of the profunda artery and the identifica- tion and isolation of the tricipital branches. This medial exposure is supple- mented with the lateral incision, through which the musculospiral nerve is identified as it penetrates the external intermuscular septum, and the attach- ment of the lateral tricipital fibers freed from this structure. In this procedure the long and lateral heads of the triceps are retracted from the humerus, expos- ing the nerve throughout its intratricipital course. The advantage of this method is obvious; it gives a complete exposure of the nerve and all its trieipi- Ki".. 170.—Showing course of musculospiral nerve, and re- lation of branches to triceps, as it passes behind humerus in musculospiral groove. Preservation of branches in transposing nerve to anterior position. (Xey. Annate of Surgery, 1921) NEUROSURGERY 1001 tal branches; it permits of satisfactory hemostasis, in that the profunda artery may be secured above and the veins below; and in the presence of extensive continuity defects, it permits transposition of the nerve to an antebrachial position by allowing mobilization of the nerve trunk, without endangering its branches and without additional incisions. The proximity of the musculospiral nerve to the humerus in its dorsal course frequently calls for the preparation of a new nerve bed. When this is necessitated, because of extensive callus or scar tissue, the nerve may be separated from direct contact with the bone by changing its course from the musculospiral groove to a lower position where it is made to pass behind the medial head of the triceps. This procedure requires mobilization of the nerve through its lateral portion, and low separation of the lateral head of the triceps from the external intermuscular septum, permitting the nerve to follow a lower dorsal course between the medial and lateral heads of the triceps. When extensive bone callus or scar tissue involves the posterior surface of the humerus and the tricipital lieads, recourse should be had to an antebrachial transposition, in which the nerve is directed anterior to the humerus, between the biceps and the brachialis anticus. VENTROLATERAL PORTION The ventrolateral portion of the musculospiral nerve constitutes that portion of the nerve which lies lateral and ventral to the humerus on the external aspect of the arm, beginning at the external intermuscular septum and termi- nating in front of the external humeral condyle, where it bifurcates into its two terminal branches. In its ventrolateral course, in passing down the lower third of the arm, the nerve is deeply placed between the brachioradialis and brachiahs anticus. In the region of the external humeral condyle, the nerve is covered by the brachioradialis and rests upon the brachialis anticus. This portion of the nerve gives off a branch to the brachioradialis shortly after entering the lateral surface of the arm. A little lower, a branch is given off to the extensor carpi radialis longior. These motor branches emerge from the lateral side of the musculospiral trunk, the branch to the brachioradialis being the most ventral of the lateral group of motor fibers. Immediately behind this branch lies the bundle containing the fibers to the carpal extensors. The branch to the extensor carpi radialis brevior is occasionally given off with the branch to the long carpal extensor, though more frequently it leaves the nerve trunk from its terminal posterior interosseous division. It has. however, a long intraneural course, and if followed up the nerve will be found to spring from a bundle common to both radial extensors. Injuries to the musculospiral in this region are probably more often encountered in military surgery than injuries to any other nerve. It is a common complication of fractures of the lower third of the humerus, and in civil life the frequency of its occurrence is approximated only by lesions of the ulnar in the region of the internal epieondvle. In simple fractures the trauma to the nerve consists usually in stretching, or bruising against bone fragments; in the absence of an open wound it is rarely divided. Paralysis of the musculo- 1QQ2 SURGERY spiral nerve bv pressure has frequently been observed following the use of a tourniquet, and surgeons who insist upon its use should remember this possi- bility and endeavor to protect the musculospiral region by properly placed pads. ' Frpo^ure of the I ate rove nt ml portion of the musculospiral is made through a longitudinal incision, extending from the insertion of the deltoid to a point midway between the biceps tendon and tiie external condyle of the humerus. In the lower part of the incision the cephalic vein is divided between forceps. In the upper part of the incision, the lateral cuta- neous branches may be met, and, Fig. 171.—Landmarks for exposure of musculospiral nerve in its latero-ventral aspect, showing external intermuscular septum, from the ventral side of which arises fibers of the brachioradialis, and from its dorsal surface, fibers of the lateral head of triceps. Musculo- spiral nerve is exposed by deepening the cleft be- tween brachioradialis and biceps which lies ventral to the latter muscle. A, Biceps; B, brachioradialis; C, triceps, lateral ^head; D, external intermuscular septum Fig. 172.—Musculospiral nerve, latero-ventral as- pect, showing emergence on lateral surface of arm, after penetrating external intermuscular septum. A, Biceps; B, brachialis anticus; C, musculospiral nerve; D, superior profunda artery; E, triceps, lateral head; F, external intermuscu- lar septum; Q, brachioradialis if necessary, sacrificed with impunity. The line of cleavage between the brachioradialis laterally and the biceps and brachialis anticus medially is identified and these muscles retracted. In the cleft, deeply placed, the muscu- lospiral nerve is found accompanied by a small terminal branch of the superior profunda artery. Occasionally, the inferior external cutaneous branch, which NEUROSURGERY 1003 is of fairly large size, will be found passing along the external intermuscular septum and should not be mistaken for the musculospiral trunk. It will often serve as a guide, if followed upward, in locating the musculospiral.1 The musculospiral trunk should be isolated above the lesion to facilitate branch identification and preservation, even though it be necessary to invade its dorsal or intratrieipital portion. In following the nerve downward, between Fki. 173— Musculospiral nerve, postero-lateral aspect; lat- eral head of triceps divided close to attachment to exter- nal intermuscular septum, exposing nerve in lateral as- pect of its dorsal course in musculospiral groove. A, Musculospiral nerve; B, triceps, lateral head, divided; C, biceps; D, brachialis anticus; E, external intermus- cular septum; F, brachioradialis Fig.. 174.—Musculospiral nerve at elbow, showing ter- minal posterior interosseous and radial divisions. Brachioradialis divided. Intraneural dissection of branches shows them springing from lateral side of musculospiral trunk. Radial nerve is given off from ventro-medial aspect of musculospiral trunk; poste- rior interosseous nerve arises from dorso-lateral por- tion of trunk. A, Musculospiral nerve; B, poste- rior interosseous nerve; C, radial nerve; D, brachi- oradialis, divided; E, brachialis anticus; F, extensor carpi radialis longior; (}, branch to extensor carpi radialis brevior the brachioradialis and the brachialis anticus, extreme care should be used in preserving motor branches. In the upper part of this region, if the circum- ference of the musculospiral nerve be divided into a lateral, posterior, and medial sector, the lateral sector will be found to contain motor fibers to the brachioradialis and carpal extensors, the posterior sector will contain those f Th writer has on one occasion reoperated a case of musculospiral paralysis which failed to regenerate, and found the proximal end of the musculospiral anastomosed to the distal segment of this branch; in the original operation, the surgeon tu.l apparently mistaken the cutaneous branch for the musculospiral trunk. 1004 SURGKRY motor fibers which eventually form the posterior interosseous nerve, and the medial sector will contain sensory fibers ultimately forming the radial terminal division. In the region of the external condyle, the musculospiral nerve lies upon the brachialis anticus and under cover of the brachioradialis. Strong lateral retraction of the latter muscle will expose the nerve where its two terminal branches may be identified—the posterior interosseous, arising from its lateral and posterior sector; and the radial, arising from its medial sector. INTEROSSEOUS NERVES The posterior interosseous nerv<, containing mostly motor fibers, innervates the supinator, extensor carpi ulnaris, and extensors to the fingers and thumb. and it constitutes the terminal motor portion of the musculospiral trunk. After its separation from the radial nerve on the undersurface of the brachio- radialis. it passes under the long and short carpal extensors and swings around the shaft of the radius to the dorsum of the forearm, by passing through a a canal in the substance of the supinator brevis muscle, in a line almost at right angles to the direction of the supinator fibers. After emerging from the lower border of the supinator on the dorsal surface of the forearm, the posterior in- terosseous nerve fans out into a leash of branches supplying the extensors of the fingers and thumb. Lesions of the posterior interosseous nerve below the upper third of the forearm are rarely amenable to suture, due to the breaking up of the nerve into a series of small branches. Suture may be effected, as a rule, only when the nerve is found injured in the substance of the supinator or proximal to that muscle. Occasionally, however, it will be found possible to complete a satis- factory neurolysis in the region where the nerve breaks up below the supinator. When it is found impossible to restore the nerve supply to the digital extensors. it is advisable to complete the operation by tendon transplantation. Exposure of the posterior interosseous nerve.—A longitudinal incision is made down the posterior surface of the forearm in the midline, beginning at a point two centimeters medial to the external condyle and ending in the middle third of the forearm. The deep fascia is divided "and the line of cleavage be- tween the extensor carpi radialis brevior and the extensor communis digitorum identified. These muscles are separated up to their common origin at "the ex- ternal condyle and retracted, exposing the fascia covering the supinator brevis muscle below. The course of the posterior interosseous nerve through the supinator is at almost right angles to its fibers, and its position may often be identified by palpation. Failing in this, separation of the muscle fibers in their hue of cleavage will usually serve to locate the nerve, which is areatlv flattened as it passes around the shaft of the radius. Exposure of the lower border of the supinator will also aid in its identification, as it emei-es from this muscle. ^ The posterior interosseous nerve may bo completely exposed bv dividing the superficial fibers of the supinator covering the nerve; bv flexin^ the W arm and retracting the radial carpal extensors and the brachioradialis it may be followed to its junction with the radial. Extreme care however N K. UROS URGE11Y 1005 should be used in avoiding the branches supplying the supinator, wliich are usually given off just before the nerve enters this muscle or during its passage through the muscle. Lesions within the supinator region of the posterior interosseous as a rule may be satisfactorily exposed through the dorsal forearm incision; but when the lesion is located in its presupinator portion, it is best exposed by separating the long radial extensor from the brachioradialis Fig. 17...—A. Supinator brevis exposed by separating extensor carpi radialis brevior and extensor longus digitorum. B, Intrasupinator portion of pos- terior interosseous nerve exposed by dividing superficial fibers of supinator brevis. Branches to supinator shown leaving the nerve in the substance of the muscle. At lower border of supinator, posterior interosseous fans out into a leash of branches, below which repair is difficult. A,'Extensor carpi radialis brevior; B, supinator brevis; C, extensor longus digitorum; D, pos- terior interosseous nerve; ... branches to supinator; F, posterior interosseous, below supinator through a slightly more anterior incision, corresponding to a continuation of of tluTiteral musculospiral incision to the dorsum of the forearm. In exposing that portion of the nerve lying between its origin and the supinator (pre- supinator portion), great care must be utilized to prevent injuring the branch to the short carpal extensor, which is given off from the anterior surface of the nerve. It is usually of sufficient size to permit of separate suture, and efforts should always be made toward its conservation or repair. 1006 SURGERY RADIAL NERVE The radial nerve constitutes the terminal sensory division of the mus- culospiral trunk; it first lies under the brachioradialis and upon the brachialis anticus, medial to the posterior interosseous. It progresses down the ventral and radial surface of the forearm under cover of the brachioradialis muscle. At the junction of the upper and middle third of the forearm it is joined by the radial artery, which lies on its medial side and accompanies it through the middle third of the forearm. At the beginning of the lower third it leaves the artery and passes under the tendon of the brachioradialis to enter the posterior surface of the forearm, where it supplies sensation to the dorsum of the wrist, hand, and fingers. SURGERY The radial nerve, being entirely sensory, is seldom exposed for repair. It is, however, occasionally used as a graft for filling continuity defects in other nerves, because of its fairly large size and the minimal degree of disability re- sulting from its sacrifice; when used for grafts, its uppermost portion is usually selected. Exposure of the radial nerve may be accomplished through an incision begin- ning just above the bend of the elbow, midway between the external humeral condyle and the biceps tendon, and carried longitudinally down the radial surface of the forearm as far as necessary, paralleling the medial border of the brachioradialis. The deep fascia is divided and the medial edge of the brachi- oradialis exposed and retracted. The radial nerve may be identified passing along the under surface of this muscle, and may be followed up to a point where it joins the posterior interosseous to form the musculospiral trunk. CONTINUITY DEFECTS The correction of defects in the continuity of the musculospiral nerve differs in no way from those methods used in overcoming defects in other nerves except in transposition, when the musculospiral nerve is changed from its spiral course around the posterior aspect of the humerus to the more direct ventral course anterior to the humerus, where it is made to pass between the biceps and the brachialis anticus, following a course similar to that taken by the musculocuta- neous nerve. TECHNIQUE OF MUSCULOSPIRAL TRANSPOSITION The musculospiral nerve is exposed in its medial portion (see technique of low exposure of the medial portion of the musculospiral nerve p 997)- the branches to the triceps are identified by retraction of the triceps and mobilized from the musculospiral trunk. The musculospiral is exposed and freely mobilized from the external inter- muscular septum to its terminal branches, using eare to prevent injurv to branches in this region. The lateral head of the triceps is separated from its attachment to the external intermuscular septum and carefully separated from the humerus along the course of the musculospiral groove. A piece of tape is passed through the tunnel between the lateral and medial incisions and the NEUROSURGERY 1007 triceps by this means retracted from the bone, completely exposing the nerve. It is important that the ends of the nerve be marked with identification sutures before the nerve trunk has been rotated during mobilization. A second tunnel is made connecting the lateroventral incision with the medial, by identifying the medial and lateral borders of the biceps and by blunt dis- section, separating this muscle from the underlying brachialis anticus, follow- ing the line of cleavage between these muscles and using care to prevent injury to the musculocutaneous nerve. The musculospiral nerve is now drawn from its intratrieipital course and made to pass in as direct a line as possible from the neurovascular bundle below the axilla to its position medial to the external humeral condyle below the biceps. After transposition, the surgeon may avail himself of flexion-relaxation to assist in overcoming any part of a defect not corrected by the transposition. . It is particularly important to prevent torsion of the nerve trunk during suture, and the early placing of accurate identification sutures is essential as a guide for restoring physiologic alignment. Physiologic Approximation of the Musculospiral and its Terminal Divisions. The musculospiral nerve, by virtue of its motor branches, lends itself to physiologic approximation more readily than any other nerve. While the prevention of torsion is perhaps best accomplished through effectively placed identification sutures, there are certain instances, particularly in secondary sutures, where this means of identification can not be relied upon. In effecting suture of the medial portion of the musculospiral nerve, identi- fication of tricipital branches will immediately demonstrate the medial side of the nerve. In its posterior position, the tricipital branches likewise indicate the medial side of the nerve, though the lower branches to the triceps occupy a more dorsal position. In the region of the external intermuscular septum, the nerve occupies a rather fixed position, which is not readily disturbed by trauma; in this position, the motor fibers lie in the lateral portion of the trunk, the sensory fibers to the medial side. The nerve in its course around the humerus, first contains its motor fibers in its medial side. Later, in the musculo- spiral groove, they become posterior, the sensory fibers being in contact with the humerus. In the region of the external intermuscular septum the nerve presents a different arrangement, due to a slight natural torsion in its spiral course. In its lateroventral position, the motor bundles lie on the lateral and dorsal surface of the nerve, whence springs its motor branches and which ultimately terminate in the posterior interosseous nerve. The sensory portion of the trunk, having a more medial and anterior position, terminates in the radial nerve. By keeping these facts in mind, torsion may be prevented to a tfreat deo-rec in lateroventral sutures of the musculospiral; the motor portion of the trunk being readily identified by the position of its motor branches, also bv the posterior interosseous nerve, springing from its lateral and some- what dorsal quadrant; the sensory portion of the nerve being identified by the absence of branches and by the position of the radial nerve. To make topographical matching still more accurate, it should be remembered that the branch to the brachioradialis occupies the most ventral motor position. More 46997—27---66 1008 SURGERY laterally in the nerve trunk will be found the bundle sending fibers to the long and short radial extensors. That portion of the nerve immediately behind these funiculi ultimately forms the posterior interosseous trunk. Torsion in the posterior interosseous nerve is not so serious an eventuality as in mixed nerves, because most of the nerve trunk is composed of motor fibers. In the supinator region, the nerve is greatly flattened and its fixation so secure that reasonable care should prevent torsion. If doubt exists in suturing the musculospiral nerve as to the location of its sensory segment, recourse should be had to the electro-anatomic method, in which the sheath of the upper segment of the nerve is opened and the bundles subjected to very weak faradic stimulation. Stimulation of the sensory bundles will elicit a sensation of tingling or pain localized in their cutaneous distribution, while stimulation of a motor bundle will demonstrate the pres- ence of myo-sensory fibers. (See general technique, p. 951.) Secondary Suture of the Musculospiral Nerve. Surgery of the musculospiral nerve has perhaps given more satisfactory end results than that of any other nerve, which may be attributed to the fol- lowing facts: 1. The greater number of injuries occur in its lateroventral portion or in the lateral part of its dorsal portion, which leaves a comparatively short dis- tance for the neuraxons to regenerate to reach their ultimate muscle termina- tion. This feature, facilitating an earlier restoration of neuromuscular junc- tions saves the muscles from that extreme degree of degeneration encountered when denervated for a long period of time—a condition which can not be avoided in nerves injured at a great distance from the muscles they supply. 2. The extensor muscles, supplied by the musculospiral are relatively large in bulk and the chance of receiving a greater number of regenerated nerve fibers is thereby enhanced. 3. The extensor function of the wrist is accomplished by three extensor muscles, supplemented by the common extensors of the fingers, so that defects in one or more muscles may not seriously affect extensor function. 4. Extensor paralysis of the wrist is more generally and earlier recognized and lends itself more readily to splinting than any other types of paralysis- it is thereby often saved from prolonged muscle stretching. A careful examination of regenerating musculospiral lesions will demon- strate that, though the functional end results of musculospiral sutures are more satisfactory than any other nerve, from a standpoint of individual muscle function defective regeneration is present in the great majority of musculo- spiral sutures, and that those muscles which have a relatively small bulk and which are innervated at some distance from the point of lesion, present the same degree of defective regeneration as observed in other nerves Vfter mus- culospiral suture, radial carpal extension and brachioradialis action are com- monly restored. Less frequently, however, do we observe a return of function in he ulnar carpal extensor, and m the extensor communis digitorum w ile in the extensors of the thumb, index, and little fingers function is wlntlv not regained. Lndoubtedly, they enter into thaWxtreme degree S degeneration common to muscles of small bulk, long denervat^l NEUROSURGERY 1009 Indications for Reoperation Before the musculospiral nerve is subjected to secondary surgical inter- vention, certain facts regarding the failure of regeneration should be definitely determined: 1. The absence of neuraxon regeneration beyond the point of suture, or de- fective or retarded regeneration through the distal segment.—Tinel's sign, elicited with the same degree of intensity below the suture line, as at the suture line, indicates successful neuraxon regeneration. The downward progression at the rate of 1 inch per month, of the point at which formication can be elicited indicates that regeneration is not retarded, at least in so far as sensory fibers are concerned. A complete absence or a greatly diminished reaction of formica- tion below the suture line indicates absence or defective neuraxon regenera- tion. After three months, a failure to elicit formication below the suture line suggests the absence of regeneration, particularly if this reaction is intense at the suture line, though it may mean only a delay in regeneration. A decision, therefore, should not be definitely made until a lapse of six months, at which time absent or greatly diminished formication in the distal segment of the nerve should call for secondary surgical intervention. 2. Torsion of the nerve trunk resulting in the physiologic misplacement of fibers is another common cause for defective musculospiral regeneration. The writer has reoperated a case in which at the original operation, the operator failed to identify the posterior interosseous terminal division of the nerve and united the musculospiral trunk wholly to its radial terminal division, the lesion being in the region of the internal condyle. In this case, the long carpal extensor branch was individually divided and not repaired, leaving a complete musculospiral paralysis below the supinator. Frequently, however, torsion has occurred during the primary suture and the radial sensory fibers have passed down the posterior interosseous nerve and the motor fibers to the radial nerve: obviously, the misdirected fibers arc physiologically lost. This misdirection of fibers may occur to any degree and the advisability of secondary operation for its correction depends entirely upon the extent of misplacement and the degree of motor function regained. We must again rely upon Tinel's sign to deter- mine the position of sensory fibers, and the musculospiral nerve in its terminal divisions readily lends itself to convey this information. Percussion of the nerve trunk below the suture line may give an intense reaction of formication, but when percussion of the radial nerve (which normally should convey these sensory fibers) elicits no tingling or only a slight reaction, the sensory fibers are absent and have probably been misdirected, if sufficient time has been allowed for them to reach the radial trunk. Percussion of the posterior interosseous on the dorsum of the forearm in the region of the supinator will normally give little or no tingling, as it contains mostly motor fibers. "When there has been any <>reat misdirection of radial fibers through the posterior interosseous nerve, its percussion will elicit intense tingling which is localized on the dorsum of the hand. This localization of tingling is important as it demonstrates that the sensory fibers in the posterior interosseous nerve are definitely radial in origin, it being remembered that in percussing the musculospiral or the posterior inter- osseous nerve the examiner may elicit reactions in the external cutaneous 1010 SURGERY branch of the musculospiral, in which event the tingling sensation would be localized along the dorsal portion of the forearm and not the hand. Frequently, the presence of sensory fibers in the extensor muscles on the back of the fore- arm may be demonstrated by pressure on their atrophied bellies, this pressure eliciting a strong formication. Regenerative defects, due to misdirection of fibers are unfortunate, in that the muscles have been allowed to reach an extreme degree of degeneration because of their greatly delayed reinnervation. If muscle degeneration is extreme, recourse must be had to tendon transplantation for correction of the motor defect. If, however, these muscles have been preserved and still respond to galvanic stimulation, secondary suture should be attempted for the purpose of correcting torsion. In the secondary operation, the surgeon must not be guided by anatomically placed identification sutures, but the motor side of each segment of the nerve trunk should be identified by the position of its branches or by the electro-anatomic method, and the nerve resutured in a manner which will approximate1 motor segment to motor segment. (See physiologic approximation of the musculospiral nerve, p. 1007.) 3. Defective musculospiral regeneration due to extensive muscular degenera- tion.—Percussion of the musculospiral trunk has demonstrated by Tinel's sign the progressive downgrowth of neuraxons: percussion of the radial and pos- terior interosseous nerves reveals the presence of radial sensory fibers in the former and their absence in the latter; therefore, neuraxon regeneration has probably not been seriously impeded or misdirected. The return of deep sensibility in the muscles suggests regeneration of myo-sensory fibers which normally accompany motor fibers, and their presence probably indicates the regeneration of motor fibers to the muscles. The clinical degenerative phe- nomena continue to persist in the paralyzed muscles (complete loss of electrical and mechanical irritability and a total absence of voluntary motion, with extreme atrophy). Instances of this kind are by no means rare and are usually due to prolonged denervation and ischemia. In this type of regenerative failure, secondary operations upon the nerve are absolutely useless and con- traindicated. In some cases, time may effect improvement, particularly if accompanied with energetic treatment to improve circulation and muscle nutrition. In most of these instances, the only hope of restoring extensor tunction to the wrist and fingers lies in tendon transplantation. TENDON TRANSPLANTATION FOR MUSCULOSPIRAL PARALYSIS Probably no other tendon transplants give results so satisfactory as those devised for the drop wrist and fingers in musculospiral paralysis " tion s ZZT, 7eiTble def"'tS °f the m™*>spiral nerve', transplanta- on is indicated for three conditions, namely, wrist-drop, finger-drop, and thumb-drop In low lesions (posterior interosseous), carpal eftension may be preserved transplantation being required only for the digitis. This may be the case also m defective musculospiral regeneration, though more frequently the disability is confined to the thumb extensors. It is th&e practle of ome surgeons when repairing the musculospiral nerve to transplant the prona" ladn teres into the radial extensors, as this procedure will give immediate NEUROSURGERY 1011 extension of the wrist without sacrificing the function of any muscle or inter- fering with the natural progress of regeneration. We shall therefore consider individually the transplant necessary for the correction of each of these various conditions, though one or all may be corrected during the course of a single operation. For Restoration of Carpal Extension a. Pronator radii teres into the extensors carpi radialis longior and brevior to give dorsal flexion of the wrist. b. Divided extensor carpi ulnaris tendon into the flexor carpi ulnaris prevent radial deviation of the hand. Technique. 1. The incision extends along the radial border of the forearm in its middle third. The line of cleavage is found between the brachioradialis and the carpal extensors and deepened to expose the radius, where the ribbon-like tendon of the pronator teres is found partially encircling this bone; this tendon is mobilized and divided at its insertion. The tendons of the extensors carpi radialis longior and brevior are now identified, and with the wrist held in hyperextension, the pronator tendon is passed through a slit in these tendons and anchored after proper tension has been attained. 2. To prevent radial deviation of the wrist during extension through pronator teres action on the radiocarpal extensors, the ulnar carpal extensor tendon may be divided and transplanted into the flexor carpi ulnaris. Oc- casionally also in defective musculospiral regeneration, the extensor carpi ulnaris fails to regain power, and extension of the wrist is associated with marked radial deviation. This transplant is usually very satisfactory for the correction of this condition. Frequently the tendon of the flexor carpi ulnaris is used as a transplant to produce extension of the third, fourth, and fifth fingers, and occasionally also the index; in which case the fleshy part of the flexor carpi ulnaris tendon, which is attached to the ulnar border of this tendon, is detached and separately transplanted into the extensor carpi ulnaris tendon, or the extensor carpi ulnaris tendon may be divided some distance above its insertion and transplanted into the detached fleshy fibers of the flexor carpi ulnaris. For Restoration of Extension of the Digits a. Flexor carpi radialis into the extensor ossis metacarpi pollicis, extensor pollicis brevis, and extensor pollicis longus, and occasionally into the extensors indices and communis tendons of the index finger. b. Palmaris longus into the tendon of the long extensor of the thumb, when the palmaris is present (about 20 per cent of cases) and when the flexor carpi radialis is not used for terminal flexion of the thumb. c. Flexor carpi ulnaris into the extensor tendons of the little, ring, and middle fingers, and also the index finger when its tendon is not anastomosed to the flexor carpi radialis. Inasmuch as isolated extension of the index finger is important, with extension of the thumb, in picking up objects, the writer prefers to use the flexor carpi radialis for both thumb and index extension. Some of our most 1012 SURGERY satisfactory results in extension of the distal phalanx of the thumb have attended flexor carpi radialis transplantation into the long extensor in common with the other extensors of the thumb, though a separate transplantation of the palmaris longus into this tendon is a very satisfactory procedure. Technique. a. Through a long incision, extending from the insertion of the flexor carpi radialis tendon to the middle of the forearm on its radio-ventral aspect, the tendon of the flexor carpi radialis is exposed, divided at its insertion and freely mobilized to the upper part of the incision, care being taken to avoid injury to the radial artery and nerve lying along its radial border. b. A second ventral incision of the same length is made along the ulnar border of the forearm, exposing the ulnar tendon, which is divided at its attach- ment and freely mobilized. The tendon of the flexor carpi ulnaris is split close to its ulnar border, to which muscle fibers are attached almost to its insertion. The splitting of the ulnar flexor tendon in this manner preserves the insertion of its fleshy fibers to which portion the divided extensor carpi ulnaris tendon may be anastomosed. This separation of the flexor carpi ulnaris tendon is extended to the middle third of the forearm, where it is lost in the fleshy portion of its belly. The radial border of the muscle should, however, be mobilized some distance higher, care being taken to avoid injury to the ulnar vessels and nerve which lie below. c. A mid-dorsal incision is now carried from the wrist joint to the middle third of the forearm, and the fat of the superficial fascia medially and laterally undermined around both radial and ulnar borders of the forearm, connecting subcutaneously, on the radial side, with the radioventral incision, and, on the ulnar border, with the ventroulnar incision. The direction of each tunnel should be arranged in a manner permitting a straight pull from the upper ventral surface of the forearm to the dorsal surface of the wrist, by the trans- posed extensor tendons. The mobilized flexor carpi ulnaris tendon is now passed through the tunnel to the dorsal aspect of the wrist and passed through a slit in both extensor tendons of the little finger and the common extensor tendons of the ring and middle fingers, while the fingers and wrist are held in complete extension, which extension must be maintained throughout the operation and during subsequent treatment. The undermining of the superficial fascia along the radial border of the wrist will expose the tendons of the extensor ossis meta* carpi pollicis and the short extensor of the thumb. Through the dorsal incision the long extensor of the thumb and both extensors of the index finger are identi- fied. The tendon of the flexor carpi radialis is passed through a slit in these tendons, while the thumb is in complete extension and abduction, and the index finger fully extended. When the proper tension has been obtained, the trans- plant is fixed to each tendon by linen sutures. When it is desired to use the palmaris longus for terminal extension of the thumb, the writer prefers mobiliz- ing and dividing the long extensor of the thumb some distance above the wrist and transposing it to the ventral surface of the wrist for anastomosis into the divided tendon of the palmaris longus; each tendon should be sufficiently mobil- ized to permit a pull as nearly direct as possible from origin to insertion. NEUROSURGERY 1013 After thorough hemostasis is effected, all incisions are closed, the ventral prior to the dorsal, after which the wrist, thumb, and fingers are maintained in extension by a previously made long ''cock-up" splint; care should be used in preventing any hyperextension of the metacarpophalangeal joints. It is often desirable to permit slight flexion of these joints, which greatly adds to the com- fort of the patient. (Subsequent treatment and reeducation follow the usual rules for tendon transplantation.) To Supply Extensor Action to the Thumb ./. Flexor carpi radialis into the extensor ossis metacarpi pollicis, extensor brevis pollicis, and extensor longus pollicis. b. Palmaris longus into the extensor longus pollicis, when extension of the distal phalanx of the thumb alone is absent, or when it is deemed advisable to use a separate tendon for extending the distal phalanx. The palmaris longus tendon does not appear to be a suitable transplant to use for all the extensors of the thumb. Technique. The procedure for transplanting the flexor carpi radialis into the extensors of the thumb or supplementing this with the palmaris longus to the long ex- tensor of the thumb varies in no way from the method described above, except that the mid-dorsal incision ma}^ now be shortened and made nearer the radial border of the wrist. MEDIAN NERVE GENERAL ANATOMY The median nerve is formed in the axilla by a union of the anterior divi- sions of the outer and inner cords of the brachial plexus. The outer cord formed by the fifth, sixth, and seventh cervical nerves contributes the outer head of the median, while the inner cord formed by the eighth cervical and first dorsal supplies the inner head of the median; the union of the two heads takes place usually just below the tendon of the pectoralis minor muscle. The median nerve then passes down the medial side of the arm in the neuro- vascular bundle in close relation to the axillary and brachial artery. In the axilla the artery will usually be found lying between the forked head of the nerve, being crossed by the inner head before the median trunk is formed. In the lower part of the axilla and upper part of the arm the artery lies immediately behind the nerve. As it progresses down the arm the artery first lies medial to the nerve, but toward the middle of the arm the relation is reversed, the arterv crossing to the lateral side. In the upper part of the arm the median nerve is overlapped bv the coracobrachialis muscle and the medial border of the biceps. In the lower half of the arm the nerve lies upon the brachialis anticus. becoming superficial as it assumes a more anterior position entering the antecubital fossa. In the antecubital fossa the nerve passes under the bicipital fascia and begins its course down the forearm; passing beneath the superficial or humeral head of the pronator radii teres, it enters its deep posi- tion in the forearm by passing under the tendinous arch of the flexor sublimis 1014 SURGERY digitorum. Crossing the ulnar arterv it follows the under surface of the sub- limis digitorum, lying upon the flexor profundus. As it approaches the wrist the nerve again becomes superficial, lying in this region under the tendon of the palmaris longus medial to the flexor carpi radialis and lateral to the sub- limis tendons. It passes below the anterior annular ligament; and in the palm, lying under the palmar fascia, it remains lateral to the sublimis tendons, where it divides into its terminal digital branches. BRANCHES The only branch given off by the median nerve in the arm is in the lower portion of the lower third, where a small branch supplies the elbow joint, though, occasionally, the branches to the pronator radii teres arise in this region. There are, however, many instances in which the median in the arm com- municates in various degrees with the musculocutaneous. (See musculocu- taneous nerve, p. 9U.'..) As the median nerve enters the antecubital fossa it gives off branches, usually three in number, to the pronator radii teres. Occasionally the three branches may leave the main median trunk in a single sheath, dividing after leaving the parent nerve. The next branches given off are to the palmaris longus, flexor carpi radialis, and flexor sublimis digitorum, in the order named. Occasionally, however, at this point a single large motor branch is given off from the median, supplying all the median innervated extrinsic muscles. In such cases the branches to the palmaris longus, flexor carpi radialis, and flexor sublimis digitorum first leave this motor portion. The remainder of this trunk, carrying branches to the deep muscles, is commonly known as the anterior or volar interosseous nerve and is accompanied in its course down the arm by the anterior interosseous artery. This branch occupies a position somewhat deeper than the main trunk of the median nerve, lying in the cleft between the flexor profundus digitorum and the flexor longus pollicis, giving branches to these muscles in its earlier course and terminating in the wrist by supplying the pronator quadratus muscle and sending filaments to the radioulnar articu- lation and the wrist joint. The motor branches to the extrinsic muscles, however, may leave the parent trunk with many variations, superficially arising from both sides of the median trunk. When, however, these branches are followed a short distance up the parent trunk it will be found that they arise from those funiculi which occupy the medial half of the nerve, the most ventral fibers supplymg the pronator radii teres. Medial and slightly posterior to the pronator funiculi lie the fibers to the palmaris longus, flexor carpi radialis, and flexor sublimis digitorum, while the funiculi to the flexor profundus digitorum and flexor longus pollicis encroach upon the posterior surface of the nerve. All these motor branches, however, are located on the medial side of the nerve and may be followed up the nerve trunk by an intraneural dissection for some distance, occasionally as high as the middle of the arm. Often the branches supplymg the deep muscles (volar interosseous nerve) leave the median trunk as an individual lower branch. Just above the wrist the median nerve gives off a sensory palmar cutaneous branch, which passes above the annular liga- NEUROSURGERY 1015 ment, After passing into the palm the median gives off motor branches from its radial side to supply the opponens, abductor, and superficial head of the flexor brevis pollicis. In the region of the superficial palmar arch the nerve becomes enlarged and flattened, dividing into two branches, which in turn sub- divide into five terminal cutaneous sensory branches. These branches, shortly after their origin and occasionally before, give off motor branches to the first and second lumbricales muscles. SURGERY IN THE ARM Axillary portion.—Lesions involving the median nerve in the axilla are seldom isolated lesions; they are usually combined with injuries to contiguous elements in the neurovascular bundle, so that from a surgical standpoint lesions of the median nerve in the axilla are treated as lower plexus lesions. (Sec lower plexus lesions, p. OS4.) In the arm.—Lesions of the median nerve in the arm are seldom confined to this nerve. The close proximity of the ulnar trunk, the brachial artery, the basilic vein, and the internal cutaneous nerve makes combined lesions more frequent in the upper two-thirds of the arm, while in the lower third the ulnar and internal cutaneous are frequently spared. Exposure of the median nerve in the arm is best accomplished with the arm in abduction and outward rotation. The incision follows the medial border of the coracobrachialis above and the biceps below. These structures somewhat overlap the nerve along its humeral course. In the upper part of the arm the nerve will be found lying lateral and anterior to the artery; below the mid portion it crosses the artery and lies on the medial side. The vein and artery are so commonly involved in median injuries in this location that special care should be used in dealing with these structures to prevent undue bleeding, particularly if the lesion is associated with much scar tissue. It is always essential that these vascular structures be isolated above and below the field of scar tissue invasion. With the control of these vascular channels, the surgeon is usually master of the situation and the dissection is greatly facilitated. In the arm the median nerve gives off no important branches; however, often it communicates by various types of anomalies with the musculocutaneous, explaining certain median lesions in which, at operation, the nerve is found to be completely divided, though the clinical examination reveals incomplete median anesthesia, or the retention of motor power in the median muscles. In making a diagnosis of partial median injury, anomalous communications between the median and musculocutaneous nerves should always be borne in mind. Electrical stimulation of the median nerve in suspected partial lesions will produce contraction in the unparalyzed median muscles, if it be a true par- tial lesion. If this stimulation fails to elicit contraction in these muscles, stimu- lation of the musculocutaneous, which is easily accomplished by identifying its trunk on the dorsal surface of the biceps, will indicate the nature of the inner- vation if it be due to a median and musculocutaneous anomaly. Retained ]()16 SURGERY function, motor or sensory, when the median trunk shows complete anatomical division, is usually due to median fibers passing down the musculocutaneous trunk and joining the median below the lesion. This refers entirely to the extrinsic muscles; the intrinsic hand muscles, particularly the superficial head of the flexor brevis pollicis may not be paralyzed in complete median paralysis, in which case it is probably wholly innervated by ulnar branches. When median lesions in the arm are associated with irritative or marked vasomotor phenomena, particular attention should be given to complete isola- tion and decortication of the brachial artery (peri-arterial sympathetectoiny, after the method of Leriche). In the writer's experience this has occasionally relicved painful nerve syndromes where all other methods have failed. In median causalgia or severe median irritative lesions without anatomic division of the nerve an internal neurolysis is also indicated if the median trunk pre- sents any evidence of scar induration upon palpation. The prevention of torsion of the median trunk in the arm is best accomplished bv the use of accurately placed identification sutures before the nerve has been completely isolated from its bed. The anatomic method of fascicular identi- fication, by relying upon motor branches, can be utilized only in low lesions in the region of the internal condyle, where a branch is given off to the pronator teres. This branch, however, may be followed some distance up the median trunk as a well identified funiculus. Its intraneural localization will reveal the anterior and medial portion of the nerve trunk in this region, it being the most anterior of the motor bundles. The determination of funicular topography above the branches to the pronator radii teres is possible only by the electro- anatomic method, which will serve, if properly conducted, to identify the posi- tion of the sensory bundles, which lie in the lateral aspect of the median trunk. When secondary sutures are indicated, because of torsion during the original suture, identification sutures are of no value and resuturing must be guided by localization obtained by the electro-anatomic method of identification. IX THE ANTECUBITAL FOSSA AXD UPPER TWO-THIRDS OF THE FOREARM The position of the arm for exposure of the median nerve in this region is one of abduction and external rotation, with the forearm in complete supi- nation. The median nerve, after entering the antecubital fossa at the bend of the elbow assumes a very deep position through the upper two-thirds of the forearm, though it becomes more superficial as it approaches the wrist. Exposure of the nerve in the forearm is greatly facilitated by a clear understanding of certain ana- tomic relationships. The operator attempting this exposure should avail himself of an opportunity to become familiar with these points, by recourse to the dis- secting room, if his visualization of this regional anatomy is at all obscured. The following anatomic points require special consideration: (1) The anatomy of the antecubital fossa; (2) the relation of the pronator radii teres to the median nerve; its insertion in the radius and its relation to the flexor carpi radialis; (3) the radial origin of the flexor sublimis digitorum and the arching fibers of this origin, which surround the nerve; (4) the relation of the median nerve in the wrist to the tendons of the palmaris longus and flexor carpi radialis. NEUROSURGERY 1017 The antecubital fossa is a triangular space, the base above being formed by an imaginary line connecting the humeral condyles. The medial boundary is formed by the lateral edge of the pronator radii teres, while the lateral border is formed by the medial edge of the brachioradialis. The biceps tendon passes through the lateral side of the fossa. Both nerve and artery rest upon the floor of the fossa which is formed by the bra- chialis anticus. In the lower part of the fossa, the brachial artery divides into its radial and ulnar portions. The fossa is covered by the deep fascia and in its lower part by that thickened portion of the deep fascia which constitutes the bi- cipital fascia. Exposure of the nerve in or just above the antecubital fossa is facil- itated by identifying the medial border of the biceps and its tendon; both the nerve and artery lie to its medial side. A tape placed around the artery in the upper part of the incision will facilitate its con- trol in case of emergency, while making a scar tissue dissection, the vein being controlled from below. The pronator radii teres passes from the internal humeral condyle diagonally across the forearm to be inserted in the middle of the radius by a long flat tendon which partially encircles the bone. This muscle forms the lower medial boundary of the antecubital fossa. It is composed of two heads, a large superficial head taking origin from the internal condyle in common with the other superficial mucles. The deep head of the pronator arises from the ulna and is very much smaller than the superficial head. The median nerve passes in the cleft between the two heads of the pronator. The radial artery, after the division of the brachial, passes to the radial side of the forearm above the pronator teres, while the ulnar artery directed to the ulnar side, passes beneath the deep head of the pronator and is thus separated from the median nerve. The lower or medial border of the pronator has a direct fascial attachment with its adjoin- ing muscle, the flexor carpi radialis. The insertion of the pronator into the radius is covered bv the brachioradialis, and along the under surface of the latter passes the radial nerve. The median nerve in the antecubital fossa Fig. I7(i.—Exposure of median nerve in lower arm and upper forearm, showing its relation to the brachial artery and biceps; both artery and nerve are covered by the bicipital fascia A, Median nerve; B, brachial artery; C, branch to pronator teres; D, radial artery; E, bicipital fascia; F, inter- nal intermuscular septum; G, ulnar nerve; II, medial epicondyle; I, deep fascia covering super- ficial flexors 1018 SURGERY and under the superficial head of the pronator gives off its important motor branches to the extrinsic muscles. In this region great care must be used for the preservation of these branches. Their exit from the parent trunk may be, superficially, from either side. Their deep origin within the me- dian trunk is from the medial portion of the nerve; the lateral being the sensory portion. The branches to the pronator, the flexor carpi radialis, and Fig. 177.-A Exposure of median nerve in the antecubital fossa; bicipital fascia divided pronator dMaeTand^JaTdltS *"" * ^ ^ »***■ B' H—' ^ad of pronl t divided and retracted, exposing branches of the median nerve in this region. Deep head of pro- nator is seen passing below the median nerve and crossing the ulnar artery. Branches o the Tt^^cTZr?"™?™"^'™ ^ ^^ Side ^ Medtn nerv" musdes111^18 l0ngUS ^ ^^ g™ °ff ^^ than the branches to the deeP Exposure of the nerve under the pronator is best accomplished bv dividing neVvefnd T ** vT^ ^ ^ radlUS' CMe beinS taW to avoids radial neive and artery which pass over the tendon in this region. The radial artery must be mobilized and freed from this muscle, which will necessitate^ the 1 ga- NEUROSURGERY 1019 tion of several small branches. After the tendon of the pronator has been divided, this muscle may be reflected toward the medial side of the forearm, exposing its under surface and deep head which will be found passing around the median nerve. After the division of the pronator tendon, its medially adjacent muscle, the flexor carpi radialis, may be partially retracted toward the medial side of the forearm, exposing the flexor sublimis dig- itorum and its tendinous arch, which in reality is the keynote of the situation. The flexor sublimis digi- torum.- -The points to be re- membered in connection with this muscle are that it covers the median nerve, wliich passes along its posterior surface; it arises from four heads, the first three of wliich are from the ulna side and more or less in common with the superficial muscles; the fourth head is from the radius, and the fibers radiating between the ra- dial and humeral lieads form an arch under which the median nerve and ulnar artery pass. The radial head should be care- fully divided and the muscle gently retracted toward the me- dial side of the forearm with the pronator. This procedure will give adequate exposure of the median nerve throughout its deep portion. The median nerve above the wrist occupies a relatively super- ficial position, lying beneath and to the radial or lateral side of the palmaris longus tendon; in the absence of this tendon, the nerve will be found just internal to the tendon,of the flexor carpi radialis. If the forearm has suffered extensive scar invasion, with destruction of tendons, etc., it may be necessary to first locate the nerve in this position at the wrist. Fig. 178.—Intraneural dissection of median branches in the forearm, showing their origin from the medial or motor side of the median trunk. Highest branches to be given off are to the pronator, whose branches originate from the most ventral portion of the motor quadrant. The volar interosseous likewise arises from the medial side of the median trunk, though occupying a more dorsal position than the bundles to the superficial muscles. A, Median nerve; B, branch to pronator teres; C, branches to superficial flexors; D, branch to deep flexors; E, branch to pronator quadratus; F, division of brachial artery; G, ulnar artery; H, pronator teres, superficial head; I, pronator teres, deep head: J, flexor carpi radi- alis; K, palmaris longus; L, portion of flexor sublimis digitorum; M, flexor carpi ulnaris 1020 SURGERY Exposure in the Forearm Exposure of the median nerve in the forearm is accomplished by a straight incision of the desired length, extending from the medial side of the biceps just above the antecubital fossa, in a line toward the insertion of the flexor carpi radialis tendon. In most instances, it is necessary to extend the incision from the upper part of the antecubital fossa to the lower third of the forearm. In the upper part of this incision the median basilic vein is exposed and divided between forceps. At a point corresponding to the insertion of the biceps tendon, the sensory portion of the musculocutaneous nerve is usually encoun- tered in the superficial fascia and its fibers preserved if possible. In the upper part of the incision the contents of the antecubital fossa arc exposed by dividing the deep and bicipital fascia: the median nerve and the brachial artery are now identified as they pass along the medial side of the biceps tendon, the art en- lying between the nerve and the tendon. The median nerve may- now be fol- lowed to where it passes below the superficial head of the pronator. In the antecubital fossa, great care should be exercised in avoiding injury to the motor branches to the pronator and the extrinsic muscles. If this exposure is not sufficient to identify the lower segment of the nerve, it must be approached in the lower third of the forearm and followed upward. To permit a lower ex- posure, the skin incision is extended to the lower third of the arm and the deep fascia divided, exposing the tendon of the flexor carpi radialis, and the median nerve located below the tendon. At the junction of the middle and lower third of the forearm, the median nerve is somewhat deeper than at the wrist, and it may be exposed by retracting the tendon of the flexor carpi radialis laterally, exposing below the aponeurotic medial edge of the flexor longus pollicis: the nerve will now be found in the cleft between the latter muscle and the flexor sublimis digitorum. The median nerve, having been exposed in the upper and lower thirds of the forearm, will require exposure in its middle third, where it is deeply placed between the sublimis and profundus digitorum muscles. Exposure of the median nerve in the middle third of the forearm is the most difficult step in the operation, and is accomplished by dividing the tendon of insertion of the pronator radii teres and reflecting this muscle with the flexor carpi radialis medially, exposing the radial head of the flexor sublimis digitorum, which in turn is divided and also retracted medially; the nerve is identified as it lies on the ventral surface of the profundus digitorum. If precaution is not taken, serious trouble may be experienced in this exposure through injury to arterial twigs leaving the radial artery. The brachial artery, before it divides into its terminal radial and ulnar divisions in the antecubital fossa. may be secured for control by the passage of tape around the vessel, which may be tightened at will. The radial artery passes over the tendon of the pronator radii teres near its insertion in the radius and passes down the forearm under cover of the brachioradialis, accompanied by the radial nerve. In its course down the forearm, the radial artery gives off numerous twigs which must be ligated before attempting division and retraction of the pronator. After the radial artery has been mobilized, it is retracted medially with the brachioradialis. exposing the flattened tendon of the pronator, which is divided, and the muscle belly reflected. The radial or lateral edge of the flexor carpi radialis is freed NEUROSURGERY 1021 and retracted with the pronator, exposing the ventral surface of the flexor sublimis digitorum. With the reflection and exposure of the under surface of the pronator, the median nerve will be found passing between its two heads, the deep head of this muscle being but little larger than the median trunk- it may be divided to permit mobilization of the nerve. The median nerve may now be followed to where it disap- pears below the arched fibers connecting the two heads of the flexor sublimis digi- torum. The radial head of this muscle is small and fibrous, and should be divided to permit its medial reflection, which is readily accomplished after freeing its radial border: the median nerve is now completely exposed throughout the fore- arm. Its important motor branches are given off in the lower part of the antecu- bital fossa, in the middle third of the fore- arm beneath the pronator and the early part of its course below the sublimis. In making this exposure, great care should be used in preventing injury to these branches. The identification of branches should pro- ceed from above downward, resorting to electrical stimulation to confirm identifica- tion, if branches are intact. (See general anatomy of the median nerve, p. 1013.) Physiologic Approximation- in the Upper Two-Thirds of the Forearm Before complete dissection of the nerve is attempted, the center of its ventral epiadrant should be marked with identification sutures to be used in sub- sequent alignment during approximation. In approximation of the median nerve in the upper forearm, it is essential that the branches to the pronator and long flexor muscles be identified and preserved during dissection, and if they have suffered individual division, they should be separately sutured. Inasmuch as most of the branches to the extrinsic muscles are given off in the region of the pronator teres, lesions above this point will probably involve most of these branches before they have left the median trunk. It is essential, therefore, that the medial side of tlie nerve trunk be accurately identified in both proximal and distal ends of the divided nerve, as the bundles forming the motor branches are locate*I in this portion of the median trunk, the fibers to the pronator being more Fig. 179—Median nerve lesion in middle third of forearm; nerve exposed above and below lesion and marked with identification sutures. In this in- stance the nerve is exposed below the pronator teres by dividing the flexor sublimis digitorum. A, Branch to pronator teres; B, pronator teres; O, bicipital fascia; D, flexor carpi radialis; E, me- dian nerve, upper segment; F, flexor sublimis digi- torum, split; G, median nerve, lower segment; H, median nerve; I, brachial artery; J, radial artery; K, brachioradialis 1022 SURGERY ventral than those to the palmaris longus, flexor carpi radialis, and sublimis digitorum. Often in this region a dissection of the median trunk will reveal all its motor branches incorporated in an individual sheath, lying along the medial side of the nerve. In such instances, individual approximation of the motor segment is possible. Fig. 180.—Transposition of median nerve to a plane superficial to superficial head of pronator radii teres, intraneural mobilization of branches. Continuity defect may now be overcome by flexion-relaxation of elbow. A, Median nerve; B, motor branches, mobilized; C, brachial artery; D, radial artery; E, brachioradialis; F, bicipital fascia; G, pronator teres; H, flexor carpi radialis; I, flexor sublimis digitorum Fig. 181.—Median nerve transposed to overcome median defect and sutured; nerve now passes superficial to pronator radii teres and below flexor carpi radialis. Nerve sheath partly closed. A, Median nerve; B, brachial artery; C, radial artery; D, pronator teres; E, motor branches; F, brachialis anticus; G, biceps; H, bicipital fascia; I, brachioradialis; J, flexor carpi radialis; K, flexor sublimis digitorum Lesions of the median trunk below the pronator seldom involve all its motor branches, though in extensive lesions many of them may suffer individual injury. The motor branches to the profundus digitorum, flexor longus pollicis, and pronator qiiadratus may be given off from the medial side of the nerve below the flexor sublimis digitorum, as individual branches, but more often they NEUROSURGERY 1023 leave the nerve trunk as the volar interosseous nerve in the region of the pronator, and occasionally it is possible to effect individual suture of this rather large branch, which will be found passing down the cleft between the profundus digitorum and the flexor longus pollicis, accompanied by the volar interosseous artery. After the motor branches to the extrinsic muscles have left the median trunk, its content in motor fibers consists solely of those to the median intrinsic hand muscles, which lie in the dorsal quadrant of the nerve. Though the intrinsic hand muscles seldom recover function after a long period of denervation, the operator should exert just as great care in preventing torsion of the median trunk in this region, for a disturbance of its sensory pattern will result in de- fective tactile localization, which will greatly diminish the functional usefulness of the digits. CONTINUITY DEFECTS If the continuity defect of the nerve be too great to be overcome by primary stretching and flexion-relaxation of the elbow and wrist joints, transposition is indicated, in which the median nerve is transposed to a position above the superficial head of the pronator teres. In order to make this procedure avail- able, the motor branches must be gently mobilized by an intraneural dissection of the nerve trunk after its sheath is opened; failure to do so will result in their destruction. Most of these motor branches may be readily isolated from the parent trunk to some distance above the medial condyle. The median nerve in its transposed position passes along the radial border of the flexor carpi radialis above the pronator teres. A transposition of this nature will usually shorten the distance of a defect from 4 to 7 cm. during forearm flexion. If, after transposition, it still remains impossible to approximate the nerve ends, the unsectioned ends of the nerve should be sutured for secondary stretching and resort made to the two-stage operation, rather than to grafting. Failing in this, the surgeon's only recourse will probably be to grafting, for which the radial nerve, lying just under the exposed brachioradialis may be used to advantage. MEDIAN LESIOXS AT THE WRIST AND COMBINED TENDON INJURIES Most lesions involving the median nerve at the wrist are combined with lesions of the flexor tendons. It is therefore necessary to exercise great care in these dissections, for the normal anatomic relationships are frequently lost with the destruction of the tendons. It is advisable always to first identify and isolate the median nerve to prevent secondary injury to this structure during the dissection of the tendons. Exposure at the Wrist It is essential to identify the tendon of the palmaris longus, if this muscle be present; likewise the tendon of the flexor carpi radialis. The median nerve passes under the annular ligament just below the palmaris longus tendon, to tlie ulnar side of the flexor carpi radialis tendon and to the radial side of the 4!>7—-~------tw 1024 SURGERY sublimis tendon; identification of these structures will usually facilitate exposure of the nerve. If the lesion is low, it may be necessary to divide the annular ligament and palmar fascia, exposing the nerve in the palm where it may be readily identified as it passes along the radial side of the sublimis tendons. If difficulty is experienced in locating the upper end of the nerve, the flexor carpi radialis tendon should be followed up, exposing the line of cleavage between the tendon of the flexor sublimis digitorum and the flexor longus pollicis. Retraction of the flexor sublimis digitorum will usually reveal the nerve on the under surface of this muscle. If this exposure fails to reveal the location of the nerve, it may be necessary to locate it as it passes under the pronator radii teres and the tendinous arch of origin between the heads of the flexor sublimis digitorum, as in middle forearm exposures. The palmar cuta- neous branch is given off from the anterior surface of the median, a few centi- meters above the annular ligament; in the presence of much scar tissue its identification is extremely difficult and when possible its repair should be attempted. After the median nerve has been located and before it has been completely isolated from its bed, it should be carefully marked with identifi- cation sutures, as in the lower third of the forearm funicular topography can not be determined by branch identification. Occasionally, advantage may be taken of the fact that the anterior surface of the nerve is frequently marked by the comes nervi mediana artery passing along its sheath; this artery is quite large and its presence may facilitate surface identification. Electro- anatomic identification at the wrist is of but little value, as the greater bulk of the nerve in this region consists of sensory fibers, its only motor fibers being those to certain intrinsic hand muscles which are located in the dorsal part of the nerve trunk. Even though the nerve is mostly sensory in this region, it is necessary to prevent torsion during suture, for sensory fibers normally innervating one finger may be directed to another, resulting in confusion of tactile localization. The writer has observed an officer whose median nerve was sutured at the wrist; after four years there was a complete return of all forms of sensation, though touch on the third finger was always localized in the thumb, which inhibited to a considerable extent manipulative dexterity in handling small objects. This officer is gradually becoming accustomed to this sensory perversion, by psychological reversion and experience. This case serves to illustrate the confusion arising from the distortion of sensory fibers during suture. Repair of Tendons in Combined Nerve and Tendon Lesions After the nerve has been properly identified and isolated, and before suture or the resection of scar tissue from its ends, the injured tendons must receive careful attention. They should be completely isolated from the scar tissue and every vestige of scar carefully removed with as little trauma as possible. Tendons completely divided should be resutured and when this is impossible, because of extensive destruction, they should be united to neighbor- ing tendons having like function. The surgeon should always endeavor in reconstructive surgery of the wrist, where distortion of the original tendon NEUROSURGERY 1025 pattern is necessary, to provide tendon anastomoses of a physiologic type for both ends of each divided tendon. After the tendons have been properly cared for and perfect hemostasis assured, the ends of the divided nerve may be prepared and approximated, with due respect to physiologic alignment. Flexion of the wrist will assist in facilitating approximation, though when this is necessary in the presence of combined tendon lesions, flexion of the fingers is not advisable. Early gentle passive movements are essential to success in combined nerve and tendon lesions of the wrist, and these passive movements should be persistently encouraged throughout the healing process, until such a time as they may be replaced by active movements, endeavoring always to simulate the full range of normal coordinated hand and finger move- ments; the importance of these passive exercises can not be too strongly emphasized; they should be begun not later than 48 hours after the operation. Surgery of the Median Nerve in the Hand Only occasionally is it possible to effect suture of the terminal digital branches of the median nerve. In the presence of extensive scar tissue it will probably be found impossible, though small incised lesions may lend themselves to successful repair. The writer has on two occasions been successful in effecting satisfactory suture of the median nerve in the palm where the injury was caused by a penetrating gunshot wound. In one instance, the suture was effected just before the nerve divided into its terminal digital branches. In the other instance, the division was about the point where the terminal branches were given off. In this case the individual branches were collected and united to the end of the trunk, apparently without torsion, as regeneration resulted in accurate tactile localization, Occasionally the median nerve in the hand may be incorporated in scar tissue, producing an irritative syndrome, with retained sensation. Neurolysis will usually give relief. Incised wounds of the fingers occasionally present sensitive neuromas, which are a source of constant annoyance. In such instances the nerve should be exposed and sutured if possible; when approxi- mation fails, the neuroma should be excised, the end of the branch strongly ligated and, proximal to the ligature, injected with pure alcohol. Exposure in the Palm Exposure of the median nerve in the palm is accomplished by an incision extending from the insertion of the palmaris longus tendon into the palmar fascia to a point corresponding to the interval between the index and ring fingers. The incision is carried through the integument and fat of the super- ficial fascia, exposing the palmar fascia, which is divided in the line of the cutaneous incision. The long flexor tendons are identified, and at the base of the palm the median nerve will be found lying to the radial side of these tendons. Shortly after the nerve passes under the annular ligament branches are given off, which pass radially to innervate the superficial thenar muscles, and supply sensation to the thumb. It is highly essential that these branches be preserved as they control to a great extent the opposing function of the thumb. 1020 SURGERY As the median nerve progresses through the palm it attains a po.-dtiun superficial to the flexor tendons, but passes below the superficial palmar areh. Proximal to the metacarpophalangeal joints the nerve divides into its terminal branches, where it is enlarged, flattened, and, in contrast to the fatty tissue in which it lies, has a somewhat pinkish color. The median divides into five terminal branches, supplying sensation to the first three and radial half of the fourth fingers. These branches may readily be identified, as they lie imbedded in the deep palmar fat, superficial to the flexor tendons, providing the operator has achieved adequate hem- ostasis, which is highly essential in such dissections and which in the writers experience has been satis- factorily accomplished only by the use of infiltration anesthesia, con- taining a small amount of active adrenalin to blanch the tissues. irreparable lesions Irreparable median nerve lesions present a serious problem. Though the action of extrinsic muscles be retained and finger and thumb move- ments fairly well preserved, the loss of sensation in the first three fingers is a serious handicap and every en- deavor should be made to restore, if possible, some type of sensation in the median distribution to the fin- gers. The surgeon may have re- course to autogenous grafts and may utilize a segment removed from the radial nerve. If this seems imprac- tical, because of extensive scar tissue formation, the procedure of uniting the radial to the median, recom- mended and practiced by Harris, may be considered. In this procedure, the distal end of the radial nerve is divided at a point where it may be brought in contact with the lower segment ol the median, to which it is anastomosed, for the purpose of supplying the anesthetic digits with a radial sensory innervation. It must be remembered, however, that this sensation is localized in the normal radial sensory area. It may correct trophic disturbance and serve in the prevention of injuries to the digits but the function of tactile localization, so necessary to manual dex- terity, is lacking. Fig. 182— Branches of median nerve in hand. A, Palmar fascia, cut edge; B, annular ligament; C, median branches to thenar muscles; D, branches to lumbricales; E, thenar muscles; F, digital sensory branches; G, palmaris longus tendon NEUROSURGERY 1027 In median lesions with extensive continuity defects, the severity of the lesion to the surrounding parts makes the possibility of successful grafting rather remote; the functional disability remaining after radial anastomosis renders this operation a procedure of last resort. It behooves the surgeon, therefore, to exert every effort to procure end-to-end suture of the median, using the two-stage operation, and if necessary, extending the dissection high up in the arm, or even in the axilla. If there also exists a combined ulnar lesion with paralysis of the ulnar intrinsic hand muscles, which has existed beyond one year, and the proximal end of the ulnar is in a position where it may be brought in contact with the distal end of the median, the ulnar may be anastomosed into the median. This procedure will give, perhaps, better functional results than radial anastomosis, though it precludes the possibility of subsequent ulnar regeneration with a continuation of complete anesthesia in the little finger, and interossei paralysis. After one year, it is extremely doubtful whether interossei regeneration would ever occur, and the little finger, if necessary, may be amputated, if trophic changes and traumatic insults to his anesthetic member should necessitate such a procedure. TENDON TRANSPLANTATION FOR PARALYSIS OF THE MEDIAN NERVE If it is possible to provide sensation to the fingers and hand, a varying degree of functional usefulness may be restored, even though there exists a complete paralysis of all median innervated muscles. The flexor profundus digitorum, supplied by the ulnar, provides flexion of the fourth and fifth fingers, and fre- quently the middle finger. The problem, therefore, consists in restoring flexion and opposition to the thumb, and flexion to the index finger and occasionally the middle. Frequently the ulnar supplies the superficial head of the short flexor of the thumb, or a slight change in the insertion of this muscle diminishes greatly the disability of opponens paralysis, so that in a certain number of cases opposing thumb function is fairly well preserved and tendon transplantation is required only to restore function in the long flexors of the thumb and index finger. In those cases of median paralysis in which the thumb is displaced laterally and can not be made to assume its normal opposed position, an arthrodesis of the carpometacarpal joint in a position of opposition and abduction with an angle of about 60° between the first and second metacarpals, as recom- mended by Baldwin, is a very satisfactory procedure. A fibrous anky- losis probably gives better results after this arthrodesis than a solid bony ankylosis. Ney has obtained very satisfacton- opponens function of the thumb by tendon transplantation, in which the short extensor of the thumb is divided at the wrist and freed to its insertion. The palmaris longus is then exposed and divided just above the annular ligament. The short extensor of the thumb is now passed through a tunnel under the subcutaneous fat of the thenar eminence to the palm of the hand, and after being passed under the annular lio-ament is transplanted into the tendon of the palmaris longus, or, the latter muscle being absent, into the flexor carpi radialis. If the flexor carpi radialis and palmaris longus are parah-zed, it may be inserted into the extensor 102S SURGERY carpi radialis tendon or the flexor carpi ulnaris tendon, which are being utilized to restore flexion to the distal phalanx of the thumb and the index finger. This procedure for obtaining opponens action finds its greatest usefulness in com- bined median and ulnar lesions with complete intrinsic hand muscle paralysis, under which subject the technique is described in detail. For Paralysis of the Long Flexor of the Thumb and the Flexors of the Index Finger An incision is made about 5 cm. long from the base of the metacarpo- carpal joint of the thumb along the radial border of the forearm, following the radial edge of the flexor carpi radialis. Undermining this incision medially, the deep flexor tendons are exposed and the long flexor of the thumb located just below the tendon of the flexor carpi radialis. Retraction of the edges of the wound laterally will expose the tendon of the extensor ossis metacarpi pollicis which is divided near its insertion into the base of the first metacarpal bone. The radial artery and its several branches lie in the space between these tendons and may require ligation. After the tendon of the extensor ossis metacarpi pollicis has been freed and divided it is anastomosed to the divided end of the flexor longus pollicis, under sufficient tension to insure flexion of the distal phalanx of the thumb. The flexor tendons to the index finger may now be identified and freed. An incision on the dorsum of the wrist over the tendon of the extensor carpi radialis is made from its insertion some distance up the forearm. The tendon of the radial carpal extensor is divided, carefully mobilized, and passed through a subcutaneous tunnel from the dorsum of the forearm to the incision on the ventral surface and trans- planted into both flexor tendons of the index finger. During this procedure the wrist is held in flexion and the index finger about half flexed. It is essen- tial in the postoperative treatment that early passive movements be instituted to prevent adhesions, which would tend to keep the index finger in permanent flexion. In our experience these procedures have given perhaps the best results, though very satisfactory results have followed a transplantation of the index flexor tendons into the flexor carpi ulnaris. ULNAR NERVE GENERAL ANATOMYr The ulnar nerve arises from the inner cord of the brachial plexus in com- mon with the inner head of the median and the internal and lesser internal cutaneous nerves, most of its fibers being derived from the anterior divisions of the eighth cervical and first thoracic roots. The nerve lies medial to the inner head of the median and lateral to the internal cutaneous. In passing through the axilla and the upper two-thirds of the arm, the ulnar occupies a position medial to the artery and the median nerve in the neurovascular bundle. In the lower part of the middle third of the arm the nerve leaves the neurovascular bundle, and penetrating the internal intermuscular septum follows a posterior course to a position posterior to the internal humeral con- dyle, lying in close relation to the posterior surface of the internal intermu>- cular septum, and crossing the fibers of the medial head of the triceps, which NEUROSURGERY 1029 arise from this portion of the septum. In this region the ulnar nerve is ac- companied by the inferior profunda artery, which usually lies on its ventral surface. The profunda artery in the region of the internal humeral condyle anastomoses freely, as does its vena, comites, with the posterior ulnar recur- rent artery and veins. Behind the medial condyle the ulnar nerve occupies a very superficial position and is covered by a thick, aponeurotic fascia, which extends from the condyle to the olecranon. The nerve enters the forearm by passing under an aponeurotic arch, connecting the humeral and ulnar heads of the flexor carpi ulnaris, and continues its course down the forearm, covered by the belly of this muscle and lying on the profundus digitorum. In the upper third of the forearm the ulnar nerve is separated some distance from the ulnar artery, while in the middle and lower thirds they lie in direct contact. In the middle and lower thirds of the forearm the ulnar nerve lies dorsal to the tendon of the flexor carpi ulnaris; at the wrist it passes through a special compartment in the anterior annular ligament to the radial side of the pisiform bone to enter the palm, where it divides into its terminal super- ficial and deep palmar branches. BRANCHES The only branches of the ulnar nerve given off in the arm are in the region of the internal humeral condyle, where several small twigs are distributed to the elbow joint. About 2 cm. below the medial condyle two branches are given off to the two heads of the flexor carpi ulnaris; at a slightly lower level another set of branches is given off to the ulnar side of the flexor pro- fundus digitorum. These motor branches arise from the medial side of the dorsal quadrant of the nerve; they pursue a relatively long intraneural course and may be followed up the ulnar trunk for some distance above the medial condyle by an intraneural dissection. In the middle third of the forearm the ulnar gives off a relatively insignificant palmar cutaneous branch, which distributes branches to the ulnar artery and follows the artery to the annular ligament, over which it passes to supply a small area at the base of the hypo- thenar eminence. At the junction of the middle and lower third of the fore- arm there springs from the medial side of the ulnar trunk a large dorsal cuta- neous branch, which at times nearly approximates the ulnar trunk in size This dorsal cutaneous branch, after passing under the tendon of the flexoi carpi ulnaris to the dorsal aspect of the wrist, becomes cutaneous and sup- plies sensation to the ulnar dorsal border of the hand, and to the dorsum of the little finger as far as its terminal phalanx and the ring finger to its middle phalanx. Terminal palmar branches.—After passing under the annular ligament the ulnar nerve terminates in a superficial and deep branch. The superficial branch, beyond giving a few twigs to the palmaris brevis muscle, is strictly sensory and supplies sensation to the ulnar side of the palm and divides into an outer and inner digital branch, supplying sensation to the little finger and adjacent side of the ring finger. The deep branch is principally motor; after its separation from the ulnar trunk, it gives off branches to the muscles of the little fino-er and enters its deep course in the palm, accompanied by the ulnar 1030 SURGERY artery, by passing between the abductor and flexor brevis minimi digiti mus- cles, penetrating the opponens minimi digiti. It follows the course of the deep palmar arch beneath the flexor tendons, giving off branches to the dorsal and palmar interossei muscles and the two inner lumbricales, and terminates by sending motor branches to the adductor pollicis and the inner head of the flexor brevis pollicis. SURGERY Lesions of the ulnar nerve in the axilla are usually combined lesions of the terminal plexus type, and are dealt with as such. In the upper arm the ulnar nerve lies within the neurovascular bundle, and any traumatism sufficient to injure the ulnar will probably result in injury to the median. As the ulnar nerve leaves the axilla under the lower border of the pectoralis major, it passes across the tendon of the latissimus dorsi, in close relation to the musculospiral, and in this region both occasionally suffer simul- taneous injury. EXPOSURE IN THE ARM Exposure of the ulnar nerve in the upper part of the arm is obtained as with the median, through a long incision, paralleling the neurovascular bundle. This incision differs, however, in that at the junction of the middle and lower third of the arm it diverges posteriorly, following the internal intermuscular septum to the medial humeral condyle. The deep fascia is now opened and the medial border of the coracobrachialis above and the biceps below retracted, exposing the neurovascular bundle, which lies in the cleft between these muscles and the long head of the triceps. At the lower part of the axilla the neurovas- cular bundle is covered by the pectoralis major and, to obtain an axillary exposure, the pectoral tendon will require division. The neurovascular bundle is opened, exposing its contents and the ulnar nerve identified above the lesion. About the junction of the middle and lower third of the arm the lower segment of the ulnar nerve is identified posterior to the internal intermuscular septum, after it has left the neurovascular bundle. Before disturbing the circum- ferential relationship of the nerve by complete isolation, in both upper and lower positions, the center of its lateral quadrant should be carefully marked with accurately placed identification sutures. The dissection of the nerve may now progress to the point of lesion. If the identification sutures previously placed are found to be some distance from the lesion, as the dissection progresses they should be supplemented with additional sutures, carefully observing the surface markings of the nerve. Much difficulty is experienced in the dissection of the neurovascular bundle, particularly when it is invaded with scar tissue due to bleeding from numerous venous and arterial radicals. This difficulty may in a large measure be obviated by isolation of the basilic and brachial veins below, and the application of permanent or temporary constriction. Arterial hemorrhage may be controlled by isolating the brachial artery above and applying a tape which may be adjusted to control its circulation while branches are being ligated or accidental wounds in the arterial wall repaired Defects in the continuity of the ulnar trunk in the arm, if of a magnitude not correctable by primary nerve stretching, will call for transposition of the NEUROSURGERY 1031 nerve from behind the medial condyle of the humerus to a more ventral position, after which advantage may be taken of elbow flexion-relaxation. When this procedure fails to overcome the defect, the ulnar nerve should be freely mobilized in the axilla and recourse taken to the two-stage operation. SURGERY IN THE REGION OF THE INTERNAL HUMERAL CONDYLE The ulnar nerve, as it passes behind the internal humeral condyle is exposed to frequent trauma. Its involvement in war injuries is second only to lesions of the musculospiral. Its lateral surface, being in direct contact with the bone, and its medial surface being very superficial, renders it particularly susceptible to trauma. PROGRESSIVE PERIPHERAL ULNAR PARALYSIS Severe injury to the ulnar nerve usually results in complete immediate paralysis, while frequently repeated slight trauma will result in a gradual progressive type of peripheral paralysis, in which sensation is slowly lost and atrophy of the intrinsic hand muscles supervenes. The ulnar nerve, because of its exposed position behind the medial humeral condyle, is commonly the recipient of frequent mild degrees of trauma, though of sufficient intensity to institute a gradual compression paralysis, due to the production of intraneural scar tissue. Occasionally this type of ulnar paralysis will develop years after a trauma to the medial condyle or the elbow joint. The original trauma may escape memory, but is probably responsible for the institution of some anatomic change in the bone proximal to the nerve, or for a thickening of the aponeurotic fascia covering the nerve, producing compression or intensifying the effect of ordinary trauma to this region. In lesions of this type, the ulnar nerve should be transposed from its exposed position behind the humeral condyle to the less traumatized region anterior to the condyle. This procedure will usually suffice to correct most progressive peripheral lesions, though when the nerve is found to be indurated, its sheath should be opened and the bundles subjected to internal neurolysis. The nerve sheath is allowed to remain open for its decompressive effect. Exposure The surgery of the ulnar nerve in the region of the internal condyle neces- sitates exposure in its lower humeral and upper forearm course. With the arm fully abducted and in external rotation, the forearm flexed and in extreme supination, a curved incision is carried from the junction of the middle and lower third of the arm, beginning along the medial border of the biceps, follow- in»- the course of the nerve downward behind the internal condyle to the fore- arm where it follows its anterior ulnar border to the junction of its upper and middle third. In the line of this incision, the deep fascia is divided and the nerve identified distal and proximal to the lesion. In its lower humeral course, the nerve will be found, after having penetrated the internal intermuscular septum, following the posterior border of this structure, lying upon the internal head of the triceps or covered by its superficial fibers. It is accompanied by the inferior profunda artery which may usually be separated from the nerve 1032 SURGERY to the internal condyle, where ligation will be required, as in this region the artery and its vemv comites anastomose freely with the ulnar recurrent artery and vein. The preliminary ligation of these vascular structures, both above and below the internal condyle, where they lie in direct contact with the nerve, will greatly enhance the dissection. The ulnar collateral branch of the museulo- spiral nerve, supplying the medial head of the triceps, follows a course along the posterior border of the internal intermuscular septum in close relation to the ulnar nerve and care should be used in avoiding its injury. At the internal medial condyle, the ulnar nerve is protected by a thick aponeurotic membrane stretching from the medial condyle to the olecranon, as they are occasionally adherent, Before the relationship of the nerve has been disturbed in its bed, it should be carefully marked by sheath identification sutures to prevent torsion during subsequent suture. The nerve, after being uncovered in its course posterior to the medial condyle, will be found entering the foramen by passing under the tendinous arch, connecting the two heads of the flexor carpi ulnaris. The fibers of this arch are divided and the line of cleavage between the two heads of the muscle separated for a short distance, exposing the nerve in its passage below this muscle, where it lies upon the muscular fibers of the flexor profundus. In the region of the condyle and below, important branches will be found innervating the flexor carpi ulnaris and the ulnar half of the profundus digitorum; these motor branches spring from the medial and pos- terior quadrant of the nerve. The branches to the flexor carpi ulnaris leave the ulnar trunk somewhat higher than those to the profundus—usually about the level of the condyle. The fibers innervating the flexor carpi ulnaris may leave the nerve trunk as a single bundle, subsequently dividing to supply its two heads, or these branches may leave the parent trunk after their division. If the ulnar sheath is opened, however, they will be found united into a single branch or bundle, and may be followed some distance above the internal condyle. The lower branch, innervating the ulnar half of the flexor profundus digitorum, may likewise leave the nerve trunk as a single branch, or after its division. Within the nerve trunk, however, it may be followed as a single bundle some distance above the condyle, where it will be found to join with the bundle containing the fibers to the flexor carpi ulnaris. After these two bundles have combined, their intraneural course may frequently be followed as high as the middle third of the arm. The intraneural dissection of these branches is extremely important in transposing the nerve to a position anterior to the humeral condyle, in the correction of continuity defects—it is our only means of preserving these branches during such a procedure. Occasionally, in lesions in the region of the medial condyle, these motor branches may be found divided; and if they can not be identified and repaired, provision should be made for ulnar profundus paralysis by dividing the two medial profundus tendons above the wrist and uniting them with the two lateral profundus tendons which are supplied by the median nerve. TRANSPOSITION OF THE ULNAR NERVE Transposing the ulnar nerve from its position behind the internal humeral condyle to the anterior surface of the elbow is a valuable procedure in over- NEUROSURGERY 1033 coming defects in the continuity of the nerve; it is also indicated in progressive peripheral ulnar paralysis in which the nerve is subjected to trauma when occupying its normal position. In overcoming defects, transposition of the ulnar nerve will shorten its course and render it suscentible to flexion-relax- j.„, is:*.— ulnar nerve, showing scar tissue as found at operation. Nerve exposed by splitting the two heads of flexor carpi ulnaris; exposure of distal and proximal segments. Identification sutures placed. A, Medial epicondyle; B, olecranon; C, ulnar nerve, proximal segment; D, flexor carpi ulnaris, ulnar head; E, ulnar nerve, distal segment; F, flexor carpi ulnaris, humeral head; G, internal intermuscular septum Fig. in 4.—Ulnar nerve exposed above medial humeral condyle preparatory for transposition anterior to the condyle. Intra- neural exposure and mobilization of branches to ulnar half of flexor sublimis digitorum and flexor carpi ulnaris; mobili" zation of branches should be carried at least 3 cms. above condyle. A, Medial epicondyle; B, flexor carpi ulnaris, humeral head; C, ulnar nerve; D, wall of ulnar canal; E, branch to flexor carpi ulnaris; F, branch to flexor profundus digitorum; G, ulnar nerve, distal segment ation ot the elbow, when defects in the forearm of three or four inches may be readily overcome. The incision for ulnar transposition follows the course of the nerve from the middle of the arm to the middle of the forearm. The deep fascia is divided the line of the skin incision and the nerve exposed throughout the length in 1034 SURGERY of this incision, care being taken to place a sufficient number of identification sutures to assure alignment of the nerve, if suture is required. The anterior skin flap containing the fat of the superficial fascia is reflected, exposing the medial border of the biceps and its tendon. The ulnar nerve is now followed upward to the middle third of the arm where it penetrates the internal inter- muscular septum; the septum is divided and the nerve made to pass along its ventral border, following the course of the neurovascular bundle to the ante- cubital fossa. To transpose the nerve below the medial condyle so that it will follow a straight line down the arm and forearm, its motor branches to the flexor carpi ulnaris and the profundus digitorum must be mobilized some distance up the nerve trunk to prevent stretching and tearing in transposing the nerve. The nerve in its transposed position passes over those muscles arising from the medial condyle. If the cutaneous structures in this region have been well preserved and contain sufficient subcutaneous fat, the writer 1 £_&& Fig. 185.-Ulnar nerve transposed; defect overcome by transposition and flexion-relaxation of elbow- branches preserved through mobilization prefers transplanting the nerve in this superficial position, where it is covered merely by the fat of the superficial fascia. Some operators, however prefer directing the nerve through a muscular tunnel below the common heads of origin of the superficial muscles springing from the medial condyle, the bed of the nerve being the flexor profundus digitorum. This may be accom- plished m two ways, depending upon the ability to preserve the motor branches to the flexor carpi ulnaris and profundus digitorum. If the motor branches have been sacrificed, the nerve is passed through a tunnel between the sublimis wiln^Th . ^t^1^ b-y P«»ing forceps between these muscles, widening the tunnel and drawing the free end of the nerve through The second method consists in dividing the superficial muscles close to their origin Ibove 7dl^C°n^vle;^T* tho nerve in the ^ ^d resuturing the muscles above it This has the disadvantage of possibly interfering with the nerve supply of normal muscles, and also of inflicting additional trauma to the NEUROSURGERY 1035 structures surrounding the nerve. While the tunneling procedure is less apt to injure the nerve supply of adjacent muscles, it undoubtedly invites an excess of scar tissue by virtue of the trauma inflicted. EXPOSURE IN THE MIDDLE AND LOWER THIRDS OF THE FOREARM An incision extending from the radial side of the pisiform bone toward the medial condyle will follow the course of the ulnar nerve in the forearm. After the deep fascia has been divided, the tendon of the flexor carpi ulnaris is identified. It will be remembered that the lateral or radial border of the flexor carpi ulnaris is tendinous for some distance up the forearm, while from its medial or ulnar border muscular fibers radiate almost as far down as the wrist joint. The ulnar nerve, accompanied by the ulnar artery and its vena1 comites, lies beneath the radial border of the flexor carpi ulnaris tendon and to the ulnar side of the flexor sublimis digitorum. Following upward the cleft between these muscles, the ulnar nerve will be found resting upon the flexor profundus digitorum and covered by its thin sheath. It is advisable to first identify the nerve in the region of the wrist, after which it may be fol- lowed upward by separating the loose attachment between the flexor carpi ulnaris and the flexor sublimis digitorum: the identification of the line of cleavage between these muscles is facilitated by following up the radial ten- dinous edge of the flexor carpi ulnaris. If difficulty is encountered in ex- posing the proximal end of the nerve, it may be readily identified at the medial condyle, which it leaves to pass between the two lieads of the flexor carpi ulnaris. These two heads may be separated for some distance and the nerve followed as it passes below the belly of the humeral head, which latter may be conveniently elevated by tape retraction, its radial border having been previously separated from the sublimis and palmaris longus. In the upper part of the middle third of the forearm, the ulnar artery joins the nerve and follows it throughout the remainder of its course. In the middle third of the forearm a small palmar cutaneous branch is given off, which follows the ulnar artery down the forearm and passes over the annular ligament: this branch is unimportant and may be sacrificed with impunity. About the lower third of the forearm, though at times much higher, a large dorsal cutaneous branch arises from the medial side of the ulnar trunk and passes under the tendon of the flexor carpi ulnaris to supply the integument of the ulnar dorsal side of the hand and fingers. This branch is occasionally of rather large size and must not be confused with the main ulnar trunk. It follows a relatively long intraneural course and its preservation is important, as it supplies sensation to the much traumatized ulnar border of the hand and little finger. Lesions of the ulnar nerve in the lower two-thirds of the forearm are commonly associated with more or less tendon injury, which should be repaired before the nerve is sutured. If sublimis or profundus tendons on the ulnar side are injured, they should be freed of all scar tissue and reunited if possible. If suture of the divided tendons is not possible, they should be anastomosed to intact sublimis or profundus tendons, and their bellies above freed of scar and likewise united. Occasionally the palmaris longus may be transplanted into the distal end of the divided sublimis tendons. 1036 SURGERY SURGERY OF THE ULNAR NERVE IN THE PALM The ulnar nerve enters the palm by passing through the annular ligament in a compartment of its own along the radial border of the pisiform bone, and in the palm divides into its two terminal branches—a superficial branch, mainly sensory, and a deep branch, principally motor to the ulnar intrinsic hand muscles. These terminal ulnar branches do not lend themselves favorably to surgical repair, though as with the median, occasional instances will be found where extremely localized injuries involving the nerve with small de- fects will permit repair. Exposure Exposure is made through an incision extending from the radial border of the pisiform bone to the interspace between the fourth and fifth fingers. The nerve is localized at the wrist and followed into the hand by dividing the annular liga- ment, the palmar fascia and the palmaris brevis, exposing the flexor brevis minimi digiti and the op- ponens of the little finger. By retracting the ulnar border of the incision, the deep branch may be followed and exposed as it passes in a cleft between the flexor brevis and abductor, which muscles require careful identification as they are important landmarks. If the inter- space between these muscles is spread, exposing the opponens, the nerve may be followed to a point where it penetrates the latter muscle. After penetrating the opponens, the deep palmar branch passes below the flexor tendons and in this region is practically inaccessible. The superficial palmar branch may be identified by its superficial position and by the distribution of its digital branches. Occasionally it is possible to effect individual suture of these digital branches, their arrangement being similar to the median digital branches. In attempting repair of the small cutaneous or motor branches of the median or ulnar nerve in the hand, the operator should proceed with extreme care and a full appreciation of the difficulties involved, in that the disability resulting from the inflicted surgical trauma may be greater and overshadow the original disability. Fig. 186.—Branches of ulnar nerve in hand. A, Digital cuta- neous branch, fourth and fifth fingers; B, digital cutaneous branch, fifth finger; C, palmaris brevis; D, motor branch to intrinsic muscles; E, ulnar nerve; F, ulnar artery; G, palmar fascia; H, palmaris longus tendon; I, annular ligament NEUROSURGERY 1037 DEFECTS IN CONTINUITY Because of the passage of the ulnar nerve posterior to the internal humeral condyle, it does not lend itself to flexion-relaxation of the elbow joint. In fact, flexion of the elbow joint tends to stretch the nerve, which normally is relaxed by forearm extension. It therefore becomes necessary in most ulnar defects to resort to transposition of the nerve from its posterior position behind the internal condyle to an anterior position, by which the operator utilizes the elongating effect of directing the nerve from an angular to a straight course, and wliich also permits an extensive relaxation of the nerve during forearm flexion. Defects in the forearm up to 3 or 4 inches may be overcome by utilizing transposition of the ulnar nerve with flexion-relaxation of the elbow. Defects of greater magnitude in the forearm require extensive mobilization of the nerve, which should be continued to the wrist below and to the upper third of the arm above, when another inch may be added by ulnar flexion of the wrist and abduction of the arm. If the surgeon, having availed himself of these procedures, finds difficulty in obtaining end-to-end approximation, he must then resort to the two-stage operation, described under general technique. An endeavor should always be made to preserve the motor branches at the elbow, though they may be sacrificed if their extensive intraneural mobilization fails to give sufficient relaxation to the nerve. If it becomes necessary to sacrifice the motor branches to the flexor carpi ulnaris and ulnar half of the profundus digitorum, the function of the profundus tendons may be maintained bv transplanting them at the wrist into the two remaining active profundus tendons. The surgeon is rarely justified in sacrificing the dorsal cutaneous branch of the ulnar for relaxation purposes. If it is found to interfere with ulnar mobilization, it should be freed as far as possible along the ulnar border of the forearm. Sacrifice of the dorsal cutaneous branch involves a permanent anesthesia of the ulnar border of the hand and little finger, which may in itself necessitate amputation of these parts, because of the constant irritation of trophic or traumatic sores. In the arm, large defects of the ulnar nerve necessitate exposure well up into the axilla and well down into the forearm. Flexion-relaxation is inhibited in upper defects of the nerve by the motor branches at the elbow, and to obtain its full effect, sacrifice of these branches is usually necessary. In trans- posing the ulnar nerve for the correction of defects, the surgeon should assure himself that the nerve is freely mobilized in the region of the internal inter- niuseular septum. Ulnar defects, which can not be overcome by stretching, transposition, and flexion-relaxation of the elbow, wrist, and shoulder are prob- ably beyond repair, though in such cases the surgeon should not neglect the possibilities of a successful graft, but grafting may be used only as a procedure of last resort. SECONDARY SUTURES Surgery of the ulnar nerve gives perhaps more unsatisfactory results than any other nerve, primarily because of failure in regeneration of the ulnar intrinsic hand muscles. In the writer's experience, regeneration of the inter- 1038 SURGERY ossei muscles is absent, after four years, in 94 per cent of ulnar sutures. These delicate, highly specialized intrinsic hand muscles reach an extreme degree of muscle degeneration in a comparatively short period. In several cases of ulnar paralysis, resulting from compression lesions, in wliich there has been a satisfactory restoration of ulnar sensation following neurolysis, the ulnar intrinsic hand muscles have remained paralyzed where the uncorrected lesion had existed beyond one year. The writer has observed a number of cases in which some function had returned in the muscles of the hypothenar eminence and the adductor pollicis, though no action could be demonstrated in the interossei. The restoration of function in the ulnar portion of the profundus digi- torum and the flexor carpi ulnaris occurs in approximately 60 per cent of cases, following suture. In most cases of ulnar suture in which there has been some degree of axis cylinder regeneration, some return of sensation is found in the ulnar border of the hand and little finger. This sensation, in most instances, after a period of two years is nondiscriminative in character, all types of sensa- tion being described as tingling. Usually after the third year, the power to discriminate between various sensations gradually returns to a greater or lesser degree, but usually sufficient to afford protection to this region of the hand. In view of these facts, a failure of interossei regeneration should not be considered as defective regeneration beyond our usual experience, and this defect does not call for secondary surgical intervention. The failure of sen- sory restoration in the ulnar region is indicative of defective regeneration and does not call for intervention. In considering defective regeneration in the ulnar nerve, sensation deserves the greatest attention. Any hope of regen- eration, to a satisfactory degree, in the intrinsic hand muscles may be practi- cally abandoned for an uncorrected paralysis of one year's standing. Paralysis of the flexor carpi ulnaris and ulnar half of the profundus digitorum is pro- ductive of no great disability and the slight disabdity existing from their paralysis may readily be overcome by tendon transplantation. DETERMINATION OF REGENERATION The examiner must depend entirely upon Tinel's sign for information durmg the early stages of ulnar regeneration following suture. Alter six months, if formication is not elicited in the distal segment of the nerve, it should be considered as defective neuraxon regeneration, and secondary sur- gical intervention is indicated. Certain precautions must be taken in the presence of much scar tissue in the region of the suture, in eliciting this reaction. The tugging of a scar upon a neuroma or suture line may elicit the reaction of formication in a region below the regenerated nerve fibers. When Tinel's sign is elicited throughout the distal nerve trunk and this reaction is intense, it may be prognosticated that sensory fibers are regenerating satisfactorily, and the patient assured of some degree of sensory restoration. A persistent loss of sensation in the ulnar region with a sensitive suture line, giving evidence on palpation of neuroma formation, suggests defective suture and secondary exposure is indicated NEUROSURGERY 1039 The writer has observed several instances in which there was no evidence of regeneration following a neurolysis of the ulnar nerve. Such failures, fre- quently commented upon by other writers, need not, necessarily, call for resec- tion of the nerve and suture, unless an internal neurolysis has demonstrated a complete blocking of the scarred trunk, with obliteration of motor bundles. These defective end results, following neurolysis, are usually due to imperfect surgical judgment at the time of operation, when an external neurolysis was probably the extent of the operation; the real compressive factors evidently were overlooked. In complete persisting failure of regeneration, and in irreparable defects, where the anesthetic area is constantly being subjected to trauma, and suffer- ing trophic disturbances, amputation of the little finger offers the only solution. Occasionally this amputation must also include the ulnar metacarpal region. A very deforming fibrous griffe may be allowed to develop in the little finger, greatly diminishing the usefulness of the hand, which also may justify amputation. COMBINED LESIONS OF MEDIAN AND ULNAR NERVES The close anatomic relationship existing between the median and ulnar nerves in the middle and upper thirds of the arm makes their combined lesions comparatively frequent. Less often are combined lesions of these nerves experienced below the lower third of the arm, where they pursue a divergent course, though combined lesions are by no means uncommon in extensive gun- shot injuries of the forearm. The importance of combined median and ulnar lesions is emphasized by the seriousness of the resulting diasbility, in which all of the extrinsic and intrinsic flexion power of the fingers is lost, as well as the power of pronation; this paralysis, combined with complete anesthesia of the palm and fingers, renders the extremity practically useless. The surgical repair of combined median and ulnar lesions differs in no respect from the individual repair of these nerves, each of which should be treated surgically as an individual unit. The necessity for a separate considera- tion of combined median and ulnar lesions is advisable, however, because of supplementary surgical procedures indicated in a total absence of or defective nerve and muscle regeneration. In the great majority of instances following a successful end-to-end approximation in both median and ulnar nerves (if due respect has been given to the prevention of torsion during suture) there will be a restoration of volun- tary motor power in the pronators, wrist flexors, and extrinsic digital flexors, with a gradual return of sensation; the total anesthesia of the fingers is replaced at first by a nondiscriminative type of anesthesia, which later, after two or three years, is slowly supplemented with the power of tactile localization and discrimination. This degree of functional restoration following the suture of these nerves is probably as complete as may reasonably be expected. The residual disability is confined to a loss of function in the intrinsic hand muscles, expressed by: (1) Loss of opponens function of the thumb; (2) inability to flex the metacarpophalangeal joints; (3) loss of extension of the interphalangeal joints with hyperextension of the metacarpophalangeal joints. 4(U*07—27----(»S 1040 SURGERY These disabilities produce a deformity commonly characterized as the " claw hand" of complete intrinsic hand-muscle paralysis. The long flexors of the lingers are unable to conjointly flex the metacarpophalangeal joints and ter- minal phalanges; attempts at flexion are followed by a rolling up of the terminal phalanges, in which the nails, instead of the palmar surface of the fingers meet the palm, due to the fact that flexion of the metacarpophalangeal joints does not occur synchronously with phalanx flexion, and when flexion does occur at the metacarpophalangeal joints it is only after the interphalangeal joints are completely flexed. The thumb disability consists in the loss of opponens action, and though flexion of the distal phalanx is restored through the long flexor of the thumb, this member rests against the radial border of the hand, and normal thumb and index finger opposition ("pinch action") is replaced by a very defective and ineffectual approximation, in which the nail of the thumb meets the radial side of the index finger, objects being held between the thumb nail and this finger very much as a small boy holds a marble for shooting. The extensor communis digitorum is capable of extending the terminal phalanges when the long flexors are completely paralyzed, but it seems to lack this power when they are active. Its principal action is extension at the meta- carpophalangeal joints. In intrinsic hand-muscle paralysis the fingers can not be completely extended; during attempts at extension the terminal phalanges remain partially flexed, while the metacarpophalangeal joints are hyperextended. The interossei, by virtue of their insertion into the extensor tendons beyond the metacarpophalangeal joints, accomplish terminal phalangeal extension; in this they are assisted by the lumbricales, which also by virtue of their origin from the tendons of the profundus digitorum and their insertion with the interossei into the extensor tendons, near the center of the first phalanx, prevent hyper- extension of the metacarpophalangeal joints, as the lumbricales are flexors of these joints and antagonists to the extensor communis digitorum. The function, therefore, which we wish to restore in intrinsic hand-muscle paralysis is the opposing action of the thumb, and flexion of the metacarpophalangeal joints, with extension of the terminal phalanges, metacarpophalangeal flexion is particularly important in the index finger. For the restoration of opponens function, or rather the maintenance of the thumb in the opponens position, Major Baldwin attempted arthrodesis of the first metacarpophalangeal joint and fixed it in an opposed position at an angle of GO degrees, which is practically the normal angle existing between the first and second metacarpals during pinching action. This operation, though restor- ing the opponens position of the thumb and greatly improving its function, has a distinct disadvantage; it does not permit abduction and extension, the thumb remaining continuously opposed over the palm, in which position it is like the drop thumb of extensor paralysis and is frequently in the way. The writer devised and practiced a tendon transplant for the restoration of opponens function in the thumb, which duplicates this action perfectly, at the same time allowing its complete extension. The procedure consists in directing the short extensor tendon of the thumb through a tunnel under the fat of the NEUROSURGERY 1041 superficial fascia; from the palm it is directed under the annular ligament to the wrist where it is anastomosed to the palmaris longus. The end results of this procedure have been observed in a series of cases for a period of more than three years. In each instance the opposing action of the thumb has remained excellent and has gradually increased in power with the development of the palmaris longus muscle. TENDON TRANSPLANTATION FOR RESTORING OPPONENS ACTION TO THE THUMB IN INTRINSIC HAND-MUSCLE PARALYSIS This procedure is conducted entirely under local anesthesia, which assists materially in hemostasis; it also permits the testing out of the transplant during operation, by voluntary contraction of the palmaris longus, the patient having been previously instructed in the contraction of this muscle. Technique a. A midventral wrist incision is made over the course of the palmaris longus tendon, extending from the base of the palm just below the annular ligament, upward for a distance of about 7 cm. The palmaris longus tendon is identified and freed, and its attachment to the palmar fascia divided, after it has passed over the annular ligament. The median nerve lies immediately below the palmaris tendon and is usually exposed with the retraction of this tendon. A pair of blunt-curved forceps is now passed under the annular ligament at this point, and made to emerge below its palmar border, by penetrating the palmar fascia, the forceps being spread to enlarge the opening. The opening in the palmar fascia is enlarged sufficiently, by excising its edges, to prevent subsequent constriction of the transposed extensor tendon, which is passed through this opening. b. A dorsal thumb incision from the base of the proximal phalanx extends to the radiocarpal articulation, bisecting the " anatomical snuffbox." To the palmar side of this incision the short extensor tendon is located as it lies in a separate sheath in juxtaposition with the dorsal border of the tendon of the extensor ossis metacarpi pollicis. The long extensor tendon, which lies to the dorsal side of the incision, must not be confused with the short extensor tendon—traction on the tendon of the long extensor produces extension of the distal phalanx. The sheath of the short flexor is opened and the tendon fol- lowed downward to the metacarpophalangeal joint of the thumb. This short flexor tendon is divided about 10 cm. above its insertion, where it lies in close approximation with the tendon of the extensor ossis. c. A tunnel is now maed between the lower ends of the two incisions, undermining the fat of the superficial fascia in a line connecting the annular ligament and the metacarpophalangeal joint of the thumb. Through this tunnel a pair of forceps is passed from the ventral to the dorsal incision and the divided end of the extensor brevis pollicis tendon caught and drawn through the tunnel to the opening in the palmar fascia. Its end is then grasped by the previously placed subannular forceps, drawn through the opening in the 1042 SURGERY palmar fascia under the annular ligament to the wrist, where it is anastomosed to the palmaris longus tendon, with sufficient tension to produce marked abduction and opposing rotation of the thumb. When the palmaris longu> is absent, as it is in approximately 20 per cent of cases, the transposed extensor tendon may be passed through a slit in the flexor carpi radialis tendon tion^d^Zt^T ^Tg°TmmV°^- FlG-188-Tendon transplant for restoring opponens nZw T , , ? lntnDS1C haDd mUSde P0siti0n and function ^ the thumb in intrinsic hand paralyse exposure of palmaris longus tendon muscle paralysis. TendoQ of palmaris longus ^ vided; opening made in palmar fascia at upper part of annular ligament and sutured, without division of the tendon of the latter muscle. (In the writers experience, more satisfactory end results have followed transplantation into the palmaris longus.) The thumb now lies across the palm in an opposed and abducted position and with the wrist slightly flexed; the skin incisions are closed, and the hand dressed with the thumb and fingers grasping an unrolled NEUROSURGERY 1043 bandage, which tends to maintain the thumb in the desired position. The fist, with the wrist flexed, is firmly supported with suitable bandages or splint- ing to insure the maintenance of this position. The subsequent treatment is conducted along lines common to the after- treatment of all tendon transplantations. Reeducation is, as a rule, not Fn,. 189—Tendon transplant for restoring op- ponens position and function to the thumb in intrinsic hand muscle paralysis; exposure of short extensor of the thumb Fig. 190.—Tendon transplant for restoring op- ponens position and function to the thumb in intrinsic hand muscle paralysis. Passage of the divided short extensor tendon through a subcutaneous tunnel in the thenar eminence and through opening in palmar fascia, where it passes below the annular ligament and is anastomosed to the palmaris longus tendon, holding the thumb in the opponens position difficult and a few demonstrations will usually be found sufficient to institute effective opponens action of the thumb in individuals of ordinary intelligence. This transplant is synergetic, in that forceful prehension of the thumb is accompanied normally by contraction of the palmaris longus. 1044 SURGERY TEXDOX TRAXSPLAXTATIOX FOR RESTORIXG METACARPOPHALANGEAL FLEXIOX AND EXTEXSIOX OF THE TERMIXAL PHALAXOES (LUMBRICALES AND INTEROS- SEI FUNCTION) For the restoration of metacarpophalangeal flexion, Stiles devised an ingenious operation in which he alters the insertion of the flexor sublimis digi- torum tendons, rendering them flexors of the metacarpophalangeal joints by suturing them to the exterior communis tendons distal to the knuckle, which makes them also extensors of the interphalangeal joints, thus causing the flexor sublimis digitorum to subserve the function of both interossei and lum- bricales. This procedure may be carried out on each finger or it may be limited to the index. Technique a. Through a mid-dorsal incision, the skin and fascia are divided, and the common extensor exposed. The insertions of the interossei and lumbricales into its lateral aspect are identified and freed. b. An incision is made along the flexor aspect of the digit from the trans- corse palmar crease to the distal interphalangeal joint, exposing the flexor sheath, which must not be opened through the line of incision. About the base of the metacarpophalangeal joint, the sublimis tendon divides to permit the passage of the profundus tendon. The lateral and medial slips of the tendon then pass forward to be attached into the sides of the middle phalanx. Near their insertion a small incision is made through the sheath of each tendon slip and the tendon divided. Next the tendon is identified opposite the meta- carpophalangeal joint, where it has just begun to split; an opening is made in the sheath at this point, and each tendon slip pulled out of its sheath. Stiles emphasizes the importance, in making these openings in the sheath, of not disturbing the small bands which hold the profundus tendon in place opposite each phalanx, "otherwise the tendon will stand forward under the skin like a bowstring when the patient attempts to flex the finger, and will lose its pull on the terminal phalanx." Each half of the sublimis tendon is now passed through a subcutaneous tunnel on each side of the digit to the dorsal incision and threaded through an opening made in the expanded portion of the extensor sheath which receives the insertion of the interossei and lumbricales. The two tendons are sutured in this position with linen, with the knuckle flexed at right angles and the interphalangeal joints straight. Any excess of tendon is cut away and the raw ends buried by a suture through the two sides of the communis. Both wounds are closed and the fingers fixed by pads and bandages in a position of metacarpophalangeal flexion and terminal phalanx extension. IRREPARABLE DEFECTS OF THE MEDIAN AND ULNAR NERVES An irreparable defect of the median and ulnar nerves is attended with such a degree of disability to the extremity that it may be considered as permanently useless, unless some flexion function can be restored to the fingers through tendon transplantation. The accompanying anesthesia, however, seriously diminishes the functional usefulness of the hand, even though digital flexion is regained through tendon transplantation. Before resignation is NEUROSURGERY 1045 Fig. 191.—Diagrammatic explanation of viable neuroplastic transplant for filling of median defect in irreparable lesion of both median and ulnar nerves. A, Showing large irreparable defect of both median and ulnar nerves; the upper segments of both nerves are marked with identification sutures. B, Proximal end of both nerves united by end-to- end suture. Ulnar nerve divided to permit degeneration of fibers, the central end of which is injected with alcohol to prevent regeneration of ulnar fibers in that portion of ulnar trunk which is to be used later as a viable trans- plant. C Second stage of operation, showing transplant which now contains regenerated median fibers turned down and approximated to the end of the distal segment of the median, overcoming the defect, the ulnar nerve being sacrificed to repair the median 1046 SURGERY made to an irreparable median and ulnar defect (the two-stage operation for nerve repair and grafts having failed), the surgeon should consider the possibility of preserving some type of sensation in the fingers by nerve anastomosis. Harris suggested anastomosing the radial nerve to the distal stump of the median. This procedure may be followed by some restoration of sensation in the median sensory area of the hand and fingers; this sensation, however, is attended with dorsal localization, and although it protects the fingers by replacing anesthesia with a defectively localized sensibility, it contributes little to functional usefulness. SACRIFICE OF THE ULNAR NERVE AS A VIABLE NEUROPLASTIC TRANSPLANT FOR THE REPAIR OF A MEDIAN DEFECT When all hope has been definitely abandoned of effecting approximation in both median and ulnar nerves, the disability may be diminished by using the ulnar nerve as a viable neuroplastic transplant for bridging the defect in the median, in the hope of restoring at least median sensation, and possibly function, in the extrinsic muscles of the hand. If this motor restoration is possible, opponens function and metacarpophalangeal flexion may be restored by tendon transplantation, and a very useful hand provided; if it is found impossible to restore motor function, flexion of the digits may be restored to some degree by tendon transplantation and some usefulness, at least, regained. Technique First stage.—The proximal ends of both median and ulnar nerves are exposed, the scar tissue and neuroma resected, after which they are carefully approximated, following the usual technique of end-to-end suture, extreme care being taken to prevent torsion of the nerve trunks in this approximation. This procedure results in the formation, after anastomosis, of a loop uniting the proximal ends of these nerves. Without disturbing the bed of the ulnar nerve any more than necessary, it is exposed some distance above the anasto- mosis and divided to permit Wallerian degeneration of the nerve fibers in that portion of the ulnar trunk which at the second operation will be turned down to meet the distal end of the median as a transplant. This transplant should be slightly longer than the defect—if the defect be 5 inches, the ulnar nerve should be divided 5^ or 6 inches above its anastomosis to the median. The upper end of the divided ulnar trunk is injected with alcohol or treated after the manner of amputation neuromas, to prevent regeneration of ulnar fibers down the transplant. It is essential in this procedure to conserve in every way the nutrition of that portion of the ulnar trunk which is being used as a transplant; hence the necessity of not disturbing its bed. The median fibers, m regenerating, will now pass around the loop and follow the transplant upward, and if sufficient time be allowed they will form a neuroma at the upper end of the transplant where the ulnar nerve was divided. Inasmuch as re- generation occurs, approximately, at the rate of 1 inch per month, the second operation should be postponed until the median fibers have completely traversed the transplant; in a 5-inch transplant the second operation should be planned at the end of the sixth month, allowing a month of grace. NEUROSURGERY 1047 Second stage.—Both proximal and distal segments of the median nerve are now exposed; in the lower segment the center of the ventral quadrant is marked by identification sutures before disturbing its relations; in the upper segment the loop of anastomosis between the median nerve and the transplant is now carefully exposed and the transplant followed upward to its end, where identification sutures are placed in the center of its exposed ventral quadrant. The transplant is freed by careful dissection and turned down to meet the end of the distal segment of the median; the scar tissue is now resected from both ends of the nerve and approximation effected, with strict care toward the prevention of torsion. The selection of a satisfactory bed for the transplant is important. In the above procedure the defect in the median nerve is filled by a viable transplant through which median fibers have regenerated and is far more likely to prove successful than nonviable grafts. When the ulnar nerve has been sacrificed and the ulnar portion of the hand and little finger is the subject of traumatic and trophic sores amputation is indicated. If, however, the skin of the ulnar portion of the hand remains in good condition through proper protection, restoration of sensation can be obtained in certain instances by anastomosing the radial nerve to the ulnar. TENDON TRANSPLANTATION FOR COMPLETE FLEXOR PARALYSIS If passive movements of the wrist and fingers are unrestricted, tendon trans- plantation may be utilized to restore, to some extent, digital flexion; though flexion may be restored to a certain degree through transplantation of extensors, the loss of the intrinsic hand muscles greatly limits the usefulness of the hand beyond the ability to hold or carry objects. Technique a. Splitting the tendon of the extensor carpi radialis longior, one slip of which is transplanted into the sublimis and profundus tendons of the index finger, a second slip is transplanted into the same tendons of the ring finger—through a long incision, extending from the base of the thumb to the upper third of the dorsum of the forearm, the long ribbonlike tendon of the extensor carpi radialis longior is identified between the extensor brevis, to its ulnar side; and the brachio- radialis, to the radial side. At the wrist, these tendons are crossed by the bellies of the extensor ossis metacarpi pollicis, extensor brevis pollicis, and the tendon of the long flexor of the thumb. The tendon of the long radial extensor is divided at its insertion into the second metacarpus. Its sheath is opened high up and the tendon withdrawn and split. The tendon of the brachioradialis is now identified and divided, and its borders freed from fascial attachments some distance up the forearm; in mobilizing the brachioradialis caution should be used in the isolation of the radial nerve and artery, which lie on its under surface. Several muscular branches of the radial artery will require ligation. b. Transplantation of the brachioradialis tendon into both flexor tendons of the rino- and little fingers—a ventral incision is now made, extending from the base of the thumb, near the insertion of the flexor carpi radialis tendon, along the radial border of the flexor surface of the forearm to the junction of its upper 1Q4,S .SURGERY and midcUe thirds. The skin and fat of the superficial fascia is undermined between the two incisions, permitting the passage of the extensor and brachio- radialis tendons to the ventral aspect of the forearm in a straight course. Medial retraction of the ventral incision permits exposure oi the long flexor tendons each of which should be identified and arranged in pairs, sublimis and profundus for each finger. The long flexor of the thumb is identified and sepa- rately isolated With the fingers completely flexed, the lateral slip of the divided Ion-"extensor tendon is passed through a slit in the sublimis and profundus flexors of the index finger; the medial half of the radial extensor tendon is anas- tomosed into both flexor tendons of the ring finger. The tendon of the brachio- radialis is now brought forward in as direct a line as possible and inserted in a like manner into the flexor tendons of the ring and little fingers. c. Transplanting extensor ossis metacarpi pollicis into the flexor longus pollicis—the extensor ossis metacarpi pollicis tendon is divided at its insertion and transplanted into the long flexor of the thumb, with the thumb flexed over the previously Hexed fingers, making a fist. After the proper tension has been placed on these transplanted tendons, so that the fingers are flexed equally, and with the wrist in partial flexion, the tendons are anchored. Both dorsal and ventral skin incisions are now closed while the hand is maintained in complete digital and partial wrist flexion. This position is maintained by suitable pads and bandages, after a small unrolled bandage is placed in the hand. (After-treatment and reeducation are conducted along the usual lines.) THE SCIATIC TRUNK AND ITS TERMINAL DIVISIONS GENERAL ANATOMY The sciatic trunk is formed by the ventral and dorsal divisions of the fourth and fifth lumbar, and second and third sacral nerves. The ventral divisions go to make up the medial or tibial portion of the sciatic trunk, while the dorsal form its lateral or peroneal portion. The tibial and peroneal portions of the sciatic trunk are from a physiologic standpoint totally differentiated, though anatomically they are usually incorpo- rated into a single nerve trunk for some distance down the thigh. The extent of their union, however, varies, and occasionally the sciatic trunk is replaced by two distinct nerves, emerging from the great sacrosciatic foramen. More often, however, their union continues to the upper part of the popliteal space, where the sciatic trunk divides into its terminal divisions; the medial or tibial portion becoming the internal popliteal nerve, while its lateral or peroneal forms the external popliteal nerve. The separation in the thigh of the component tibial and peroneal portions of the sciatic trunk is always more or less evident, varying from a complete separation, in which each nerve has a distinct and separate sheath, to the type in which inspection alone fails to demonstrate the anatomical division and in which palpation is required to give the surgeon a clue as to the line of cleavage. These nerves, when combined in a single sheath, are anatomi- cally separated by a septal prolongation of the sheath, which is usually evident on cross section. As the trunk proceeds down the thigh, the demarcation between its component parts becomes more conspicuous on its surface, and its dividing septal sheath shows greater development. NEUROSURGERY 1049 Though the tibial portion of the sciatic trunk is usually described as lying medial, and the peroneal portion lateral, the line of division does not strictly follow a ventrodorsal plane; the tibial portion lies somewhat more ventral than dorsal, while the peroneal portion occupies a dorsolateral position. After emerging from the pelvis to the dorsum of the thigh, through the great sacrosciatic foramen under the pyriformis muscle, the sciatic trunk passes down the posterior aspect of the thigh to the popliteal space. In its upper part it lies on the external rotators of the thigh, and below these upon the dorsal surface of the adductor magnus. In its gluteal portion, the nerve is covered by the gluteus maximus; in the thigh it runs parallel with and to the lateral side of the flattened tendon of the semimembranosus, and is crossed and covered in most of this portion by the thick belly of the ischial head of the biceps. NERVE TO HAMSTRING MUSCLES The nerve to the hamstring muscles, while commonly incorporated within the sheath of the tibial portion of the sciatic trunk, should not be regarded as a collateral branch of the tibial nerve, but rather as one of the three separate elements, which, being bound together by a common sheath, constitute the great sciatic trunk, namely, from within outward, nerve to the hamstrings, tibial nerve, and peroneal nerve. The nerve to the hamstrings may or may not be incorporated within the sheath of the sciatic trunk, but always lies to the medial side of the tibial portion of the sciatic; when incorporated within its sheath it is usually anatomically separated by a well-developed sheath of its own and mav be readily separated from the sciatic trunk. The short or humeral head of the biceps, however, is supplied about the middle of the thigh by a branch which leaves the lateral surface of the peroneal portion of the sciatic. This branch has a distinct intraneural course and may or may not be regarded as a collateral branch of the peroneal nerve. The nerve to the hamstrings supplies the semitendinosus, semimembranosus, long head of the biceps, and a portion of the adductor magnus. TERMINAL BRANCHES 77.. tibial nerve (internal popliteal), which formerly occupied a ventro- medial position, upon leaving the sciatic trunk in the lower third of the thigh, enters the popliteal space, where it lies in a pad of fat, superficial to the popliteal vessels. It passes longitudinally through the middle of the popliteal space, from which it emerges by passing ventral to the union of the two heads of the o-astrocnemius. It terminates at the lower border of the popliteus muscle, bv passim* through an arch in the soleus muscle, accompanied by the popliteal artery and vein, where it becomes the posterior tibial nerve. in the popliteal space, motor branches arise to supply the gastrocnemius, plantaris, soleus, and popliteus muscles; these branches are given off from the dorsal surface of the nerve. At the upper part of the popliteal space, a large branch diverges from each side of the nerve trunk to the two heads of the Gastrocnemius. Though usually given off as separate branches, their intra- neural orio-in is from a bundle common to all of the above-mentioned muscles; it has a rather long intraneural course, lying on the dorsal aspect of this portion 1050 SURGERY of the sciatic trunk. Occasionally, the nerve to the soleus leaves the parent trunk in common with the branch to the lateral head of the gastrocnemius. The branches to the plant oris and popliteus are usually given oft individually, but their intraneural course is common with the gastrocnemius and soleus fibers Below the branches to the gastrocnemius, a sensory branch is given off, the communicans tibialis, which passes downward in the sulcus between the two heads of the gastrocnemius, becoming superficial in the calf by piercing the deep fascia where it joins the peroneal communicating to form the external or short saphenous nerve, which supplies sensation to the lower third of the lc" on its outer side, and the outer side of the foot and little toe. The tibial neYve also gives off branches to the knee joint and to the posterior tibial vessels. The posterior tibial nerve, the terminal portion in the leg of the tibial (internal popliteal) nerve, passes down the leg, occupying a dee]) position between the deep and superficial muscles of the calf, in a special compartment in the intermuscular septum between these muscles, accompanied by the posterior tibial artery and its vena? comites, in relation to which it holds a superficial or dorsal position. In the lower part of the leg, it lies medial and ventral to the tendo Achillis; after passing behind the internal malleolus it enters the sole of the foot, to terminate as the internal and external plantar nerves. Immediately after the posterior tibial nerve is formed by passing through the arch of the soleus muscle, it breaks up into a number of branches which supply the lower portion of the soleus, the tibialis posticus, the flexor longus digitorum and the flexor longus hallucis. The peroneal nerve (external popliteal), considerably smaller than the tibial nerve, after leaving the common sciatic trunk, at the apex of the popliteal space, follows the lateral border of the fossa and the medial margin of the biceps tendon. Passing over the plantaris and lateral head of the gastrocnemius, it winds around the neck of the fibula, where it enters a canal in the origin of the peroneus longus muscle, and breaks up into its terminal branches. In the popliteal space, the peroneal nerve gives off the following collateral sensory branches, from the dorsal portion of its trunk: The communicating peroneal which passes medially across the lateral head of the gastrocnemius, pierces the deep fascia on the back part of the leg and unites with the commu- nicating tibial to form the short or external saphenous nerve; the sural branches. which may arise in common with the communicating peroneal or at a lower origin to supply the skin over the back and outer side of the calf and leg. Intra - neurally, the fibers forming these nerves originate from a single bundle which occupies a long intraneural course on the dorsal surface of the peroneal portion of the sciatic trunk. The terminal branches of the peroneal nerve are given off after it swings around the neck of the fibula and passes through a canal in the peroneus longus muscle. They are the musculocutaneous, anterior tibial, and tibial recurrent. The anterior tibial branch springs from the lower portion of the flattened pero- neal trunk and has a long intraneural course, composed of a single bundle which in the upper part of the popliteal fossa lies in the ventral portion of the nerve. The musculocutaneous branch arises from the ventral portion of the trunk and likewise has a long, intraneural course, though composed of two bundles one NEUROSURGERY 1051 of which contains motor fibers to the peronei muscles, the other containing the sensory fibers. The musculocutaneous nerve, lying at first between the peroneus longus muscle and fibula, passes obliquely downward and forward; it is deeply placed and located in a fibrous canal in the septum between the peronei and extensor longus digitorum; it supplies the peroneus longus and brevis with motor branches. In the middle of the leg it penetrates the deep fascia and divides into an internal and external branch, supplying the skin of the front of the leg and dorsum of the foot and toes. The anterior tibial nerve, originating from the peroneal between the recurrent tibial and musculocutaneous, passes downward and forward beneath the ex- tensor longus digitorum to the ventral surface of the interosseus membrane, where it passes down the leg accompanied by the anterior tibial artery and its venae comites, lying between the tibialis anticus and the extensor longus hallucis. At the ankle it is crossed by the tendon of the extensor longus hallucis, as it jiasses to the dorsum of the foot, where it divides into its external and internal terminal branches. The anterior tibial nerve supplies motor fibers to the tibialis anticus, extensor longus hallucis, extensor longus digitorum and peroneus tertius. Its external branch supplies the extensor brevis digitorum, and its internal branch the integument between the first and second toe and a small area on the dorsum of the foot adjacent to these toes. The tibial recurrent nerve, the smallest, most anterior and highest of the three terminal branches of the tibial nerve, passes between the origin of the peroneus longus and the fibula, giving motor branches to the upper portion of the tibialis anticus and articular branches to the knee joint. SURGERY OF THE SCIATIC TRUNK In war surgery injuries of the sciatic trunk are far more common than any other nerve lesion in the lower extremity. While severance of the entire trunk does occasionally occur, this incident is rare. The nerve to the ham- strings seldom shows complete paralysis, and very frequently the peroneal portion of the sciatic trunk alone suffers injury. This is probably due to the position of the peroneal in the sciatic trunk, where it occupies a dorsolateral position and tends to protect the tibial portion of the nerve. The components of the sciatic trunk may suffer injury in any part of their course in the but- tocks, thigh, popliteal space, or leg. Throughout its entire course the tibial nerve is afforded greater protection than the peroneal. The peroneal is par- ticularly liable to injury in the region of the head of the fibula, where it occu- pies a very superficial position. The surgery of the sciatic trunk resolves itself into the surgery of its component elements, and not infrequently exposure will reveal the entire trunk extensively involved in scar tissue when clinically the lesion is confined only to its peroneal portion. The surgeon must therefore be governed by clinical indications rather than by the gross pathologic appearance of the nerve at operation, and thereby avoid the sacrifice of intact sciatic elements. Sur- gery of the sciatic trunk resolves itself into the exposure of three regions, namelv: For must in ^nv instances determine the end result. NEUROSURGERY 1089 TRANSPLANTS In 17 experiments conducted by Huber14 a defect of 3 cm. was successfully bridged by an autotransplant, and in 6 experiments a homotransplant was used with evidence which justified the indorsement. He was successful not only with fresh homotransplant but also with those stored in 50 per cent alcohol for 40 days. These brilliant results in the experimental laboratory in the use of the transplant, as a means of repairing defects, are in striking contrast to the reports from the peripheral nerve centers. In approximately 1,414 operations upon the peripheral nerves in the Army hospitals there were in the neighborhood of 60 transplants used to repair defects. Of this number the writer has been unable to find the record of any "successful" result, except in a few isolated instances. In one "very marked improvement" is recorded after the use of three strands of a cutaneous nerve to repair a defect 6 cm. long in the musculospiral nerve; in another, "consid- erable improvement after one year" is recorded in a defect of 4 cm. in the external popliteal nerve, to repair which strands of a cutaneous nerve were used. In one instance the employment of an autotransplant to repair a defect in the ulnar nerve at the wrist was followed by definite contraction of the zone of anesthesia. One neurosurgeon reported that in 14 attempts there was but 1 case of transplant in the median nerve where, after four years, the patient's only sensation was a sense of tingling in the median distribution. That there is little need for the use of transplants to repair defects may be gathered from the experience of individual operators. In one series of 196 operations an auto- transplant was used only three times. In another of 570 operations an auto- transplant was used six times and homotransplant eight times. Considering the total number of cases and the results as recorded, the employment of the transplant either "auto" or "homo" as a practical method of bridging defects in peripheral nerves has proven a dismal failure in the hands of the surgeons of our country. The results of nerve stretching in a two-stage operation for the correction of large defects, even when a nerve is sutured under great tension, greatly surpass these obtained from the use of the transplant. Why the results in the experimental laboratory can not be reproduced in human surgery has never been explained. To be sure, there are physical factors in the pathology of peripheral nerve lesions of the human that are wanting in the experimental animal, and what is of no small moment, the length of the graft employed in the experimental laboratory is only one-fourth or one-half of that required to repair the defect in the resections of extensive peripheral nerve lesions. Just as the transplant has proved successful in the laboratory, so has lateral implantation of the peripheral and central segments into an adjacent nerve, but so far as the writer is aware, neither the nerve flap operation nor nerve crossing or implantation has been applied successfully in the recon- struction of peripheral nerve injuries. Both operations seem illogical, and neither has found favor with those who, in dealing with hundreds of cases, have acquired an intimate knowledge of the problems involved. 1090 SURGERY REFERENCES (1) Based on sick and wounded reports made to the Surgeon General. (2) Annual Report of the Surgeon General, U. S. Army, 1919, ii, 1096. (3) Letter from the Surgeon General to Maj. George Muller, M. C., January "31, 1919. Subject: Peripheral Nerve Commission. On file, Record Room, S. G. O., 024.14 (Surgery of the Head). (4) Clinical Records, entitled "Peripheral Nerve Register." On file, Record Room, S. G. O., 700.6-1. (5) Act of Congress, approved June 27, 1918; also, Act of Congress, approved March 3, 1919. 10> Public Act No. 47, 07th Congress, August 9, 1921. (7) Sachs, Ernest, and Malone, Julian Y.: A More Accurate Clinical Method of Diagnosis of Peripheral Nerve Lesions and of Determining the Recovery of a Degenerated Nerve. Archives of Neurology and Psychiatry, Chicago, 1922, vii, No. 1, 58. (8) Ney, Karl Winfield: The Indications for Surgical Intervention in Peripheral Nerve Injuries. Journal of the American Medical Association, Chicago, November 8, 1919, lxxiii, 1427. (9) Stoffel, A.: Die moderne Chirurgie der peripheren Nerven. Medizinische Klinik, Berlin, August 31, 1913, ix, 1401. Also: Vulpius, Oskar and Stoffel, Adolf: Orthopadische Operationslehre. Ferdinand Enke, Stuttgart, 1911. (10) Marie, Pierre: Les localisations motrices dans les nerfs peripheriques. Bulletin de I'academie de mSdecine, Paris, December 28, 1915, 3 s. lxxiv, 798. (11) Kraus, Walter M., and Ingham, Samuel D.: Peripheral Nerve Topography. Archives of Neurology and Psychiatry, Chicago, 1922, iv, No. 4, 259. (12) Dustin, A. P.: Le service de neurologie a l'ambulance "Ocean." Travaux de l'ambu- lance Ocean. Masson et Cie, Paris, July, 1918, ii, 135. (13) McKinley,. J. C: The Intraneural Plexus of Fasciculi and Fibers in the Sciatic Nerve. Archives of Neurology and Psychiatry, Chicago, October, 1921, vi, 377. (14) Huber, G. Carl: Repair of Peripheral Nerve Injuries. Surgery, Gynecology and Obstet- rics, Chicago, 1920, xxx, No. 5, 464. CHAPTER XIII EXPERIMENTAL OBSERVATIONS ON PERIPHERAL NERVE REPAIRa INTRODUCTION In no field of medicine, perhaps, is the interdependence of experimental and clinical work so clearly demonstrated as in peripheral nerve surgery. Questions which concern the structure, development, growth, degeneration, and regeneration, after injury, of the peripheral nerves have engaged the attention of observers for more than a century, and there exists an extensive literature, dealing with these and relative problems, to which both the experi- menter and the clinician have contributed. A study of this literature, while showing constant advance in knowledge, as concerns all phases of the questions involved, will reveal also wide and fundamental divergence of opinions which have influenced and retarded progress as regards structural interpretations and their clinical applications. The nervous system consists of independent, anatomic units, the neurons, related to each other by contiguity and not by continuity. The peripheral nervous system is, therefore, both on anatomic and functional considerations, a part of the central nervous system, and in its surgical treatment should be regarded as such. There are 31 pairs of spinal nerves, quite symmetrically arranged, which course singly or join to form plexuses and which throughout the thoracic and upper lumbar regions and for certain sacral nerves are con- nected with the ganglia of the sympathetic system through the white rami or preganglionic branches. Considered structurally, each spinal nerve consists of bundles of nerve fibers, certain of which are processes of neurons, known as neuraxes or axons, the cell bodies of which are situated in the ventral gray of the central nervous system or in the sympathetic ganglia and carry nerve impulses from the central nervous system to the periphery, and are thus known as efferent nerve fibers, while other nerve fibers are processes of neurons known as dendrites, the cell bodies of which are found in the spinal ganglia and conduct nerve impulses toward the central nervous system and constitute the neuraxes of afferent nerve fibers. The neuraxes and neuraxes dendrites, forming the nerve fibers of the spinal nerve, may be ensheathed in a layer of myelin, known as myelinated or medullated nerve fibers, or they may be naked, and are then known as nonmyelinated or nonmedullated nerve fibers. Considered function- ally, we recognize in each spinal nerve nerve fibers belonging to one of four o Report of the work of the Neurosurgical Laboratory, Department of Anatomy, University of Michigan, Ann Arbor Mich. The following medical officers, on special assignments, collaborated in the experimental work for stated periods: Lieut. Col. Dean Lewis, Maj. J. F. Corbitt, Maj. Byron Stookey, and Maj. T. Roberg. During the latter portion of this investigation technical laboratory assistance was made available through a grant received from the committee on research of the American Medical Association, for which acknowledgment is here made. 1091 1092 SURGERY functional systems, designating a functional system "as the sum of all the neurons in the body which possesses certain physiological and anatomical characters in common so that they may react in a common mode." * The functional systems of the spinal nerves are designated: 1, Somatic efferent; 2, visceral efferent; 3, somatic afferent; 4, visceral afferent. The nerve fiber composition of a spinal nerve may be represented graphically as shown in Figure 211. FlGts^S^ visceral efferent system; D, static aff rent neuron S T f"^ ^^ °' Vost*™&°™ neuron of the E, visceral afferent neuron 'oZ££^^?&' n T- T™ ^ nonmed^ted Processes; Clonic bundle or gray ramus; si o! ^S^^^ZX^cZ^' ^ ^ °" P°St" bodiefoYXtfT'f ^ ^f 211"A) ^ the n™s of neurons the cell bodies ol uhich are located m the ventral portion of the spinal crav They »^^e^^ thG ^^ r°°tS ^ te™e - skelet^muscl n to thStotLnolU f ^ m°i T^ endlngS- The nerve fibers bel°ngmg tins; Junctional system are relatively large, myelinated fibers the slXrv: tru^ ^ ^ "^ ^ C)' or the ^Pathetic fibers of are sTtuatedTn ho T? s^^" neurons, the cell bodies of which 1 tn! pathetic ganglia of the sympathetic trunks. They con- stitute the postganglionic nerve fibers. They enter the spinal nerves through NEUROSURGERY 1093 the gray rami communicantes, each spinal nerve having such connection with the sympathetic trunks. The sympathetic ganglion cells of the sympathetic trunks are in synaptic relation with the preganglionic neurons, the cell bodies of which are situated in the visceral efferent column of the spinal gray, their neuraxes leaving the spinal cord by way of the ventral roots of the successive thoracic and four upper lumbar nerves and by way of the white rami, branches reaching the sympathetic ganglia where they form synaptic relations with the sympathetic nerve cells, it being well known, through the fundamental exper- imental researches of Langley, that there are always two neurons concerned in carrying an impulse from the central nervous system, through the spinal nerves to involuntary muscle and glandular tissue. The investigations of Boeke make it probable that the visceral efferent fibers may play a part in the innervation of certain skeletal muscle fibers. The somatic afferent fibers (figs. 211-D and D') of the spinal nerves are the dendritic branches of sensory neurons, the cell bodies of which are situated in the spinal ganglia and convey impulses from the periphery to the central nervous system. A certain per cent of these nerve fibers are relatively large myelinated fibers, which have origin in peripheral nerve endings, both encap- suled and nonencapsuled. They are connected with the larger and more complex ganglion cells. A certain per cent of somatic afferent nerve fibers are nonmyelinated (Ranson) or are very fine myelinated fibers (Langley) which are connected with the smaller and simpler ganglion cells of the spinal ganglia. They are distributed in large part to the skin but also to the muscular branches. The visceral afferent fibers (fig. 211-E), strictly speaking, are not primarily distributed to the peripheral nerves of the body wall and extremities, but to the thoracic and abdominal viscera which they reach by way of the white rami. The cell bodies of these fibers are in the spinal ganglia, their neuraxes pass through the respective dorsal roots to the dorsal column of the spinal cord. According to function, the somatic afferent neurons are classified either as exteroceptive fibers, which carry impulses from sense organs and from the surface of the body, or as proprioceptive fibers, carrying impulses arising from within the body, from joint, tendon, and deep connective tissue and from muscular tissue, and also from the semicircular apparatus of the ears. The visceral afferent nerve fibers are said to cam- interoceptive nerve impulses. There is no recognizable structural differentiation in afferent nerve fibers to be correlated with the type of impulses carried, though each group of afferent fibers is connected with special receptors or sensory nerve endings in the periphery and with distinctive neuron paths in the central nervous system. The cranial nerves, structurally considered, are very similar to the spinal nerves, but collectively considered contain additional functional systems having restricted distribution and specialized function; considerations which need not receive special discussion here. F STRUCTURE OF A XERVE The efferent and afferent fibers of a nerve trunk are intermingled and run together in small bundles known as funiculi. A funiculus may approach a millimeter in size. Each funiculus is surrounded by a connective tissue sheath known as the perineurium, composed of several lamelhr of flattened collagenous 1094 SURGERY connective tissue bundles; anastomosing here and there, between these flat- tened connective bundles, spread out fibroblasts are found which, on the inner surface of the perineurium, form a fairly distinct layer. The writer has not been able to demonstrate the fairly definite layer of endothelioid cells described by Key and Retzius. A few wandering cells and a few clasmatocytes are found between the lamellae of the perineurium. Relatively few elastic fibers, arranged in network, are found in the perineurium. Flattened trabecule of collagenous connective tissue pass from the perineural sheaths to the interior of the funiculi and there is found a loose connective tissue, consisting of fibrils and fine fibers of collagenous connective tissue and a few elastic fibrils, disposed as a network and found between the fibers or small bundles of such, and forming more or less distinct tubular sheaths for the fibers of the funiculi. This constitutes the endoneurium of the funiculus. In it are found a few fibroblasts and a few clasmatocytes and wandering cells. The spinal nerves generally consist of more than one funiculus, and certain of the larger ones have many funiculi. Surrounding the whole nerve trunk and extending between the funiculi, there is found an areolar connective tissue, continuous with the surrounding con- nective tissue, which is known as epineurium. The name would suggest that this sheath is upon the nerve. It should be understood that the epineurium extends between and surrounds the several funiculi of a nerve trunk; therefore, an epineurial stitch or suture may pass through a nerve trunk, conceivably between the funiculi. The epineurium consists of looser and denser areolar connective tissue with often, especially in the larger nerves, an appreciable amount of adipose tissue, disposed in small groups of fat cells or in scattered cells. In the epineurium are found the larger blood vessels and the lymph vessels of a nerve trunk, also sensory nerve endings for the nerve itself. The cells of the epineurium are largely of the type of the fixed fibroblasts; wandering cells and clasmatocytes are also found, but in variable numbers; mast cells have been described. The details of the ultimate distribution of the blood and lymph vessels of a nerve trunk require further study and should be given special con- sideration for each of the several larger nerve trunks, subject to injury. The larger blood vessels, both arteries and veins, course in the epineurium. Ter- minal arterioles pass through the perineural sheaths of the several funiculi and break up into capillaries which course in the endoneurium, between the nerve fibers, forming long-meshed anastomoses. The capillaries of the funiculi are relatively scanty. Definite lymph vessels and lymph capillaries have not been shown to exist withm the funiculi and perineural sheath. They have been demonstrated by mjection in the epineural sheath. Special interest was drawn to the funicular structure of peripheral nerves through the studies and publications of Stoffel' and his followers, who claimed that the several peripheral nerves presented a definite funicular morphology which extended throughout the nerve trunk and was fairly constant, so that definite sensory and motor paths could be demarked in the internal topographv 1 nT; 7 \bOTa^ was not especially concerned with this problem, realizing that during healing or regeneration of a cut nerve, in the field of the P^nT? ,6 KSt ^^ the funicular Pattern is t0 a larSe extent lost. Extended researches bearing on this problem were undertaken by Heinemann » NEUROSURGERY 1095 Borchardt and Wyasmenski,4 Langley and Hashimoto,5 Compton,6 Dustin.7 and Kunzel.8 These observers have shown, either by careful dissections of macerated nerve trunks, or by means of carefully oriented serial sections of nerve trunks, that Stoffel's views can not be maintained. It has been shown that an extensive anastomosis and exchange of nerve fiber bundles exists be- tween funiculi and that the funicular pattern is not the same even at relatively short intervals and not necessarily alike in the same anatomic nerve in dif- ferent individuals. This question has been well summarized by Stookey,9 who has reviewed the pertinent literature. STRUCTURE OF NERVE FIBERS Nerve fibers are either myelinated—medullated, or nonmyelinated—non- medullated. A myelinated nerve fiber consists of the neuraxis or axon, the myelin or the medullary sheath, and the neurolemma with its neurolemma nuclei or sheath cells. The neuraxis is the direct continuation of the respective nerve cell or neuron, the essential and conducting part of a nerve fiber, and passes uninterruptedly from the cell body to its destination. It must be regarded as in protoplasmic continuity with the cell body of the neuron, its trophic center. The neuraxis is devoid of any sheath in the immediate vicinity of the nerve cell and very generally loses all sheaths before termination. It consists of neurofibrils, continuous with the neurofibrils of the cell body of the peripheral neuron, embedded in a homogeneous neuroplasm. A delicate, periph- eral protoplasmic sheath may be present, known as the axolemma, but this is difficult to establish conclusively. The myelin sheath in the living and struc- turally unaltered nerve fibers appears as a homogeneous and structureless sheath which is interrupted from place to place at stated intervals, at the nodes or constrictions of Ranvier. These nodes occur at regular intervals of a length approximately one hundred times the diameter of the fiber. The segment of a nerve intervening between two nodes is known as an internodal segment. The structure of the myelin has not been fully determined, nor is it clear whether the myelin layer is to be regarded as a part of the neuron or as a special sheath quite distinct from the neuraxis. The myelin sheath presents quite distinctive structural appearances depending on the mode of fixation and staining of the nerve fibers. In segments of the same nerve, treated with different reagents in fixation and staining, quite dissimilar pictures of myelin structure may be obtained. It would seem that from the complex material which forms the myelin, largely made up of lecithin, there separates out a coagulable substance which under certain treatment forms a reticulum, keratin- like in nature, and known as the neurokeratin net, the arrangement of which varies with different fixations. The majority of the special structural charac- teristics described for myelin are regarded as fixation artifacts. It is stained black in osmic acid and is differentially stainable by a variety of methods. It presents special manifestations in degenerating nerves. In early stages of development of nerve fibers or in early stages of regeneration of peripheral nerves, the myelin seems to appear as a continuous, delicate sheath, a differen- tiation of the peripheral part of the neuraxis; in further development the nodes of Ranvier appear. There is at hand evidence, though not conclusive, to 1096 SURGERY warrant considering the myelin sheath as a part of the respective neuron. The suggestion that the myelin is in its histogenesis closely related to the neurolemmal sheath is not without its supporters. In a comprehensive histo- logic and histopathologic study of peripheral nerves by Doinikow,10 in wliich extended consideration is given to the structure of the myelin sheath, the conclusion is reached that the plasma cells of Schwann consist of a denser nuclear zone and a looser meshwork which pervades the myelin sheath of th_ entire internodal segment, in the meshes of which is contained myelin substance. Not unlike this conclusion is that of Xemiloff,11 who regards the nuclei of the neurolemma sheath as related to a protoplasmic reticulum which pervades the myelin sheath. According to these observations, the myelin sheath is not a part of the neuron but an ensheathing structure. The neurolemma forms the outermost layer of the myelinated nerve fiber of peripheral nerves. It is a very thin, apparently homogeneous layer closely applied to the myelin sheath. There is at hand evidence of a delicate fibrillar structure of the neurolemmal sheath. The flattened, oval nuclei found lying on the inner surface of the neurolemmal sheath, one for each internodal segment, are considered as part of the neurolemmal sheath and are known as neurolemmal cells or sheath cells. Ilistogenetically considered, they are of ectodermal origin. It has not been possible to obtain conclusive evidence as to whether the neurolemma forms a continuous sheath or is interrupted and cemented end to end at the nodes of Ranvier. In degenerating nerve fibers the neurolemmal sheaths form a delicate tubular structure which does not fragment with the neuraxis and myelin and the sheath cells proliferate and separate from its inner surface. The neurolemma sheath is absent from nerve fibers of central nervous system; its place is there very probably taken by the neuroglia tissue. A nonmedullated fiber consists of a neuraxis which is made up of neurofibrils and neuroplasm with a delicate outer protoplasmic layer or axolemma. They present nuclei at relatively frequent intervals; nuclei which have the appearance of neuro- lemma or sheath nuclei, although it is difficult to demonstrate clearly a definite neurolemmal sheath. It is quite possible that in the nonmedullated fibers the sheath cells do not form a continuous neurolemmal sheath. DEVELOPMENT OF PERIPHERAL NERVE FIBERS Since histogenesis and experimental embryology of the nervous system has done much to clarify the problems of degeneration and regeneration of peripheral nerves, a brief consideration may here be given to the question of development of peripheral nerves. It is now generally believed that the nerve fibers of the entire nervous system are derived from the neurosensory ectoderm through the neuroblasts; the afferent fibers and the visceral or sympathetic efferent fibers largely from the neural crest, the anlage of the spinal and in- directly of the sympathetic ganglia; the somatic efferent fibers from the neural tube. The "outgrowth theory" of nerve developments first formulated by His 12 is now very generally accepted. According to this theory the neuraxis (and the dendrites) of a neuron are regarded as the outgrowth from a single cell, the neuroblast, no matter what the length of these processes. The grow- ing tip of the neuraxis shows an expansion, known as the end-disc or the in- XEUROSURGERY 1097 cremental cone; this is thought to have ameboid properties. The theory of His does not admit of demonstration in adult tissue, but admits of "near proof" in early embryonic stages, especially in tissues stained in differential neuron stains. Harrison's13 experimental observations of growing in coagulated lymph ganglion cells from the spinal cord of amphibian embryos, in which growing and budding neuraxes could be observed under the microscope, very substantially confirmed the outgrowth theory of nerve development. Grow- ing neuraxes of the ventral and dorsal roots of suitably early embryonic stages are from the beginning accompanied by cellular elements which are in very close apposition with the growing nerve fibers. These cells, which were regarded as of mesodermal origin by earlier observers, are now known to be of ectodermal origin and are variously thought of as contributing to the formation of sheath cells or as participating in the formation of the neuraxis itself. The constant presence of these sheath cells in the early stages of growing nerve roots led to the formulation of the ''chain theory" of peripheral nerve development, accord- ing to which, in essential, each internodal segment is thought to be derived from a cell, the neurons thus constituting a colony of cells in chain, or a syncyt- ium. With this theory the names of Balfour,14 Dohrn,15 and Bethe,16 are especially associated. Modifications and interpretation of these two theories of peripheral nerve origin and growth are extant. Hensen17 early contended for a primary connection between the nerve cells and the muscular and other tissues and thought that out of this primary syncytial net the nerve fibers were developed. Held18 has more recently amplified this view. Such ques- tions are not determined by a study of sections alone, although such study has contributed largely to the solution of the problem; experimental embryology has been of material assistance. Harrison19 was able to ablate the neural crest in very young amphibian embryos, thus removing the anlage of the dorsal spinal ganglia without injuring the ventral part of the spinal cord from which the ventral root fibers have origin. It was found on development of the ventral root fibers that these were devoid of sheath cells. Further experiments by the same observer and others, including limb transplantation in young amphibian embryos, which on attachment and outgrowth in new positions became neurotized, indicate that there does not exist a primary connection between nerve cells and the peripheral tissues, a sine qua non to nerve growth. Observations made and deductions drawn from experimental embryology bearing on peripheral nerve development have been summarized as follows by Streeter:20 "It was shown that no peripheral nerve fibers would develop in an embryo from which the nerve center had been removed, thus establishing the fact that the ganglion cells are an essential element of the fibers. It was shown that the sheath cells of Schwann, upon the influence of wliich in the formation of the fibers many histologists had placed much emphasis, were not essential to the growth of the nerve fiber, and that the axis cylinders will develop and extend out in the surrounding tissues in the normal way and reach their normal length in specimens where the sheath cells have been eliminated. It was shown by modifying the environment of the developing nerves that fibers will form in surroundings entirely different from their natural path and establish completely foreign connections." Histogenetic studies have shown quite 1098 SURGERY conclusively that the neuraxis is a protoplasmic outgrowth from a single neuro- blast. The prevailing opinion is that the neurolemmal sheath and its sheath nuclei are of ectodermal origin, derived directly or indirectly from the neuro- sensory ectoderm, as also the capsule cells of spinal and sympathetic ganglia. These neurolemmal sheath cells, however, are not to be regarded as potential neuroblasts. There exists less certainty as to the development of the myelin sheath. This sheath seems a part of the neuraxis, which in its deposition is influenced by the sheath cells. Very careful studies of the histogenesis of the myelin are required before the structure of the myelin sheath and its relation to the neuraxis can be fully determined; in such studies experimental embry- ology must play its role. DEGENERATION AND REGENERATION OF PERIPHERAL NERVES There exists a very extensive literature dealing with the problem of peripheral nerve degeneration and regeneration, far too extensive to receive even cursory review here; certain main phases of the development may be noted and briefly considered, since such treatment will obviate repeated restatement in discussing the experimental work. Arnemann,21 as early as 1787, recognized the fact that a severed nerve lost its conductivity, and Cruikshank22 and Haighton 23 believed themselves to have demonstrated experimentally regenera- tion of a severed peripheral nerve. However, it was not until 1852 that Waller2i clearly demonstrated that the portion of a nerve fiber separated from a "ganglion cell," when a nerve is severed, undergoes degeneration and is regenerated through down growth from the central part. Ranvier 25 and Vanlair 26 mate- rially extended our knowledge more particularly as concerns the down growth of central fibers m regeneration. Their views were controverted by Schiff Erb and Wolberg, so that about 1890 there existed three main views concerning the mode of regeneration of severed peripheral nerves: 1, The view of Waller that after degeneration of the peripheral stump regeneration was through down growth of neuraxes derived from the central stump; 2, that after secondary St;? n™* fvel°Ped m the peripheral stump which were secondarily united to the central fibers; 3, that the neuraxes of the peripheral stump did not Srlti b t GVT f0UTng 189° tW ~d a «*» * mono- graphic contributions dealing with this problem: Biingner," Howell and Huber,28 Stroebe- Huber- Bungner, in his frequently quoted co_ca- tion paid especial attention to sheath-cell proliferation, Ld definedcTeTrly the ^Xt^h^' "^i fr°m ^ *^ sheath cl^^ weTlet^TZ bandfrm' ^ aPP-r during the second and third nTrve fiber Stioebo WerVnterPreted b^ h™ - new nerve fibers or potential Iwn thedowi^™ ^ 5* "P™U1 StUdlGS' believes himself to have sZbe^meZd^T "T^ ^ the cen" stump. Huber, using n rveTefeTs^11^T W T^ m ™ exPe™-tal study of bridging raxes ^*^T* de™nstrated the downgrowth of central L ^^^tTlL^"08^ regeneratl0n a^ the incremental cone at the mTveipmen Ld "' ^ M ^ °n the ^0wi^ tiPs of praxes m development, and m neurons grown in tissue cultures. These observations ,ere followed by studies of Galeoti and Levi « Kennedy,* .n^^H NEUROSURGERY 1099 of whom favored the view of peripheral autoregeneration in degenerated nerve. At about 1900 two main and opposing views as to the regeneration of degener- ated nerve were held: 1, What is known as the monogenetic conception of nerve regeneration, according to which regeneration of a degenerated severed nerve is through downgrowth of neuraxes derived from the neuraxes of the nerve fibers of the central stump, at all times connected with central nerve cells; 2, a poly- genetic conception, according to which regeneration is obtained through cells derived from both the central and peripheral stump. The technical staining methods then at the disposal of observers were inadequate to admit of clear and differential staining of neuraxes, leading often to differences in the inter- pretation of observations made. Bethe 16 hoped to bring solution to the problem through a series of especially devised experiments in which downgrowth of central fibers was thought to be obviated. Bethe believed he had demonstrated new nerve fibers in a distal stump completely separated from the central connec- tion. The experiments of Bethe seemed conclusive, and received wide con- sideration; they were refuted by the experimental observations of Langley and Anderson,34 Lugaro,35 and others. Several lines of investigation in correlated fields did much to bring solution to the problem: The experimental embryonic observations of Harrison and others contributed largely to the confirmation of the neuron doctrine and the outgrowth theory of nerve development, as above stated; the histogenesis of neurons was much more carefully studied; marked improvement in technical histologic methods was effected, especially as con- cerns the silver precipitation methods of Golgi, Cajal, Bielschowski, and Ranson, and the intra vitam methylene blue method of Ehrlich. A series of experimental studies on nerve degenerations and regenerations was undertaken, controlled by careful histologic studies, in which the downgrowth of the neuraxis in regeneration could be followed step by step. This more recent literature includes contributions by Perroncito,36 Poscharissky,37 Cajal,38 Ranson,39 Boeke,40 41 Dustin,42 Ingebrigsten,43 and others, in all of which the modern silver precipitation methods for staining neuraxes have been used to control experi- mental results, the consensus of their work confirming the monogenetic or downgrow-th theory of neuraxis development. An injury to a peripheral nerve, producing severance of continuity induced by crush, sharp instrument, bullet wound or laceration, calls forth a series of structural changes in the distal segment, known as secondary degeneration or Wallerian degeneration, involving at about the same time the entire distal stump, except for a narrow zone in the immediate vicinity of the wound, a zone of traumatic injury the width of which rarely exceeds 0.5 cm. These structural changes are influenced by the presence or absence of the myelin and will be described separately for the two types of nerve fibers. DEGENERATION OF MYELINATED NERVE FIBERS For a period of three to four days in dog and man, two to three days in the rabbit and 55 introduced the use of alcohol injection into a nerve trunk or the tissue surrounding the nerve trunk for the relief of neuralgia or other peripheral nerve irritations. Brissaud, Sicard, and Tanon 56 record the use of alcohol injection for facial spasms. Since then the method has been extensively used in the operative relief for neuralgic conditions. Experimental observations on alcohol injection into a living nerve trunk are first recorded by Finkelnburg57 who, taking part in a general discussion on the treatment of neuralgia, reports briefly on experimental observations in which 0.6 c. c. to 1.5 c. c. of 60 per cent to 80 per cent alcohol was injected into the sciatic of dogs after exposure of the nerve or into the tissues surrounding the nerve. A complete paralysis was produced on injecting the nerve, lasting for months, with complete degeneration of the nerve in the wound region and the peripheral segment of the nerve. A much more extended and careful study of the question was undertaken by May.58 He injected the infraorbital as a pure sensory nerve, the sciatic and anterior crural as mixed nerves, and also the Gasserian ganglion. General histologic methods, as also CajaFs and Bielschowsky's silver impregnation methods for neuraxis staining, w-ere used. The protocols of the experiments made are given, as also figures illustrative of the changes resultino- in the nerve on injection of alcohol. The following are certain of the conclusions reached by May: 58 1. Alcohol injected into the trunk of a peripheral nerve produces more or less complete local necrosis of the nerve at the point of injection. HIS SURGERY 2. The change is not an ascending one; the nerve above the point of injection remains normal; the cells of origin of the fibers may show some degree of chromatolysis, but do not exhibit signs of permanent injury. 3. The conditions produced by such injection are more favorable to regeneration than those resulting from simple section without suture. The anatomical continuity of the nerve trunk favors rapid regeneration, though this is to some extent retarded by the fibrosis which occurs to a greater or less extent in every case of alcohol injection. Harris 59> 60 and Patrick 61 have reported extensive clinical observations. dealing mainly with the injection of the trigeminal ganglion for the relief of trifacial neuralgia, an operation experimentally studied by May.58 The injec- tion of a nerve trunk with alcohol in causalgia was first recommended by Sicard82 and has since received consideration by a number of other observers, who have used the method with success. The experimental observations in this series were undertaken with a primary view of gaining experimental data for comparison and correlation with the experiments reported upon under Series No. 3, dealing with the amputation neuroma. The histologic findings in the several experiments are of interest per se. especially as concerns the more immediate effects of the alcohol on the living nerve fibers. Our observations were made on the sciatic nerve of the rabbit. This nerve, in the rabbit, can be exposed from the popliteal space to the sciatic notch with very little bleeding. The exposed nerve was then freed from its bed at about the middle of its course and raised slightly on a blunt hook and injected through a fine hypodermic needle inserted if possible beneath the perineural sheath of the large funiculus and into the epineural sheath sur- rounding the smaller funiculi and in a direction nearly parallel to the long axis of the nerve. The injection of the alcohol was made slowly and with the nerve exposed, so as to enable the observer to follow the immediate result of the injec- tion. The nerve for the length of 1.5 cm. to 2 cm. presents, after successful injection, a "milky white" appearance. The few drops of alcohol which might escape into the wound were taken up with cotton. The wound was then closed with deep catgut or silk stitches and the skin wound with interrupted silk stitches. PROTOCOLS Experiment Xo. 1.—Rabbit No. 24a. Large; full grown; 1 hour. March 12, 1918, 4 p. m., right sciatic exposed and injected while in place, with absolute alcohol. Nerve not cut. Wound closed. March 12, 5 p. m., wound opened, one hour after alcohol injection. A slight hemorrhage is found at the point of injection. The part of the nerve affected by the alcohol, a little over 1 cm. in length, presents a dull white appearance. The sciatic removed and fixed in neutral formalin. Bielschowsky's differential staining method used. Microscopic findings.—In series of longitudinal sections, including the field of alcohol injection and the nerve trunk adjacent, central and distal thereto, it may be observed that in the nerve fibers found in the field of alcohol injection the neuraxes are not interrupted and present the staining reaction of normal neuraxes. The myelin of many of the fibers presents a distinctly granular appearance; the granules appear to have been derived from the neurokeratin net. In other fibers the "Golgi funnels" are clearly differentiated. The neurolemma sheaths in the injected field are well maintained; of regular contour and found deeply stained. Not as yet distinct structural changes noted as the result of alcohol injection. Experiment No. 2.—Rabbit No. 40a; full grown; 3 hours. March 23, 1918, 11 a. m., left sciatic exposed and injected while in place with absolute alcohol. Nerve not cut. Wound closed. March 23, 2 p. m., three hours after alcohol injection. Wound opened and left NEUROSURGERY 1119 sciatic exposed. The area of alcohol injection recognized by the dull white appearance presented by the nerve trunk in this region. This area extends along the length of the nerve trunk for a distance a little over 1 cm. Calf muscles do not contract when nerve is cut central to field of alcohol injection. The nerve removed and fixed in neutral formalin. Bielschowsky's silver stain used. Microscopic findings.—Of the several series of longitudinal sections, in those including the injected area, it may be observed that the neuraxes of the nerve fibers found in the alcohol injected area are as yet unfragmented and show normal differential staining. In one small area a few segmented neuraxes noted. The myelin sheaths present a distinctly gran- ular appearance; neurolemma sheaths have normal appearance. The nerve fibers of this area present structurally no distinct departure from that presented by the normal fibers. Experiment No. 3.—Rabbit No. 61a; large; full grown; abscess on neck; 6 hours. March 23, 1918, 11.20 a. m., the right sciatic exposed and injected while in place with abso- lute alcohol. Nerve not cut. Wound closed. March 23, 5.20 p. m., wound opened and sciatic exposed. Area of alcohol injection easily recognized by its dull white color. Muscles do not contract when nerve is cut central to field of injection. Nerve fixed in neutral forma- lin. Bielschowsky's silver staining method used. Microscopic findings.—In several series of longitudinal sections including the area of alcohol injection, in the immediate alcoholized field and especially in the larger internal popliteal bundle, many of the nerve fibers are found to contain fragmented neuraxes. These fragments of neuraxes are of longer or shorter length; certain of the fragments present a wavy course; others are coiled. Certain other neuraxes present a granular disintegration. In the external popliteal funiculus, fragmentation of neuraxes not so distinct. The myelin of the nerve fibers presents a granular appearance; the neurolemma sheaths are found well maintained. Experiment No. 4.—Rabbit No. 6a; large; full grown; 1 day. February 21, 1918, right sciatic exposed and injected while in place with absolute alcohol. Nerve not cut. Wound closed. February 22, killed, 24 hours after injection; wound opened and nerve exposed. Area of alcohol injection recognized by dull white color of nerve in the region of alcohol injections. Muscles do not contract on cutting central sciatic. Nerve removed and fixed in neutral formalin. Bielschowsky's silver staining method used. Microscopic findings.—Several series of longitudinal sections made. In the series including the field of alcohol injection numerous fragmented neuraxes are found. These neuraxes fragments stain differentially in the silver stain; they vary in length; many are distinctly coiled, like a spiral spring; others present a wavy course; others show alternate enlargements and constrictions. Many of the nerve fibers more peripherally placed in the sections do not show this neuraxis fragmentation. Presumably such fibers were not affected by the alcohol. In the affected nerve fibers the myelin presents a granular appearance; the neurolemma sheaths do not show a distinct structural change. Experiment No. 5.—Rabbit No. 6; large; full grown; 2 days. February 20, 1918, left sciatic exposed and injected in place with absolute alcohol. Nerve not cut. Wound closed. February 22, killed, two days after alcohol injection. On exposing the nerve the area of alcohol injection is recognized by its dull white color. The nerve removed and fixed in neutral formalin. Bielschowsky's silver staining method used. Microscopic findings.—Several series of longitudinal sections made. In such of the sections as include the field of alcohol injection, the majority of the neuraxes are found frag- mented into longer and shorter segments, which take the differential silver stain. Many of these neuraxis segments appear to be breaking up into granules, which granules are differ- entially stained. A certain number of nerve fibers having unfragmented neuraxes are found here and there in the sections. Nerve fibers with fragmented and unfragmented neuraxes are often found in close proximity. The myelin of the nerve fibers distinctly gran- ular- the neurolemma sheaths found of normal contour and appear structurally well pre- served. The sheath cells not clearly differentiated. Experiment No. 6.—Rabbit No. 7a; full grown; 3 days. February 22, 1918, right sciatic exposed and while in place injected with absolute alcohol. Nerve not cut. Wound closed. 46997—27----73 1120 SURGERY February 25, killed. On exposing the nerve the field of alcohol injection recognized by the dull white color assumed by the nerve in this region. Nerve removed and fixed in neutral formalin. Bielschowsky's silver staining method used. Microscopic findings.—Several series of longitudinal sections made. In such as include the field of alcohol injection, it is observed that nearlv all of the neuraxes of the nerve fibers show a fragmentation. The majority of these neuraxes segments are of relatively short length, many of which appear to be breaking down into granules. In certain of the nerve fibers neuraxes segments are no longer evident. Here and there in the field, nerve fibers with unbroken neuraxes are to be seen. The myelin of the nerve fibers presents a granular appear- ance; neurolemma sheaths well maintained. Experiment No. 7.—Rabbit No. 7; full grown; 4 days. February 21, 1918, left sciatic exposed and while in place injected with absolute alcohol. Nerve not cut. Wound closed. February 25, killed. Wound nearly healed. On exposing the sciatic, area of injection with absolute alcohol no longer dull white color, but appears slightly congested; has not the glistening appearance of normal nerve trunk. Sciatic removed and fixed in neutral formalin. Bielschowsky's silver staining method used. Microscopic findings.—Several series of longitudinal sections made. In such as include the area of alcohol injection, the neuraxes of nearly all of the nerve fibers found broken in segments of very variable length; relatively few unfragmented neuraxes observed. In many of the neurolemma sheaths, no longer any fragments of neuraxes found; in others again the neuraxes segments are quite long and of wavy or spiral course. The myelin of the nerve fibers granular; neurolemma sheaths of the great majority of the fibers seem well preserved. Experiment No. 8.—Rabbit No. 61; large; full grown; abscess on back; 11 days. March 12,1918, left sciatic exposed and while in place injected with absolute alcohol. Nerve not cut Wound closed. March 23, killed, wound well healed. The area of alcohol injection not clearly defined. For a short segment the nerve seems congested. Sciatic removed and fixed in neutral formalin. Bielschowsky's silver staining method used. Microscopic findings.—Three series of longitudinal sections made, of a little over 3 cm of the nerve trunk including area of alcohol injection. In such sections as include the area of alcohol injection, the neurolemma sheaths of the nerve fibers clearly made out- within the great majority of these a granular detritus with only here and there a fragment of neuraxis remaining. In other neurolemma sheaths deeply stained globular masses; the histogenesis of which is not clearly made out. Evidence of in-wandering of leucocytes is noted; though the stain used does not clearly define these. In longitudinal sections of the nerve distal to the field of alcohol injection, the microscopic field is quite different. In such segments longer and shorter segments of neuraxes are found, differentially stained. A few fibers in which unbroken neuraxes are present are seen. The distal nerve segment sectioned presents the appearance of degenerating peripheral nerve fibers. *ww<™^ Experiment No 9—Rabbit No. 26a; full grown; 62 days. March 19, 1918 Right "Z d T" 23 kihed '? ^ "^ ^ abS°1Ute ^ N^ ^ ^ ^n closed. May 23, k lied. Severe neurotrophic changes right hind foot On exposing the n^eS 11LtZTt d' alC°htGl inJeCti°n " ^"^ by reaS°n °f a ^ ^oZL of a^™ -inirs^t^ sections made-in -ch «**- of neuraxes havin! \TthT i P-l ° lnJectl™, numerous smaller and larger bundles are f0TdSeparated bv l * l°»Slt?d™1 c™™> but here and there exchanging fibers vesicuTr ce2^ mutuallv "' Spmf "f^ areas containing granular detritus and large ^TZtl^'lZTJc^^' U Cr°SS SGCti0nS °f the nerVe in proximately the nJT^mc^J^T^'Tf011' ' m&y bG °bSerVed that the fibrous sheaths of the raxes arrangdLsmalW ^1 ^"^ StmCtUrG °f the nerVe is lost" Numerous neu- cells anTS^rTeWh,^ ^ *TP8 ^ °bserVed * Cr°SS Secti°ns- Areas of vesicular areas In cross secton of th7 ^ ^ "^ S°me fGW neUr&XeS are found in such m cross section of the nerve trunk, approximately 2 cm. distal to the place of alcohol NEUROSURGERY 1121 injection, the funicular structure of the nerve is again observed, with new down-growing neuraxes observed in all of the funiculi. Experiment No. 10.—Rabbit No. 65; full grown; 66 days. March 21, 1918, the right sciatic exposed and while in place injected with absolute alcohol. Nerve not cut. Wound closed. May 25, killed; much emaciated; for three weeks posterior extremities partially paralyzed. Cause not ascertained. On exposing the right sciatic, in what appears as the region of alcohol injection the nerve trunk shows distinct spindle-shaped enlargement; nerve is here somewhat adherent to the surrounding connective tissue. No contraction of calf muscles on cutting nerve central or distal to place of alcohol injection was observed. Nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. No wholly success- ful silver differentiation of neuraxes attained. Microscopic findings.—Three series of longitudinal sections made, including the field of alcohol injection. In these series it can be observed that numerous neuraxes growing from the central portion of the nerve have reached the portion distal to the field of alcohol injection. In longitudinal sections including the region of the spindle-shaped enlargement bundles of neuraxes are found to cross and crisscross in all directions. These microscopic fields give the impression that many of the nerve fibers were torn at the time of alcohol injection, the appearance being that of neuraxes passing through a fibrinous wound region. Distal to this spindle-shaped enlargement, they have a more regular longitudinal course much as seen in regenerating peripheral stump. The differential staining in this series is not wholly satisfactory; neuraxes in sufficient numbers were found differentially stained so that their course could be determined at different levels. Experiment No. 11.—Rabbit No. 46a; full grown; 71 days. March 20, 1918, right sciatic exposed and injected while in place with absolute alcohol. Nerve not cut. Wound closed. May 31, rabbit found dead in the morning; severe neurotrophic changes in the right hind foot. • On exposing the right sciatic in the region of alcohol injection, the nerve trunk presents a slightly smaller diameter and appears slightly congested; there is further a light yellow color. The distal segment presents the appearance of a degenerated nerve. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—Three series of longitudinal and one of cross sections made. In series of longitudinal sections including the field of alcohol injection, numerous larger and smaller bundles of neuraxes having in the main a longitudinal course are to be observed; between these bundles of neuraxes long spindle-shaped areas or columns composed of granular detritus and mutually compressed vesicular cells occur. In the series of cross sections made through the field of alcohol injections, the main funiculi (internal and external popliteal) are found demarked. Neuraxes arranged in smaller or larger groups and seen in cross section are found; these are separated by irregularly round or oval areas composed of granular detri- tus and vesicular cells. In the longitudinal sections made distal to the field of alcohol in- jection the nerve presents the appearance of a regenerating peripheral nerve. Experiment No. 12.—Rabbit No. 64; full grown; 137 days. March 21, 1918, right sciatic exposed and while in place injected with absolute alcohol. Nerve not cut. Wound closed. August 5, killed. Rabbit in good condition; small neurotrophic ulcer on right heel. On exposing the sciatic, this in the middle of the thigh, the region of the alcohol injection presents for a length of about 1.5 cm. a somewhat smaller diameter than the nerve central and distal thereto, and presents the appearance of a normal nerve though the funicular structure can not be made out and is in this region moderately adherent to the underlying muscle. On cutting the sciatic central and then distal to the field of alcohol injection, after exposure of the calf muscles, these muscles were seen to contract and twitch. Sciatic removed and fixed in ammoniated alcohol. Fair silver differentiation attained. Microscopic findings.—Series of longitudinal and cross sections were made at successive levels. Nerve fibers certain of which are myelinated, can be traced from the central nerve through the field of alcohol injection to the distal nerve. In cross sections of the nerve through the field of alcohol injection, it can be seen that the funicular structure of the nerve is lost in this region. The neuraxes are found arranged in smaller and larger bundles, separated by strands of endoneural connective tissue, which is very materially increased in this region. 1122 SURGERY Very little remains of the old nerve fibers observed. The nerve distal to the field of alcohol injections contains numerous both myelinated and nonmyelinated nerve fibers. The muscle tissue was not studied in sections. SUMMARY AND CONCLUSIONS In Experiment Xo. 1, in which the nerve was removed for study one hour after the injection of absolute alcohol, the gross changes observed in the nerve in the field of injection were more evident than the microscopic changes. In the region of the spread of the alcohol, the nerve is coagulated, appears "milky white" or "dull white'' and there is evidence of capillary hemorrhage. Unfor- tunately the record of this case does not state whether the nerve responded to mechanical stimulation on being cut central to the region of acohol injection. There is only very slight evidence of structural change in the region of alcohol injection as seen under the microscope when the nerve is removed soon after the injection; the neuraxes of the nerve fibers presenting, on the whole, a normal appearance and showing normal staining reaction on silver impregnation. In Experiments Xo. 2, Xo. 3, and No. 4, in which the nerve was removed for study at a progressively longer period after the injection of alcohol, beginning with three hours after the operation, the nerve did not respond to mechanical stimulus on being sectioned central to the field of injection, while the nerve distal to this field presented normal structure and function. In the field immediately influenced by the injected alcohol, there is evident a fragmenta- tion of neuraxes and myelin sheaths of nerve fibers not comparable to that observed in secondary degeneration, in that the change is not accompanied by proliferation of sheath cells and comes on soon after injury. Not all of the nerve fibers of an injected nerve trunk are equally affected. A certain number of nerve fibers, the number varying in the several experiments, appears not to be affected by the alcohol. The number of nerve fibers not affected, it would seem, is greater in case the alcohol is injected into the surrounding tissue rather than into the nerve trunk. Beginning with the third day after the alcohol injection, the neuraxes fragments, many of which may still stain differentially, begin to show evidence of further breaking down and, by the eleventh day after alcohol injection, the neurolemma sheaths (the sheaths of Henle?) are found filled with a granular detritus in which neuraxis fragments may or may not be found. The breaking down nerve fibers in the region of alcohol injection do not present the successive stages of secondary nerve degeneration, leading to the formation of nucleated, syncytial, protoplasmic bands, but present a micro- scopic picture which resembles more that of a nerve transplant removed some 10 to 15 days after transplantation. The segment of the nerve peripheral to the field of alcohol injection, on the other hand, presents the histologic changes characteristic of secondary nerve degeneration, as also the region immediately central to the field of alcohol injection. In a nerve removed approximately two months after alcohol injection, Experiments No. 9 and Xo. 10, there is found abundant evidence of regenera- tion although this has not extended far into the distal segment. In the region of alcohol injection, readily recognized in section, remains of the old nerve fibers are found m the form of granular detritus and also there are found large vesicu- lar cells with relatively small nuclei, presumably with phagocytic function NEUROSURGERY 1123 arranged in irregular columns or spindle-shaped areas; these may be found within or between old neurolemma sheaths and endoneural connective tissue septa. In this region there are found new neuraxes grouped in smaller and larger bundles, traceable to the central segment, having in the main a longi- tudinal course but here and there exchanging neuraxes. The new neuraxes did not appear in the distal regions of the peripheral segment. In only one experiment, Xo. 12, was the animal kept for a period long enough to admit a regeneration of the distal segment. In this experiment the nerve was removed somewhat over four months after the operation, at which time there was func- tional evidence of nerve regeneration. The region of alcohol injection is recog- nized by the absence of funicular structure, which structure is evident central and distal to the region. Bundles of nerve fibers, both myelinated and non- myelinated, are found in the "wound" region, separated by relatively large areas of connective tissue. These bundles have in the main a longitudinal course but are serpentine as they wind through the connective tissue. The appearance of a wound region after severance and suture of a nerve trunk with not especially good approximation of ends is not unlike that of the region of alcohol injection followed by regeneration, except that this special area in an old alcohol injected nerve extends over a longer distance in the course of the nerve. Peripheral to the region of alcohol injection the process of regeneration is as after nerve section. The conditions resulting from injection of alcohol into a nerve trunk May 58 speaks of as a "chemical section" of the nerve and thinks that it is probable that regeneration would follow more quickly than after mechanical section. This, it would seem, depends entirely on the thor- oughness and extent of the alcohol injection. If a number of point injections are made extending over several centimeters of nerve the resulting fibrosis would be quite extensive. So far as can be determined there is no selective action as regards afferent and efferent nerves as a result of alcohol injection. In cases of causalgia in which 60 per cent alcohol was injected, it was thought by certain observers that motor functions might persist even though reaction of degeneration were present. It is difficult to explain such selective action, except on the possible ground that the larger myelinated motor nerve fibers are more resistant to the weaker solutions of alcohol than the smaller myelinated or nonmyelinated fibers of the exteroceptive pain and temperature functional systems. In cases of causalgia treated by the injection of alcohol into the respective nerve, ultimate regeneration of the injected nerve may be anticipated wTith reasonable assurance. SERIES NO. 2 INJECTION OF FULL STRENGTH ACETONE INTO LIVING NERVE WITHOUT CUT- TING THE NERVE In this series of three experiments full strength acetone was injected into the sciatics of rabbits precisely as was described for Series Xo. 1, except that acetone solution was used instead of absolute alcohol. PROTOCOLS Experiment No. 13.—Rabbit No. 32a; full grown; 65 days. March 19, 1918, right sciatic exposed and injected with about 0.5 c. c. of full strength acetone. Nerve not cut. H^d, SURGERY Appearance of portion of nerve injected resembles closely that obtained when absolute alcohol is injected; dull white color. Wound closed. May 23, killed Rabbit presents severe neurotrophic changes right hind foot. On exposing the right sciatic, increase of con- nective tissue about nerve in region of acetone injection; when nerve is dissected free^ nerve trunk presents slight enlargement in this region. Calf muscles exposed; atrophic. Muscles did not contract on cutting nerve central and distal to field of acetone ejection. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—Four series of longitudinal sections were cut taken at successive levels and including the field of acetone injection and the nerve just proximal and distal thereto In the series of sections including the nerve about 1.5 cm. proximal to the point of acetone injection, practically normal nerve structure is observed, the stained neuraxes, both myelinated and nonmyelinated, having a longitudinal direction. Here and there "end discs," the distal ends of down-growing neuraxes, are encountered. In longitudinal sections of the immediate field of acetone injection, numerous neuraxes in the form of larger and smaller bundles, having in the main a longitudinal course, but here and there interchang- ing fibers, are encountered. These bundles of neuraxes are separated by areas and columns of vesicular cells with small nuclei as well as granular detritus. Areas of crisscrossing of neuraxes are here and there encountered. In more distally placed sections many neuraxes are found growing distalward on the inner surface of the perineural sheath; such neuraxes interlace and have a plexus form of arrangement. In sections placed distal to the field of injection, new nerve fibers are found in large numbers, having again a longitudinal course. The nerve trunk in this region presents the appearance of a regenerating peripheral nerve after severance of continuity. Experiment No. 14.—Rabbit No. 35a; full grown; 78 days. March 19, 1918, right sciatic exposed and injected while in place with full strength acetone. Nerve not cut. Wound closed. June 5, rabbit found dead in the morning. On exposing the right sciatic this is found nonadherent to the surrounding connective tissue. In the middle of the thigh, the region of acetone injection, the sciatic presents a short segment having a light yellow color. The nerve of this region is not thickened nor adherent. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Only in part successful silver differentia- tion attained. Microscopic findings.—In the several series of longitudinal sections made, sufficiently good silver differentiation obtained to determine the fact that central down-growing neuraxes, in large numbers, pass through the field of acetone injection into the nerve trunk distal to this field. In the field of acetone injection are observed areas and columns of granular detritus and large vesicular cells, separating bundles of neuraxes. At the point of injection, distinct increase of endoneural and perineural connective tissue is noted. Experiment No. 15.—Rabbit No. 53a; nearly full grown; 323 days. March 20, 1918, right sciatic exposed and injected while in place with full strength acetone. Nerve not cut. Wound closed. January 17, 1919, rabbit found dead in the morning; seemed in fairly good condition the day before, though somewhat emaciated. On exposing the right sciatic there is found no material increase in the connective tissue surrounding the nerve; central portion of the nerve adherent to underlying muscle. The main funiculi of the nerve evident practi- cally the entire length. A slight increase in the diameter of the nerve is noted in the region of acetone injection. The calf muscles presented normal size and color; owing to death of animal could not be tested functionally. Sciatic removed and fixed in ammoniated alcohol or pyridine-silver staining. Good but faint differentiation attained. Microscopic findings.—In three series of longitudinal sections, numerous both myeli- nated and nonmyelinated neuraxes, having in the main a longitudinal course, can be traced through the field of acetone injection. Scarcely any of the remains of the degenerated por- tions of nerve fibers found. In cross sections of the nerve, made just central to the place of acetone injection but in the region affected by the acetone, the funicular arrangement of the nerve trunk is found to be maintained. Within the several funiculi there is found a distinct increase of the endoneural connective tissue. So far as can be determined from histologic findings, very complete regeneration of the nerve distal to the place of acetone injection has taken place. Pieces of calf muscle were not removed for histologic study. NEUROSURGERY 1125 CONCLUSIONS So far as can be determined from the limited number of experiments in which full strength acetone was injected into the nerve instead of absolute alcohol as in Series No. 1, this may be regarded as a safe procedure and affects the nerve in the region of the injection very much as does absolute alcohol. There is a "chemical section" of the nerve and the operation is followed by loss of function in the peripheral field of the respective nerve. In due time regeneration, through the region immediately affected by the acetone, takes place in a manner as after alcohol injection. INJECTION INTO DIVIDED NERVE TO PREVENT AMPUTATION NEUROMA SERIES NO. 3 INJECTION OF ABSOLUTE ALCOHOL INTO THE CENTRAL END OF A DIVIDED NERVE TO OBVIATE THE FORMATION OF AMPUTATION NEUROMA SERIES NO. 4 AMPUTATION NEUROMA FORMATION IN ASEPTIC WOUNDS The experimental observations here reported under Series No. 3 and No. 4 were undertaken with a view of studying the factors which cause and govern neuroma formation and if possible to devise a safe and practical method to pre- vent their formation, and to determine if possible the general principle accord- ing to which methods suggested to prevent neuroma formation might be judged critically on the basis of experimental observations. There has been abundant opportunity to study the neuroma formation in experimental operations other than those recorded under Series 4, since in many of the operations listed under other series, nerves were cut and resected incidental to the respective operation; this in experiments made on dogs as well as on rabbits. The work here reported was supplemented by further experiments, in which several of the methods suggested for the prevention of neuroma formation were tested experimentally. In these supplementary experiments, made post bellum, the operative work was done by Dean Lewis, in the animal laboratory of Rush Medical College, in affiliation with the University of Chicago, while the histologic study was under- taken by Huber at the University of Michigan. Their joint work formed the basis of a communication63 dealing with the question of amputation neuromas, their development and their prevention, in which many of the experiments here listed under Series No. 3 and No. 4 were given consideration. PROTOCOLS Experiment No. 16.—Rabbit No. 24; large; full grown; 11 days. March 1, 1918, left sciatic exposed; large nerve. Absolute alcohol injected in several point injections; approximately 2.5 cm. of nerve well injected. Nerve cut distal to field of injection and resected about 1 cm. Wound closed. March 12, killed. Sciatic exposed. Distal end of central sciatic stump surrounded by a small amount of pus. Nerve ends in slight en- largement having light yellow color. Hemorrhage into nerve trunk, extending for a distance of about 3 cm. from end. Central stump removed and fixed in neutral formalin. Tissue stained after the Bielschowsky silver staining method. H2() SURGERY Microscopic findings.—In several series of longitudinal sections, of successive levels of the distal end of the central sciatic stump, in the region affected by the injected alcohol the neuraxes of the nerve fibers are found in the form of short irregular segments. The myelin of the fibers is present in the form of a granular detritus and smaller and larger globules. The neurolemma sheaths appear well preserved. Here and there irregularly formed cellular elements are found within the neurolemma sheaths, the histogenesis of which is not clearly determined. Experiment No. 17.—Rabbit No. 40; full grown; IS days. March 5, 1918, left sciatic exposed and absolute alcohol injected; in the larger internal popliteal bundle several point injections. Quite a little absolute alcohol escaped into the wound. The nerve cut distal to the injection and resected. The wound closed. March 23, rabbit killed. Wound well healed. On exposing the sciatic no material increase of connective tissue about nerve. Distal end of central sciatic stump tapers to a fine point; slightly adherent to underlying muscle. About 2.5 cm. of end of central stump of light yellow color. Central sciatic stump removed and fixed in neutral formalin for Bielschowsky silver staining. Microscopic findings.—In two series of longitudinal sections of successive levels of the distal end of the central sciatic stump it may be clearly ascertained that both of the main bundles of the sciatic were well injected, in that in practically all of the nerve fibers only scat- tered neuraxis fragments are to be found. The myelin remains found in the form of granular detritus. The neurolemma sheaths present, many showing spindle-shaped enlargement at irregular intervals. Small nuclei of doubtful source found scattered through the granular myelin detritus. The fibrous tissue sheaths of the distal end of the central sciatic stump thickened; fibrous tissue at the cut end of the nerve. Experiment No. 18.—Rabbit No. 14; full grown; 20 days. February 26, 1918, left sciatic exposed and injected with absolute alcohol, making several point injections. Verv little alcohol escaped to wound. Nerve cut distal to place of injection and resected 1 cm. Wound closed. March IS, rabbit found dead in the morning. Wound well healed. On exposing the sciatic, the distal end of the central stump found tapering to a fine line adherent to the underlying muscle. A small blood clot found surrounding the distal end of the central sciatic stump. Central sciatic removed and fixed in neutral formalin. Sections stained in iron hematoxylin and picro-fuchsin. Microscopic findings.—-In the several series of longitudinal sections made at successive levels, the structural appearance presented is such that the sections would not be recognized as sections of peripheral nerve tissue, endoneural connective tissue strands and neurolemma sheaths being the only portion of nerve structure recognized within the funiculi of the larger internal popliteal bundle. Within these sheaths, the neuraxes of the fibers have completely disappeared. The myelin remains are found in the form of a granular detritus or as inclu- sions in large vesicular cells having very small nuclei. In the external popliteal bundle, not so fully injected, certain normal fibers are to be found; other fibers showing degeneration phenomena, resembling those found in a peripheral nerve after section, are observed The perineural sheaths of both the internal and external popliteal bundles present a structural appearance which is not unlike that of a normal nerve. Experiment No. 19.—Rabbit No. 28; small; half grown; 21 davs. March 1, 1918, left sciatic exposed and injected with aboslute alcohol; very successfully injected; hardly any alcohol escaped. Nerve cut distal to injection and resected. Wound closed. March 22, rabbit found dead in the morning; seemed well nourished; wound well healed. On exposing the left sciatic this found only slightly adherent to the muscle bed. Distal end of central stump for about 1.5 cm. tapers to fine strand and is of light yellow color. Distal end of central stump removed and fixed in neutral formalin. Sections stained in iron hematoxylin and picro-fuchsin. J ri*J i C-°SC7- ^ fi?fngs-rIn several series °f longitudinal sections, including the area of a cohol injection the perineural sheaths of the funiculi appear slightlv thickened. Of the disannellf''I' }neUr°lemma sheath* only in part present; areas in which they have ZrlZt hY ^^ and WitMn di8tended ^rolemma sheaths in other parts. nclusions Th if ^SlCUl\Cells' mutuall>' compressed, having granular and globular inclusions. The cells have small nuclei. In the most distal part of the central stump such cells are less numerous, with a consequent reduction in the size of the nerve NEUROSURGERY 1127 Experiment No. 20.—Rabbit No. 11; full grown; 24 days. February 26, 1918, left sciatic exposed and injected with absolute alcohol; cut distal to place of injection and resected. Wound closed. March 22, rabbit found dead in the morning; seemed well nourished; wound well healed. On exposing the nerve this was found only slightly adherent to the underlying muscle. Distal end of central stump presents tapering end. The central stump removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.—In series of longitudinal sections of the distal end of the central stump, including the area injected with absolute alcohol and 2 cm. central, perineural sheaths found well maintained. In the injected area, practically only the old neurolemma sheaths observed; many of these greatly distended, and here and there small areas where these have disappeared. In such areas and within certain of the neurolemma sheaths large vesicular cells with small nuclei are observed. Both of the main bundles equally involved. Experiment No. 21.—Rabbit No. 1; large; full grown; 36 days.' February 18, 1918, left sciatic exposed and raised from bed for several centimeters. Lifted on hook and injected with absolute alcohol. Area well injected presents a milky white appearance. Cut distal to injection and resected 5 mm. Wound closed. March 26, rabbit died during morning; still warm when found. Very much emaciated. Abscesses filled with "cheesy" pus in various parts of body. The wound was well healed. On exposing the nerve it was found that the external popliteal was not cut at the operation and apparently was not injected. The internal popliteal stump found with tapering end. Nerve fixed in neutral formalin. Bielschowsky silver staining; good differentiation of neuraxes. Microscopic findings.—From a study of several series of longitudinal sections, it is evident that the external popliteal was insufficiently injected in that a large portion of this nerve bundle seems not to have been affected by the alcohol; showing normal nerve fibers. In the part of the nerve affected by the alcohol the neuraxes and myelin sheaths have dis- appeared and are replaced by a granular detritus and large vesicular cells with protoplasmic inclusions. Perineural sheaths not materially thickened. Experiment No. 22.—Rabbit No. 21; full grown; 36 days. February 28, 1918, left sciatic exposed and injected with absolute alcohol; injected in two regions about 8 mm. apart. Nerve cut distal to field of injection and resected. Wound closed. April 5, rabbit found dead in the morning; emaciated; wound well healed. On exposing the nerve a discoloration about distal end of central stump noted (probably due to hemorrhage). The distal end of the central stump tapers to nearly a point and presents a light yellow color. About 1.5 cm. proximal to the distal end of central stump nerve presents a normal appearance. Nerve removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro- fuchsin. Microscopic findings.—In three series of longitudinal sections taken at successive levels, including about 3 cm. of the distal end of the central stump, the following observations are permitted. Approximately 2 cm. central to the place of injection normal nerve tissue is reached. Distal thereto in progressive degree, neuraxes and myelin are replaced by gran- ular detritus, globules and phagocytic cells, in part within neurolemma sheaths, in part in areas in which the neurolemma sheaths have disappeared, only strands of endoneural con- nective tissue remaining. Down-growing nerve fibers, in part with very thin myelin sheaths, can be traced from the central undegenerated portion into the degenerated area. These fibers are found singly or in small bundles; present a very regular course, with direction in the main parallel to the long axis of the nerve, and reach to within 1 cm. of the distal end of the central stump. Here and there strands of nucleated bands of syncytial protoplasm are noted in the degenerated portion of the nerve. Experiment No. 23.—Rabbit No. 2; large; full grown; 49 days. February 18, 1918, right sciatic exposed; partly freed and injected with absolute alcohol; cut distal to injection and resected 5 mm. Wound closed. March 18, wound completely healed; hair growing over shaved area. April 8, found dead in the morning. On exposing nerve it was found that the external popliteal bundle was cut but not the internal bundle. External popliteal presents slight enlargement of distal end of central stump; end tapers to fine strand and is of light vellow color. Nerve removed and fixed in neutral formalin. Seetion stained in iron-hematoxylin. 112S SURGERY Microscopic findings.—Only the cut external popliteal nerve sectioned. Evident from series of longitudinal sections that this branch was only partly injected, since in it only a small area in which neuraxes and myelin sheath distintegration is observed. The remainder of the stump resembles in structure closely- amputation neuroma, with proliferation of connective tissue and down-growing neuraxes. This experiment can not be regarded as successful. Experiment No. 24.—Rabbit No. 43; half grown; 52 days. March 5, 191S, left sciatic exposed and injected with absolute alcohol; one injection. Quite a little alcohol escaped to wound. Nerve cut and resected. Wound closed. April 25, killed. Rabbit in good con- dition. On exposing nerve, this presents normal appearance to about 2.5 cm. from distal end of the central stump. Distal end shows a slight spindle-shaped enlargement central- ward, then tapers to a fine strand. Streaks of yellow-white color, parallel to long axis ob- served. The distal end of the central stump removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Miseroscopic findings.—In three series of longitudinal sections, taken at different levels, it may be observed, that in the distal part of the central stump to the extent of about 2 cm. the neuraxes and myelin and in part the neurolemma sheaths of the nerves have been re- placed by granular and globular detritus and vesicular cells, arranged in columns or groups separated by strands of endoneural connective tissue and neurolemma remains. Single neuraxes or small groups of such, growing from the central undegenerated portion of the nerve can be traced into degenerated area. These neuraxes have a regular course, in the main parallel to the long axis of the nerve. Neucleated protoplasmic strands accompany these neuraxes. In the distalmost part of the central stump as yet no new neuraxes are found; from this part also the granular detritus and vesicular cells have disappeared. Experiment No. 25.—Rabbit No. 22; full grown; 56 days. February 28, 1918, left sciatic exposed and injected with absolute alcohol; well injected. Nerve cut distal to field of injection and resected. Wound closed. April 25, killed. Rabbit in good condition; slight neurotrophic ulcer left foot. Wound well healed. On exposing nerve it is found that it presents a normal appearance to about 1.5 cm. from distal end of the central stump, which presents only very slight enlargement, is of yellow-white color, and tapers to fine strand, which seems continuous with surrounding connective tissue. Nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Successful silver differentiation attained. Microscopic findings.—In series of longitudinal sections taken at successive levels it may be observed that numerous new neuraxes growing from the central undegenerated portion of the nerve have grown distally into the portion injected with absolute alcohol. rh.lniTKaX!ii C°Te Singly °r in SmaU bundles' havin§ in the main a longitudinal course, the small bundles of neuraxes showing here and there interchange of fibers. Between these neuraxes are found columns or areas of granular detritus and vesicular cells. The down- growing neuraxes have practically reached the distal end of the central stump. There is observed no tangling or crisscrossing of neuraxes as seen in a neuroma, nor in the intergrowth of neuraxes and connective tissue as observed at the end of a neuroma left s^tr™1 ,N°- 26-TRabbit N°- 41' lar^ ful1 S™™; 58 days. March 5, 1918, ormer twoT°Se+ ^^ *** extemal P°pUteal bundles inJ'ected separately; the Wound c7osed JeCM°n^ Wel^fted- Nerve «* distal to injection and resected V cm. oophteal rlh iyH ' rfbblV°Und deEd in thG m0rnin*- Neurotrophic changes left heel; tape s to finTl t !i "^ °U eXP°Slng the nerve [t is found that ^ central stump cen II stumn Zr ' T^* ^^^ color" About 2 cm. central to distal end of and fixed SfI ?™*?* ^^ appearance> wit* funiculi distinct. Nerve removed licht gSn. g Chr0m-0smic"acetic solution. Sections stained in safranine and it mafbrobSrvtd^b S"~In thre+tSeries of longitudinal sections taken at successive levels myehn otheT™ fih^T? TuV^ m°St distaUy placed series> that the praxes and stands of endon , ™ b°th °f the main funiculi have entirely disappeared, with fine fpen me^Ld nXork ^^T ^ "* neurolemma ■*»«_ remainsforming a very are scattered II' SU;r° T areas of ^anular and globular detritus, through which scattered small round or oval nuclei. In the series of the next higher level the same NEUROSURGERY 1129 general structure is found for the greater part of the section. In the more central portion of the sections small strands of syncytial nucleated bands of protoplasm are observed, which become more numerous in the centrally placed of the three series. These nucleated proto- plasmic bands have grown into the degenerated portion of the nerve from the central unde- generated portion. Experiment No. 27.—Rabbit No. 38; nearly full grown; 63 days. March 5, 1918, left sciatic exposed; quite a little bleeding; controlled. Two injections of absolute alcohol made; both bundles injected. Nerve cut and 5 mm. resected. Wound closed. May 13, rabbit found dead in the morning; in fairly good condition. On exposing the nerve, distal end of central stump found tapering to fine strand slightly adherent to muscle bed. The distal end for a distance of about 2 cm. presents a light-yellow color; central to this nerve normal appearance. Nerve removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.—In several series of longitudinal sections taken at successive levels, it is observed that in the distal end of the central stump, in the area of the alcohol injection, neuraxes and myelin of the nerve fibers have entirely disappeared, fine strands of endoneural connective tissue and remnants of neurolemma sheaths remaining. This portion of the nerve consisting almost wholly of granular and globular detritus, sur- rounded by the perineural sheaths. More centralward in the series of sections, nucleated protoplasmic bands growing distally from the undegenerated central nerve are to be observed, to one side, near the perineural sheath, these protoplasmic bands extend distally to near the distal end of the central stump. Experiment No. 28.—Rabbit No. 18; full grown; 65 days. February 27, 1918, left sciatic exposed; large vein cut; clamped. Absolute alcohol injected and nerve cut just distal to injected field and resected. Wound closed. May 5, found dead in the morning. Protocol incomplete, simple statement, "No neuroma." Experiment No. 29.—Rabbit No. 10; full grown; 71 days. February 26, 1918, left sciatic exposed and injected with absolute alcohol. Nerve cut distal to field of injection; resected 1 cm. Wound closed. May 8, killed. Rabbit not in good condition; emaciated; "fungus" ears. On exposing, the left sciatic central stump is found ending in fine tapering strand, not especially adherent to the muscle bed; of light-yellow color. About 2 cm. central to distal end nerve presents the appearance of normal nerve. The nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good differential silver staining attained. Miscroscopic findings.—From the microscopic appearances presented in the several series of longitudinal sections taken at successive levels, it is evident that the injection of alcohol was not wholly successful in this experiment. Numerous neuraxes may be traced from the central portion of the nerve, toward the end of the central stump, numerous large end-discs found at various levels. Especially to one side of the nerve, and about 2 mm. from its distal end, numerous complex spirals of neuraxes are to be observed. At the distal end of the central stump, crossing and recrossing of neuraxes is noted, though there is not observed that intergrowth of neuraxes and connective tissue as is generally seen in a neuroma. In the entire series of sections, few remains of myelin and neuraxes of the old nerve fibers observed. The conclusion seems warranted that at the time of operation the nerve trunk was partially injected with absolute alcohol, and that after section of the nerve a partial neuroma developed. Experiment No. 30.—Rabbit No. 32; full grown; 80 days. March 4, 1918, left sciatic exposed. Several injections of absolute alcohol made, spaced at intervals of about 5 mm. Well injected. Nerve resected 1.3 cm. just distal to field of injection. Wound closed. May 23, killed. Rabbit in good condition; severe neurotrophic changes left hind foot. On exposing left sciatic, this presents a normal appearance to within 2 cm. of distal end of central stump. The end presents first a slight enlargement, then tapers to a fine strand only loosely adherent to the surrounding connective tissue. Distal nerve segment completely degenerated. Central sciatic removed and fixed in ammoniated alcohol for pyri- dine-silver staining. Good differential silver staining attained. 1130 SURGERY Miscroscopic findings.—In three series of longitudinal sections and one series of cross sections approximately 3 cm. of the distal end of the central sciatic stump was sectioned. The most centrally placed sections include a portion of the normal nerve. Numerous down- growing neuraxes may be traced from this portion of the nerve into that portion immediately influenced by the absolute alcohol. In this latter portion areas and columns of globular and granular detritus are found, coursing between which there may be observed smaller and larger bundles of neuraxes, which have in the main a regular course, with here and there inter- change of fibers. These down-growing neuraxes may be traced to the distal end of the central stump, but present no tangling or intertwining as observed in a neuroma. The peri- neural sheath surrounds these down-growing neuraxes. Experiment No. 31.—Rabbit No. 26; full grown; 83 days. March 1, 191S, left sciatic exposed and injected with absolute alcohol. Well injected. Nerve cut distal to field of injection and resected 8 mm. Wound closed. Mav 23, killed. Rabbit in good condition. On exposing the left sciatic, this presents normal appearance to within 2 cm. of distal end of central stump. Distal end of central stump presents slight enlargement, then tapers to fine strand, adherent to underlying muscles. Nerve removed and fixed in ammoni- ated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—In two series of longitudinal sections in which approximately 4 cm. of nerve is sectioned, it is observed that numerous neuraxes growing distalward from the central uninjured portion of the nerve extend into the portion affected by the absolute alcohol. These neuraxes are inclosed within the thickened perineural and epineural sheaths and have in the main a longitudinal course, except those found in close proximity to the fibrinous sheaths; many of them cross and recross and intertwine on the inner surface of the perineural sheath. These down-growing neuraxes can be traced to the attenuated end of the central stump. The remains of the fibers affected by the absolute alcohol found in areas of granular detritus, interspersed with large vesicular cells and fat cells, between which course the neuraxes. Experiment No. 32.—Rabbit No. 29; full grown; 83 days. March 1, 1918, left sciatic exposed and injected with absolute alcohol; well injected. Nerve cut distal to field of in- jection and resected. Wound closed. May 23, rabbit found dead in the morning. Left femur found broken; apparently some days before death. On exposing the sciatic, tissues about nerve found much congested and containing extravasated blood, owing to fracture. The distal end of the central sciatic found to taper to fine strand; relations not clear owing to extravasated blood. Nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.~In two series of longitudinal sections including approximately 4 cm. of the distal end of the promixal stump, large number of down-growing neuraxes may be traced from the uninjured central portion of the nerve to its distal end. These neuraxes are inclosed in the thickened fibrous tissue sheaths of the nerve and have in the main a regular course, tt ithin the area injected with absolute alcohol a few columns and areas of granular detritus, certain large vesicular cells and many fat cells are found. Such columns and areas are separated by bundles of down-growing neuraxes, a few of which cross such fields either as single fibers or as small bundles of such. Experiment No. 33.-Rabbit No. 17; nearly full grown; 84 days. February 27, 1918, ^h«v tt^T 'h T^? Wlth abS°1Ute alC°h0L First inJection not successful nerve slightly torn. Second attempt at a higher level, was successful; well injected. Nerve cut and resected. * ound closed. May 22, rabbit found dead in the morning; seemed in good Itafen^ oTZ Tw^* ?T*" Wt Wnd foot- °n exp0sin* **>™ -Lie" the muscle Sever.1 I ^^ " f°Und t0 t&P6r t0 fine strand; adherent to the under ying oi about enThe 7It "T b"ndleS aPPGar t0 GXtend °n the muscle bed for a distance removed and fid ^-T* °f ^ ^^ Xo evidence of a neuroma noted. Nerve silvertainhttt^T™!** alC°ho1 f°r P^e-silver staining. Good differential PortTon a han,^ 1 / POTtl°n of the ™ve amoved in this experiment was lost; the httle ov« 11 PrGSe thG m°St dlStal P°rti0n °f the central stumP *>r the length of a NEUROSURGERY 1131 Microscopic findings.—In a series of longitudinal sections, small bundles of fine neuraxes inclosed within the thickened fibrous sheath are observed. These bundles of neuraxes are found separated by areas of granular detritus and fat cells. Experiment No. 34.—Rabbit No. 42; half grown; 84 days. March 5, 1918, left sciatic exposed and injected with absolute alcohol; larger bundle in two stages; smaller bundle, one injection. Well injected. Nerve cut and resected 1 cm. Wound closed. May 29, rabbit found dead in the morning. Protocol incomplete. Nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—In three series of longitudinal and cross sections in which approxi- mately 4 cm. of nerve were cut, central neuraxes are found passing distalward through the area injected by absolute alcohol, and have reached the distal end of the central stump, and as scattered neuraxes or as small bundles of such can be traced into the connective tissue overlying the muscle bed for a distance of about 1 cm. beyond the cut end of the nerve. In the main these neuraxes have a very regular longitudinal course. Very little detritus, the remains of the injured nerve fibers found in the area injected with absolute alcohol. Experiment No. 35.—Rabbit No. 8; full grown; 90 days. February 23, 1918, left sciatic exposed and injected with absolute alcohol; well injected. Nerve cut just distal to injection; resected 1 cm. Wound closed. May 23, killed. Rabbit very much emaciated; severe neurotrophic changes foot, two toes missing; large ulcer on heel. On exposing the sciatic, this is found of normal appearance to about 1.5 cm. from end of central stump. End of stump presents slight enlargement then tapers to a fine strand. The nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Faint but differential neuraxis staining attained. Microscopic findings.—In three series of longitudinal and one of cross sections, taking in a little over 4 cm. of the distal end of the nerve the following may be observed: Neuraxes in large numbers can be traced from the central practically uninjured portion of the nerve, through the area affected by the alcohol to the distal end of the central stump. In a series of cross sections, taken about 2 cm. above the point of puncture for alcohol injection, the funicular structure of the nerve is not lost; the perineural sheaths are distinctly thickened. Within the funiculi, numerous neuraxes seen in cross section, four to ten within one neuro- lemma sheath. Not all of the funiculi found equally affected. In the more distal portion of the nerve, in two series of longitudinal sections, numerous neuraxes, having in the main a longitudinal course, and arranged in larger or smaller bundles, and separated by elongated areas and columns of granular detritus, vesicular cells and fat cells, are to be observed. inclosed within the thickened fibrous sheaths. Experiment No. 36.—Rabbit No. 37; full grown; 93 days. March 5, 1918, left sciatic exposed and injected with absolute alcohol; both bundles well injected. Nerve cut about 5 cm. distal to place of injection and resected 1 cm. A small amount of alcohol escaped to wound. Wound closed. June 6, killed. Rabbit in fair condition; neurotrophic ulcer on left heel. On exposing the sciatic nerve is found to present normal appearance to near end of distal stump which tapers to a fine strand. Nerve removed and fixed in Flemming's chrom-osmic-acetic mixture. Sections stained in safranine and licht grim. Microscopic findings.—In several series of cross and longitudinal sections made from the distal 4 cm. of the central stump the following observations are made: In the series of longi- tudinal sections small bundles composed of nucleated protoplasmic bands and fine myelinated nerve fibers may be traced from the central normal portion of the nerve to the end of the distal stump. Between these there are found broader or narrower columns composed of, in the main, large vesicular cells with small nuclei, having globular and granular protoplasmic inclusions. These cells would appear to have phagocytized the remains of the nerve fibers affected by the absolute alcohol. The fibrous sheaths of the distal end of the central stump are found mate- rially thickened. In the distal 1.5 cm. the funicular structure of the nerve is lost. Experiment No. 37.—-Rabbit No. 34; full grown; 94 days. March 4, 1918, the left sciatic exposed and injected with absolute alcohol; well injected. Nerve cut 5 mm. distal to place of injection and resected 1 cm. Wound closed. June 5, killed. Much emaciated; severe neurotrophic ulcer, left heel. On exposing the left sciatic nerve found normal to within 1.5 cm of end of the central stump; presents slight enlargement, then tapers to fine strand; 1132 SURGERY adherent to the underlying muscle. Nerve removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Tissue not well embedded, sections torn. Microscopic findings.—In the sections remaining it can be determined that nucleated protoplasmic bands extend from the central undegenerated portion of the nerve to the distal end of the central stump. These bands of nucleated protoplasm regarded as nonmyelinated fibers. Between such bands or bundles are found columns or long spindle-shaped areas of large closely arranged vesicular cells with globular or granular inclusions. Experiment No. 38.—Rabbit No. 39; small rabbit; not full grown; 95 days. March 5, 1918, left sciatic exposed; free venous bleeding. Absolute alcohol injected; larger bundle in several places; smaller bundle one injection. Well injected. A small amount of alcohol escaped to wound. Wound closed. June 8, rabbit found dead in the morning. On expos- ing the left sciatic this presents a normal appearance to within a short distance of the distal end of the central stump, which tapers to a fine strand. Nerve removed and fixed in am- moniated alcohol for pyridine-silver staining. Silver differentiation is not successful. Microscopic findings.—Several series of longitudinal sections, though not showing differentiation of neuraxes, are sufficiently stained to admit of making the interpretation that there was no neuroma formation; the arrangement of the connective tissue warrants this conclusion. Experiment No. 39.—Rabbit No. 27; full grown; 97 days. March 1, 1918, left sciatic exposed and injected with absolute alcohol. On first attempt, movement of animal prevents successful injection; on second trial successful injection made. Nerve cut distal to injection and resected. June 6, killed. Rabbit in good condition. On exposing the left sciatic the nerve presents normal appearance to near distal end of the central stump, which appears to end in fine tapering strand. The relations of distal end of central stump not clearly made out owing to presence of dense cicatricial tissue at end of the fine tapering strand. Nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation attained; sheath nuclei as well as neuraxes stained. Microscopic findings.—Several series of longitudinal sections made. In these it is possible to trace numerous neuraxes from the more centrally placed sections, through the field affected by the alcohol injection to the distal end of the central stump. At the distal end of the central stump the neuraxes are found to cross and recross, especially those found in close relation to the outer fibrous sheath. In the more central portion the neuraxes present a more regular longitudinal course. In this portion of the nerve, between small bundles of neuraxes, large spindle-shaped areas composed of vesicular cells and granular detritus are to be found. In relation with the distal end of the central stump there was noted at the time the nerve was removed a small irregular mass about 5 mm. in diameter which appeared to consist of dense fibrous tissue. In sections this mass was found to contain a nucleus of osseous tissue surrounded by dense fibrous tissue. In this fibrous laver, mainly to one side, several small bundles of neuraxes were found. A study of this series of sections suggests imperfect alcohol injection, as a result partial neuroma formation, with proliferation of fibrous tissue consequent to escape of alcohol into the wound Experiment No. 40.-Rabbit No. 15; full grown; 102 days. February 26, 1918, left sciatic exposed and injected with absolute alcohol; nerve cut distal to injection and resected 1 cm. Wound closed. June 4, killed. Animal not in good condition; severe neurotrophic ulcer on left heel; popliteal lymph gland greatly enlarged. On exposing the left sciatic, the central stump found tapering to fine strand; distal end of light-yellow color. Connective tissue in proximal part of popliteal space quite dense. Central sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained; especially more central portion of nerve. ^tfJZZ?^ Mf7SrTw° Series of longitudinal sections, including the 2 cm. of the fibrouIfJl? . , T: T^ In thG m°re distally placed series' *ithin the thickened down trowin^'nP^11 ^ ^ VeSiCUlar CeUs °CCUp^ near^ the entire area. No iTe cent , if TT ^ t0 ^ reached this Vorti™ of the central stump. In the more centrally placed series, numerous new neuraxes are found; those more axially placed have a regular course; those more peripherally placed crisscross on the inner surface of the fibrous tissue but do not present the intere-row+i. «f «k™. +• j =>u_._.««,e u_ .uc the distal end of a neuroma. g fibr°US tlSSUG &nd nGUraxeS as noted at XEUROSURGERY 1133 Experiment No. 41.—Rabbit No. 3; large; full grown; 108 days. February 18, 1918, left sciatic exposed and injected with absolute alcohol. Nerve cut about 5 mm. distal to place of injection; not resected. Wound closed. June 6, killed. Left hind foot slight neurotrophic changes on heel. On exposing the sciatic it is found that the external popliteal was not cut, and probably not injected. Internal popliteal central stump presents a tapering end. Some delicate fine strands seem to extend beyond the cut end; on cutting of these "fibers," no twitching of calf muscles observed. The nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—The noncut and noninjected external popliteal sectioned with the cut and injected internal popliteal, cut together in series of longitudinal sections. In the sections, the external popliteal presents the appearance of a normal nerve; here and there a few degenerated fibers are noted. In the distal end of central stump of the internal popliteal, central down-growing neuraxes can be traced to the distal end, having in the main a regular longitudinal course, and separated into smaller and larger bundles by long spindle-shaped areas, occupied by granular detritus and large vesicular cells. A few neuraxes can be traced into the connective tissue surrounding the distal end of the central stump of the internal popliteal. Experiment No. 42.—Rabbit No. 25; half grown rabbit; 150 days. March 1, 1918, left sciatic exposed and injected with absolute alcohol. Well injected; practically no alcohol escaped to the wound. Sciatic cut 5 mm. distal to place of injection and resected 1 cm. Wound closed. July 30, killed. Rabbit not in good condition. On exposing the left sciatic the central stump is found to end in a fine tapering strand. No bulb. No nerve fibers could be traced beyond the cut end of the nerve. Central sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. During embedding the end of the central sciatic stump became bent, so that it was not possible to cut longitudinal sections including the entire length of the piece. Microscopic findings.—It is evident on study of the entire series, that down-growing neuraxes coming from the central uninjected portion of the nerve, have passed through the area injected with absolute alcohol and have reached the distal end of the central sciatic stump. These neuraxes have in the main a longitudinal course. Toward the distal end some crisscrossing of neuraxes is observed; not to the extent found in a neuroma, and such crisscrossing of neuraxes as is observed occurs within the fibrous tissue sheath and mainly on its inner surface. Experiment No. 43.—Rabbit No. 23; nearly full grown; 157 days. March 1, 1918, left sciatic exposed and injected with absolute alcohol. Well injected. A small quantity of alcohol escaped to the wound. Nerve cut just distal to place of injection and resected. Wound closed. August 5, killed. Rabbit in good condition; foot missing; stump completely healed. On exposing the sciatic the central stump is found to end in fine tapering strand from the distal end of which a fine filament can be traced toward the distal sciatic stump, but does not reach it. Calf and foot flexor muscles completely degenerated. Central sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Not wholly successful differentiation attained; patchy. Microscopic findings.—In fairly complete series of longitudinal sections, taking in the distal 2 cm. of the central sciatic stump, it may be observed that numerous neuraxes, both myelinated and nonmyelinated, grow distal through the field of alcohol injection to the extreme distal end of the central stump. Here the connective tissue sheath of the nerve is found very materially thickened, the connective tissue extending into the interior of the nerve end and separating the nerves into small intertwining bundles. More centrally the neuraxes have a more regular longitudinal course, except those found in close relation to the fibrous tissue sheath, which course along the inner surface without definite arrangement. The structural appearances presented are not those of a neuroma. The following eight experiments are briefly listed but not numbered: Rabbit No. 30. Small rabbit; full grown; 1 day. March 1, 1918, left sciatic exposed; injected with absolute alcohol; cut; resected. Wound closed. March 2, found dead in the morning. On opening wound, evidence of hemorrhage along line of incision. Portion of 1134 SURGERY sciatic injected with alcohol of soft consistency; no gross hemorrhage into nerve. Tissue not 1 'Rabbit No 45. Full grown; 7 days. March 5, 1918, left sciatic exposed; injected with absolute alcohol; large bundle in three stages. Nerve cut and resected. Wound closed. March 12 found dead. Reported too late to use tissue for microscopic study. Rabbit No. 44. Nearlv full grown; S days. March 5, 1918, left sciatic exposed; absolute alcohol injected. A small amount escaped to wound. Nerve cut and resected. Wound closed March 13, a second operation attempted on right sciatic. Rabbit did not recover from second operation. Left sciatic wound found well healed. The distal end of the central sciatic stump found loosely adherent to the underlying muscle and presenting a slightly- tapering end. Central sciatic removed and fixed in neutral formalin. Tissue lost in washing after fixation. Rabbit No. 49. Half grown; 9 days. March 6, 1918, left sciatic exposed; injected with absolute alcohol. Nerve cut and resected. Wound closed. March 15, found dead in the morning. Reported too late to be used for microscopic study. Central end of sciatic found slightly tapering. Rabbit No. 31. Half grown; 10 days. March 4, 1918, left sciatic exposed and injected with absolute alcohol. Nerve cut and resected. Wound closed. March 14, found dead in the morning. Must have been dead many hours. Wound well healed. Central sciatic stump found slightly tapering. Tissue not studied microscopically. Rabbit No. 36. Full grown; 11 days. March 5, 1918, left sciatic exposed and injected with absolute alcohol. Nerve cut and resected. Wound closed. March 16, found dead in the morning. Rabbit dead many hours. Tissue not used for study. Central sciatic stump found slightly tapering. Rabbit No. 19. Full grown; 93 days. February 27, left sciatic exposed and injected with absolute alcohol. Nerve cut and resected. Wound closed. June 1, rabbit found dead in the morning. Severe neurotrophic changes of left hind foot; secondary injection. On exposing the sciatic this is found to taper to fine strand. No neuroma. The tissue not studied. Rabbit No. 30. Full grown; 98 days. February 28, 1918, left sciatic exposed and absolute alcohol injected. Wound closed. June 6, rabbit found dead in the morning. Reported too late to be of use in study of the tissue. On exposing the nerve this is found to taper to a fine strand. No neuroma. Experiment No. 44.—Rabbit No. 28a; small; half grown; 9 days. March 13, 1918, right sciatic exposed; cut and resected 1.2 cm. Wound closed. March 22, rabbit found dead in the morning. Wound well healed. On exposing the sciatic, a small swelling on the distal end of central sciatic stump noted. Beginning of neuroma. Central sciatic stump removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro- fuchsin. Microscopic findings.—In longitudinal sections of the distal end of the central stump early stages of amputation neuroma formation noted, evidenced structurally by fragmenta- tion of the myelin to the extent of about 8 mm. of the distal end of the central nerve fibers; proliferation of the sheath cells in this region; proliferation of the connective tissue. Experiment No. 45.—Rabbit No. 12; full grown; 25 days. February 26, 1918, left sciatic exposed; cut and resected. Wound closed. March 23, killed. Wound healed. On exposing nerve a distinct bulb on distal end of the central sciatic stump found. Removed and fixed in ammoniated alcohol for pyridine-silver staining. Tissue misplaced; not sectioned. Experiment No. 46a.—Rabbit No. 16; small rabbit; not full grown; 28 days. Febru- ary 26, 1918, left sciatic exposed; cut and resected. Wound closed. March 26, killed. Rabbit in good condition. On exposing the left sciatic distinct bulb found on central end of the distal stump. A delicate filament, having the appearance of a small nerve, traced a short distance beyond the distal end of the nerve bulb. Bulb removed and fixed in neutral formalin for silver staining. Bielschowsky silver method used. Microscopic findings.—In longitudinal section it is noted that the neuraxes were not differentially stained, but that the fibrous tissue is verv clearly differentiated. This enables NEUROSURGERY 1135 the observation that in a neuroma the endoneural connective tissue as well as the perineural sheaths show distinct proliferation. Experiment No. 46b.—Rabbit No. 4; full grown; 34 days. February 19, 1918, left sciatic exposed; cut and resected. Wound closed. March 26, killed. Wound well healed. On exposing the left sciatic a long spindle-shaped enlargement is found on the distal end of the central sciatic stump, from which is seen to pass a fine nerve bundle, lost in the con- nective tissue a short distance distal to the bulb. Central sciatic and bulb removed and fixed in neutral formalin for Bielschowsky's silver staining method. Microscopic findings.—In longitudinal sections of the distal end of the central stump amputation neuroma evidenced structurally; branching of down-growing neuraxes, many ending in terminal disks; neuraxes with irregular serrated borders; neuraxes showing spiral arrangement are observed; endoneural connective tissue proliferated. Experiment No. 47.—Rabbit No. 47; full grown; 35 days. March 6, 1918, left sciatic exposed; cut and resected 2 cm. Wound closed. April 10, rabbit found dead in the morning; severe neurotrophic changes of heel; wound well healed. Nerve not exposed until about 18 hours after death. Central sciatic stump found to end in distal spindle-shaped bulb. Central sciatic and bulb removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.—In a series of longitudinal sections of the distal end of the central sciatic stump, neuraxes coming from the distal end of the bulbous enlargement can be traced into the connective tissue distal, in the form of small myelinated fibers, either singly or in small bundles. These have a very irregular course in the connective tissue and extend for a distance of about 3 mm. beyond the end of the bulb. A distinct mass of connective tissue, blending the internal and external popliteal bundles and extending through the bulb region centralward, is found to contain many small bundles of nerve fibers. There is found a distinct increase in the thickness of the connective tissue sheaths in the bulb region, and also of the endoneural connective tissue. Experiment No. 48.—Rabbit No. 22a; full grown; 44 days. March 13, 1918, right sciatic exposed; cut and resected 1.5 cm. Wound closed. April 25, killed. Wound well healed. On exposing the right sciatic its central stump found to end in a long spindle-shaped bulb adhering to the underlying muscle. Nerve and bulb removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good differential silver staining attained. Microscopic findings.—In removal of the distal end of this nerve there was removed with it a portion of underlying fascia and muscle; in the serial longitudinal sections these tissues are included in normal relation. In study of the series of sections it is found that down- growing neuraxes have grown distally beyond the limits of the bulbous enlargement, and after passing a tangled irregular course in the connective tissue penetrate the underlying fascia, and in smaller and larger bundles extend distally between muscle fibers in quite regular longitudi- nal course for a distance of at least 1 cm., the distal limits of the section. Certain of these neuraxes are found to end abruptly in terminal discs, these often showing branching, so that two or three discs are found at the distal end of one neuraxis. Within the bulbous enlarge- ment marked increase in number of neuraxes is noted. Experiment No. 49.—Rabbit No. 10a; full grown; .57 days. March 12, 1918, right sciatic exposed; cut and resected 1.8 cm. Wound closed. May 8, killed. Rabbit much emaciated; "fungus" ears. On exposing the right sciatic its central stump is found to end in a distinct bulbous enlargement, from the distal end of which several fine nerve bun- dles, spreading out fan-shaped, can be traced for a short distance on the fascia overlying the muscle. Nerve and bulb removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—In a series of longitudinal sections neuroma structure is evidenced by the great increase in the number of down-growing neuraxes, and their irregular crisscross course at the level of nerve section. Numerous small bundles of neuraxes traced into the connective tissue distal to the bulbous enlargement; these are lost in the connective tissue. Experiment No. 50.—Rabbit No. 17a; nearly full grown; 71 days. March 12, 1918, right sciatic exposed; cut without lifting from bed; resected 1.5 cm. Wound closed. May 46997—27----74 1136 SURGERY 22 rabbit found dead in the morning. On exposing the right sciatic its central stump found to'end in a distinct bulbous enlargement, not adherent to the underlying fascia and muscle. Nerve and bulb removed and fixed in ammoniated alcohol for pyridine-silver staining. Only fair differential silver staining attained. " Microscopic findings.—In section, sufficient neuraxes staining found to determine neuroma structure; few neuraxes have grown distally beyond the limits of the neuroma. Experiment No. 51.—Rabbit No. 60; full grown; 79 days. March 12, 1918, left sciatic exposed; nerve cut and resected 0.6 cm. Not resected. Wound closed. May 31, rabbit found dead in the morning; severe neurotrophic changes in left hind foot. On expos- ing the left sciatic, no distinct bulbous end noted on distal end of central stump, in place of bulb a long spindle-shaped enlargement from the distal end of which several fine nerve bundles can be traced to the central end of the distal sciatic stump, which end is slightly enlarged. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—In several series of longitudinal sections including the central and distal resected nerve ends and the intervening connective tissue, it can be observed that when structurally considered there is present a well-developed amputation neuroma. Many neuraxes spirals are found, with evidence of great increase in the number of neuraxes. In the region representing the central cut end of the nerve, neuraxes in smaller and larger bundles intertwine with bundles of fibrous tissue; certain of the neuraxes bundles extend distally in the connective tissue, and may be traced to the central end of the distal stump; others can be traced to the underlying muscle, between muscle fibers of which they course. Experiment No. 52.—Rabbit No. 34a; full grown; 84 days. March 13, 1918, right sciatic exposed; cut and resected 1.3 cm. Wound closed. June 6, killed. Severe neuro- trophic changes right foot. On exposing the right sciatic, its distal end is found to end in a distinct, long, spindle-shaped bulb, from the distal end of which several small nerve bundles can be traced to the central end of the distal sciatic stump. The central bulb and these nerve strands not adherent to the underlying muscle. No contraction of the calf muscles observed on cutting nerve central and then distal to place of sciatic resection. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentia- tion good for the more centrally placed series of sections; for more distal series, incomplete. Microscopic findings.—In longitudinal sections of the central bulb region amputation neuroma evidenced structurally from the distal end of which many small bundles of neuraxes can be traced into the connective tissue intervening between the resected nerve ends. In cross sections of this connective tissue area numerous small bundles of neuraxes, cut in cross, oblique or, for a distance, in longitudinal section, are found separated by connective tissue. In longitudinal sections of the central end of the distal sciatic stump the silver differentiation not wholly successful, sufficient neuraxes staining observed to warrant the conclusion that certain of the central neuraxes have reached the distal sciatic stump through the connective tissue intervening between the resected nerve ends. Experiment No. 53.—Rabbit No. 46; full grown; 85 days. March 6, 1918, left sciatic exposed; cut and resected 2 cm. Wound closed. May 31, rabbit found dead in the morning; slight neurotrophic changes in the left foot. On exposing the left sciatic very distinct bulbous ends on both the main branches noted; these bulbs taper distalward into fine nerve strands which can be traced a short distance beyond the nerve bulbs. Central sciatic and bulbous enlargement fixed in ammoniated alcohol for pyridine-silver staining. Good differ- ential silver staining attained. Microscopic findings.—In a series of longitudinal sections of the central bulbous enlarge- ment amputation neuroma evidenced structurally; many spirals of neuraxes found, numer- ous branching neuraxes and terminal end-discs noted. Relatively few neuraxes can be traced into the connective tissue distal to the bulb. Experiment No. 54.-Rabbit No. 15a; large; full grown; 87 days. March 13, 1918, right sciatic exposed; cut and resected 1.5 cm. Wound closed. June 8, killed. Severe neurotrophic changes of right foot. On exposing the right sciatic distinct bulbous enlarge- ment on distal end of central sciatic stump found. A fine strand of nerve fibers can be traced from the distal end of the central bulb to the central end of the distal sciatic stump. NEUROSURGERY 1137 Sciatic removed and fixed in ammoniated alcohol for pyridine silver staining. Good silver differentiation attained. Microscopic findings.—In sections a large amputation neuroma evidenced structurally; in this noted spirals of neuraxes, end-discs, crisscrossing of neuraxes, especially at its distal end. Relatively few neuraxes can be traced to the connective tissue distal to the neuroma. The distal sciatic degenerated; no evidence of regeneration. Experiment No. 55.—Rabbit No. 35; full grown; 93 days. March 4, 1918, left sciatic exposed; cut and resected 1 cm. Wound closed. June 5, rabbit found dead in the morning. On exposing the left sciatic the distal end of the central sttfmp presents a well-formed, relatively large bulbous end. Several fine nerve strands traced a distance beyond the bulb; lost in the connective tissue. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Unfortunately tissue lost; not sectioned. Experiment No. 56.—Rabbit No. 25a; half grown; 129 days. March 20, 1918, right sciatic exposed; cut and resected 1.2 cm. Ends of cut sciatic placed in alignment, and muscles sutured over them. Wound closed. July 30, killed. Rabbit not in good con- dition. On exposing the right sciatic the central stump is found to end in a long spindle- shaped bulbous end, the distal end of which reaches the central end of the distal sciatic stump; the nerve bundles uniting the resected nerve ends is adherent to the underlying muscle. The distal sciatic stump presents a spindle-shaped enlargement nearly as large as that found on the central sciatic stump. Sciatic nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Only partial differential staining attained. Microscopic findings.—In series of longitudinal sections, well-developed amputation neuroma evidenced structurally, from the distal end of which larger and smaller bundles of neuraxes can be traced to and through the connective tissue intervening between the resected nerve ends. In the central end of the distal sciatic stump relatively large numbers of neuraxes observed in such portions of the series of sections in which the silver differen- tiation is sufficiently good to determine them. Experiment No. 57.—Rabbit No. 13; full grown; 160 days. February 26, 1918, left sciatic exposed; cut and resected 1 cm. Wound closed. August 5, killed. Much emaciated; left foot missing; healed over. On exposing the left sciatic a distinct bulbous end on the distal end of the central sciatic stump noted, from the distal end of which fine nerve strands can be traced toward the central end of the distal sciatic stump, but do not appear to reach it. Calf muscles found atrophic. Central sciatic and bulb fixed in am- moniated alcohol for pyridine-silver staining; distal internal popliteal fixed in neutral for- malin. Only fair differential silver staining attained. Microscopic findings.—Well-developed amputation neuroma evidenced structurally, from the distal end of which only a few neuraxes can be traced into the connective tissue distal to the neuroma. The nerve fibers of the distal internal popliteal found completely degenerated; relatively few nuclei observed; neurolemma sheaths found thickened and collapsed. Experiment No. 58.—Rabbit No. 58; full grown; 179 days. March 12, 1918, left sciatic exposed and cut high in thigh; the cut ends retracted so as to be separated 8 mm. Wound closed. September 8, killed. Rabbit in fairly good condition; somewhat emaciated; "fungus" ears. On exposing the left sciatic there is observed a spindle-shaped enlargement on the central sciatic stump, the distal end of which continues to the central end of the distal sciatic stump, the intervening bundle being of nearly the same size as the sciatic. The distal sciatic presents the appearance of a normal nerve. The distal end of the central bulb, as also the intervening nerve bundle, presents a light red color as though more vascular than the remainder of the nerve. The sciatic and a segment of the internal popliteal and posterior tibial fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.—In longitudinal sections of the central bulb it is seen that numerous nerve fibers both myelinated and nonmyelinated, pass from the distal end of the bulb into the connective tissue. Of these, those coming from the more axial portion of the bulb have in the main a longitudinal direction, while those which come from the more peripheral por- tion of the bulb present a very irregular course. In the central end of the distal stump and 1138 SURGERY at levels to the middle of the leg in the posterior tibial, in cross sections, numerous myelinated nerve fibers are to be seen. Experiment No. 59.—Rabbit No. 57; full grown; 180 days. March 12, 1918, left sciatic exposed and cut high in thigh; ends retracted so as to be separated 6 mm. Muscles stitched over cut nerve ends. Wound closed. September 9, rabbit found dead in the morn- ing; left foot missing; stump healed. On exposing the sciatic a nerve bundle of a diameter nearlv as large as the sciatic extends from a central sciatic bulb to the distal sciatic stump. The distal sciatic presents the appearance of a normal nerve. Sciatic removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht- griin. Microscopic findings.—In longitudinal sections of the central bulb region numerous nerve fibers arranged in small bundles can be traced from the distal end of the central bulb into the connective tissue distal to the bulb. In cross sections of the nerve bundle intervening be- tween the resected nerve ends, it is observed that the nerve fibers are arranged in numerous small funiculi, having no definite perineural sheaths and separated by intervening connective tissue. In the distal sciatic stump, in both cross and longitudinal sections, numerous mye- linated fibers are observed among fibers not yet regenerated. Experiment No. 60.—Rabbit No. 51; full grown; 10 months. March 11, 1918, left sciatic exposed, cut high in thigh; ends retracted 7 mm. Wound closed. January 9, 1919, rabbit seemed normal 4 p. m.; found dead 9 p. m.; still warm. Toes of left foot found missing; healed. On exposing the left sciatic, except for slight central enlargement and loss of the funicular structure in the region of the nerve section, sciatic nerve presented the appear- ance of a normal nerve. Calf muscles and foot extensors seemed fully regenerated. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Faint but differential silver staining attained. Microscopic findings.—In longitudinal sections of the bulbous enlargement on the central sciatic stump the neuroma structure evidenced by the crisscrossing of the neuraxes and loss of the funicular structure of the nerve. In cross sections of the tissue intervening between the resected nerve ends, numerous small funiculi of both myelinated and non- myelinated nerve fibers, separated by bands of fibrous tissue are observed. In a series of longitudinal sections embracing the central end of the distal stump, both myelinated and nonmyelinated nerve fibers, with regular order of direction are found in the connective tissue over the end of the distal stump and can be traced into the distal nerve in which they assume a definite longitudinal course. Experiment No. 61.—Rabbit No. 53; nearly full grown; 11 months. March 11, 1918, left sciatic exposed and cut; ends retracted 5 mm. Wound closed. January 17, 1918, rabbit found dead in the morning; somewhat emaciated. On exposing the left sciatic the nerve is observed to present two spindle-shaped enlargements about 2 cm. apart, in the region of the nerve section. These are found united by a nerve bundle of about the same size as the sciatic. In the region of the two enlargements and the intervening bundle the nerve adherent to the underlying muscle. Calf and extensor foot muscle seem regenerated; presenting normal size and color. The animal was found dead too long after death to make tissue of much value for special differential neuraxes staining. Fixed in ammoniated alcohol for pyridine-silver staining. Imperfect differentiation attained. Microscopic findings.—Sufficient silver differentiation of neuraxes obtained to determine in several series of longitudinal sections that both myelinated and nonmyelinated nerves coming from the central bulb, passing through the intervening connective tissue, have reached the distal sciatic. Experiment No. 62.—Rabbit No. 55; large; full grown; 1 year. March 11, 1918, left sciatic exposed and cut high in thigh, end retracted 8 mm. Very little bleeding. Muscle stitched over nerve. Wound closed. March 11, 1919, killed. Active, in good condition; left foot missing; healed. On exposing the left sciatic two slight, spindle-shaped swellings are observed about 1 cm. apart, the distance bridged by a nerve bundle nearly the size of the sciatic; this in the region of nerve section. In this region nerve is adherent to the underlying muscle. On exposing calf and foot extensor muscles, these present a normal appearance. On cutting nerve near sciatic notch, vigorous contractions of calf and foot extensor muscles noted; the same on cutting nerve in the popliteal space. Sciatic fixed in ammoniated alcohol NEUROSURGERY 1139 for pyridine-silver staining; portions of calf muscles stained in gold chloride. Very good silver differentiation attained. Microscopic findings.-—In longitudinal sections of the central bulb numerous myelinated and nonmyelinated nerve fibers are seen to cross and recross in the distal end of the central bulb and enter the connective tissue intervening between the resected nerve ends. In cross sections of the field a large number of small nerve funiculi, without special fibrous sheaths but separated by bands of fibrous tissue, can be observed. In longitudinal sections of the distal end of the central sciatic small nerve bundles with very sinuous course can be traced from the connective tissue into the distal sciatic in which the neuraxes assume a regular longitudinal course. Cross and longitudinal sections of the distal sciatic at several levels present an appearance which resembles closely that of a normal nerve. Differentiation of nerve and endings in the muscle not successful. Experiment No. 63.—Rabbit No. 56; full grown; 1 year. March 11, 1918, left sciatic exposed; cut high in thigh; cut ends retracted 8 mm. Very little bleeding. Muscle stitched over nerve. Wound closed. March 11, 1919, killed. Rabbit in good condition. On exposing the sciatic the two resected ends found united, without appreciable enlargement of the central or distal resected ends. Calf and foot extensor muscles present normal appearance and contract vigorously when nerve is cut central and distal to the region of section. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—In series of cross and longitudinal sections, including the field of operation and the nerve distal, it can be observed that numerous neuraxes coming from the distal end of the central bulbous enlargement pass through the connective tissue intervening between the resected nerve ends and enter the distal sciatic, in which they are found in large numbers in all of the funiculi. In cross section of the connective tissue found between the resected nerve ends the neuraxes, both myelinated and nonmyelinated, are found in the form of numerous small nerve funiculi, separated by bands of connective tissue. For more than a century consideration has been given to the swellings which form on the distal end of the proximal stump of a completely or partially severed nerve and known as neuroma or neuromata. The literature dealing with the structure of neuroma is quite extensive and the surgical literature dealing with the operative means for the prevention of neuroma formation covers a period of many years. The histologic description of neuroma, presented by various writers, differs widely, especially for the period preceding the intro- duction of specific neuraxis stains. It is not thought necessary to review here at length this extensive literature; certain of the more pertinent references will be given incidental consideration. The operations reported upon under Series No. 4 were made under strictly aseptic precautions and with as little bleeding as possible, hemorrhage and suppuration having been looked upon as important causative factors in neuroma formation. The structural changes observed in the distal end of the proximal stump of a divided nerve, severed by means of a sharp instrument placed in an aseptic wound, are, during the first few days after the operation, precisely the structural changes observed in the distal end of the proximal stump of a severed nerve, immediately sutured under aseptic conditions. For a distance of from 5 mm. to 1 cm. from the cut surface, both myelinated and nonmyelinated nerve fibers show degenerative changes accompanied by proliferation of sheath cells, comparable in every way to the degenerative changes noted in the peripheral stump. The abortive regenerative changes, considered in the general introduction, may also be observed. The connective tissue of the nerve trunk early shows reaction to the injury, evidenced by cell proliferation 1140 SURGERY in the re-ion of the cut surface and exudate covering it, so that the cut end of the nerve is early covered bv a connective tissue cap which becomes continuous with the epineurium of the nerve and less with the surrounding tissue. This connective tissue cap occurs quite regularly in neuromas. It is found organiz- Fig. 218.—A longitudinal section of a typical neuroma removed from the sciatic of a dog 31 days after section; pyridine-silver preparation. The relations of the epineurium and the connec- tive tissue cap found on the end of the neuroma are clearly seen. Note the regular arrange- ment of the nerve fibers and neuraxes in the upper half of the figure and the crisscrossing and otherwise irregular arrangement of the neuraxes as evident in the lower half of the figure ing when the central neuraxes show the early evidences of regeneration and downgrowth. These evidences of regeneration, as concerns the neuraxes, are best seen and studied in silver preparations, and consist of end and side branches of neuraxes often found terminating in end-discs, very much as observed in regeneration of a severed nerve and subsequent suture. There is distinct NEUROSURGERY 1141 Fig 219.—Longitudinal section of an atypical neuroma from the sciatic of a dog, is days after sec- tion; pyridine-silver preparation. The general structure of the neuroma is clearly evident. The atypical form was due to pressure consequent to scar tissue formation 1142 SURGERY evidence of sheath cell proliferation, but their relation to the budding and growing neuraxes is not quite clear in silver preparations nor can they be definitely differentiated from the proliferating connective tissue cells. During the second week after resection of the nerve, neuraxis budding and down- growth is clearly demonstrable. The down-growing neuraxes approach the region of neuroma formation with fairly regular and approximately parallel course; as the}' approach the region of the fibrous cap, single neuraxes or small bundles of such begin to intertwine; many are deflected from their course, even to the extent of turning centralward, and many terminal end-discs are observed. There is fairly distinct interlacement of organizing connective tissue bundles. Very characteristic of the earlier stages of neuroma formation are peculiar spiral complexes, first described by Perroncito, and formed of a single relatively large neuraxis or several neuraxes in axial position, about which are wound in spiral form a variable number of neuraxes and their branches, mam- ending in end-discs and all found within a neurolemma sheath. These Per- roncito spirals may be scattered singly here and there or be fourid in larger or smaller groups. As such a spiral grows in diameter it would seem that the old neurolemma sheath disappears so that the spirals come to lie in the endo- neural connective tissue. The connective tissue of a neuroma is deserving of consideration. It is composed of loosely woven, wavy, connective tissue bundles, is quite cellular and differentiates quite slowly into a compact tissue. One gains the impression that the growing neuraxes, as they reach the region of the connective tissue cap and the sides of the growing neuroma, for some time stimulate connective tissue to growth. The formation of the central budding i and growing neuraxes and the connective tissue of the neuroma progress simultaneously and there develops an intergrowth of connective tissue and neuraxes which characterize the terminal part of the neuroma. A neuroma is to be regarded as a thwarted attempt at regeneration of the nerve, the down- growing neuraxes being blocked by scar tissue. In many instances a well developed neuroma has formed in a strictly aseptic wound by the end of the third or the beginning of the fourth week after operation. As time progresses, in many instances, neuraxes singly or in small bundles, penetrate the cap over the end of the neuroma and penetrate the surrounding connective tissue, pass into intermuscular septa and may penetrate adjacent muscle and course between muscle fibers. In course of time, the down-growing neuraxes may reach the central end of the distal stump and bring about at least partial neurotization of the distal segment. The importance of the participation of growing and budding central neuraxes in neuroma formation, is clearly seen in pyridine-silver preparations of suitable stages. Cone64 has stressed the fact that three-fourths of each painful bulb consists of nerve fibers and we are led to think that their proliferation against resistance is a cause of pain. All neuroma in the earlier stages of development consist, to a large extent, of nerve fibers or of neuraxes and in all neuromata there is to be noted proliferation of neuraxes against resistance. This fact led us to feel that any measure employed with a view of preventing neuroma formation, in order to attain success, must be directed primarily toward the neuraxes and not the connective tissue of the severed nerve end. Huber and Lewis 63 tested experimentally NEUROSURGERY 1143 several methods recommended in clinical surgery and directed more particularly toward the connective tissue at the end of the severed nerve, such as "swing door operation" and "crush and tie," and under most favorable conditions of asepsis, neuroma formation was accentuated rather than obviated. In the experiments in which absolute alcohol was injected in the nerve, the procedure was directed toward the neuraxes and it was hoped distinct delay in neuraxis downgrowth would be attained. It may be stated that the escape of a few drops of alcohol, an accomplishment more likely to occur while injecting a nerve the size of that of the sciatic of rabbit, than the larger nerves of the extremities of man, is not to be regarded as of serious consequence, since the records show that the escape of absolute alcohol into the wound was not followed Fig. 220.—Spiral formations of neuraxes from neuroma shown in Figure 219. The figure presents a number of end- discs, certain of which are the terminations of neuraxes participating in the spiral structures by excessive scar tissue formation. One can not agree, therefore, with Corner 65 who states that " injection of alcohol, quinine, and urea should not be used, as about three or four fifths of an injection flows out of a nerve into the surrounding tissue, causing later large formation of scar tissue round the nerve and subse- quent strangulation." The procedure employed in the experiments listed under Series No. 3 was to inject the central stump of a resected nerve approximately 1.5 cm. from the cut surface with absolute alcohol, through a hypodermic needle, inserting the needle very obliquely and centralward. Enough alcohol was slowly injected to give the nerve in the region of the injection and for a distance of approxi- mately 2 cm. a milk white appearance or the appearance of cooked white of egg. If alcohol escaped into the wound, this was taken up with sterile cotton 1144 SURGERY and the wound closed. At the end of stated periods the operated nerves were removed and studied macroscopically and microscopically as detailed in the pro- tocols of the several experiments of Series No. 3. SUMMARY From a study of the protocols of the series it may be noted that as a con- sequence of alcohol injection there ensues a fragmentation of the neuraxes and a granular breaking down of the myelin sheaths, and a destruction of the shenth cells in the region of the alcohol injection while the fibrous tissue sheaths and the endoneural connective tissue are not affected to the extent of losing their fibrillar structure. These changes affect a region of approximately 2 cm. in the nerves experimented with, namely, the sciatic of rabbits. There is then in the distal portion of the proximal stump thus treated no neuraxis regeneration nor fibrous tissue proliferation of the tissue under consideration. Iiv the end of the third week and the beginning of the fourth week, the frag- ments of the old neuraxes have disappeared as also much of the myelin detritus. The old neurolemma sheaths seem to persist, and large vesicular cells, many with relatively small nuclei, and having lipoid granules and globules in their proto- plasm, the histogenesis of which it is difficult to determine in the pyridine- silver preparations, make their appearance. They are wholly unlike the hyper- trophied sheath cells of degenerating nerves. A resected nerve without alco- hol injection, or with "swing door" or "crush and tie" operation after resec- tion, shows by the end of the first month after operation a well-developed neuroma. Beginning with the fifth or sixth week after operation, a down- growth of central neuraxes into the region affected by the alcohol begins to be noted. The down-growing neuraxes, as observed in pyridine-silver preparations, in longitudinal section present a fairly regular course in the main parallel to the long axis of the nerve. They appear to course, in part at least, within old neurolemma sheath remains (or sheath of Henle) and gradu- ally reach the distal end of the proximal stump by the end of the second or the middle of the third month after operation. The down-growing neuraxes are accompanied by sheath cells, it is thought derived from central sheath cells. Even in nerve ends seen four to five months after resection and injection of alcohol there is no evidence of neuroma formation, although central neuraxes, both myelinated and nonmyelinated, have passed through the injected portion of the nerve to the extreme distal end of the proximal segment. The connective tissue sheaths of this region are distinctly thickened and the endoneural tissue increased so that the nerve fibers found in the distal end are seen in small inter- lacing and intertwining bundles, separated by connective tissue. In none of the nerves studied in this series was there any distinct evidence of neuroma formation except in cases in which alcohol injection was not successful. As a result of observations on experiments of Series No. 3 and No. 4, evidence at hand warrants the statement that a neuroma indicates an attempt at nerve regeneration which is thwarted by the formation of scar tissue found at the end of the neuroma; that they form in aseptic wounds and their forma- tion is in no sense dependent on the presence of blood clot or infection result- ing in suppuration. We believe ourselves to have demonstrated that absolute NEUROSURGERY 1145 alcohol injected into the nerve, 2 cm. to 2.5 cm. from its cut surface in several point injections arranged so as to involve all parts of the nerve trunk, is a procedure which is successful in preventing neuroma formation. NERVE TRANSPLANTS The great majority of the experimental observations listed in the following series deal with cases in which, owing to loss of nerve substance at the time of injury, the severed nerve ends were separated to such extents that they could not be brought together for suture. The question of bridging defects in nerve resulting from loss of substance at the time of injury is one that has received consideration for a time nearly coincident with that of the use of suture in uniting severed nerves. It is not proposed to enter on a general discussion of the methods used or suggested for the purpose of bridging nerve defects nor to consider critically the extensive literature bearing on this question; incident- ally, certain pertinent references will be considered. Certain of the methods suggested as of service in bridging nerve defects which have received general recognition, such as suture a, distance, tubular suture, nerve implantation and nerve flaps, were tested experimentally by Huber 30 several decades ago and discarded as not justified on experimental grounds. A few of these methods, such as the operation of nerve flap made from the central or distal stump, or from both stumps are still in use by surgeons. A critical review of all of the cases in which the operation of nerve flap was used to bridge a nerve defect was made by Stookey 50, who found that in not a single case was there conclusive evidence of regeneration. There has been a revival of the operation of nerve implantation, in case of loss of nerve substance in peripheral nerves, as a result of the advocacy of this method by Hofmeister 51, but there is no warrant for this method if properly done. It is only when nerve fibers are cut in the sound nerve at the seat of implantation, in which case the operation becomes one of nerve crossing, that there is any justification for attempting the method. Con- sideration is given to tubular suture in Series No. 20. The use of a segment of nerve to bridge a defect due to loss of substance in a nerve has long been advocated, by both the experimenter and the clinician. This procedure was first tried experimentally by Philipeaux and Vulpian 66 and was first used by Albert67 in human surgery. A segment of nerve used to bridge a defect in a peripheral nerve, taken from another nerve from the same indi- vidual, is designated an autogenous transplant or graft—an auto-nerve trans- plant; a segment of nerve taken from another individual but of the same species is known as a homogenous transplant or graft—a homo-nerve transplant; a nerve segment taken from another individual but of a different species is called a heter- ogenous transplant or graft—a hetero-nerve transplant. Having in mind the practical application in human surgery, various types of nerve transplants were tested experimentally, such as normal or degenerated nerves; fresh and pre- served or stored in aseptic state; as single nerves or a bundle of nerves, the latter known as "cable-nerve transplant" or "multi-nerve transplant"; and wrapped or unwrapped in protecting membrane or sheath. These series constitute a very comprehensive experimental study of the question of nerve transplant. 1146 SURGERY SERIES NO. 5 AUTO-NERVE TRANSPLANTS, INCLUDING CABLE-AUTO-NERVE TRANSPLANTS General surgical experience regarding the question of tissue graft or trans- plants, and the favor with which autogenous tissue grafts are regarded, made it imperative that auto-nerve transplants be given special consideration, even though it was recognized that in using an autogenous nerve transplant a normal functioning nerve was of necessity resected to the extent necessary to bridge the existing defect, with consequent loss of function in the nerve resected, throughout its entire field of distribution. Consideration should be given the fact that a nerve transplant should have a cross-section area approximately that of the nerve to be repaired, in order to admit of ready downgrowth of central neuraxes. The mere question of determining the relative value of an auto-nerve transplant as over against other types of nerve transplants did not appear to have sufficient value, since it could hardly be regarded as good sur- gery to resect one major nerve of an extremity to repair another even though an auto-nerve transplant should on experimentation prove to have special merit. In our endeavor to make auto-nerve transplants of practical use in surgery, the operation here known as cable-auto-nerve transplant was developed and tested experimentally. This operation consists in using several segments of a nerve which could be resected without serious inconvenience as a result of loss of function. Certain cutaneous nerves were selected for this purpose and a sufficient number of segments placed side by side so that their combined cross- section area approximated that of the nerve to be repaired. These operations were made with great care, especially those in which cable transplants were made. It is so essential to obtain good end-to-end approximation in nerve suture and it was our special endeavor to obtain this. In valuating these and other experiments in the light of possible application to human surgery, it is recognized that a direct transfer of results is not permissible. The aseptic wounds in normal tissue and the nerve resected by means of sharp instruments present a condition not found in a severed nerve torn or crushed by high ex- plosive or otherwise, perhaps wound infected, and perhaps not seen until months- after injury with abundant formation of scar tissue. It was felt, however, that certain general deductions could be made and certain general principles formu- lated. In suturing the nerve transplants very fine silk threads, waxed with sterile wax, were used. It is essential and necessary to have good approxima- tion of the cut surface. This is more readily attained with waxed silk sutures. passed through the nerve transplant and the resected ends of the nerve than when catgut is used. Stookey « and Elsberg °9 have described special technical methods, recommended for use in cable-auto-nerve transplants in human surgery This operation is not an easy one and is very time consuming It generally necessitates the making of a second wound, which even though it is quite superficial, is of necessity of some length. It is suggested that for purpose of cable-auto-nerve transplant the internal saphenous nerve, the anterior femoral cutaneous, and the sural nerve from the lower extremity and the cutaneous branch of the musculocutaneous (lateral antibrachial cutaneous) NEUROSURGERY 1147 and dorsal antibrachial cutaneous from the upper extremity are, of the larger cutaneous nerves, available. The protocols of experiments under Series No. 5, auto-nerve transplants and cable-auto-nerve transplants follow: PROTOCOLS Experiment No. 64.—Dog No. 6; large; full grown; somewhat emaciated; 119 days. April 11, 1918, left sciatic exposed for a distance of 6 cm. Incision made through skin and muscle; free bleeding. Superficial radial of right forearm exposed and freed of connective tissue. Using No. 60 linen thread and fine, straight, round needles, two sutures passed through nerve about 3 cm. apart. Radial cut with scissors 2 mm. proximal and distal to suture lines and nerve segment transferred to sciatic wound. One needle and suture passed through sciatic centrally and sciatic cut 2 mm. distal to suture line; central suture tied. Distal suture passed through sciatic and the nerve cut 2 mm. proximal; distal suture tied. Only fair central and distal approximation of nerve ends attained. Radial segment has much smaller diameter than the sciatic nerve. Wounds closed. August 8, killed. Dog much emaciated, has not been well for several days. Left hind foot, small neurotrophic ulcer of heel; does not stand on ball of foot. Scar tissue found in line of sciatic wound; extends to deeper tissues. Left sciatic found surrounded by dense fibrous tissue. On dissecting free, a large central bulb noted. A small nerve bundle can be traced from this to distal sciatic stump. Distal sciatic presents the appearance of a partially regenerated nerve. Calf muscles exposed and sciatic and the transplant freed from the bed. On slowly cutting with scissors, sciatic central to the transplant, distinct twitching of calf muscles noted; same when sciatic is cut distal to the transplant. Sciatic and transplant and internal and external popliteal branches removed and fixed in ammoniated alcohol for pyridine-silver staining. After silver staining this material was by accident overheated in oven; section series unsatisfactory. Microscopic findings.—In very broken and irregular sections, sufficient evidence of down- growth of neuraxes from the central bulb to warrant the conclusion that neuraxes coming from the central bulbous enlargement had grown through and outside of transplant to the distal sciatic stump. Details could not be determined. Experiment No. 65.—Dog No. 7; large; full grown; well fed; 120 days. April 12, 1918, left superficial radial exposed and freed from connective tissue. Two silk sutures passed 2.8 cm. apart and nerve cut central and distal to sutured lines with sharp razor blade. Right sciatic exposed and freed. Radial segment transferred to sciatic wound and the sutures passed at the proper distance before the nerve was cut. Sciatic resected distal and proximal to suture line and sutures tied. Good approximation of nerve ends attained. Wound not quite dry; wounds closed. August 10, killed. Dog emaciated, but seems in good condition. Walks well; uses right hind foot quite normally; standing on ball of foot. On exposing the right sciatic a relatively large bulbous enlargement is found on the distal end of the central sciatic stump. A small bundle of nerves leads from this to the distal stump, the central end of which is not materially enlarged. Central sciatic bulb and the transplant not especially adherent to underlying muscle. Calf muscles exposed. After completely freeing the sciatic from notch to popliteal space, on slowly cutting the nerve central to the transplant distinct twitching and contraction of the calf muscles noted. Sciatic and transplant, external and internal popliteal and pieces of calf muscles and extensor leg muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—Large oval, central bulb evidenced structurally, from the distal end of which numerous down-growing neuraxes can be traced to the central end of the trans- plant and also into the connective tissue surrounding the central wound. In cross sections of the transplant its funicular structure is found retained, with the fibrous sheath thickened. Numerous neuraxes found in each of the funiculi of the transplant, also in small bundles in the connective tissue surrounding the transplant. In successive cross and longitudinal series of sections these neuraxes can be traced to and through the distal wound into the distal sciatic branches* in the internal popliteal nearly to the level of the heel; in the external popliteal to the region of the head of the fibula. In sections of the calf muscles new neuraxes are found 1148 SURGERY in the larger and smaller muscular branches, and as single nerve fibers, between and on the muscle fibers. Here and there quite well developed motor nerve endings were noted. Experiment No. 66.—Dog No. 3; small dog; full grown; 132 days. March 8, 1918, left sciatic cut, high up; wound closed. March 27, left sciatic exposed, nineteen days after section. Difficult to find central stump; much bleeding; muscles somewhat torn. Ends of cut sciatic stumps resected. Right ulnar exposed and a segment transplanted to the resected sciatic. Ulnar segment somewhat short; central suture gave way; difficult to suture again. One central and distal catgut suture used. Not good approximation attained; transplant ultimately 1.5 cm. in length. Wounds closed. August 6, killed. Dog in good condition; not materially emaciated. Uses left hind leg well; now and then steps on dorsum of foot; small ulcer on dorsum of foot. On exposing left sciatic large bulbous enlargement is found on central sciatic stump; from this a small bundle of nerves leads to distal sciatic stump. Distal sciatic, especially internal popliteal branch presents the appearance of a regenerated nerve. Central bulb and region of transplant surrounded by quite dense fibrous tissue; adherent to underlying muscle. After exposing calf muscles and freeing the sciatic from bed on slowly cutting sciatic central to transplant, feeble twitching of calf muscles noted. Muscle not fully recovered, pale red color, streaked with yellow white. Sciatic nerve and transplant, internal popliteal and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Fair differential silver staining attained. Microscopic findings.—From the distal end of a long spindle-shaped bulbous enlarge- ment, down-growing neuraxes may be traced through a long fibrous union, extending several millimeters, to the central end of the transplant. In cross sections of the transplant, about 1 cm. distal to the central wound, the funicular structure of the ulnar can only be partially made out; there is observed material increase of its fibrous sheaths. New neuraxes are observed within the funiculi of the transplant and also in the surrounding connective tissue, especially to one side. These new neuraxes can be traced in sections, to the distal wound and through it to the distal internal popliteal, the external popliteal not having been united to the transplant at the distal wound. In sections of the calf muscles, new neuraxes are noted in the muscular branches entering the several calf muscles, and in many of the inter- fascicular nerve branches. Experiment No. 67.—Dog No. 8; large dog; full grown; 282 days. August 12, 1918, the left superficial radial exposed and freed from connective tissue. The right sciatic exposed by cutting through muscle; good direction of incision; free bleeding. Sutures passed through radial branch, 3 cm. apart before cutting the same, and transplanted to the resected right sciatic; good approximation attained. Muscle stitched over sciatic and transplant and the wounds closed. May 21, 1919, killed. Dog in good condition. Uses right foot well, though has slight limp in walking. On exposing right sciatic this is found embedded in loose connective tissue, interspersed with small fat globules. Large central bulbous enlargement noted, which extends in a fine nerve strand to the distal sciatic. In the region of the trans- plant diameter not quite half that of the sciatic. Calf and plantar muscles exposed. After freeing sciatic and the transplant from the bed, on slowly cutting the nerve with scissors, central to the transplant, distinct contraction of the calf and interossei muscles observed. On cutting the internal popliteal distal to the transplant the same observation noted. Sciatic transplant and the internal popliteal and several interossei muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—Long spindle-shaped central bulb evidenced structurally, from the distal end of which numerous neuraxes pass into the transplant and into the connective tissue surrounding it. In cross sections taken about 1.5 cm. distal to the central wound, it may be observed that the funicular structure of the transplant is still retained, surrounded by a distinct though not dense layer of fibrous tissue. Numerous new neuraxes are found within the surrounding connective tissue. In sections these new neuraxes may be traced to and through the distal wound into the distal popliteals. In the posterior tibial, both myelinated and nonmyelinated fibers may be traced to the level of the heel. In sections of several interossei muscles new neuraxes are to be observed in the muscular branches and here and there motor end organs are noted. Regeneration of distal popliteal to foot muscles, through the transplant. NEUROSURGERY 1149 Experiment No. 68.—Dog No. 2; medium size; full grown; 439 days. March 7, 1918, left sciatic exposed and cut high in thigh. March 26, 19 days later, severe neuro- trophic changes left foot; foot in part missing. Left sciatic exposed; large central bulb noted. Central and distal sciatic stump resected. A segment of the right ulna of 2 cm. length transplanted. One central and distal No. 000 catgut suture used. Distal external popliteal resected for another operation; transplant sutured distally only to internal popliteal branch. Wounds closed. June 12, left foot completely healed; dog in good condition. May 20, 1919, killed. Dog in good condition; very active. Left foot to metacarpals missing. On ex- posing left sciatic this is found surrounded by loose connective tissue. Large bulb on central sciatic stump; this continuous distally with a nerve bundle about the size of ulnar traced to distal internal popliteal; external popliteal attached loosely to internal popliteal; no organic union. Calf muscle fully exposed; these have the appearance of normal muscle tissue. After completely freeing the sciatic from its bed, on slowly cutting the nerve with scissors central to the transplant, distinct contraction of the calf muscles observed. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation attained. Microscopic findings.—Very large bulbous enlargement on central sciatic stump evidenced structurally, from the distal end of which numerous new neuraxes can be traced distally through a wide, central, fibrous wound, into the transplant and into the connective tissue surrounding the same. In cross sections of the transplant, about 1 cm. distal to the central wound, one large funiculus of the transplanted nerve segment clearly outlined by perineural sheath. Within this numerous myelinated and nonmyelinated nerve fibers, separated into small bundles by endoneural connective tissue, are observed. In the connective tissue sur- rounding the transplant numerous small bundles of nerves are found. These neuraxes can be traced through the distal wound into the distal internal popliteal, in which they are present in all of its funiculi, both as myelinated and nonmyelinated nerve fibers. Regenera- tion to lower level of popliteal space (the extent of nerve removed). Experiment No. 69.—Dog No. 1; medium size; full grown; 81 days. May 16, 1918, right sciatic exposed and freed. Left ulnar exposed. Two segments of the left ulnar of approximately 3 cm. length transplanted to the resected right sciatic. Each ulnar segment sutured centrally and distally, separately to resected sciatic ends. Waxed, fine, silk thread sutures used; good approximation of the nerve ends attained. Wounds closed. August 5, killed. Dog in good condition; slight foot-drop right hind leg; very little neurotrophic change right hind foot. On exposing the right sciatic, transplants found well in place; no distinct central bulb. Transplant surrounded by loose connective tissue, not adherent to underlying muscle. Calf muscles exposed. After freeing transplant from bed on slowly cutting nerve central to the transplant, no contraction of calf muscles observed. Sciatic removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation only partially successful. Microscopic findings.—In longitudinal sections through the central wound a central bulbous enlargement is clearly made out structurally, from the distal end of which numerous neuraxes traced into the transplant. In cross sections of the transplant the two ulnar seg- ments clearly made out, each retaining its funicular structure. The two nerves are found surrounded by a common fibrous tissue sheath. Within the transplants new neuraxes found about equally distributed. The down-growing neuraxes can be traced into the distal wound and through this into the distal sciatic in which they may be traced in lessening numbers, approximately 3 cm. distal to the distal wound. Experiment No. 70.—Dog No. 4; large dog; full grown; 152 days. March 8, 1918, left sciatic exposed and cut high in thigh. Wound closed. April 15, slight neurotrophic changes left heel; left sciatic again exposed, 38 days after section. Large neuroma on central sciatic stump; central end of distal sciatic only slightly enlarged. Central bulb removed and distal sciatic stump resected 5 mm. Two superficial radial branches, having parallel course, exposed and freed from connective tissue, brought together and clamped with artery forceps. Two No. 110 silk thread sutures formed 4 cm. apart and nerve cut with safety razor blade 2 mm. bevond sutures. The two nerve segments transferred to sciatic wound and sutured to resected sciatic ends; good approximation attained. Diameter of the two radial branches 1150 SURGERY not as great as the resected sciatic. Muscle stitched over nerve and transplant and wounds closed. April 23, superficial sciatic wound open to the extent 2.5 cm.; deeper wound seemed healed; no infection. August 7, killed. Dog very much emaciated; has not been feeding well for several days; left foot in part missing; nearly healed. Had had very severe neurotrophic changes of the foot. On exposing the left sciatic, contiguous muscles found to have yellow red color and much reduced in size. Large central sciatic bulb noted. A small nerve bundle extends from this to the distal sciatic stump. No material increase of fibrous tissue about the nerve. Calf muscles exposed; these appear very atrophic and not of normal color. After freeing nerve and slowly cutting the same central to the transplant no distinct contractions of calf muscles noted. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. In part good silver differentiation attained; not uniformly stained. Microscopic findings.—Large central bulbous enlargement evidenced structurally, from the distal end of which numerous neuraxes can be traced to the central ends of the trans- planted nerve segments and the connective tissue surrounding the same. In cross sections of the transplant, about 1.5 cm. distal to the central wound, both of the transplanted nerve segments clearly made out, with the funicular structure retained. The transplanted nerve segments surrounded by a common, fairly dense, fibrous sheath, which extends between the nerves. Within the funiculi of the transplant many new neuraxes observed; there appear to be more of these in one nerve than in the other, though this can not be definitely determined since the silver differentiation is not uniform. In the connective tissue surrounding the trans- plant many small bundles of nerve fibers encountered; this mainly to one side. New neuraxes in large numbers may be traced to and through the distal wound into the distal popliteal stump, for a distance of about 4 cm., the extent of the nerve removed for sections. Experiment No. 71.—Dog No. 15; large, black hound; full grown; 376 days. May 8, 191S, superficial radial exposed and freed from connective tissue cut to segments about 4 cm. length, placed side by side and clamped at each end with artery forceps. Thus suspended, two fine, silk sutures passed through the two nerve segments 2.2 cm. apart, cut beyond suture lines and transplanted to the resected left sciatic, in suturing only the internal popliteal bundle used, external popliteal disregarded. Fairly good approximation of nerve ends attained. Wounds closed. May 20, 1919, killed. Dog in very good condition; still favors the left hind foot; no distinct foot or toe drop noted. Shape and size of bulb in part due to large bulbous end on external popliteal. From the distal end of the bulb there may be traced a nerve bundle to the internal popliteal. Calf muscles and foot muscles exposed. After freeing sciatic and the transplant from the bed, on slowly cutting with scissors central to the transplant, good contraction of calf muscles noted; foot muscles contraction feeble and uncertain. External popliteal cut, but not included in the sutures, is distally found closely united to internal popliteal. Cutting of external popliteal near head of fibula calls forth good contraction of leg flexors. Sciatic and transplant and two interossei muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.-Ycvy large bulbous end on central sciatic evidenced structurally. In longitudinal sections of this bulb, the unabsorbed central suture observed. Down-growing neuraxes crisscrossing in every direction, reach the distal part of the bulb and can be traced to central ends of the transplants and the surrounding connective tissue. In cross sections of the transplant at two levels, near central and distal wounds, only one nerve bundle is ttnSanZ H 7^ *"" ^ " mr °f ^ and °<**™ ™™ bundle was ranspianted and not two as recorded, or whether one of the bundles pulled free centrally dense Zd ' " Yfit ™ ? determined" The "ingle nerve present is surrounded by a nonnvelinatn 7 T", T" Within itS iUnieuli numerous, both myelinated and conn etlr itZ Tl ' ^ """^ ln SmaU bundles seParated ^ endoneural Zallv nlaced crn + C°nneCtlVe tissue surrounding the transplant in centrally and w^ht and wthTt%t I0113' 77 ^^ bUndleS °f nerVe fibers found- Praxes found SpmeaMn whth in tranSplant ""* be traced th™gh the distal wound to the distal tc^net "of th"he.i^CCTGSS1Ve+leVelVhe^ «« observed in cross and longitudinal sections mall in w • i I SeCtl°nS °f lnterossei ^scles new neuraxes are observed in the small interfascicular nerve branches and in one instance in a neuromuscular spindle Com- NEUROSURGERY 1151 plete distal regeneration of the internal popliteal and branches, through the transplant, attained. Experiment No. 72.—Dog No. 14; relatively large dog; full grown; 91 days. May 2, 191S, left sciatic exposed and freed. Two branches of the cutaneous radial exposed and freed from connective tissue. Two segments of the larger nerve of 2.5 cm. length trans- planted to the resected internal popliteal branch of sciatic; one central and distal silk suture and one segment of the smaller nerve of 2.5 length transplanted to the resected external popliteal; one central and distal silk suture; good central and distal approximation attained in all three segments of cutaneous nerves used as transplants. Muscles stitched over nerve and transplant and wounds closed. May 14, severe neurotrophic changes left foot; possible infection of foot. Sciatic and forearm wounds healed. August 2, found dead in the morning; had not been eating well for several days; very much emaciated; still neurotrophic changes of foot. On exposing the left sciatic indistinct central bulb noted. Several bundles of nerves lead from this to the distal sciatic; can not determine definitely whether these nerve bundles are within the transplanted nerve segments. Distal sciatic does not present the appearance of normal nerve. Sciatic and internal popliteal removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation only partially successful. Microscopic findings.—In longitudinal sections of the central wound, scarcely any evi- dence of central bulb noted on microscopic inspection, under the microscope crisscrossing of central neuraxes as they pass to transplant is noted. In cross sections of the transplant, the three transplanted nerve segments quite clearly made out; found surrounded by a common fibrous tissue sheath. Within the three transplanted nerve segments the funicular arrange- ment quite clearly retained. In each of these funiculi are found new neuraxes, quite evenly distributed. Very few neuraxes found in the connective tissue outside of the funiculi. The new neuraxes may be traced into the distal stump in which they are found in good numbers 3 cm. beyond the distal wound, the extent of the nerve sectioned. Experiment No. 73.—Dog. No. 9; large; full grown; 323 days. June 29, 1918, right sciatic exposed and freed from bed. Two branches of the left cutaneous radial exposed and freed from connective tissue. Three segments of these nerves having a length of 2 cm. each sutured separately between the resected ends of the sciatic, using three No. 00 catgut sutures softened for a short time in sterile distilled water. Only fair approximation of the nerve ends attained. Dry field obtained by use of adrenalin. Wounds closed. May 18, 1919, killed. Dog in good condition; walks well; severe skin disease; nails on two inner toes long and curved so as to form complete circle. On exposing the right sciatic no material increase of connective ti.ssue about the nerve noted; quite large central bulb, with transplant well in place. Calf muscles exposed; sciatic and transplant freed the entire length. On slowly cutting with scissors the nerve central to the transplant, good contraction of calf and flexor leg muscles noted. Foot muscles exposed, on cutting posterior tibial near heel, good con- traction of the plantar interossei muscles observed. Sciatic, transplant, posterior tibial, pieces of calf and interossei muscles removed and fixed in ammoniated alcohol for pyridine- silver staining. Good silver differentiation attained. Microscopic findings.—In longitudinal sections of central wound region a large central bulb evidenced structurally from the distal end of which numerous neuraxes extend to the central end of the transplant. In cross section of the transplant at two levels, near central and distal wounds, only two of the transplanted nerves made out, both of these have retained their funicular structure. The fate of the third nerve segment can only be conjectured; it is thought that it pulled free centrally and completely degenerated. Within the funiculi of the two nerve segments present there are found numerous new neuraxes. In the more centrally placed cross sections numerous small nerve bundles are found in the connective tissue sur- rounding the transplant; scarcely any of the extra funicular nerve bundles are found in the cross sections of the lower level. New neuraxes were traced in the distal internal popliteal to the level of the heel and in sections of the interossei muscles into the smaller interfascicular muscular branches- motor and sensory muscle nerve endings were observed in sections of the interossei muscles. Complete peripheral regeneration attained, so far as distribution of peripheral motor branches is concerned. 4( III! i"—27------75 1152 SURGERY Expehiment Xo. 74.—Dog No. 12; large; full grown; 11 days. April 26, 191S, left sciatic exposed and freed. Two superficial cutaneous radial branches exposed and freed from connective tissue. Free venous oozing in the wound; after freeing nerves they were bathed in partlj- clotted blood for about fifteen minutes. Four segments were made of the cutaneous radial branches, placed side by side, and clamped together at the ends with artery forceps. A single silk thread suture passed centrally and distally through the four nerve segments 2.5 p,0^S™:z^^ ^-N..,, „ „_.s _„„ „P„. ssr.- SS.ZTS r...ut Tnd the sutures and the ■«*<«• tw, thus axed between the esc...ede„d/„.he".W..°h "T™ .""*~*™i *> «***> wound and XEUROSURGERY 1153 controlled. Closed. May 7, killed. Forearm wound open; superficial sciatic wound open to the extent of 3 cm.; deep wound healed. Left sciatic exposed; transplants found well in place; surrounded by newly forming connective tissue. A small amount of sanguineous exudate surrounds nerve and transplants. Sciatic and the transplants removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good differential silver staining attained. Microscopic findings.—In longitudinal sections of the central wound, taking in 1 cm. each of central end of transplant and distal end of proximal stump; early stages of the downgrowth of central neuraxes very beautifully shown; the ends of the down-growing central neuraxes have reached the fibrous wound, which the more advanced are in the act of penetrating. Many of the central neuraxes terminate in relatively large end-discs, others show division, others still early stages of spiral formation. As yet no new neuraxes can be traced to the central end of the transplant. In cross sections of the transplant the four Fig. 222.—Cross section through the middle of a cable-auto-nerve transplant, Experiment No. 75, 26 days after the oper- ation; pyridine-silver preparation. The funicular structure of the four segments of the nerve used is well maintained. Xewly formed epineural tissue has united the nerve segments so as to form a single nerve trunk segments of nerve transplanted can be clearly made out, with the funicular structure of each stained and perineural sheaths not thickened. The four nerves surrounded by a com- mon connective tissue layer, forming a new epineural sheath common to the four nerves. In both cross and longitudinal sections of the transplant the neuraxes of the transplanted nerves appear fragmented into irregular segments, still staining differentially in silver. Sheath nuclei only here and there noted; not well stained in silver. Distal sciatic in early stages of degeneration. Experiment No. 75.—Dog No. 10; large dog; full grown; 26 days. April 24, 1918, the left sciatic exposed and freed. Two cutaneous radial branches exposed and freed from connective tissue. These nerves cut into four segments of a little over 4 cm. length, placed side bv side in two groups and together clamped at the ends with artery forceps. Two fine silk thread sutures passed 2 cm. apart in each group of two nerves, and the nerves cut a little bevond the suture. These segments of the cutaneous radial, with sutures in place, were transferred to the sciatic wound, and each pair sutured separately to resected ends of 1154 SURGERY the sciatic. Good approximation of nerve ends attained. Muscle stitched over nerve ami transplant; wound closed. May 20, dog died during the afternoon; nerve removed about two hours after death; left hind foot, severe neurotrophic changes, slightly infected; sciatic wound well healed; forearm wound partly opened. On exposing the left sciatic no evidence of infection is noted; transplant found well in place and firmly united to resected ner.e ends. Quite distinct bulbous enlargement on central sciatic noted; central end of distal stump not materially enlarged. The four transplanted nerve segments surrounded by newly formed connective tissue so as to form one bundle. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good silver differentiation attained. Microscopic .findings.—In longitudinal sections through the central wound and about 1 cm. each of sciatic and transplants, the central bulbous enlargement is seen to include the central wound and central sutures. Numerous neuraxes coming from the central sciatic can be traced through the central wound, in which they are found to crisscross in all direc- Fig. 223.—Longitudinal section through the central wound region, cable-auto-nerve transplant, Experiment No. 75, 26 days after operation; pyridine-silver preparation. The central end is found directed toward the left. The actual wound region found between the central and distal loops of the respective sutures is clearly seen in the figure tions, into the central ends of the transplanted nerve segments. In cross section of the transplant, 1 cm. distal to the central wound, the four nerve segments transplanted can be clearly made out, each retaining its funicular structure, and are surrounded bv a common fibrous tissue sheath serving as an epineural sheath, the whole transplant presenting the appearance of a relatively large nerve trunk with 10 larger and smaller funiculi; in about equal distribution there are found large numbers of new neuraxes, many found to be within old neurolemma sheaths, others in the endoneural tissue between these sheaths. Very few neuraxes observed in the connective tissue surrounding the several transplanted nerve segments. In longitudinal sections of the distal wound and adjacent nerve trunk it mav be observed that certain of the down-growing neuraxes have reached the distal wound trans- plant only 2 cm. in length), having thus nearly reached the central end of the distal sciatic In this series of sections there was obtained very successful differential staining of neuraxes \ ery often when this is the case the cellular elements of the tissue are not clearlv stained- therefore this series of sections is not satisfactory for determining the behavior of the sheath cells of the transplanted nerve segments. 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"1 ______ *^ 1 m _____■ #r * i -idf ^U ImA IL^J ■_ m * h-.m___b -f-fc«. / Jw * ^i_H_ni»>_H___i ini i Fig. 224.—From a longitudinal section of the central wound region in cable-auto-nerve transplant, Experiment No. 75, 26 days after operation; pyridine-silver preparation. The figure illustrates clearly the course of the central neuraxes in passing through the scar tissue of the central wound. The funicular structure of the central stump is lost as the down-growing neuraxes pass through the wound 1156 SURGERY Experiment No. 7o.—Dog No. 11; large dog; full grown; 109 days. April 2">, 1918 left sciatic exposed and freed. The cutaneous radial branches exposed and freed from connective tissue. Quite a little venous oozing in the radial wound, so that the isolated cutaneous radial branches were bathed in partly clotted blood for 15 to 20 minutes. The cutaneous radial branches cut into segments of about -1 cm. lengths and placed side by side and together clamped at each end with an artery forceps. Two fine silk thread sutures passed 2.5 cm. apart, and nerves cut 2 mm. beyond the sutures. The sutures were then tied loosely and cut short, thus forming a compact nerve bundle of 2.5 cm. length, consisting of four segments of cutaneous radial. This bundle was transplanted to the resected left sciatic, and sutured centrally and distally by means of two fine silk thread epineural stitches. Fairly good approximation of cut nerve ends attained. Muscle stitched Fig -...-From a cross section of a cable-auto-nerve transplant, Experiment No. 75, 26 days after operation; pyridine- silver Preparation. The figure presents a portion of one of the larger funiculi of a transplanted nerve segment as seen in Figure 222 The black dots represent cross sections of a single neuraxis or small bundles of such which grew through the central wound and into the neurolemma sheaths of the transplanted nerves over nerve and transplant and wound closed. Forearm wound open a long time; not well protected; in part dry; bleeding not fully controlled. Wound closed. Both wounds healed well. August 12, killed. Slight foot- and toe-drop of left hind foot; walks quite well. On exposing the left sciatic no material increase of connective tissue about nerve and transplant is found. Quite distinct bulbous enlargement of the central sciatic is noted; slightly adhe- rent to underlying muscle. From distal end of the central bulb several small nerve bundles can be traced to the distal sciatic stump, which presents the appearance of a regenerated nerve of nearly normal size. On exposing the calf muscles, these appear of nearly normal size and color and manifest quite rhythmic twitching. After freeing sciatic and transplant rom bed on slowly cutting sciatic with scissors, central to the transplant, distinct contrac- tions of the calf muscles observed; the same on cutting distal to transplant. The sciatic NEUROSURGERY 1157 Fig. 226.—From a longitudinal section of the central third of a cable-auto-nerve transplant, Experiment No. 75, 26 days after operation. The figure presents a portion of one of the larger funiculi as seen in longitudinal section. Note the regular course of down-growing neuraxes, indicating that they are extending distally within the neurolemma sheaths of the transplanted nerves. (Compare with fig. 224) 115S SURGERY and transplant, internal and external popliteal and posterior tibial, portions of calf and leg flexor muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. In part very good differential silver staining attained. Microscopic findings.—In longitudinal sections of the central wound and adjacent nerve ends, central bulbous end is seen to include central wound and sutures and an area of small cell infiltration near one of the central sutures. Many new neuraxes can be traced from the central sciatic through the central wound into the central end of the transplant; others in the form of small nerve funiculi, having very tortuous course, are traced distally in the connective tissue outside of the transplant. In cross sections of the transplant, made about 1.5 cm. distal to the central wound, the four transplanted nerve segments with their respective funiculi can be clearly made out, and are found surrounded by a common fibrous tissue sheath, consisting of quite densely felted fibrous tissue. Numerous new neuraxes are found in each of the funiculi of the several transplanted nerve segments, also in the form of small nerve bundles in the connective tissue surrounding the nerve transplants. Neuraxes in large numbers can, in sections of successive levels, be traced through the transplanted nerve segments and distal wound into the distal sciatic stump. In cross sections of the inter- nal popliteal at the lower level of the popliteal space, numerous new neuraxes are found in all of the several funiculi. In alternate cross and longitudinal sections of the distal internal popliteal, posterior tibial, and internal plantar new neuraxes were observed, these becoming progressively less numerous distalward, so that in the internal plantar only a few scattered neuraxes were found in an otherwise degenerated nerve. In sections of the calf muscles, numerous new neuraxes are found in the larger and smaller intramuscular nerve branches and as single nerve fibers on and between muscle fibers; here and there motor nerve endings are to be seen. Regeneration of the distal sciatic through a cable autonerve transplant attained. Partial regeneration of the distal nerve to the level of the internal plantar. Experiment No. 77.—Dog No. 5; medium size; full grown; 152 days. March 8, 1918, left sciatic exposed and cut quite high in thigh; nerve ends retracted 8 mm. Wound closed. April 16, left sciatic exposed, 39 days after section. Dog in good condition; only slight limp noted. Large bulb found on the central sciatic stump, from which extends a fine nerve thread, which appears to reach the distal sciatic stump, which presents slight central enlargement; central and distal sciatic stumps resected; end 3 cm. apart. Two branches of the cutaneous radial exposed and freed of connective tissue, and cut in segments about 4.5 cm. long; placed side by side and clamped at each end with an artery forceps. Two No. 110 linen thread sutures passed through the four nerve segments 3 cm. apart. Nerves cut beyond suture lines and sutures tied loosely so as to form compact bundle. The same suture used to unite this nerve bundle to the ends of the resected sciatic; one extra epineural stitch central and distal; fairly good approximation of cut nerve ends attained. The four nerves together are only about two-thirds the diameter of the resected sciatic. Drv field; muscle stitched over nerve and transplant; wounds closed. Wounds healed well August 7 killed. Dog emaciated; skin diseases; toe-drop on left hind foot; small ulcer on dorsum of foot. On exposing the left sciatic, there is noted an increase of connective tissue about nerve and transplant, especially in region of central and distal wound. No distinct central bulb observed and central end of distal sciatic only slightly enlarged. The four trans- planted nerve segments surrounded by a common connective tissue sheath so as to form one nerve bundle about two-thirds as large as the distal sciatic. After exposing the calf muscles and freeing the sciatic and the transplant from its bed, on slowlv cutting the sciatic with scissors central to the transplant, indistinct, feeble twitching of calf muscles observed; this observed somewhat more clearly on cutting internal popliteal distal to the transplant. S£«r8H\^ °t f 7nt n°rmal COl°r; Pale red With narrow> W vellow streaks. sciatic and the transplant with internal and external popliteal and portions'of calf muscles T.rt- ^ ln/mmoniated al™ho1 f«r pyridine-silver staining. Good differential silver staining attained. nerv^nT/Z'^Tm111 ^r^^1 8ections °f the Central wo"nd and the adjacent ZZ % US enlar*ment is found to embrace the central wound and central suture . .\ umerous new neuraxes coming from the central stump can be traced through the central wound, in which they are seen to crisscross in all directions into the central ends of NEUROSURGERY 1159 the transplanted nerve segments. Many neuraxes are seen to pass distally in the connective tissue surrounding the transplanted nerve segments. In cross sections of the transplant, the four nerve segments transplanted are seen clearly demarked; each retaining its funicular structure. They are found surrounded by a common connective tissue sheath which serves as an epineural sheath. Numerous new neuraxes found in each of the funiculi of the four transplanted nerve segments. In the surrounding connective tissue, especially to one side, some 15 to 20 small nerve bundles are to be observed. New neuraxes can be traced in successive sections through the distal wound into the distal sciatic in which they are found in large numbers in all of the several funiculi. In sections of the calf muscles, new neuraxes are to be observed in the larger and smaller intramuscular nerve branches, and as single nerve fibers between and on the muscle fibers; a few motor nerve endings observed. Only partial regeneration of nerves in the calf muscles attained. Fig. 227.—Cross section of cable-auto-nerve transplant, Experiment No. 77, 152 days after operation; pyridine-silver preparation. The four nerve segments used as a nerve bridge in this operation are clearly made out nearly four months after the operation Experiment No. 78.—Dog No. 9; large dog; full grown; 389 days. April 24, 1918, left sciatic exposed and resected; quite free bleeding from the central stump; small artery ligatured. Two branches of the right superficial radial exposed and freed from connective tissue; cut into segments about 4 cm. long, placed side by side, and clamped at each end with an artery forceps. Two fine silk thread sutures passed through the four nerve segments 2 cm. apart and nerve cut beyond sutures. The sutures tied loosely, so as to form one compact bundle. This bundle transferred to sciatic wound and with one continuous suture each of the four nerve segments was sutured separately, centrally and distallv to the resected nerve ends; fine vessel silk was used for this suture. Muscle stitched over nerve and transplant; wounds closed. May 18, 1919, killed. Dog not in good condi- tion, severe skin disease, active; walks well. Nails on two of the toes very long and curved. On exposing the left sciatic quite a large bulb found on the central sciatic; no distinct enlarge- ment of central end of distal sciatic; transplant found well in place. Distal sciatic presents the appearance of a normal nerve. Calf muscles exposed; these have the appearance of normal muscle. After freeing sciatic from the bed, on slowly cutting nerve with scissors, central to transplant, calf muscles found to contract well, even though this functional test was made nearly forty minutes after the dog was killed. Contraction of the foot muscles not so clearlv made out; they had not been exposed. Sciatic and transplant, distal popliteal and portions of interossei muscles removed, fixed in ammoniated alcohol for pyridine-silver staining. Cood silver differentiation attained. 1160 SURGERY Microscopic findings.—In longitudinal sections of the central wound and adjacent nerve ends, the central bulbous enlargement is found to include the central nerve wound and central sutures. Numerous neuraxes can be traced from the central sciatic through the central wound, in which they crisscross in all directions into the central end of the transplant. In cross sections of the transplant, though more than one year after operation, the four transplanted nerve segments can be clearly demarked, each with distinctive funicular structure. These four nerves are surrounded by a common fibrous tissue sheath which serves as an epineural sheath. Numerous neuraxes, many of which are myelinated, pass through the transplant to the distal sciatic; these are found about equally distributed through the several funiculi of the four transplanted nerve segments. Only very few neuraxes, in the form of several small nerve bundles, are found in the surrounding connective tissue. In longitudinal sections of the distal wound and adjacent nerve ends, there is also observed a crisscrossing of neuraxes; the neuraxes having here a very irregular course. In sections of the popliteal branches of the sciatic, to the level of the posterior tibial at the heel, new neuraxes in large numbers are to be observed. Unfortunately the pieces of interossei muscles removed at post mortem were lost in process of staining and can not be reported upon. In so far as miscroscopic evidence of nerves is concerned, nearly complete regeneration of distal branches of the sciatic was obtained. Experiment No. 79.—Dog No. 13; large dog; full grown; 385 days. April 30, 1918, left sciatic exposed; resected. Two cutaneous radial branches exposed and freed from con- nective tissue. Each branch cut centrally and distally and pinned out, side by side, on piece of smooth wood, which had been sterilized with the instruments. With the nerves thus pinned out, sutures were passed so as to form two bundles of nerves, each with two nerve segments with sutures at each end; nerve bundles of 2.5 cm. length. Each of the two bundles, each composed of two nerve segments, was sutured separately between the resected nerve ends. One bundle was cut longer than the other, so that when they were sutured in place, one of the bundles presented a wavy course. Fairly good central and distal approximation of the nerve ends attained. Muscles stitched over nerve and the transplant; wounds closed. May 20, 1919, killed. Dog in very good condition; well fed and active; still seems to favor left hind leg a little; small ulcer on dorsum of the foot; two nails on this foot of large and irregular form. On exposing the left sciatic a distinct bulbous enlargement on central sciatic is found, from the distal end of which several nerve bundles are seen to pass to the distal sciatic stump. Distal sciatic and the popliteal branches present the appearance of normal nerves. Calf and leg flexor muscles fully exposed; after freeing sciatic and transplant from bed, on slowly cutting sciatic central to the transplant, vigorous contractions of the calf and leg flexor muscles observed. Cutting of the posterior tibial at heel does not call forth distinct contraction of the interossei muscles. Sciatic and the trans- plant, internal and external popliteal branches, portions of calf and interossei muscles re- moved and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—In longitudinal sections of the central wound and the adjacent nerve ends, it is quite clearly to be made out that good approximation of the severed ends was not obtained at the time of operation. Down-growing neuraxes coming from the central stump, on reaching the central wound, present a felt-work arrangement, crisscrossing in all directions; many can be traced into the connective tissue surrounding the transplants. In cross sections of the transplant, about 1 cm. distal to the central wound, the field is made up of large numbers of small nerve funiculi separated by fibrous tissue and three quite distinct funiculi, surrounded by perineural sheath. The latter appear to be the only funiculi sur- viving out of about ten as found in other experiments in which four segments of the cutaneous radial nerves were transplanted. Numerous neuraxes may be traced through the distal wound into the distal sciatic, in which they are found in sections taken at successive levels to the posterior tibial at the level of the heel. In both cross and longitudinal sections, made of pieces taken from the interossei muscles, new neuraxes may be observed in the intramus- cular nerve branches, and nerve endings in at least one neuromuscular spindle. No fully formed motor endings were observed; however, this may be due to imperfect silver differentia- tion. Regeneration of the distal popliteal to the level of the interossei muscles attained. NEUROSURGERY 1161 Experiment No. 80.—Rabbit No. 2a; large; full grown; 21 days. March 18, 1918, left and right sciatic exposed. A segment of the right sciatic having a length of 1.5 cm. trans- planted to the resected left sciatic. One through-and-through Chinese silk suture placed centrally and distally; wounds closed. April 8, rabbit found dead in the morning. Wounds well healed. On exposing the left sciatic transplant is found well in place. Distinct bulb on distal end of central sciatic stump noted. Sciatic and the transplant removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.—In longitudinal sections taken from the transplanted nerve segment, numerous small round cells, found mostly in the looser connective tissue outside of the peri- neural sheath, observed. In the transplanted nerve fibers, the myelin is found in the form of irregular globules, separated by a granular detritus. Neuraxis remains not clearly made out. No distinct proliferation of sheath cells can be observed in such broken-down fibers. The picture is not that of a Wallerian degeneration. Strands of what appear to be syncytial protoplasmic bands, with short, rod-shaped nuclei, are noted. These bands resemble those found in a peripheral nerve trunk after section. Small bundles of such protoplasmic bands are separated by areas having neurolemma sheaths in which myelin remains are found. In all of the experiments of auto-nerve transplants, kept for a time suffi- ciently long to admit of nerve regeneration, the results obtained were very satisfactory. In five of these experiments (No. 64 to No. 68), only one small nerve was used to bridge a defect in a resected sciatic, in three (No. 69 to No. 71), two segments of ulnar or superficial radial nerves were used to bridge such a defect, and in two experiments (No. 72 and No. 73) three pieces taken from the cutaneous radial were sutured between the resected ends. In all of the several experiments there was noted a nerve bulb on the distal end of the central sciatic stump, in general the more prominent the less adequately the nerve defect was bridged. On the whole there appeared to be little difference in the results attained in a primary operation in which the nerve transplant was sutured in place at the time of resection of the sciatic or in a secondary opera- tion (No. 66 and No. 88) in which the sciatic was resected, the wound closed to be reopened some weeks later, and a nerve transplant made. A study of the protocols of the respective experiment will show that the central neuraxes were found to grow through the transplant, and to a variable extent in the connective tissue surrounding the nerve transplanted, to reach the distal seg- ment of the resected nerve. It is not the purpose to discuss at this time the relative merits of the auto-nerve transplants. This will be undertaken after considering the observations considered in Series No. 6 and No. 7. A some- what further consideration may here be given to the six experiments (No. 74 to No. 79) in which four segments of the radial cutaneous nerves were used to bridge a defect in sciatic nerves the result of resection. This operation we have designated a "cable-auto-nerve transplant" or a multiple nerve trans- plant. The radial cutaneous branches of the dog are relatively small nerves consisting of three or four major funiculi and presenting the form of a flattened oval in cross section. Four segments of these nerves arranged in parallel bundles were sutured singly or in pairs or as one bundle between the resected ends of the sciatic, by both central and distal sutures. In the dog killed 11 days after the operation (No. 74), before regeneration could have taken place, attention is called to the fact that on exposing the nerve, the four nerve seg- ments transplanted were found united in one compact bundle, having the appearance of a single nerve trunk, by newly formed connective tissue. This 1162 SURGERY newly formed connective tissue forming an epineural sheath surrounding and enclosing the four segments of nerve transplanted, giving in cross section the appearance of a nerve trunk with many funiculi. A little study of the cross section reveals the fact that each of the four nerve segments has in reality maintained its own identity, each showing its respective funiculi surrounded by perineural sheaths. In this experiment there is distinct evidence of an active downgrowth of central neuraxes, which have reached tlie central wound region but have not as yet penetrated the transplants. In the experiment (Xo. 75), which terminated 26 days after the operation, the transplanted nerve segments were found united in one compact bundle by a newly formed epineural sheath. However, in each nerve segment there can easily be determined the several funiculi, each surrounded by a distinct perineural sheath. The transplanted nerve segments were found firmly united to the central and distal stumps of the resected nerve. The nerve segment removed for study included the distal end of the central stump to the extent of about 2 cm., the transplant, and some 3 cm. of the distal sciatic. This segment was divided into pieces so as to admit of longitudinal sections of the central and distal wound regions and contiguous transplant and sciatic segments and cross sections of the middle of the trans- plant. Nearly complete serial sections of the several pieces were made after the tissue had been stained by the pyridine-silver method. In the series of longitudinal sections of the central wound region, central neuraxes may be traced in large numbers through the central wound and into the central part of tlie nerve transplant. The picture presented is very much that of a section through the wound region after primary suture, except that in the cable auto- transplant the approximation of nerve ends is not so good; there is much more crisscrossing of the down-growing neuraxes. The cross-section series is very instructive. In the sections, taken from about the middle of the transplant, new neuraxes are found in all of the funiculi of the several transplanted nerve segments and in approximately equal distribution. Many of the neurolemma sheaths of the transplanted nerve fibers contain more than one neuraxis, others only one, and again others none. Very few neuraxes are found in the connective tissue outside of the funiculi. In the longitudinal sections, including the distal wound, it may be noted that the down-growing neuraxes in lessening number have penetrated the transplant to the region of the distal wound. The distal sciatic presents the picture of a degenerated nerve, the majority of the neuro- lemma sheaths containing syncytial strands. In the remaining four of the cable auto-nerve transplants (No 76 to Xo «9) ranging m length of observation from nearly 4 months to a little over 1- months, even m those of long duration, could there be made out readily the four segments of nerve transplanted each with its several funiculi showing conclusively that the severed nerve segments formed definite paths along wliich the down-growing central neuraxes proceeded to reach the distal seg- ment In each of these four experiments was there a return of motor function as tested on the exposed muscles. This is corroborated by the presence of new motor endings m the calf muscles of certain experiments and even in the foot muscles of other experiments. The morphologic evidence of regeneration through several nerve segments as used in the operation of auto-nerve trans- NEUROSURGERY 1163 plants, it seems, is conclusive. It is here shown that it is possible to use several segments of a relatively small cutaneous nerve to bridge a defect in a major nerve, such as the sciatic, thus making available in human surgery the operation of auto-nerve transplant. SERIES NO. 6 HOMO-NERVE TRANSPLANTS Under Series No. 6 are presented observations on six experiments, all but one on the sciatic nerve of the rabbit, in which the sciatic was resected in one animal and a segment of requisite length removed from the sciatic of another animal used as a nerve bridge. The operation of homo-nerve transplant in human surgery has limited opportunity for application since it is to a large extent chance that would make available normal, fresh human nerve tissue to be used for purpose of transplant. As a secondary operation, where the opera- tion of nerve repair may be timed, nerves from amputations may be made use of. We present an extended series of observations on the use of stored homo-nerve transplant which will be considered under a separate heading; in this series only operations in which fresh homo-nerve transplants were used are included. PROTOCOLS Experiment No. 81.—Rabbit No. 11a; full-grown rabbit; 8 days. March 14, 1918, right sciatic exposed and resected to the extent of 1 cm. A segment taken from the right sciatic of another rabbit, of 1.2 cm. length, used as a transplant. One central and distal Chinese silk suture placed. Fairly good approximation of nerve ends attained. Wounds closed. March 22, rabbit found dead in the morning. Sciatic wound healed. On exposing the sciatic, transplant found in place and united to the resected nerve ends. Sutures still show clearly. No distinct central bulb observed. Sciatic and transplant removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.—In series of longitudinal sections of the transplant, the myelin of the transplanted nerve fibers seen to be fragmented in many of the fibers. The neurokeratin net is clearly made out even in the fragments of myelin. Neurolemma sheaths very distinct. Sheath cells evident but do not manifest proliferation. Experimemt No. 82.—Rabbit No. la; large rabbit; full grown; 8 days. March 18, 1918, the right sciatic exposed and resected 1.3 cm. The right sciatic of another rabbit exposed and a segment of 1.5 cm. length transplanted. One central and distal Chinese silk suture placed. Good approximation attained; a little clotted blood between nerve ends in distal wound. Wound closed. March 26, rabbit found dead in the morning. On exposing the right sciatic it is found that the central suture had given away a little; distal suture good. Sciatic and the transplant removed and fixed in neutral formalin for Biel- schowsky silver staining. Microscopic findings.—In a series of longitudinal sections of the transplant it is found that the epineural sheath has been invaded by numerous small round cells. In the trans- planted nerve fibers the neuraxes are found to be fragmented; these fragments, differentially stained are either bent upon themselves, are coiled, or have a wavy course. The myelin is not clearly defined; appears granular. The neurolemma sheaths intact and appear thickened. Sheath nuclei not differentiated. Experiment No. 83.—Dog No. .'.(.a; medium size; full grown; 17 days. June 4, 191X, right sciatic exposed and internal popliteal freed, and resected. A segment of 3 cm. length taken from the right internal popliteal of another dog, under the anesthetic at the same time, used as a transplant. One central and distal fine silk thread suture placed; very good approxi- mation. The uncut external popliteal funiculus lies at the side of the operated internal pop- 1J54 SURGERY liteal Clean field; wound closed. June 21, dog found dead in the morning; very slight neurotrophic changes right hind foot. Wound well healed. On exposing the right sciatic the transplant is found well in place; appears as if slightly swollen; united to the resected nerve ends, though distally the wound had separated a little. No distinct central bulb noted. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good silver differentiation for the central segment attained. " Microscopic findings.—In longitudinal sections of the central wound and the adjacent nerve ends, central wound is clearly demarked by the presence of the central suture; good fibrous union. Only indistinct central bulb evidenced structurally. Numerous down- growing neuraxes of the central stump, end, often after branching, in large end-discs at the point of the fibrous union. Others have penetrated the fibrous tissue of this region and are found in the central end of the transplant in which they may be traced distally, becoming gradually less numerous, for a distance of nearly 1.5 cm. Now and again more than one neuraxis may be observed in old neurolemma sheath of the transplant. In cross section of the transplant about 1 cm. distal to the central wound relatively few neuraxes are to be found, scattered fairly evenly through the several funiculi of the transplanted nerve. In the distal popliteal stump early nerve degeneration stages observed. No new neuraxes traced to the distal nerve. Experiment No. 84.—Rabbit No 62; full grown; 23 days. March 21, 1918, right sciatic exposed and resected 1.2 cm. Right sciatic of another rabbit exposed, while nerve was being exposed rabbit died under anesthetic; operation completed and nerve used in trans- plant. One central and one distal Chinese silk suture placed; fair approximation. Wound closed. April 13, killed. Caudal half of rabbit paralyzed; cause not determined. Sciatic wound well healed. On exposing nerve, transplant was found well in place; slightly adherent to muscle bed. Central and distal sutures clearly made out; no distinct central bulb. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good silver differentiation attained. Microscopic findings.—-In longitudinal sections through the central wound region and adjacent nerve ends, numerous down-growing neuraxes, crisscrossing through the fibrous wound, can be traced into the central end of the transplant. In cross sections of the trans- plant, about its middle, the funicular arrangement of the transplanted nerve segment is found well retained. The fibrous sheaths of the funiculi found thickened, within them and between the funiculi are found numerous small round cells. Within the funiculi numerous down- growing neuraxes are to be seen. In many instances four to six or eight new neuraxes found in one old neurolemma sheath. Certain of these down-growing neuraxes have reached the distal wound and can be traced to the distal sciatic in which they extend for a distance of about 1 cm. Experiment No. 85.—Rabbit No. 8a; full grown; 68 days. March 16, 1918, right sciatic exposed and resected a little over 1 cm. A segment of equal length taken from the right sciatic of another rabbit used as transplant. One central and distal Chinese silk suture placed; good approximation. Wound closed. May 23, killed. Severe neurotrophic changes right foot; rabbit in good condition. On exposing the right sciatic, transplant is found well in place; sutures clearly seen. Small spindle-shaped central bulb. After exposing the calf muscles and freeing nerve from bed, no contraction of muscles observed on cutting nerve central to the transplant. Calf muscles appear atrophic and of yellow-red color. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound and the adjacent nerve ends, it may be observed that numerous neuraxes pass from the central stump through the central wound to the central end of the transplant. In cross sections of the transplant it is to be observed that its fibrous sheaths are materially thickened and that its funicular structure is not fully maintained. Numerous new neuraxes are observed both within the funiculi of the transplant and especially to one side in the surrounding connective tissue. In sections taken at successive levels, the down-growing neuraxes may be traced into and through the distal wound into the distal sciatic in which they are found in good number 2 cm. beyond the distal found; the extent of the sections. NEUROSURGERY 1165 Experiment No. 86.—Rabbit No. 27a; full grown; 83 days. March 15, 191S, right sciatic exposed and resected about 1 cm. A segment of equal length taken from the right sciatic of another rabbit and used as transplant. One central and distal Chinese silk suture placed. The muscle stitched over the nerve and transplant and the wound closed. June 6, killed. Wound well healed; rabbit in good condition. On exposing the right sciatic trans- plant was found well in place, with nerve sutures still evident. Small central bulb observed. Transplant of smaller diameter than resected nerve and slightly adherent to the underlying muscle. After freeing nerve from bed and exposing the calf muscles, on slowly cutting cen- tral sciatic no contraction of calf muscles noted. Sciatic and the transplant and the internal popliteal removed and fixed in ammoniated alcohol for pyridine silver staining. Fairly good silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound, the central suture appears in the sections, clearly indicating the region of the central wound. Numerous down- growing neuraxes coming from the central stump penetrate the central end of the transplant. In cross sections of the transplant the funicular structure is clearly demarked. In the funiculi numerous new neuraxes, evenly distributed, are to be observed. Several groups of small nerve bundles are found in the connective tissue surrounding the transplant. In successive series of sections these neuraxes can be traced into the distal sciatic stump in which they are present in large numbers to the extent of the sections, 2 cm. beyond the distal wound. The experiments in which fresh homo-nerve transplants were used, though relatively few in number and of relatively short duration, nevertheless show conclusively the feasibility of using fresh homo-nerve transplants to bridge a nerve defect. In the last three of the experiments listed (No. S4 to No. 86), ranging in duration from a little over one month to nearly three months, the down-growing central neuraxes were traceable through the transplant and a variable distance into the distal sciatic stump. As seen best in cross sections of the transplant, the down-growing neuraxes are found within the neurolemma sheath of the transplanted fibers, in the endoneural tissue between the nerve fibers and in the connective tissue surrounding the perineural sheaths of the funiculi of the transplant. In Experiment NT 83, in which the sciatic of a dog was operated upon and the experiment terminated at the end of approxi- mately three weeks, the series of longitudinal sections of the central wound region presents a typical picture of regeneration from the central nerve stump with many branching central neuraxes and many down-growing neuraxes terminating at various levels in end-discs. These down-growing neuraxes are traceable through the wound region and into the central end of the transplant. Xo neuraxes are found in the distal wound region; the distal sciatic present- ing a typical picture of a degenerated peripheral nerve of about three weeks standing. SERIES NO. 7 HETERO-NERVE TRANSPLANTS There can be no question that should hetero-nerve transplants prove to be a feasible operation it would become the operation of choice in cases in which a nerve bridge was found necessar}z Therefore, it seemed to us worth while to reinvestigate the merits of a hetero-nerve transplant. In the majority of the experiments of this series (No. S7 to No. 125) one or two sciatic nerves, taken from the guinea pig, were used to bridge defects in the sciatic of rabbits, the result of resection. In a few experiments a nerve taken from a dog was used 1166 SURG EI.Y to bridge a resected sciatic of a rabbit. The operated animals were killed at stated intervals, ranging in the several experiments from three days to nearlv a year. Only fresh nerves were used for purposes of transplants. While one animal was under an anesthetic having one of the sciatic nerves exposed, re- sected, and sutures placed, a guinea pig (or dog) was placed under anesthesia, the region of the operation shaved and made aseptic, so that at the proper time the desired nerve could be exposed, a segment of requisite length taken and transferred to the host and sutured in place. In a number of instances two sciatics of a guinea pig were used to bring the diameter of the transplant to approximate that of the nerve to be bridged. Especial care was taken to suture the transplant to the resected nerve ends with as good end-to-end approximation as was possible so as to make the conditions favorable for regeneration. PROTOCOLS. Experiment No. 87.—Rabbit No. 73; old; large rabbit; 3 days. April 22, 1918, left sciatic exposed; resected about 1 cm. The two sciatics of a half-grown guinea pig exposed, cxsected and placed side by side and clamped at ends with artery forceps. Two fine silk threads passed a little over 1 cm. apart through both nerves, and nerves cut beyond sutures. The two nerves together used as a transplant and sutured to the resected ends of the sciatic. Wound closed. April 25, killed. Superficial wound found healed; deep wound easily separated. On exposing the sciatic it was observed that one of the nerves used as a trans- plant had separated from the central stump; the other from the distal stump; the respective ends lying free in the wound. The sciatic and the transplanted nerves removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation of central sciatic stump attained. Microscopic findings.—In sections it is evident that the ends of the transplanted nerve segment were not well sutured to the resected ends. In longitudinal sections of the distal end of the central sciatic stump, many of the central neuraxes present distinctly swollen ends, many of irregular shape; no distinct fibrillar differentiation is made out. No clear evidence of the downgrowth of central neuraxes is observed. Transplanted nerve segments and the distal sciatic not clearly differentiated in this series. Experiment No. SS.—Rabbit No. 73a; old; large rabbit; 3 days. April 22, 1918, right sciatic exposed and resected about 1 cm. Both of the sciatics of a half-grown guinea pig exsected and together used as transplant. One central and distal silk thread suture used. Wound closed. April 25, killed. Superficial wound found healed; deep wound easily sep- arated. On exposing nerve, transplanted nerve segments found well in place. Sciatic and transplants removed and fixed in Flemming's chromo-osmic-acetic mixture. Sections stained in safranine and licht griin. Microscopic findings.—In longitudinal sections of the central and distal wound regions, it is evident that there was good end-to-end approximation of the ends of the transplanted nerve segments and the resected sciatic. Central and distal wound region consists of a loose fibrocellular tissue. In cross section of the transplanted nerve segments, the funicular structure of the respective nerves well maintained. The two nerves found surrounded bv a common layer of exudate with beginning fibrous tissue formation. Evidence of inwandering of leucocytes; these found between the nerve fibers. Very little fragmentation of the mvelin of the transplanted nerve fibers observed; their sheath cells only indistinctlv stained: In the distal sciatic beginning fragmentation of the myelin and the beginning of proliferation of the sheath cells noted; here and there a mitotic figure in these Experiment No. 89.-Rabbit No. 74; full grown; 5 davs. April 22, 1918, the left sciatic exposed and resected 1.3 cm. The two sciatics of a half-grown guinea pig together used as a transplant. One central and distal silk suture placed. Wound closed. April 27, killed, superficial wound healed; deeper wound not fullv united. On exposing nerve transplants found well in place, though only one of the nerves is clearlv made out- not adher- NEUROSURGERY 1167 ent to the underlying muscle. Nerve and transplant surrounded by sanguineous exudate. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation in the central stump attained. Microscopic findings.—In longitudinal sections of the central wound region, beginning stages of the down growth of central neuraxes noted. Certain of these have reached the central wound region. Not good alignment of central end of the transplants and distal end of sciatic found. Silver staining not satisfactory for detail study of transplant. Distal sciatic beginning degeneration of peripheral fibers made out. Experiment No. 90.—Rabbit No. 74a; full grown; 3 days. April 22, 191S, the right sciatic exposed and resected 1.5 cm. The two sciatics of a half-grown guinea pig used as a transplant. One central and distal silk suture placed. On suturing distally one nerve was twisted over other; half spiral turn. Wound closed. April 25, killed. Superficial wound healed; deep wound not completely healed. On exposing sciatic it is found that the external popliteal bundle was not cut, the transplant found sutured to internal popliteal; transplants well in place, easily demarked by presence of sutures. Internal popliteal and the transplant removed and fixed in Flemming's chromo-osmic-acetic mixture. Sections stained in safranine and licht grim. Microscopic findings.—In longitudinal sections of central and distal wound regions, it may be observed that the ends of the transplanted nerves are bent over hook-shaped; thus not found in alignment with the resected nerve ends. In longitudinal sections of the distal end of the central stump, for a distance of about 8 mm., fragmentation of myelin of central fibers and proliferation of the sheath cells noted. In cross sections of the transplant, the funicular structure of the two nerves is well maintained, with exudate and newly forming fibrous tissue inclosing the two nerves. The perineural sheaths of the funiculi not thickened. Beginning of inwandering of cells through the perineural sheaths observed. Only in a few of the larger funiculi, and in these in the more peripherally placed fibers, is fragmentation of the myelin noted. The great majority of the nerve fibers of the transplanted nerves show as yet no distinct fragmentation of the myelin and no proliferation of sheath cells. In the distal sciatic the peripheral nerve fibers show fragmentation of.myelin and pro- liferation of sheath cells. Experiment No. 91.—Rabbit No. 69; large; full grown; 9 days. April 18, 1918, left sciatic exposed and resected 1.2 cm. The two sciatics of a half-grown guinea pig together used as a transplant. One central and one distal suture placed; good approximation. Wound closed. April 27, killed. Superficial wound healed; deep wound healing. On exposing the left sciatic transplant found well in place, surrounded by exudate and newly forming connective tissue, which unites the two nerves in one bundle. The transplant appears congested, giving it a pink-red color. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—In a series of longitudinal sections of the central wound region, numerous neuraxes growing from the neuraxes of the central sciatic can be traced to the central wound region, which they have invaded. Certain of the neuraxes are seen to branch others to terminate in end-discs; the beginning of spiral formation seems evident. Fine naked neuraxes found in the fibrocellular central wound. In the transplant, especially near the central wound, the neuraxes of the transplanted nerve, found in the form of long segments, having a regular course. Further distalward shorter neuraxis segments are found. Distal sciatic presents early stages of degeneration. Experiment No. 92.—Rabbit No. 69a; large; full grown; 9 days. April IS, 191S, right sciatic exposed and resected 1.2 cm. The two sciatics of a half-grown guinea pig together used as a transplant. One central and distal silk suture placed; good approxima- tion. Wound closed. April 27, killed. Superficial wound healed; deeper wound healing. On exposing the right sciatic the transplants found well in place and surrounded by newly forming connective tissue. Sciatic and the transplant removed and fixed in Flemming's chromo-osmic-acetic mixture. Sections stained in safranine and licht grun. Microscopic findings.—Transplant found well united to the resected nerve ends. In cross sections of the transplant, through its middle region, the two nerves transplanted clearly made out, each showing typical funicular structure. The two nerves united by a 4li0!)7—27----76 SURGK1.Y 11 OS thick common fibrous tissue sheath, in which are seen numerous small round cells; these a so m^ numbers between the two nerves. Wandering cells have invaded certain of the nerve funiculi. In certain of the funiculi the nerve fibers more peripherally placed how ragmentation of the myelin, not distinctly evident in the more centra ly p aced fibers. Not all of the funiculi react in the same way. Certain of the sheath nuclei of the trans- planted nerve fibers are found to stain deeply; others more faintly. No prohferation of the*, cells is noted. In the distal end of the central sciatic stump and in the distal scat.c there is observed a distinct increase in the number of the sheath cell nuclei; here and there mitotic division is noted. Fragmentation of the myelin, which varies in degree in different nerve fibers, is observed in the distal sciatic. 1Q1fiw+ Experiment No. 93.—Rabbit No. 67; large; full grown; 9 days. April 18, 1918, left sciatic exposed and resected 1.4 cm. The two sciatics of a nearly grown guinea pig used as transplants. One central and distal suture placed; centrally good approximation, distally "fair" Wound closed. April 27, killed. Wound healed. On exposing the left sciatic, transplants found well in place; surrounded by newly formed connective tissue and adherent to the underlying muscle. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. For central portion of nerve good silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region down- growing neuraxes in relatively small number are found to have reached the central wound region; branching of these neuraxes is observed. In longitudinal sections of the transplanted nerves', the neuraxes of the nerve fibers are found fragmented into longer or shorter segments, staining differentially in the silver. A distinct layer of fibrous tissue surrounds the transplant; this tissue incloses many small cells. Distal sciatic shows early stages of nerve degeneration. Experiment No. 94.—Rabbit No. 67a; large; full grown; 9 days. April 18, 1918, right sciatic exposed and resected 1.5 cm. The two sciatics of a nearly grown guinea pig used as transplant. One central and distal silk suture placed. Clean, dry wound. Wound closed. April 27, killed. Wound healed. On exposing the right sciatic, transplant found well in place; surrounded by exudate and newly formed fibrous tissue, not adherent to under- lying muscle. A dead space nearly surrounds transplant; in this a small amount of sanguin- eous exudate. Sciatic and transplant removed and fixed in Flemming's chrom-osmic-acetic mixture. Sections stained in safranine and licht grim. Microscopic findings.—In longitudinal sections of the central and distal wound regions, the ends of the transplants are found united to the resected nerve ends by means of fibro- cellular tissue. The wound regions surrounded by numerous small cells; these have pene- trated the distal end of the central sciatic stump for a distance of about 2 mm. In cross sections of the transplant the two nerves clearly demarked, with funicular structure well maintained. These nerves as seen in cross sections present an appearance which resembles closely that of normal nerves. At the periphery of the funiculi, beginning breaking down of the myelin is noted. Inwandered cells are found here and there between the nerve fibers; not to equal extent in all of the funiculi. The distal sciatic presents early stages of nerve degeneration, with great increase in the number of the sheath cells, and fragmentation of the myelin. Experiment No. 95.—Rabbit No. 71; large; full grown: 15 days. April 19, 1918, left sciatic exposed and resected 1.4 cm. The two sciatics of a nearly grown guinea pig used as transplants. One central and distal No. 110 linen thread suture placed; only "fair" central and distal approximation of the nerve ends attained. Wound closed. May 4, killed. Rabbit not well; emaciated; wound well healed. On exposing the left sciatic, transplant found well in place; seems of smaller diameter than when used; not adherent to muscle. Distinct central sciatic bulb noted. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. For central portion of nerve fair silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region a distinct central bulb evidenced structurally, from the distal end of which a few down-growing ceniral neuraxes have reached and penetrated the central wound region; numerous bulbous end-di><- on such neuraxes noted. Within the transplant the old neuraxes found in short segment- still showing the differential silver staining. The distal sciatic presents early stages of defen- eration. NEUROSURGERY 1169 Experiment No. 96.—Rabbit No. 71a; large; full grown; 15 days. April 19, 1918, right sciatic exposed and resected 1.2 cm. The two sciatics of a half-grown guinea pig used as transplants. One central and distal No. 110 linen thread suture placed; good central approxi- mation, "fair" distal. Wound closed. May 4, killed. Rabbit not well; emaciated; wound was healed. On exposing the right sciatic transplant is found well in place and of dull white color. The two nerves are held together by scant connective tissue. Well developed central bulb noted. Sciatic and transplant removed and fixed in Flemming's chrom-osmic-acetic mixture. Sections stained in safranine and licht grim. Microscopic findings.—Transplant found well united to resected nerve ends; fibrous union In cross sections of the transplant, the two nerves transplanted are clearly demarked with funicular structure well retained. The two nerves found surrounded by common connective tissue sheath infiltrated with small round cells; found in large numbers between the two nerves. Here and there cells which have penetrated the perineural sheaths are found between the nerve fibers. It may be observed that the peripheral fibers of the funiculi have their myelin and neuraxes more fragmented than those more centrally placed. Wandering cells found within certain of the neurolemma sheaths. In the distal sciatic the nerve fibers found in early stages of degeneration. Experiment No. 97.—Rabbit No. 88; large; full grown; 42 days. August 20, 1918, the left sciatic exposed; internal popliteal bundle freed; resected 2.8 cm. A segment of equal length taken from the left sciatic of a full-grown guinea pig used as transplant. One central and distal suture of waxed fine silk thread used; good approximation. Wound closed. October 1, rabbit found dead in the morning; neurotrophic ulcer left heel. On exposing the left sciatic, it was found that the transplant remained united to the central sciatic stump, the suture showing, but had pulled free from the distal stump; its end lying free in the wound; the portion of the transplant remaining having a yellow-white color. Large bulbous end on central sciatic stump noted. Central sciatic and remains of transplant removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grim. Microscopic findings.—In cross sections of the remains of the transplant the funicular structure of the nerve found well maintained; the perineural sheaths invaded by small round cells. Within the perineural sheaths, large and in fact multinucleated masses of protoplasm, indefinitely bounded, are to be seen. In the nerve fibers, the neurolemma sheaths found con- taining globular masses, varying in size. This more particularly in the perineural fibers of the funiculi. The more centrally placed fibers found better preserved; certain ones still showing the neurokeratin net of the myelin. Experiment No. 98.—Rabbit No. NSa; large; full grown; 33 days. August 29, 191S, right sciatic exposed; internal popliteal freed; resected 2.4 cm. The right sciatic of a full- grown guinea pig used as transplant. One central and distal waxed, fine silk-thread suture placed; good approximation. Wound closed. October 1, rabbit found dead in the morning; neurotrophic ulcer on right heel. On exposing the right sciatic, transplant was found well in place; no material increase of connective tissue. Transplant is of dull white color. No distinct bulb on the central sciatic stump noted. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. For central part of nerve good silver differentiation attained; for distal nerve not so good. Microscopic findings.—In longitudinal sections of the central wound region a long spindle-shaped bulb evidenced structurally, including the central end of the transplanted nerve segment. Down-growing neuraxes coming from the central nerve are found to enter several of the funiculi of the transplant in which they can be traced several millimeters. In cross sections of the transplant taken about 1 cm. distal to the central wound, the funicular struc- ture of the transplanted nerve is found well preserved, with the fibrous sheaths of the funiculi thickened. The old neuraxes of the transplanted nerve fibers evident within many of the neurolemma sheaths. No new neuraxes made out at this level. In longitudinal sections of the transplant, nearly all of the myelinated nerve fibers show remains of the neuraxes, as short segments of spiral form or looped, showing the characteristic silver reaction. The nerves of the distal popliteal found degenerated. SURGERY 1170 Experiment No. 99.-Rabbit No. 70; full grown; 34 days. April 19 1918 left sciatic expo^d and resected 1.2 cm. The two sciatics of a half-grown guinea pig used as transplants. O c^al and distal silk thread suture placed. Good ^^^™?ZeT^ distal not good; an additional epineural stitch improves somewhat, \\ ound closed. Ma.. 23 k lied Wo md well healed; beginning neurotrophic ulcer on the left heel. On exposing ?te kit sciatic, transplant is found well in place, surrounded by fibrous tissue and found adherent to underlying muscle. Sciatic and the transplant removed and fixed in ammoniated afcohol for pvridine-silver staining. Very good differential silver staining attained. MrcJcopic findings.-* large distinct central bulb evidenced structurally, from the distal end of which numerous neuraxes can be traced distally. Certain of the neuraxes can be traced into the central end of the transplanted nerves; others pass to the connective tissue surrounding the transplanted nerves or found between them. In cross sections of the middle of the transplant the two nerves are clearly made out. The two nerves are found surrounded bv a common fibrous tissue sheath. At this level no new or down-growing neuraxes made out within the perineural sheaths of the nerve funiculi. In many of the nerve fibers fragments of the old neuraxes may be seen. In the fibrous tissue surrounding the trans- planted nerves, mainlv to one side, there are to be found numerous neuraxes, singly or in small bundles separated bv fibrous tissue. In longitudinal sections of the distal wound region it is evident certain of the down-growing neuraxes have reached this region and may here be traced into the central end of the distal popliteal. These new neuraxes appear to reach this level mainlv bv wav of the connective tissue found surrounding the transplant. Experiment No" 100.—Rabbit No. 70a; full grown; 34 days. April 19, 1918, right sciatic exposed and resected 1.4 cm. The two sciatics of a half-grown guinea pig used as a transplant. One central and distal silk suture placed. After suture, the two nerve segments transplanted found twisted one spiral turn; the central and distal approximation "fair." Wound closed. May 23, killed. Wound appeared well healed. On removing skin over wound area, a small focus of suppuration found in wound line; does not appear to extend to deeper wound. On exposing sciatic, tissue about nerve presents no evidence of infection. The transplant found well in place, surrounded by connective tissue and adherent to under- lying muscle. No distinct bulbous enlargement of central sciatic noted. Sciatic and trans- plant removed and fixed in Flemming's chrom-osmic-acetic mixture. Sections stained in iron- hematoxylin and picro-fuchsin; safranine and licht grun. Microscopic findings.—In longitudinal sections including the central and distal wounds, the transplant appears well united to resected nerve ends; fibrous tissue union. An indis- tinct central bulbous enlargement is found, from the distal end of which down-growing neuraxes in the form of nonmyelinated nerve fibers may be observed; these approach the central ends of the transplanted nerve segments. In cross sections of the transplant, the funicular arrangement of the transplanted nerves found well retained; surrounded by a common fibrous sheath, showing much round cell infiltration. The nerve fibers of the transplant appear to be appreciably enlarged, with neurolemma sheath distinct. Within these sheaths here and there globular remains of myelin. Phagocytic cells found within the neurolemma sheaths. The nerve fibers of the distal popliteal found degenerated. Experiment No. 101.—Rabbit No. 66; full grown; 50 days. April 17, 1918, left sciatic exposed and resected 1.3 cm. The two sciatics of a half-grown guinea pig used as a transplant. One central and distal No. 110 linen-thread suture placed. Fairly good approxi- mation attained. Wound closed. June 6, killed. Rabbit good condition; no distinct neurotrophic changes of left hind foot. On exposing the left sciatic, transplants found well in place; surrounded by a common fibrous sheath; adherent to underlying muscle. A dis- tinct bulbous enlargement on the central sciatic stump noted. Calf muscles fully exposed; these appear degenerated. On cutting nerve central to transplant, no contraction of calf muscles noted. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine- silver staining. Very good differential silver staining attained. Microscopic findings.—In longitudinal sections of the central wound region, a long spindle- shaped central bulb is recognized; line of union with central end of transplants clearly recog- nized by presence in the sections of central sutures. Numerous down-growing central neuraxe. can be traced to the central end of the transplant, within which they are traced distalward for NEUROSURGERY 1171 a distance of nearly 1 cm. Certain of these neuraxes are found in the remains of the old neurolemma sheaths, found in the detritus derived from the transplanted nerve fibers. In cross sections of the transplant, taken about 1 cm. distal to the central wound, new neuraxes are to be observed within several of the funiculi of the transplanted nerve segments, even in the most necrotic portions. In longitudinal sections of the distal wound region, a few of the down-growing neuraxes can be traced from the distal end of the transplant into the distal wound and from this a few scattered neuraxes to the central end of the distal internal popliteal. Experiment No. 102.—Rabbit No. 66a; full grown; 50 days. April 17, 191S. right sciatic exposed and resected 1.5 cm. The two sciatics of a half-grown guinea pig used as transplants. One central and distal No. 110 linen-thread suture placed; fairly good approx- imation. Wound closed. June 6, killed. Rabbit in good condition; scarceby any neuro- trophic changes in right hind foot. On exposing the right sciatic, transplant found well in place; surrounded by connective tissue; only moderately adherent to the underlying mus- cle. Relatively dense fibrous tissue surrounds distal wound. Distinct bulbous enlargement noted on central sciatic stump. Calf muscles exposed; these have the appearance of degenerated muscle; do not contract on cutting nerve central to the transplant. Sciatic and transplant removed and fixed in Flemming's chromo-osmic-acetic mixture. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht griin. Microscopic findings.—In longitudinal sections of the central wound region a very large central bulb is evidenced structurally, from the distal end of which numerous young nerve fibers, the majority of which are as yet nonmyelinated, are found to extend to the central end of the transplant, in which larger and smaller syncytial masses, irregular multinucleated giant cells, occupy the regions of the transplanted nerve fibers. In cross sections of the transplant the two nerve segments are recognized by their funicular arrangement and are surrounded by a common connective-tissue sheath. Within the perineural sheaths of the several funiculi, masses of large vesicular cells and irregular masses of syncytial protoplasm and granular detritus occupj^ the greater part of the cross-section area of each funiculus. In the fibrous tissue surrounding the transplanted nerve segments, especially to one side, there is observed an area in which some fifteen small funiculi of nerve fibers are to be found. No new nerve fibers were traced to the distal sciatic. The nerves of the distal sciatic found degenerated. Experiment No. 103.—Rabbit No. 68; large; full grown; 61 days. April is, 1918, left sciatic exposed and resected 1.4 cm. The two sciatics of a nearly-grown guinea pig used as transplants. One central and distal No. 110 linen-thread suture placed; good approximation. Wound closed. June 18, rabbit found dead in the morning; severe neuro- trophic changes left hind foot. On exposing the left sciatic a large bulbous enlargement on the central sciatic stump is noted, from the distal end of which a fine strand, not quite the size of one of the sciatics used as transplant, leads to the distal sciatic stump. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. (July in part good silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region a large spindle-shaped bulbous enlargement of end of central sciatic is evidenced structurally, from the distal end of which down-growing neuraxes may be traced to the central end of the transplant and the connective tissue surrounding the transplant. In cross sections distant about 1 cm. from central wound, the funicular structure of one of the transplanted nerves can be made out, with epineural sheaths thickened. Within the fibrous sheath areas of granular detritus and faintly outlined vesicular cells are noted. This mass occupies nearly the entire cross area of each funiculus. No down-growing neuraxes recognized in this detritus nor at this level in the surrounding fibrous tissue. The distal popliteal found completely degenerated. Experiment No. 104.—Rabbit No. 68a; large; full grown; 61 days. April 18, 1918, right sciatic exposed and resected 1.5 cm. The two sciatics of a nearly-grown guinea pig used as transplants. One central and distal No. 110 linen-thread suture placed; good approxi- mation. Wound closed. June 18, rabbit found dead in the morning; very severe neuro- trophic changes right heel. On exposing the right sciatic, transplant found well in place; the two nerves distinctly evident; of dull white color. No distinct central sciatic bulb 1172 SURGERY noted. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Not well differentiated; not well embedded; sections torn. Microscopic findings.—From well-developed central bulbous enlargement down-growing neuraxes can be traced in part into the central end of the transplant, the majority to the side of the transplant into the surrounding connective tissue. The remainder of the series of sections, especially those of the transplant, so badly torn, owing to faulty embedding, the resulting sections could not be used for critical study. The nerves of the distal sciatic stump found completely degenerated. Experiment No. 105.—Rabbit No. 96; full grown; 69 days. September 6, 1918, left sciatic exposed and the internal popliteal freed and resected 2.5 cm. A segment of equal length taken from the left sciatic of a large guinea pig used as transplant. One central and distal waxed fine silk-thread suture placed; good approximation. Slight hemorrhage from central sciatic stump, not fully controlled. Wound closed. November 15, rabbit found dead in the morning; not well for several days; slight neurotrophic changes left heel. On exposing the left sciatic, the external popliteal found in close approximation to operated internal popliteal. Transplant found well in place and easily recognized by reason of its yellow-white color. Small spindle-shaped bulbous end central internal popliteal. Internal popliteal and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining, Only in part good silver staining attained; sections torn. Microscopic findings.—In longitudinal sections of the central wound region certain down- growing neuraxes are found to enter the central end of the transplant; the majority are seen to pass to the side of the transplant into the surrounding connective tissue. In cross sec- tions of the transplant it is seen that the funicular structure of the transplanted nerve is well retained, with epineural sheath thickened. In many of the old nerve fibers of the transplant remnants of the old neuraxes seen, both in cross and longitudinal sections. The neurolemma sheaths seem thickened and contain granular detritus. No new neuraxes traced to the distal wound. The nerves of the distal popliteal found degenerated. Experiment No. 106.—Rabbit No. 96a; full grown; 69 days. September 6, 1918, right sciatic exposed, internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the right sciatic of a large full-grown guinea pig used as transplant. One central and distal waxed fine silk-thread suture placed; good approximation. Wound closed. November 15, rabbit found dead in the morning; not well for several days; severe neurotrophic changes right heel. On exposing the right sciatic, the central internal popliteal is found to end in a large bulb to which the central end of the transplant is adherent. The transplant had pulled free from the distal popliteal; the distal suture is found in the free distal end of the transplant. Central and distal internal popliteal and the transplant removed and fixed in neutral formalin. The sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht-grun. Microscopic findings.—In longitudinal sections of the central wound region, active downgrowth of small myelinated and nonmyelinated neuraxes pass to the side of the trans- plant and are lost in the surrounding connective tissue. In cross sections of the transplant, just distal to central wound, it is observed that the funicular structure of the nerve is well retained; with each funiculus surrounded by a perineural sheath. The nerve fibers within the perineural sheaths of larger diameter; remnants of neuraxes noted. Under low magnifi- cation the cross sections of the transplanted nerve resemble closely in general structure a normal nerve. The nerve fibers of the distal popliteal completely degenerated ^XPEWT* f °" 11°7TRabbit Xo- 89>' ful1 8~wn; 87 days. August 30, 1918, left r?J th.Tf? ' -'I , P,°Pllteal ^^^ reSGCted 3 °m- A seSment of e^al le-gth, taken Z?AM* \L*Z V *• JTv.' fUU-gr°Wn gUlnea Pig' USGd as a transplant. One central November 2fiehK-fr 1, ^ ^^ ^^ g°°d aPP™*iniation. Wound closed. ulcer On 1• fH„***? ? ^ m°rning; mUch emacia^> on left heel neurotrophic hiht veUow?ol g S?tlC the transPlant is f™*d well in place, demarked bv its enlar'ment ^l ^ 'T" °f COnnective ***** about it. Distinct bulbous otrllZr 7™ P°? teaL Int6rnal POpKteal removed and fixed in neutral formahn. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun. large fenlTbulft^11 ^f^ Sections of ^ antral wound region, from the large central bulb, there may be traced many small myelinated and nonmyelinated nerve NEUROSURGERY 1173 fibers to the central end of the nerve transplant. In cross and longitudinal sections of the transplanted nerve segment, it may be observed that the perineural sheath of the nerve is not materially thickened. Within this sheath large areas in which are found closely arranged large vesicular cells, with globular and granular inclusions, not clearly defined. Other areas in which similar cells and granular detritus are found in what appear to be distended neurolemma sheaths. Within the perineural sheath, mainly to one side, many small funiculi of nerve fibers may be observed. No new nerve fibers traced to and through the distal wound. The nerve fibers of the distal popliteal stump found completely degenerated. Experiment No. 108.—Rabbit No. 89a; full grown; 87 days. August 30, 1918, right sci- atic exposed; internal popliteal freed and resected 3 cm. A segment of equal length, taken from the right sciatic of a large, full-grown guinea pig, used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. Novem- ber 26, rabbit found dead in the morning; much emaciated; severe neurotrophic ulcer right heel. On exposing the right sciatic, transplant is found well in place; no material increase of connective tissue and only moderately adherent to underlying muscle. Distinct central bulbous enlargement found. Internal popliteal and transplant removed and fixed in ammoni- ated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region, and series of sections at successive levels, the transplant is clearly demarked by reason of its jet-black staining. Down-growing central neuraxes can be seen to penetrate the central end of the transplant, in which they can be traced distally until the jet black, nontransparent coloration is reached; here they are lost to view. Certain of the central neuraxes pass to the side of the transplant, coursing distalward in the surrounding connective tissue. In cross sections of the transplant, the perineural sheaths are not found materially thickened. Within the sheaths the remains of the transplanted nerves so deeply stained—jet black—that no struc- tural details can be determined, and it can not be ascertained whether central neuraxes have reached this level. In longitudinal sections of the distal wound region, a few neuraxes can be traced from the distal end of the transplant to the distal wound; others appear to reach the wound region from the surrounding connective tissue. Certain few neuraxes have reached the central end of the distal popliteal in which they have grown for a distance approx- imating 1 cm. Experiment No. 109.—Rabbit No. 93; full grown; 96 days. September 4, 1918, left sciatic exposed; internal popliteal bundle freed; resected 2.5 cm. A segment of equal length, taken from the left sciatic of a full-grown guinea pig, used as a transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. Decem- ber 10, killed. Rabbit moribund; breathing when killed; much emaciated, severe neuro- trophic ulcer left heel. On exposing the left sciatic, the external popliteal is found closely adherent to operated internal popliteal; dissected free without cutting perineural sheath. Large spindle-shaped bulb on internal popliteal noted. The transplant is found well in place, but of small size; only about one-half the size as when used. Transplant presents several short stretches of yellow-white color. Calf muscles exposed; these are atrophic and of yellow-red color and do not contract nor show twitching on cutting nerve. Internal popliteal and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fair silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region, a distinct cen- tral bulbous enlargement is evidenced structurally, this included the central end of the trans- plant, recognized as a granular mass of detritus and faintly stained vesicular cells. Central neuraxes may be traced mainly to the side of this mass into the connective tissue surrounding the transplant. In cross sections of the transplant, about its mid region, a very material thickening of its fibrous sheath is noted. Within this fibrous sheath there are found numer- ous small bundles of neuraxes, separated by bands of fibrous tissue. The necrotic remains of the transplanted nerve found to one side. In longitudinal sections of the distal wound region, certain neuraxes coming from the distal end of the transplant, more numerous from the con- nective tissue surrounding the transplant, can be traced through the distal wound into the distal popliteal nerve, in which they are found, scattered through the several funiculi to the lower level of the popliteal space. \l"A. SURGERY Experiment No. HO.-Rabbit No. 93a; full grown; 96 days. September 4 191s, right sciatic exposed; internal popliteal freed; resected 2.2 cm. A segment of equal length taken from the right sciatic of a full-grown guinea pig, used as a transplant One central •md distal waxed, fine silk thread suture passed; good approximation. Wound closed. December 10, killed. Moribund; just breathing; much emaciated; severe neurotrophic ulcer right heel. On exposing the right sciatic, the external popliteal found free. Trans- planted nerve segment found well in place, of small diameter, and shows several short stretches of yellow-white color. Large central bulb noted. Calf muscles exposed; these are atrophic and of pale vellow-red color. No contraction or twitching of muscles observed on cutting the nerve, internal popliteal and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Only in part good differential silver staining attained. Microscopic findings.—-In longitudinal sections of the central wound region, a distinct central bulb evidenced structurally from the distal end of which down-growing neuraxes may be traced to the central end of the transplant and to the connective tissue by the side of the transplant. The series of cross sections of the transplant, torn and found not well differen- tiated. To one side there may be made out the necrotic remains of the transplanted nerves, occupying about one-half of the cross section area of the transplant, the remaining half consists largely of dense fibrous tissue in which small bundles of neuraxes are observed (this portion of the section is fragmented, so that relations are difficult to make out). In longitudinal sections of the distal wound region, new neuraxes in small numbers are seen to pass through the distal wound and to enter the central end of the distal popliteal, in which they extend for a distance of about 1 cm. beyond the distal wound. Experiment No. 111.—Rabbit No. 87; not quite full grown; 99 days. August 28, 1918, left sciatic exposed; internal popliteal bundle freed; resected 2.8 cm. A segment of equal length taken from the left sciatic of a large, full-grown guinea pig, used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. December 6, rabbit found dead in the morning; much emaciated; severe neuro- trophic ulcer left heel; an encapsuled, sausage-shaped, cold abscess over left tendo Achillis. On exposing the left sciatic, external popliteal found free. Transplant found well in place, throughout of light yellow color, which clearly demarks it; small diameter. Large spindle- shaped central bulb. Calf muscles are atrophic and present the appearance of degenerated muscle. Internal popliteal and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region, a large central bulb is recognized structurally, in the distal end of this a necrotic area, stained jet- black, interpreted as the central end of the transplant, by the side of this area numerous neuraxes grow distalward. In cross sections of the transplant in its mid region, the per- ineural sheath found materially thickened; to one side and within the fibrous sheath, a deeply stained black mass is found occupying about one-half of the cross area of the transplant and representing the necrotic remains of the transplanted nerves. To the other side, also within the fibrous sheath, there are found small groups of neuraxes, separated by strands of fibrous tissue; a few new neuraxes are to be observed in the region of the distal wound. These may be traced to the distal popliteal in which they are followed to the lower level of the popliteal space; the remainder of the distal popliteal found completely degenerated. Experiment No. 112.—Rabbit No. 87a; not quite full grown; 99 days. August 28, 1918, right sciatic exposed; internal popliteal freed; resected 2.0 cm. A segment of equal length taken from the right sciatic of a full-grown guinea pig, used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. December 6, found dead in the morning; much emaciated; severe neurotrophic ulcer right heel. On exposing the right sciatic, external popliteal bundle found free. The transplant found well in place, of light yellow color; on it or in it there may be traced a fine nerve bundle. Large spindle-shaped central bulb noted. Both central and distal sutures clearly evident. Calf muscles atrophic. The internal popliteal and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fair silver differentiation attained. NEUROSURGERY 1175 Microscopic findings.—In longitudinal sections of the central wound region, a large central bulb evidenced structurally, from the distal end of which new neuraxes may be traced to the central end of the transplant. In cross sections of the transplant, the perineural sheath found very materially thickened and blended with the surrounding connective tissue. Within this connective tissue sheath small bundles of neuraxes, separated by strands of fibrous tissue, are to be found; certain small funiculi of nerve fibers seen in the surrounding connective tissue. New neuraxes in relatively small numbers found in the region of the distal wound, and in the distal internal popliteal just distal. In the posterior tibial con- tinuation only degenerated nerve fibers found. Experiment No. 113.—Rabbit No. 92; large; full grown; 104 days. September 3, 1918, left sciatic exposed; internal popliteal freed and resected 2.2 cm. A segment of equal length taken from the left sciatic of a full-grown guinea pig, used as transplant; good approxi- mation. Wound closed. December 17, killed. Rabbit much emaciated; snuffles; neuro- trophic ulcer on left heel. On exposing the left sciatic, external popliteal found only loosely adherent to the operated internal popliteal. On internal popliteal large central bulb is noted. Transplant found well in place, distal two-thirds of light yellow color, with several glistening white streaks. Central end of distal popliteal found distinctly enlarged. Calf muscles found atrophic, do not respond on cutting nerve centrally. Internal popliteal and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Imperfect silver differentiation attained. Microscopic findings.—In series of longitudinal and cross sections taken at successive levels, the transplant clearly demarked by reason of its jet-black, nontransparent staining. The neuraxes of the central stump not clearly differentiated and for the remainder of the series not differentiated. Experiment No. 114.—Rabbit No. 92a; large; full grown; 104 days. September 3, 1918, right sciatic exposed and internal popliteal freed; resected 2.0 cm. A segment of equal length taken from the right sciatic of a full-grown guinea pig, used as a transplant. One central and distal waxed, silk thread suture placed; central approximation good; distal suture pulled out; an epineural stitch made. Wound closed. December 17, killed. Rabbit much emaciated; snuffles; neurotrophic ulcer on right heel. On exposing right sciatic, external popliteal bound only loosely to operated internal popliteal. The internal popliteal presents a large central bulb. The transplant found well in place; of small diameter and in the main of light yellow color. Several small bundles of nerve appear to run on or in the trans- plant to reach the distal popliteal. Calf muscles atrophic; do not respond on cutting the nerve centrally. Internal popliteal and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Imperfect silver differentiation attained; sections light yellow color, with neuraxes not differentiated. Microscopic findings.—The results of this experiment can not be clearly determined from study of sections. In cross sections of the transplant, small areas, which are quite certainly small funiculi of nerve fibers, found in the fibrous tissue to one side of the transplant; the region of the nerve fibers of the transplant only necrotic tissue made out. No neuraxes differentiated in the distal popliteal. Experiment No. 115.—Rabbit No. 91; large; full grown; 191 days. September 2, 1918, left sciatic exposed; internal popliteal freed; resected 2.6 cm. A segment of equal length taken from a large full-grown guinea pig, 12 minutes after it stopped breathing, used as trans- plant. One central and distal waxed, fine silk thread suture passed; good approximation. Wound closed. March 12, 1919, killed. Rabbit in good condition; slightly emaciated; old neurotrophic ulcer on left heel nearly healed. A large, encapsuled, cold abscess found over tendo Achillis; this does not involve deeper tissues. On exposing the left sciatic the external popliteal found free; cutting of the nerve does not cause contraction of the muscles supplied by it. The operated internal popliteal bundle presents a large central bulb; transplant found well in place but of small diameter. Calf muscles found atrophic and do not respond on cut- ting nerve central to the transplant. Internal popliteal removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region, long spindle- shaped bulb evidenced structurally from the distal end of which numerous down-growing 1176 SURGERY neuraxes are found to enter the central end of the transplant. In cross sections of the trans- plant the fibrous tissue sheaths of the nerves transplanted are found materially thickened. Numerous new neuraxes are found within the transplant, in the form of very small bundles separated by fibrous tissue. Onlv relatively few nerve fibers or neuraxes found in the sur- rounding fibrous tissue. Within the transplant only here and there necrotic remains of the transplanted nerve fibers found. Down-growing neuraxes traced to the distal wound and into the distal popliteal, in which they are found in good numbers at the lower level of the popliteal, the extent of the sections cut. The calf muscles were not studied in this experiment. Experiment No. 116.—Rabbit No. 91a; large; full grown; 191 days. September 2,1918, right sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the right sciatic of a large guinea pig, which had stopped breathing 45 minutes previous, was used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. March 12, 1919, killed. Rabbit in good condition; old neurotrophic ulcer on right heel nearly healed. On exposing right sciatic, external popliteal found free. Large central bulb noted on the operated internal popliteal, Transplant found well in place, of good size, and presenting the appearance of a small nerve bundle. The distal internal popliteal presents the appearance of a normal nerve. External popliteal cut and resected and internal popliteal freed from bed. Calf muscles exposed. On slowly cutting with scissors operated nerve central to the transplant, vigorous contraction of the calf muscles observed; same on cutting distal to the transplant. The internal popliteal and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining; portions of the calf muscles removed for gold chloride staining. Fair differential silver staining attained. Microscopic findings.—In longitudinal sections of the central wound region numerous neuraxes are observed to extend from the distal end of a large central bulb to the central end of the transplant. In cross sections of the transplant, in its mid region, the fibrous tissue sheaths of the nerve transplanted are found very materially thickened. Within the fibrous tissue sheaths numerous new neuraxes are found in the form of small bundles, separated by connective tissue. In the distal end of the central bulb and at several levels in the transplant areas of granular detritus, vesicular cells with globular and granular inclusions are to be found; remains of the transplanted nerves. New neuraxes traced to and through the distal wound into the central end of the distal popliteal. In gold chloride stained pieces of calf muscles numerous new neuraxes are found in the larger nerve bundles of the muscle and followed into the smaller interfascicular branches, but motor end plates were not found differentiated; teased muscle fibers presented normal appearance. Experiment No. 117.—Rabbit No. 90; full grown; 194 days. August 30, 1918, left sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length, taken from the left sciatic of a large guinea pig, which had stopped breathing 12 minutes previously, used as a transplant. One central and distal waxed, fine silk thread suture placed; centrally good approximation; distally "fair." Wound closed. March 12, 1919, killed. Rabbit in good condition; severe neurotrophic ulcer left heel, which appears to be healing. On exposing the left sciatic, external popliteal found free. Operated internal popliteal presents a large central bulb. Transplant in place as a fine strand extending from central bulb to the distal popliteal. Distal popliteal does not appear degenerated. On exposing the calf muscles these are found atrophic and of light yellow-red color. External popliteal removed and internal popliteal and transplant freed from bed. On slowly cutting with scissors nerve central to the transplant feeble to distinct contraction of the calf muscles observed. Internal popliteal and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained; sections somewhat torn. Microscopic findings.—In longitudinal sections of the central wound region including the central end of the transplant numerous new neuraxes can be traced from the central bulb into the transplant and into the surrounding tissue. In cross sections of the transplant the transplanted nerve segment is recognized by its distinctly thickened fibrous sheaths, within which numerous new neuraxes may be seen. Scarcely any necrotic remains of the transplanted nerve observed. In the fibrous tissue surrounding the transplanted nerve segment there are to be seen many small funiculi of nerve fibers. Down-growing neuraxes can be traced through NEUROSURGERY 1177 the central wound into the central end of the distal popliteal, in which they are found in relatively large numbers in its several funiculi. Experiment No. 118.—Rabbit No. 90a; full grown; 194 days. August 30, 1918, right sciatic exposed; the internal popliteal freed; resected 2.3 cm. A segment of equal length taken from the right sciatic of a full grown guinea pig, which stopped breathing 32 minutes previous, used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. March 12, 1919, killed. Rabbit in good condition; severe neurotrophic ulcer right heel. On exposing the right sciatic external popliteal found free. The operated internal popliteal presents a large central bulb. The transplant found in place; its distal half of light brown color. Calf muscles atrophic. Cutting of nerve central to transplant causes no contraction of the calf muscles. Internal popliteal and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region, including the central end of the transplant, numerous neuraxes can be traced from the central bulb to the central end of the transplant and surrounding connective tissue. In the distal end of the central bulb, the neuraxes are found to cross and intercross central wound region. In cross sections of the transplant, about 1 cm. distal to central wound, the perineural sheaths of the transplanted nerve segments evident and not materially thickened; within these sheaths numerous neuraxes are observed. Outside of the perineural sheaths an area of connective tissue is observed in which there are found numerous small funiculi of nerve fibers. Down- growing neuraxes can be traced through the transplant and from the surrounding connective tissue to the distal wound and through this to the distal popliteal stump in which, in the several funiculi, they are found in relatively large numbers. Experiment No. 119.—Rabbit No. 95; full grown; 277 days. September 6, 1918, the left sciatic exposed; internal popliteal freed; resected 2.7 cm. A segment of equal length taken from the left sciatic of a full-grown guinea pig, used as a transplant. One central and distal waxed, fine silk thread suture placed; central approximation good; distal approxima- tion, nerve ends not in good alignment. Wound closed. June 10, 1919, rabbit found dead in the morning; very much emaciated; severe neurotrophic ulcer left heel. On exposing the left sciatic the operated internal popliteal is found to end in a large central bulb, from the distal end of which no transplant nor nerve bundles can be traced to the distal popliteal, the central end of which ends free and presents an S-shaped curve. It would appear that the central suture gave way soon after the operation and that the transplanted nerve segment had completely disappeared. Calf muscles found atrophic and distal internal popliteal com- pletely degenerated. Central bulb and distal internal popliteal removed and fixed in am- moniated alcohol for pyridine-silver staining. Fairly good silver staining attained. Microscopic findings.—In longitudinal sections of the central bulb this is found to include the central end of the transplant, consisting of necrotic detritus. Active down- growth of central neuraxes is evident; these are lost in the surrounding connective tissue. In the distal popliteal the nerve fibers found completely degenerated. Experiment No. 120.—Rabbit No. 95a; full grown; 277 days. September 6, 1918, right sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of a large, full-grown guinea pig, used as transplant. One central and distal waxed fine silk thread suture placed; very good approximation. Wound closed. June 10, 1919, rabbit found dead in the morning; very much emaciated; severe neurotrophic ulcer right heel. On exposing the right sciatic, the operated internal popliteal found to end in a large spindle-shaped bulb; the transplant well in place and of good size. Con- ditions of calf muscles not recorded. Internal popliteal and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fair silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region a large central bulb, with characteristic structure of neuroma, including spiral neuraxes, evidenced structurally. In distal end of bulb, the necrotic remains of the central end of the trans- plant are found. Numerous down-growing neuraxes pass by the side of this necrotic area and extend distalward in the connective tissue. In the several successive series of sections the greater part of the transplanted nerve fibers, or the remains of the same, stained jet- 1178 SURGERY black in the silver. In cross sections of the transplant taken from its mid region small funiculi of nerve fibers are found in the connective tissue surrounding the transplant. In the region of the distal wound and in sections of the central end of the distal popliteal only a few neuraxes are to be observed; the greater part of the distal popliteal showing degen- erated nerve fibers. Experiment No. 121.—Rabbit No. 94; large Belgian hare; 358 days. September 5, 1918, left sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the left sciatic of a large guinea pig and used as transplant. One central and distal waxed fine silk thread suture passed. Centrally "fair" approximation attained; distally good alignment, but cut nerve ends not quite end to end. Wound closed. August 28, 1919, rabbit in good condition; still large neurotrophic ulcer left heel; appears to be healing; spreads toes of left hind foot when held up by ears. On exposing the left sciatic external popliteal is found in close apposition to the operated internal popliteal; adherent to it. Large spindle-shaped central bulb on the operated internal popliteal. Transplant found well in place and presents the appearance of a normal nerve. Calf muscles exposed and external popliteal cut at the level of head of fibula; internal popliteal and transplant freed. On slowly cutting with scissors, central sciatic, good contraction of calf muscles and less vigorous contraction of the plantar foot muscles observed. Calf muscles found of nearly normal size and of pale red color streaked with yellow. The internal popliteal and transplant, portions of calf and foot muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Quite good differential silver staining attained. Microscopic findings.—In longitudinal sections of the central wound region, from the distal end of the large central bulb, certain down-growing neuraxes can be traced into the central end of the nerve transplant, the majority into the connective tissue surrounding the transplant. In the connective tissue the small bundles of nerve fibers present a very serpentine course. In cross sections of the transplant, taken about 1 cm. distal to the central wound, numerous small funiculi of nerve fibers are found in the connective tissue surrounding the transplant, outside of the perineural sheaths. Within the transplant crosscut neuraxes, differentially stained, are found in good numbers, separated by strands of connective tissue. Only small remnants of the necrotic remains of the transplanted nerve fibers found within the transplant. Down-growing neuraxes can be traced to and through the distal wound, into the distal popliteal, in which they are found in good num- bers in all of the funiculi. In sections of the calf muscles new neuraxes are found in the larger and smaller intramuscular nerve branches and as single fibers between and on the muscle fibers. Experiment No. 122.—Rabbit No. 94a; large Belgian hare; 358 days. September 5, 1918. right sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the right sciatic of a large, full-grown guinea pig, used as transplant. One central and distal waxed silk thread suture placed; good approximation. Wound closed. August 28, 1919, killed. Rabbit in very good condition; still large neurotrophic ulcer right heel, which appears to be healing. On exposing the right sciatic, the external popliteal is found free. A long spindle-shaped bulb found on the central internal popliteal. Transplant found well in place, of small diameter but presents the appearance of a normal nerve. Distal popliteal; looks like a normal nerve. Calf muscles exposed; very nearly of normal size and of pale red color streaked with light yellow. After cutting and resecting external popliteal and freeing the operated internal popliteal from bed, on slowly cutting nerve with scissors, central to the transplant, distinct but feeble contractions in the calf muscles noted; foot muscles uncertain. Functional test 20 minutes after the animal was killed. Internal pop- liteal and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.—Only in part good silver differentiation attained; in part fine granular silver deposit in sections. In longitudinal sections of the central wound region large numbers of down-growing neuraxes can be traced from the distal end of the central bulb to the central end of the transplant and the connective tissue surrounding the transplant; the latter in the form of numerous small funiculi, very much coiled and twisted; those enter- ing the transplant follow a more regular longitudinal course after having passed the central NEUROSURGERY 1179 wound region. In cross sections of the transplant, about 1 cm. distal to the central wound, it may be observed that new neuraxes are found both within and without the perineural sheaths of the nerve segment transplanted. New neuraxes can be traced through the distal wound into the distal popliteal, in which they are found in good numbers in all of the funiculi. In the sections made from the calf muscles neuraxes are found in the larger fasicular nerve bundles and here and there as single nerve fibers on the muscle fibers. The muscle fibers so far as can be determined in silver stained preparations appear to present normal structure; here and there areas or columns of fat cells within the muscle. Experiment No. 123.—Rabbit No. 78a; large; full grown; 7 days. June 3, 1918, right sciatic exposed; fascial plane not readily found, consequence muscle torn; sciatic resected 2.5 cm. A segment of equal length taken from the right external popliteal of a full-grown dog; nerve resected two hours previous; nerve segment lying in the wound used as transplant. One central and distal waxed fine silk thread suture placed; good approximation. Ulti- mately dry field; wound closed. June 10, rabbit found dead in the morning; superficial wound healed; deep wound congested. In deep wound near distal suture a small hematoma in the connective tissue. Transplant found well in place; united to the resected nerve ends; central and distal sutures distinct. Sciatic and the transplant removed and fixed in ammoni- ated alcohol for pyridine-silver staining. Faint but differential silver staining attained. Microscopic findings.—Transplant united to central sciatic only at one border; for the remainder of the cross section separated by an appreciable distance. Distally good fibrous union obtained. In longitudinal sections of the transplant the neuraxes of the transplanted nerve fibers found fragmented into relatively long segments, having a wavy or spiral course, and stained differentially in the silver stain. The neurolemma sheaths seem well maintained, the perineural sheaths not appreciably thickened. In the distal end of the central sciatic stump early stages of the downgrowth of the central neuraxes evident. The nerve fibers of the distal sciatic present early stages of degeneration. Experiment No. 124.—Rabbit No. 75a; full grown; 13 days. May 10, 1918, right sciatic exposed and resected 2.5 cm. A segment of equal length, taken from the left internal popliteal of a dog, used as transplant. One central and distal silk-thread suture placed; good approximation. Muscle stitched over nerve. Wound closed. May 23, rabbit found dead in the morning; "snuffles;" wound well healed. On exposing the right sciatic, trans- plant found well in place; appears of slightly greater diameter than when used; found well united to the resected nerve ends. Transplant surrounded by newly formed connective tissue. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine- silver staining. Good differential neuraxis staining attained. Microscopic findings.—In longitudinal sections of the central and distal wound regions, ends of transplant found well united to the resected nerve ends. In longitudinal sections of the transplanted nerve segment, the neuraxes of the old nerve fibers are found segmented into longer and shorter segments, staining differentially in the silver stain; the neurolemma sheaths found well preserved; no distinct evidence of the proliferation of the sheath cells. Structural evidence of the beginning of a central bulb, from the distal end of which many down-growing neuraxes, terminating in bulbous end-discs, can be traced through the central wound for a short distance into the central end of the transplant. In certain of the neuro- lemma sheaths, near the central wound, remnants of old neuraxes and down-grown new neuraxes are to be found side by side. The fibers of the distal sciatic found in process of degeneration; many nucleated syncytial protoplasmic bands are seen, with proliferation of sheath cells. Experiment No. 125.—Rabbit No. 76a; large; full grown; 52 days. May 17, 1918, right sciatic exposed and resected 2 cm. A segment of equal length, taken from the left ulnar of a dog, used as a transplant. One central and distal silk-thread suture passed; good approximation. Wound closed. July 8, rabbit found dead in the morning; wound well healed. On exposing the right sciatic, transplant was found to be well in place, firmly united to the resected sciatic stumps; adherent to the underlying muscle. Transplant of yellow-white color but seems of good consistency. No well-marked central bulb noted. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. 11S0 SURGERY Microscopic findings.—In the successive series of longitudinal and cross sections, the transplanted nerve segment is clearly demarked by reason of a jet-black nontransparent coloring, the connective tissue sheaths being stained a yellow-brown color. Within the trans- plant, here and there fragments of neuraxes are found within the neurolemma sheaths. In cross sections of the transplant, wherever the dark coloring admits of the observation, in nearly every neurolemma sheath there may be observed the cut end of the old neuraxis. In longitudinal sections of the central wound region, down-growing neuraxes, traced from the distal end of the central bulb, may be seen passing by the side of the nerve transplant into the surrounding connective tissue, and in longitudinal sections of the transplant, new neuraxes are found in the fibrous tissue between the funiculi. No new neuraxes are found in the region of the distal wound. The nerve fibers of the distal sciatic are found completely degenerated. It is evident from a study of the protocols of the experiments on hetero- nerve transplant, that on the face of the results attained the statement is warranted that a hetero-nerve transplant may be used to bridge a nerve defect with probability of success, to the extent that certain of the down-growing central neuraxes will penetrate the central end of the transplant and through it reach the distal segment. In all of the experiments of this series, kept for more than three months (Xo. 109 to No. 122) after the operation, the down- growing neuraxes derived from the distal end of the central stump could be traced into the central end of the transplant, to the distal wound region, and thence to the distal sciatic stump. There seems no question that a certain number of down-growing neuraxes, the number varying in the different experi- ments, reach the distal sciatic segment through the hetero-nerve transplant. Having established this general conclusion, the protocols of the experiments of long duration may be studied more critically, and it will be found that in nearly every record of microscopic findings it is noted that the down-growing neuraxes derived from the central stump not only penetrate the central end of the trans- plant but at the central wound region pass into the connective tissue surround- ing the transplant and in close contiguity to it reach the distal wound and, per- chance, enter the distal sciatic stump. These extrafunicular nerve bundles are most easily determined in cross sections of the transplant and surrounding connective tissue. In such sections, the funicular structure of the nerve transplanted is usually readily made out, even months after the operation, and the perineural sheaths surrounding the funiculi are evident. In properly stained sections, with neuraxis differentiation, extrafunicular nerve fibers, singly or in small bundles, are easily determined. Such extrafunicular fiber bundles usually have an irregular serpentine course, as though winding their way through, the interstices of the connective tissue. It may also be noted that these extrafunicular nerve fiber bundles are on the whole much more numerous than is the case when auto- or homo-nerve transplants are used, and may include a relatively large per cent of the central nerve fibers reaching the distal wound and the distal nerve segment. It can also be shown that the rate of regeneration appears much slower when a hetero-nerve transplant is used than when using an auto- or homo-nerve transplant. Further, that the results are not so satisfactory, taking as an index the number of neuraxes which reach the distal stump through the hetero-nerve transplant, as when auto- or homo-nerve transplants are used. However, the hetero-nerve transplant does not become necrotic as is stated by certain observers. If properly sutured to the resected NEUROSURGERY 1181 nerve ends, the ends of the hetero-nerve transplant quickly form fibrous union with the resected nerve ends and become surrounded by newly formed connective tissue. In experiments terminated from six to twelve months after the opera- tion, there is usually present a prominent central nerve bulb which includes the central wound region. In the region of the transplant the nerve bundle has the appearance of a living nerve, though of smaller diameter than when the nerve was transplanted. The hetero-nerve transplant has not disappeared, since months after the transplant was placed its funicular structure can be made out. In the earlier stages of experimental operative work on nerve bridging no special consideration was given to the relative value of auto-, homo-, and hetero-nerve transplants; the need of making such differentiation was not recognized. As early as 1869, Philippeaux and Fulpian used a lingual nerve to bridge the resected hypoglossal nerve of dogs; auto-nerve transplant. These experiments were followed by others in which auto-, homo-, and hetero-nerve transplants were used, generally with indifferent or unfavorable results. Huber, in 1895, reported on a series of 26 experiments of nerve transplantation. Of this number in 10 of the experiments the animals were kept for a period of four months or more before the operated nerve was tested functionally and the nerve removed for examination. In five of these, all hetero-nerve transplants (cat's sciatic to resected ulnar of dog), the results were very satisfactory; in four others the down-growing central neuraxes had passed the region of the transplant and entered the distal nerve segment. With the microscopic methods available then, such precise neuraxis differentiation could not be had as now and it was not determined whether all of the down-growing neuraxes passed to the distal stump through the funiculi of the transplant or extra- funicular in the surrounding connective tissue. In an unsigned statement, found in the "Medical Supplement, Daily Review of Foreign Press," London, October 1, 1918, giving a review of the treatment of gun-shot injuries of nerves in Germany to the middle of 1917, the following statement appears: When a gap between the two divided nerve ends can not be obliterated, the unsettled question as to the regeneration of nerves has to be taken into consideration. The dominant view before the war was that regeneration in the peripheral segment was due entirely to the down growth of axis-cylinders from the proximal segment. But this theory does not seem to receive much confirmation. The regeneration of potential nerve fibers in the still separated distal segment, as described by Ballance and Purves Stewart, has found supporters, the poten- tial nerve fibers becoming linked up with axis cylinders in the proximal segment when the two ends are brought together * * *. The second view that the distal segment regener- ates so far affords encouragement to the method of inserting into the gap a nerve graft, which shall serve, as it were, to prolong the peripheral segment to meet the proximal end. Then the axis cylinders in the proximal segment, without growing out more than is seen in case of nerve end bulb, can become connected by a series of links with the potentially regener- ated nerve fibers, and then these become fully developed. This nerve grafting to fill gaps gains support from animal experimentation and appears to be the plan which should be adopted in surgery. The experimental observations on nerve transplantation furnish the most conclusive evidence for the monogenetic or downgrowth theory of nerve regeneration. In none of the experiments recorded under Series No. 5, No. 6, and No. 7 is there found any evidence in support of auto-regeneration of the H$2 SURGERY peripheral stump. In suitably stained pyiidine-silver preparations of a nerve | brid-ed by a nerve transplant and removed for study at the right time, in a serial order at progressive stated intervals, it can be seen that the budding central neuraxes grow to the region of the central wound and step for step into the transplant, through the transplant into and through the distal wound and into the distal segment, and in this progressively until the end organs are reached. As a result of the observations accumulated in this series of experi- ments, there is found abundant warrant for stating that the nerve bridge or nerve transplant offers a suitable path for down-growing central neuraxes and that regeneration of the distal segment after nerve bridging is only through down-growing central neuraxes. In more recent experimental observations and in the more modern surgical work more precise recognition has been given to the relative merits of the auto-, homo-, and hetero-nerve transplants as with other tissue grafts. As a result of experimental observations, Forssman 70 and a little later Merzbacher,71 whose results were confirmed by Segale,72 were the first to suggest that there were important differences between homo- and hetero-nerve transplants. As a result of their observations it was concluded that in auto- and homo-nerve transplants the transplanted nerves survived and were capable of undergoing degenerative changes while a hetero-nerve transplant was subject to a necro- biotic process owing to the fact that it did not survive in the host. On the other hand, Maccabruni.73 working in the laboratory of Golgi, found that there was little difference in the behavior of auto-, homo-, or heterogenous nerve seg- ments transplanted into connective tissue or intermuscular septa, the axial portion of each becoming necrotic while the more peripheral portions, subject to better nutrition, presented the phenomena of nerve degeneration, even proliferation of sheath cells. Ingebrigtsen has considered this question in a number of contributions. In the account of 1915,74 the following statement appears: "In the problem of transplantation of nerves the question of the fate and survival and multiplication of the cells of Schwann is of importance. The solution of this point, which is the only reliable sign of the survival of the transplanted piece, gives the key to the problem and will influence the procedure of surgeons in cases of nerve defects. If the grafts die and become necrotic they are no more suitable for bridges than strands of catgut." Writing in 1916, Ingebrigtsen73 states that Wallerian degeneration occurs in auto- and homo-nerve transplants in the same manner as in the peripheral end of a cut nerve, except that the various changes take place somewhat slowly, while in hetero-transplants there is no Wallerian degeneration and no proliferation of sheath ceUs and 12 to 15 days after transplantation the nerve becomes necrotic and on histologic examination of the later stages no new neuraxes were found in the heterogenous transplant. After more extended study and in a com- prehensive monograph (1918)43 Ingebrigtsen had broadened his viewpoint, as may be noticed from the following quotation which is presented in this quite literal translation: And we come then to the conclusion that the cells of the sheath of Schwann of the auto- and homo-nerve transplants are without biological significance whatever for the regeneration of the new neuro-fibrils of the transplant, which grow into the transplant from the central stump whether the transplant is living or dead. NEUROSURGERY 1183 In the extended series of operations on nerve transplants, included in Series No. 5, No. 6, and No. 7, auto-, homo-, and hetero-nerve transplants, primary consideration was given to the downgrowth of central neuraxes in regeneration and their relation to the transplanted nerve fibers, and for this purpose the pyridine-silver neuraxis differentiation method was largely used. This method is not suitable for a detailed study of the myelin fragmentation nor the behavior of the sheath cells of the transplanted nerves. The evidence at hand warrants the conclusion that none of the transplanted nerve fibers, whether of auto-, homo-, or heterogenous source, undergo typical Wallerian degeneration, if sheath cell proliferation is to be considered a sine qua non of Wallerian degeneration. Further, the conviction has been gained that the sheath cells of the transplant play a very subsidiary and a negligible role as concerns regeneration through a nerve transplant. (Series No. 11, No. 12, and No. 13 seem to demonstrate this conclusively.) That there is a difference in the behavior of auto- and homo-nerve transplants on the one hand, and hetero-nerve transplant on the other there can be no question. However, one can not accept the statement that heteroplastic nerve transplants become necrotic. Months after such a transplant has been placed, can its funicular structure be determined, with funiculi surrounded by perineural sheaths. That regeneration may take place through a hetero-nerve transplant the earlier observations of Huber (1895) 30 may serve to show, as also certain of the experiments of longer duration of Series No. 7. In preparations made from this series the neuraxes were differentially stained by the pyridine-silver method and in successful preparations stained by this method there is no difficulty in determining neuraxes. The results obtained as regards regenera- tion of the peripheral segment are not nearly so favorable on use of the heterog- enous transplant as when auto- and homo-nerve transplants are used. How- ever, this would seem to be due not so much to a difference in the mode of fragmentation of the myelin and a want of sheath cell proliferation but to a relatively retarded and at times imperfect phagocytosis of the products of myelin fragmentation, leaving the neurolemma tubes less suitable for neuraxis downgrowth than when homo- or auto-nerve transplants are used. The answer to the question of chemotactio or want of chemotactic action of the products of nerve degeneration and sheath cell proliferation can not now be given, since sufficient and conclusive experimental evidence is not now at hand. Conditions being approximately equal as concerns operation, relative size of nerve and sutures, the extrafunicular nerve fibers coming from the central stump and passing into the connective tissue surrounding the transplant are much more numerous when heterogenous transplants are used than with autog- enous or homogenous transplants. This is interpreted as an index that the latter are more favorable than the former for downgrowth of neuraxes. Thus, while the regeneration of the distal segment of a resected nerve can be obtained throuo-h a heterogenous nerve bridge in experimental work, the outcome is less certain and less satisfactory and it requires a longer time than when auto- or homo-nerve transplants are used. Thus, hetero-nerve transplantation is not recommended as an operation in the repair of human nerves after loss of nerve substance. 46997—27----77 11S4 SURGERY DEGENERATED NERYE TRANSPLANTS SERIES NO. 8, NO. 9, AND NO. 10 DEGENERATED AUTO-, HOMO-, AND HETERO-NERYE TRANSPLANTS In Series No. S, No. 9, and No. 10, including degenerated auto-, homo-, and hetero-nerve transplants, the nerve segment selected for the transplant was taken from a nerve which had been caused to undergo Wallerian de- generation as a result of nerve section some weeks before the nerve segment was used as a nerve bridge. This series of experiments was undertaken to test a number of hypotheses relative to nerve transplants. It was conjectured that since a transplanted nerve segment degenerates after transplantation. the process of regeneration through a nerve transplant might be facilitated by using a nerve segment already degenerated to the extent of presenting the nucleated syncytial strands (" bandfasern ") in the neurolemma sheaths. In a measure one may regard the nucleated syncytial strands, the product of sheath cell proliferation, as less differentiated protoplasm than developed sheath cells, conceivably a protoplasm more favorable to downgrowth of cen- tral neuraxes. Especially was it conjectured that a degenerated hetero-nerve transplant might for this reason prove more satisfactory than a hetero-nerve transplant taken from a normal nerve. It was further felt, consequent to the suggestion of certain observers who have regarded degenerating nerve fibers and proliferating sheath cells as capable of exerting a chemotactic in- fluence on down-growing neuraxes in nerve regeneration, a degenerated nerve transplant might serve to attract, from the beginning of transplantation, central neuraxes in early stages of regeneration. None of these suppositions were well founded. These three series of experiments are jointly presented and considered. The protocols of experiments 126 to 149 (Series No. 8, No. 9, and No. 10) are as follows: PROTOCOLS Experiment No. 126—Dog No. 1; medium size; full grown; 133 days. March 25, 1918, right ulnar exposed and resected 1.2 cm. As a transplant, used 1.2 cm. of the distal segment of the left sciatic of the same dog, cut March 7, 18 days previous. One central and one distal Chinese silk suture placed; good approximation. Quite a little bleeding, which was not fully controlled. Fascia stitched over the nerve and transplant. Wound closed. August 5, killed. Dog in good condition. On exposing the ulnar, the transplant was found well in place; easily demarked, since central and distal sutures are still clearly evident. Transplant has diameter slightly larger than ulnar. Ulnar distal to transplant presents the appearance of normal nerve. Forearm muscles supplied by ulnar do not con- tract when ulnar is cut central to the transplant. Ulnar and the transplant and distal ulnar removed and fixed in ammoniated alcohol. Only in part good differential staining attained. Tissues not well embedded, sections torn. Microscopic findings.—In longitudinal sections of the central wound region, distinct central bulb evidenced structurally, from the distal end of which down-growing neuraxes can be traced to the transplant. In cross sections of the transplant, the funicular struc- ture of the degenerated nerve segment transplanted, is in part retained. New neuraxes observed in the funiculi, in which they are arranged in small bundles separated by fibrous tissue; also in the connective tissue surrounding the transplant; especially to one side. In longitudinal sections of the distal wound region, new neuraxes can be traced to the distal ulnar and in this, in good numbers to the level of the elbow; the extent of the distal ulnar segment sectioned. NEUROSURGERY 1185 Experiment No. 127.—Dog No. 3; medium size; full grown; 134 days. March 27, 1918, right ulnar exposed and resected 1.5 cm. A segment of equal length, taken from the external popliteal bundle of the left sciatic of the same dog, cut March 8,18 days previously, used as transplant. One central and distal Chinese silk suture placed; fair approximation attained. Free venous bleeding, not fully controlled. Fascia stitched over nerve; wound closed. August 8, killed. Dog in very good condition. On exposing the right ulnar, a large bulb is observed on end of central ulnar stump, from which a small nerve bundle leads to the distal ulnar segment. On cutting ulnar central to the transplant, no distinct con- traction of the forearm mucles supplied by the ulnar is observed. Ulnar and transplant and segment of distal ulnar removed and fixed in ammoniated alcohol for pyridine-silver staining. Not entirely successful silver differentiation attained. Microscopic findings.—In alternate longitudinal and cross sections, new neuraxes can be traced from the central ulnar stump to the distal ulnar. In the cross sections taken from the middle of the transplant, the funicular structure of the transplanted nerve segment not clearly made out. Small funiculi of nerve fibers are observed. Their relation to the trans- planted nerve segment is uncertain. Experiment No. 128.—Dog No. 2; medium size; full grown; 420 days. March 26, 1918, right ulnar exposed and resected to the extent of 1.5 cm. A segment of equal length taken from the left external popliteal of the same dog, the left sciatic of which was cut March 7, 19 days previous, used as a transplant. One central and distal Chinese silk suture placed; good approximation. Fascia stitched over nerve; wound closed. May 20, 1919, killed. Dog in good condition. On exposing the right ulnar, distinct central ulnar bulb is found, from the distal end of which a well-formed bundle of nerves, of slightly smaller diameter than the ulnar, leads to the distal ulnar stump, the central end of which is only slightly enlarged. In the region of the transplant nerve firmly adherent to the surrounding tissue, the distal ulnar has the appearance of a normal nerve. After exposing the forearm muscles, and freeing the ulnar from its bed, on slowly cutting the ulnar central to the transplant, distinct and vigorous contraction of the forearm muscles supplied by the ulnar. Ulnar and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Micrsocopic findings.—In series of alternate longitudinal and cross sections, through transplant and distal ulnar, neuraxes coming from the central ulnar can be traced through the transplant into the distal ulnar. In cross section of the transplant, taken at its middle, it may be clearly seen that the connective tissue of the transplant is very materially increased; this blending with the perineural sheaths. Certain of the down-growing neuraxes, both myelinated and nonmyelinated, appear within a large funiculus of the transplanted nerve segment. Others are found in small bundles in the connective tissue outside of the trans- plant. In the distal ulnar, cut in cross sections 2 cm. below the elbow, both myelinated and nonmyelinated neuraxes are found scattered through all of the funiculi, in large numbers. Experiment No. 129.—Dog No. 36; medium size; full grown; 17 days. June 4, 1918, left sciatic exposed; internal popliteal bundle freed and resected 3 cm. A segment of equal length, taken from the left internal popliteal of dog No. 24, the sciatic of which was cut May 18, 17 days previous, used as a transplant. One central and distal waxed, fine silk thread suture placed; very good central and distal approximation attained. Wound closed. June 21, dog found dead in the morning; no neurotrophic changes of left hind foot. On exposing the left sciatic, transplant is found well in place, and appears of slightly larger diam- eter than when transplanted; no distant central bulb observed. The internal popliteal and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—In longitudinal sections of the central and distal wound regions, transplant found well united to resected nerve ends with only narrow fibrous tissue union intervening. Scarcely any evidence of central bulb noted. In the distal end of the central stump, active outgrowth of central neuraxes observed. These have reached the scar tissue of the central wound, which many have penetrated and which they traverse by crisscrossing in all directions. Many end-discs and evidence of branching of neuraxes seen. A certain few of the central neuraxes have passed through the central wound into the central end of 1](X6 SURGERY' the nerve transplant, These are much more numerous near the central wound than a little more distallv, but can be traced to nearly the middle of the transplant. Within the trans- plant there are observed the thickened neurolemma sheaths of the degenerated, transplanted nerve fibers, and remnants of myelin. The distal internal popliteal is found in early stage of degeneration. Experiment No. 130.—Dog No. 7; large; full grown; 36 days. July 5, 191S, loft sciatic exposed; internal popliteal bundle freed; resected 4 cm. A segment of equal length, taken from tlie left internal popliteal of dog No. 28, the sciatic of which was cut 28 days previously, used as a transplant, One central and distal waxed, fine silk thread suture placed; very good approximation attained. Wound closed. August 10, killed. Dog seemed well, though emaciated; no neurotrophic changes left hind foot; wound well healed. On exposing the left sciatic, the external popliteal bundle found free; the transplant in the internal popli- teal well in place, and clearly demarked by its light yellow color; no material increase of connective tissue about the transplant. No distinct central bulb noted. The internal popliteal removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht-gnin. Microscopic findings.—In longitudinal sections of the central and distal wound regions, transplant found well united to the resected nerve ends; fibrous tissue union at the wounds. In the sections from the central wound region, new nerve fibers, in part with fine myelin sheaths, can be traced from the central stump, through the central wound into the transplant. In cross and' longitudinal sections of the transplant, the neurolemma sheaths found give the impression of being thickened. Many of these sheaths contain large vesicular cells, having globular, myelin remains in their protoplasm; further, granular detritus; not many sheath nuclei evident. The distal nerve presents degeneration phenomena. Experiment No. 131.—Dog No. 5a; large; full grown; 37 days. July 3, 1918, the right sciatic exposed; internal popliteal freed; resected 3.4 cm. A segment of equal length taken from the internal popliteal of the right sciatic of dog No. 27, cut June 6, 27 days previous and used as a transplant. One central and distal waxed fine silk thread suture placed; good alignment attained, but distal end of transplant rotated; good approximation of nerve ends. Wound closed. August 9, killed. Dog emaciated; small neurotrophic ulcer right hind foot. Wound well healed. On exposing the right sciatic, it is found that the external popliteal is closely adherent to the operated internal popliteal; was not dissected free. Distinct increase of connective tissue in the region of operation, about the sciatic. The transplant found well in place; demarked by its light yellow color. No distinct central bulb noted. External and operated internal popliteal bundle removed together and fixed in ammoniated alcohol for pyridine-silver staining. Good differential neuraxis staining attained. Microscopic findings.—In longitudinal sections of the central wound region neuraxes from the central stump in large numbers can be traced into the central end of the trans- plant. In cross sections of the transplant, 1 cm. distal to the central wound, numerous neu- raxes are found within the transplant, in the form of small bundles, separated by strands of fibrous tissue. In longitudinal sections of the transplant, it may be observed, that while these small bundles have in the main a longitudinal direction, contiguous bundles frequently are found anastomosing. Only a small number of old myelin remnants are found in the transplant. A few of the down-growing neuraxes have reached the distal wound and can be traced for a short distance into the central end of the distal popliteal; by far the greater portion of the distal popliteal showing only degenerated nerve fibers. Experiment No. 132.—Dog No. 37; medium size; full grown; 146 davs. June 18, 1918, left sciatic exposed; internal popliteal freed, resected 2.7 cm. A segment of equal length, taken from the internal popliteal bundle of the left sciatic of dog No. 23, cut Mav 31, 18 davs previous, used as transplant. One central and distal waxed fine silk thread suture placed; good approximation. Wound closed. November 11, killed. On this dav participated in fight with another dog and nearly killed; was still breathing when found. Dog in good condition. No neurotrophic changes left hind foot noted. On exposing the left sciatic, external popliteal found free; no distinct bulb on central internal popliteal. Transplant found well in place, has the appearance of normal nerve, except that a light pink color is evi- dent. Distal nerve has the appearance of normal nerve. Calf and the plantar muscles ex- posed and external popliteal resected and removed. After freeing the internal popliteal and NEUROSURGERY 1187 transplant from the bed, on slowly cutting the nerve central to transplant, good contraction of calf and interossei muscles observed. On cutting posterior tibial at heel, interossei muscles seen to contract. Internal popliteal and the transplant, posterior tibial, internal plantar and portions of several interossei muscles removed and fixed in ammoniated alcohol for pyridine- silver staining. Good differential neuraxis staining attained. Microscopic findings.—In longitudinal sections of the central wound region, a long spindle- shaped bulb evidenced structurally from the distal end of which numerous down-growing neuraxes can be traced to the central end of the transplant. In cross sections of the trans- plant 1 cm. distal to the central wound, the perineural sheaths of the transplant found thickened. Within these sheaths are found, within the funiculi, numerous small bundles of neuraxes, certain of which are myelinated, separated by strands of fibrous tissue. Large numbers of the neuraxes in these small bundles may be traced to and through the distal wound into the distal internal popliteal, in which new neuraxes are found in all of the funiculi. New neuraxes can be traced to the interfascicular nerve branches in the interossei muscles; a few motor ending observed. Good regeneration of the distal popliteal attained. Experiment No. 133.—Dog No. 8a; large dog; full grown; 316 days. July 9, 191S, left sciatic exposed; internal popliteal freed; resected 3.8 cm. A segment of equal length, taken from the internal popliteal of the sciatic of dog No. 26, cut June 7, 32 days previous, used as transplant. One central and distal waxed fine silk thread suture placed. Good distal approximation; central good alignment, but after tying distal suture, central suture gave way slightly, so that nerve ends were nearly 2 mm. apart. Wound closed. May 21, 1919, killed. Dog in very good condition; uses left hind foot well; no neurotrophic changes. On exposing the left sciatic, the external popliteal is found free. No distinct enlargement on central internal popliteal noted. The transplant found well in place and presents the appearance of a normal nerve, though somewhat spread out and of flattened form. Distal popliteal has the appearance of a normal nerve. Calf and plantar muscles exposed; external popliteal resected and removed. After separating nerve and transplant from bed, on slowly cutting nerve with scissors central to the transplant, distinct and vigorous contraction of calf and foot muscles noted. Internal popliteal and transplant, posterior tibial, portions of calf and foot muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential neuraxis staining attained. Microscopic findings.—In longitudinal sections of the central wound region, quite dis- tinct spindle-shaped bulb evidenced structurally, from the distal end of which numerous neuraxes enter the transplant. In cross sections of the transplant, taken at levels near the central and distal wounds, the transplanted nerve segment found to be well outlined with thickened fibrous sheaths. Within the transplant are found numerous small bundles of neuraxes separated by strands of fibrous tissue. Numerous small bundles of neuraxes also found in the connective tissue surrounding the nerve transplant. Many of the neuraxes within and without t he transplant are found to be myelinated. New neuraxes can, in sections made at successive levels, be traced through the transplant into and through the distal wound into the distal popliteal, in which they are followed to the interossei muscles. In sections of portions of the interossei muscles, new nerve fibers may be observed in inter- fascicular nerve branches and as single nerve fibers, on and between muscle fibers. Motor endings found not well differentiated. Nearly complete regeneration of the distal popliteal observed. Experiment No. 134.—Rabbit No. 78; large; full grown; 7 days. June 3, 1918, left sciatic exposed and resected 2.5 cm. A segment of equal length, taken from the external popliteal of dog No. 21, the left sciatic of which was cut 16 days previous, used as transplant. One central and distal waxed fine silk thread suture placed; good approximation. Wound closed. June 10, rabbit found dead in the morning. Wound well healed. On exposing the sciatic, tissues about the nerve found congested. Transplant found well in place, though distal suture had drawn out a little. Transplant united to resected nerve ends; good color. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation of neuraxes attained. Microscopic findings.—In longitudinal sections of the central wound region the very earlv stages of a bulbous end on central sciatic stump noted. Certain of the larger neuraxes 11S.S SURGERY of the central stump present large, bulbous ends; growing end-discs noted just central tn central wound. Central wound consists of loose fibrocellular tissue, coagulum, and tissue detritus. In longitudinal sections of the transplant, remnants of old neuraxes, in the form of short segments, twisted, coiled, or bent, are to be observed. Faintly stained nuclei are found within the old neurolemma sheaths. In the distal sciatic beginning of nerve degeneration observed. Experiment No. 135.—Rabbit No. 75; full grown; emaciated; 13 days. May 10, 1918, left sciatic exposed and resected 2.5 cm. A segment of equal length, taken from the internal popliteal bundle of the left sciatic of dog No. 2, cut April 23, 17 days previous, used as transplant. One central and distal waxed, fine silk thread suture passed; good approximation. Wound closed. May 23, rabbit found dead in the morning; snuffles; wound well healed. On exposing the left sciatic, transplant found well in place; demarked by sutures. Transplant seems of slightly larger diameter than when used, and found sur- rounded by newly formed connective tissue. Beginning of bulbous enlargement on the distal end of the central stump. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good differential staining, especially central stump, attained. Microscopic findings.—In a series of longitudinal sections of the central wound region, distinct bulbous end of central stump evidenced structurally, at the distal end of which is found the wound line, consisting of fibrocellular tissue; suture found in sections. Many down-growing neuraxes of the central stump have reached the wound line. Many of these show bulbous end-discs; certain of them are directed centralward, others toward the periphery. In longitudinal sections of the transplant, the fibrous tissue sheaths are found very materially thickened by means of newly formed connective tissue containing many leucocytes. The neurolemma sheaths very materially thickened. These in longitudinal sections present a wavy zigzag course. Globules of myelin and remnants of neuraxes observed. Many wandering leucocytes are found between the old nerve fibers. The distal sciatic presents early stages of degeneration. Experiment No. 136.—Rabbit No. 85; nearly full grown; Belgian hare; 42 days. July 9, 1918, left sciatic exposed and resected 2.2 cm. A segment of equal length, taken from the right median of dog No. 26, cut June 7, 32 days pervious, used as transplant. One central and distal suture of waxed, fine silk thread placed; approximation good, though the transplant has slightly greater diameter than the sciatic resected. Wound closed. August 20, rabbit found dead in the morning; very much emaciated; large neurotrophic ulcer on left heel. On exposing the left sciatic, the transplant is found well in place; of larger diameter than the resected nerve and of yellow-white color. No distinct central bulb noted. Transplant and suture lines surrounded by relatively dense fibrous tissue and adherent to underlying muscle. Sciatic and the transplant removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht-grun Microscopic findings.— In longitudinal sections of the wound regions, the resected nerve ends and ends of transplant found firmly united. There is noted a marked increase of fibrous tissue about the transplant. In longitudinal sections of the transplant, the neurolemma sheaths of the transplanted nerve fibers appear thickened and as if consisting of a delicate fibrillar structure. Near the central and distal wound leucocytes found within the neurolemma sheaths and here and there are found to contain globules. In cross sections of the transplant about 1 cm. distal to the central wound, numerous small funiculi consisting of nonmyelinated fibers found in the connective tissue surrounding the transplant, outside Ne r ZT?\ ,S- . DlStal P°Pliteal f°Und in advance staSes of nerve degeneration. popliteal W° leuCOC^tes found ^thin the neurolemma sheaths of the distal exDofedTn™ *% 1f--Rabbi* N°- 77; full grown; 48 days. May 20, 1918, left sciatic No 22 eufAor^Q 9! H ^ * ^^ °f GqUal length taken from the ri*ht ulnar * d<* silk th™rf t»+ ', J"7" Previ0us' used as transplant. One central and distal fine Chinese n^^thfmornW P + J «?od »PPro™*tion. Wound closed. July 7, rabbit found dead oundIZ Z L ^^^^c changes left heel. On exposing the left sciatic, transplant is found well in place, of light yellow color, of slightly smaller diameter distally and surrounded NEUROSURGERY 1189 by a relatively firm layer of fibrous tissue. Only slight evidence of bulbous enlargement of central sciatic noted. Distal sciatic presents the appearance of a normal nerve. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.—In series of longitudinal and cross sections taken at successive levels, nearly the entire nerve transplant is very clearly demarked by reason of a peculiar silver reaction. Exclusive of the perineural sheaths, and the nerve fibers immediately ad- jacent, the entire transplant is stained a jet-black, making it nontransparent even in sections of 5 microns thickness, so that no structure can be made out in the parts thus stained. In longitudinal sections of the central wound region, numerous neuraxes growing from the central nerve can be traced through the wound tissue to the beginning of the transplant, but appear to pass no distance into the transplant. Certain of these neuraxes deviated to one side and may be traced for a distance of several millimeters in the connective tissue sheath surrounding the transplant. Distal sciatic degenerated. Experiment No. 138.—Rabbit No. 77a; full grown; 48 days. May 20, 1918, right sciatic exposed and resected 2.2 cm. A segment of equal length, taken from the right median of dog No. 22, cut April 29, 21 days previous, used as transplant. One central and distal fine Chinese silk thread suture placed; good approximation central; distal "fair." Wound closed. July 7, rabbit found dead in the morning; neurotrophic changes right heel. On exposing the right sciatic, transplant is found well in place, of light yellow color, of firm con- sistency; united to the resected nerve ends. No material increase of connective tissue found surrounding the transplant. Distinct central bulb noted. Distal sciatic presents the ap- pearance of a degenerated nerve. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.—In longitudinal and cross sections taken at successive levels, trans- plant clearly demarked by reason of its jet-black color after silver staining. Neuraxes from the central sciatic may be observed to grow toward the central end of the transplant, but not to penetrate it. Certain of these neuraxes deviate to one side and can be traced distalward into the connective tissue sheath of the transplant. These relatively few neuraxes can be traced in the connective tissue sheath, in cross and longitudinal sections of the transplant to near the distal wound, where they escape the plane of section. Relatively few neuraxes are again recognized in the distal wound and for a distance of about 2 mm. in the central end of the distal sciatic stump, in longitudinal sections of which only ten to fifteen neuraxes are recognized in one section, all other nerve fibers included in the section degenerated. Experiment No. 139.—Rabbit No. 76; large; full grown; 52 days. May 17, 1918, right sciatic exposed and resected 2 cm. A segment of equal length taken from the right ulnar of dog No. 21, cut April 29, 18 days previous, used as transplant. One central and distal fine Chinese silk thread suture placed; good approximation. Wound closed. July 8, rabbit found dead in the morning; severe neurotrophic changes right heel. On exposing the right sciatic an encapsuled abscess in the region of the transplant found. The transplant appears to have pulled free from distal stump and has almost completely disappeared; only a short segment, of light yellow color, adhering to central sciatic stump. Large bulbous end found on the distal end of central sciatic. Central sciatic and bulbous end removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good silver differentiation attained. Microscopic findings.—In two series of sections, the segment of the transplant remaining, clearly demarked by reason of its jet-black color. In longitudinal sections through the cen- tral bulb and contiguous central end of transplant, it is evident that there was not obtained an end-to-end suture of resected nerve end and transplant, the central end of the transplant having slipped to one side, so that the distal end of the central sciatic stump rests against the perineural sheath of the transplant. A well-developed central bulb is evidenced structurally from the end of which numerous neuraxes grow distalward; meeting the perineural sheath of the transplant, they are diverted from their course and form small convoluted bundles of nerve found in the surrounding connective tissue. Many of the central neuraxes end dis- tallv in large end-discs. In the bulb itself, just central to the wound region, numerous spirals composed of neuraxes may be observed. Central neuraxes can be traced distally for only a short distance. In cross sections of the transplant, 1 cm. distal to the central wound, no neuraxes are found in the connective tissue surrounding the transplant. The distal sciatic was found completely degenerated. surujKi.Y 1190 Experiment No. 140.-Rabbit No. S2; full grown; 62 days. July S, 191S, right sciatic exposed and re ected 2.6 cm. A segment of equal length taken from the external popliteal bundle of the 1 ft sciatic of dog No. 25, cut June 7. 31 days previous, used as a transp ant. One entral and distal waxed, fine silk thread suture placed; good approximation, tt ound closed September *. rabbit found dead in the morning; very severe neurotrophic changes r ght hind oot; foot in part missing; "fungus- ears. On expos ng the ngh sciatic, trans olanti found well in place, of distinct yellow color, thus clearly demarked from resected s fat c ends Transplant found of larger diameter than the sciatic. Well-developed cen ra. Saric bulb noted. Sciatic and nerve transplant removed and fixed in neutral formahn. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun Microscopic findings.-ln a series of longitudinal sections through the distal end of the central stump and the central end of the transplant, it may be observed that nucleated syn- cytial strands of protoplasm extend for a short distance into the central end of the transplant; beyond this region the thickened neurolemma sheaths of the transplantedI nerve fibers arc found and seem to contain granular and globular detritus, and inwandered cells There is observed a distinct small cell infiltration in this region. In the connective tissue to one side of the transplant, protoplasmic syncytial strands, grouped in small bundles, are observed m cross sections. These can not be definitely traced to the distal wound. The distal sciatic found completely degenerated. Experiment No. 141.—Rabbit No. 86; only about one-half grown; 65 days. July 9, 1918 left sciatic exposed and resected 2.5 cm. A segment of equal length taken from the external popliteal bundle of the left sciatic of dog No. 26, cut June 7, 32 days previous, used as transplant. One central and distal waxed, fine silk thread suture placed; distal approxima- tion good; central, good alignment but nerve ends about 2 mm. apart. Wound closed. Septem- ber 12, found dead in the morning; much emaciated; slight neurotrophic changes left heel; pos- terior half of body paralyzed for past few days. On exposing the left sciatic, the transplant is found well in place; clearly demarked by its light yellow color; of good size and consistency and adherent to the underlying muscle. Quite distinct central sciatic bulb noted. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Not satisfactory silver differentiation attained. Microscopic findings.—In sections, transplant clearly demarked by reason of its jet-black coloring. Neuraxes from the central nerve are seen to approach the central end of the trans- plant but do not penetrate it. Certain few neuraxes pass into the connective tissue to one side of the transplant, passing distally in the connective tissue. No new neuraxes are observed as having reached the distal wound. Distal sciatic degenerated. Experiment No. 142.—Rabbit No. 80; full grown; 61 days. July 5, 1918, left sciatic exposed and resected 3 cm. A segment of equal length, taken from the right median of dog No. 26, cut June 7, 27 days previous, used as a transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Adrenalin used to control oozing. Wound closed. September 4, found dead in the morning; seemed in good con- dition; slight neurotrophic ulcer left heel. On exposing the left sciatic, transplant is found well in place, of small diameter and of light yellow color; adherent to the underlying muscle. Distinct bulbous enlargement of the distal end of the central stump noted. The sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fair silver differentiation attained. Microscopic findings.—In longitudinal sections of the central wound region, down- growing neuraxes from the central stump in small number are seen to pass distally to one side of the transplant and enter the conne3tive tissue in which they may be traced not quite to the distal wound region. The region of the transplanted nerve fibers stained jet black; no structural details can be ascertained. Experiment No. 143.—Rabbit No. SOa; full grown; 63 days. July 3, 1918, the right sciatic exposed and resected 3 cm. A segment of the right ulnar of dog No. 26, cut June 6, 27 days previous, used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Adrenalin used to stop oozing; wound closed. Sep- tember 4, rabbit found dead in the morning; seemed in good condition; neurotrophic ulcer right heel. On exposing the right sciatic, transplant is found well in place; clearly demarked NEUROSURGERY 1191 by its light yellow color; is of good size and consistency and is found adherent to the underlying muscle. Distinct central bulb noted. Sciatic and transplant removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun. Microscopic findings.—In longitudinal sections through the central wound region, distinct central bulb evidenced structurally, from the distal end of which nucleated, syncytial, protoplasmic strands can be traced to the connective tissue found to one side of the trans- plant. In longitudinal sections of the transplant, the old neurolemma sheaths of certain of the transplanted nerve fibers seen, these appear thickened and present a wavy or zigzag course, containing a granular and globular detritus. Here and there inwandered leucocytes may be observed. The perineural sheaths present small cell infiltration. The distal nerve completely degenerated. No new nerve fibers found in the connective tissue surrounding the greater length of the transplant. Experiment No. 144.—Rabbit No. 79; full grown; 84 days. June 19, 1918, the left sciatic exposed; internal popliteal freed and resected 3.1 cm. A segment of equal length, taken from the distal ulnar of dog No. 23, cut May 31, 19 days previous, used as transplant. One central and distal waxed, fine silk thread suture placed. Good approximation of nerve ends attained centrally; distally "fair." Wound closed. September 11, rabbit found dead in the morning; scarcely any neurotrophic changes in left hind foot. On exposing the left sciatic, external popliteal found free. The operated internal popliteal presents large central bulb. The transplant found well in place; is of light yellow color, of small diameter, especially in its middle portion; and found adherent to underlying muscle. The nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. The tissues removed in this experiment were lost in process of fixing and staining; no sections made. Experiment No. 145.—-Rabbit No. 79a; full grown; 84 days. June 19, 1918, right sciatic exposed; internal popliteal freed and resected 3 cm. A segment of equal length taken from the right median of dog No. 23, cut May 31, 19 days previous, used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. September 11. Rabbit found dead in the morning; very slight neurotrophic changes right hind foot. On exposing the right sciatic, operated internal popliteal is found to present large bulb along side of which external popliteal is found closely adherent. Transplant found well in place; clearly demarked by reason of light vellow color, and is adherent to underlying muscle. Nerve and transplant removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and light grun. Microscopic findings.—In longitudinal sections of the central wound region, a large, distinct bulb is evidenced structurally, from the distal end of which nerve fibers, in part myelinated, pass to the connective tissue to one side of the transplant. In cross sections of the middle transplant region, the perineural sheaths found distinctly thickened and pene- trated by inwandered cells. Within this sheath necrotic remains of the transplanted nerve fibers are found. To one side of the transplant, and outside of the perineural sheath, numer- ous small funiculi of nerves with certain fibers myelinated are to be observed. In cross and longitudinal sections taken at successive levels, these small bundles of nerves may be traced to the distal wound region, coursing in the connective tissue outside of the transplant; certain few are found to have reached the central end of the distal popliteal, here clearly recognized as small myelinated fibers. Experiment No. 146.—-Rabbit No. 81; full grown; 93 days. July 5, 1918, left sciatic exposed and resected 2.4 cm. A segment of equal length taken from the right median of dog Xo. 28 cut June 7, 28 days previous, used as a transplant. One central and distal waxed, fine silk thread suture placed. Good central approximation attained; distal suture does not include the external popliteal branch. Wound closed. October 6, killed. Rabbit found dying; much emaciated; severe neurotrophic ulcer left heel. On exposing, the left sciatic, transplant is found well in place; is of good size and light yellow color, and only moder- ately adherent to underlying muscle. Only slight spindle-shaped enlargement on central sciatic noted. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine- silver staining, (iood silver differentiation attained. 1192 SURGERY Microscopic findings.—In series of longitudinal and cross sections taken at successive levels, the transplanted nerve segment is clearly demarked by reason of the jet-black color assumed in the silver stain. For a distance of approximately 2 mm., at the central and distal end of the transplant and in the peripheral part, adjacent to the perineural sheath the sub- stance responsible for the peculiar jet-black silver reaction noted, has apparently disappeared, in that in these regions the transplant is colored a yellow brown. In longitudinal sections of the central wound region, certain neuraxes may be traced into central end of the transplant, to the region of the jet-black coloring; here they can no longer be differentiated. Other neuraxes pass to one side of the transplant, to the connective tissue. In cross sections of the transplant, mainly to one side, numerous small bundles of neuraxes are found in the connec- tive tissue sheath. New neuraxes are observed in longitudinal sections of the distal wound region; certain of these appear to enter the distal wound through the transplant, others from the surrounding connective tissue. New neuraxes are found in good number in all of the funiculi of the distal popliteal in the region of the distal wound. Experiment No. 147.—Rabbit No. 81a; full grown; 93 days. July 5, 1918, right sciatic exposed and resected 2.2 cm. A segment of equal length taken from the right ulnar of dog No. 28, cut June 7, 28 days previous, used as a transplant. One central and distal waxed, fine silk thread suture placed; good central and distal approximation. Wound closed. October 6, killed. Rabbit found dying; much emaciated; severe neurotrophic ulcer right heel. On exposing the right sciatic, transplant is found well in place; demarked by its light yellow color. At distal suture transplant appears to have pulled away slightly from distal sciatic stump. Transplant found only moderately adherent to underlying muscle. Quite distinct central bulb noted. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation attained. Microscopic findings.—In series of cross and longitudinal sections, taken at successive levels, it may be observed that certain neuraxes coming from the central sciatic stump, enter the central end of the transplant and may be traced in it for a short distance. How- ever, the majority of the central neuraxes are found to pass into the connective tissue to one side of the transplant and in cross sections of the transplant these are found in the form of small nerve funiculi outside of the perineural sheaths. Neuraxes can be traced through the distal wound into the distal popliteal stump. Certain of these appear to take exit from the distal end of the transplant; these can not be identified more centrally by reason of the jet- black coloring of the greater part of the transplant. The neuraxes found in the distal popliteal appear to be about equally distributed through the several funiculi and can be traced distally to the end of the series of sections approximately 3 cm. beyond the distal wound. Experiment No. 148.—Rabbit No. 83; not quite full grown; 217 days. July 8, 1918, left sciatic exposed and resected 2.0 cm. A segment of equal length taken from the external popliteal of dog No. 25, the sciatic of which was cut June 7, 31 days previous, was used as a transplant. Dog No. 25 stopped breathing while under ether anesthesia, 45 minutes before the nerve was removed. One central and distal waxed, fine silk thread suture passed. Central suture not good; removed and another made; slight trauma of nerve ends; finally central and distal approximation good. Wound closed. February 10, 1919, killed. Rabbit in good condition; part of left hind foot missing; practically healed over; scarcely anv evi- dence of long-standing neurotrophic ulcer left heel. On exposing the left sciatic, a" large central bulb is found. The nerve in region of transplant adherent to underlying muscle. The distal sciatic presents the appearance of a normal nerve. After exposing the calf muscles and the leg flexors, and freeing nerve and transplant from the bed, on slowly cutting the sciatic with scissors, central to the transplant, good contraction of the calf and leg flexor muscles noted; the same on cutting nerve distal to the transplant. The calf muscles have nearlv recovered size, but are of a pale red color. The sciatic and the transplant and portions of the calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Verv good silver differentiation attained. Microscopic findings.-In series of longitudinal and cross sections, taken at successive evels, it is observed that except for two small regions, of about 1.5 mm. in length, near the distal and central ends of the transplant, which are colored jet-black, the remainder of the nerve transplant is colored a light yellow-brown, as is the remainder of the nerve. In longitudinal sections of the central wound region numerous new neuraxes can be traced from NEUROSURGERY 1193 the distal end of the large central bulb into the transplant as well as into the connective tissue surrounding the transplant. In cross sections of the transplant in its middle region many small nerve funiculi, separated by endoneural fibrous tissue, are seen with the perineural sheath of the transplant. There are also found many small nerve bundles in the connective tissue outside of the perineural sheaths of the transplant. New neuraxes can be traced to and through the distal wound into the distal sciatic. In cross sections of the internal pop- liteal, taken at the lower level of the popliteal space, new neuraxes in large numbers are found in all of its several funiculi. In sections of the calf muscles new neuraxes in good relative numbers are found in the interfascicular muscle nerves and as single fibers on and between muscle fibers; motor endings and nerve endings in neuromuscular spindles are observed. Experiment No. 149.—Rabbit No. 84; Belgian hare; not quite full grown; 240 days. July 9, 1918, right sciatic exposed and resected 2.2 cm. A segment of equal length, taken from the right ulnar of dog No. 26, cut June 7, 32 days previous, used as a transplant. One central and distal waxed, fine silk thread suture passed; good approximation. Diameter of the degenerated ulnar segment slightly greater than that of the resected sciatic. Adren- alin used to obtain dry field; wound closed. March 6,1919, killed. Rabbit in good condition. No neurotrophic ulcer on right heel. On exposing the right sciatic a large central bulb is found on the central sciatic. Transplant is found of light yellow color, of good size and adherent to underlying muscles. The distal sciatic presents the appearance of a normal nerve. After exposing the calf muscles and freeing the sciatic from bed, on slowly cutting with scissors, sciatic central to the transplant, good contraction of calf muscles observed. Calf muscles are found to have nearly recovered size but are of pale red color. Sciatic and the transplant and portions of the calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good differential silver staining attained. Microscopic findings.—In series of longitudinal and cross sections taken at successive levels the transplanted nerve segment is clearly demarked by reason of the jet-black coloring assumed by the transplanted nerve tissue. In longitudinal sections of the central wound region numerous central neuraxes can be traced to the periphery, mainly in the connective tissue outside of the transplant, as clearly seen in cross sections, taken about midway between central and distal wounds, in which two areas, situated at opposing sides of the transplant, there are found in the connective tissue numerous small bundles of nerve fibers situated outside of the perineural sheaths. Whether any neuraxes pass through the transplant can not be determined by reason of the jet-black coloring of the nerve bundle remains of the transplant. New neuraxes are observed in the distal wound and in the central end of the distal sciatic, in which they are found evenly distributed through the several funiculi. In sections of the calf muscle new neuraxes are found in the interfascicular nerve bundles, and here and there as single nerve fibers on and between muscle fibers. As concerns degenerated auto-nerve transplant, Experiments No. 126 to No. 128, while only three in number, they may serve to show that a degenerated nerve can serve the purpose of an auto-nerve transplant though there is no indication that regeneration from the central stump through such a transplant takes place more readily than when an undegenerated auto-nerve transplant is used. Indeed the results attained are, on the whole, less satisfactory, if one may judge from the relatively few experiments. There are relatively more extrafunicular nerve fibers in the experiments in which a degenerated auto- nerve transplant was used than in the experiments in which cable-auto-nerve transplants were made. In the series of five experiments (No. 129 to No. 133) in wliich degenerated homo-nerve transplants were used, the end results were on the whole very satisfactory and may compare very favorably with the end results in experi- ments in wliich a homogenous transplant was made, using a fresh nerve. Atten- tion is especially called to Experiment No. 131, terminated 37 days after the operation. A nerve segment 3.4 cm. in length, taken from the distal portion of H94 SUKGEHY a nerve cut 27 days previously, was used as a nerve bridge. In this experiment, numerous down-growing neuraxes are readily determined within the funiculi of the transplant; relatively few new nerve fibers are extra-funicular. In Experi- ment No. 132, a little over four months' duration, it was possible to trace new neuraxes to the foot interossei muscles, with good return of function. It is not likely that a degenerated nerve would be available for an auto-nerve transplant, in human surgery. It is quite within the bounds of possibility that a degenerated nerve from another individual, one to several months after injury, may be available for bridging a nerve defect, in which event it may be stated that experimental evidence warrants the use of a degenerated homo-nerve transplant. In nerve defect bridged by degenerated auto- and homo- nerve transplants, the down-growing central neuraxes make use of the patent or semipatent neuro- lemma sheath of the transplanted nerve fibers. There is no evidence that the transplanted syncytial nucleated strands stand in any definite relation to the down-growing neuraxes. since these strands undergo change, degenerate, after transplantation. The experiments on degenerated hetero-nerve transplants (No. 134 to No. 140) did not substantiate the conjecture that the less specifically differentiated protoplasm of the "bandfasern", which may be regarded as in a measure repre- senting a reversion to embryonic structure, offered a better avenue for the down growth of central neuraxes than would an undegenerated nerve trans- plant of the heterogenous origin. It may be noted that in the majority of the experiment protocols the notation is made that the transplant presents a light yellow color when the nerve is exposed some time after the operation. This enables ready demarkation of the transplant and is indicative of a necrobiotic change, involving not only the transplanted nerve fibers but the fibrous tissue1 sheaths of the nerve funiculi. The products of this necrobiotic change show a peculiar reaction to the pyridine-silver stain in that they assume a jet-black color, in which no tissue elements can be made out, and would mask any neu- raxes in case they were present. This series of sixteen experiments need not be discussed seriatim; they range in time after operation from 7 days to 244 days. The results may be summarized by stating that a degenerated hetero-nerve transplant was found less serviceable than a nondegenerated nerve transplant of heterogenous origin owing to the fact that a degenerated hetero-transplant undergoes further change of necrobiotic nature, resulting in the formation of tissue detritus which appears to offer an effective block to the down-growing neuraxes. Whether this block is largely of a mechanical or to a large part of a chemical nature has not been determined. In all of the experiments under observation after the initial operation for more than 45 days, down-growing neuraxes could be traced into the central wound, but no distance into the trans- plant. Numerous neuraxes could be traced into the connective tissue surround- ing the transplant, thus having extrafunicular position. Only in a few experi- ments were nerve-fibers in number found within the nerve funiculi of the trans- plant. Cross sections of the transplant region with good differential neuraxis staining are necessary to determine the relative position of the neuraxes, whether extrafunicular or intrafunicular, the latter indicating the efficacy of the trans- plant. NEUROSURGERY 1195 STORED HOMO-NERVE TRANSPLANTS SERIES NO. 11 HOMO-XERVE TRANSPLANTS, STORED TN STERILE VASELINE SERIES NO. 12 HOMO-NERVE TRANSPLANTS, STORED IN LIQUID PETROLATUM SERIES NO. 13 IIOMO-NERVE TRANSPLANTS, STORED IN 50 PER CENT ALCOHOL In these series of stored homogenous transplants, totaling 67 experiments, we present a body of experimental observations, which we regard as of crucial importance in determining the true function of a nerve transplant. In none of these experiments can the transplant be regarded as being in the state of a living tissue. The experiments under Series No. 11 were suggested to us through the publication of Dujarier and Francois,76 who reported briefly a series of 20 cases in which homogenous nerve transplants, stored in vaseline, were used to bridge nerve defects. Dujarier and Francois recommended that nerves removed from amputated limbs under aseptic precautions be placed in sterile vaseline and kept at nearly 0° temperature. In their work as reported, nerves were kept in this way for 41 days. Before use the vaseline was warmed to melting, the nerve segment removed and rinsed in warmed serum, then sutured between the severed nerve ends. In the cases reported, healing took place by primary intention. Not enough time had elapsed from the time of operation to the time of the publication to make a report on the ultimate results. At the time our observations were undertaken we were not aware of any experimental observations in which stored nerve transplants had been used. We followed as closely as possible the method as briefly outlined by Dujarier and Francois. The sciatics of large and full grown rabbits were removed under aseptic precautions, placed in large tube vials containing sterile melted vase- line, after which the tube vials were plugged with sterile cotton plugs. The tube vials were then placed in a small ice chest regulated to 3° C, in which they remained for periods varying in the several experiments from 9 days to 13 days. The nerves thus stored were used to bridge defects in the sciatics of rabbits caused by resection. Just before use the vial containing the nerve to be selected for the experiment was carefully warmed to an extent sufficient to melt the vaseline. The contained nerve segment was then removed and rinsed in warmed sterile serum, and a segment of proper length cut and sutured to the resected stumps of a rabbit's sciatic nerve. One fine, waxed silk suture was placed centrally and distally. The experimental operations are relatively simple. A nerve segment stored in vaseline is readily manipulated; the small amount of vaseline clinging to the nerve was disregarded at the operation, since it seemed to play no special part in the healing of the wound. The necessary warming of the vaseline, so that the nerve segment may be readily removed with possibility of overheating the nerve segment, more particularly the washino- of the nerve segment in serum, seemed to be objections to the 1196 SURGERY method as suggested by the French observers. It occurred to us that the same ends might be attained by using liquid petrolatum as a medium for stor- ing nerve segments. This method of procedure was tested in Series No. 12, 40 experiments, in which homogenous nerve transplants stored in liquid petro- latum were used. In our experiments we used Squibb's liquid petrolatum, which is a clear, bland fluid. The required quantity was placed in large tube vials, corked with cotton plugs and autoclaved on successive days. After cooling to room temperature the tube vials were placed in a small ice chest regulated to 3°C. The sciatics of rabbits were removed under asepsis, placed in sterile cooled liquid petrolatum and stored in the ice chest until required for operation, for periods varying from 7 days to 39 days in the several experi- ments. Before an experiment the tube vial containing the nerve selected was taken from the ice chest and placed in the operating room, and when required the nerve segment was taken from the tube vial by means of forceps and, grasping the nerve segment at one end, was allowed to drain for a few minutes. The sutures were then placed at requisite distance and the nerve cut about 2 mm. distal to the suture and the nerve transplant sutured proximally and distally to the resected nerve ends. Nerve segments stored in liquid petrolatum have good consistency four to five weeks after removal from the animal and have nearly the same appearance as a normal nerve. The excess of liquid petrolatum drains off very readily; the thin coating clinging to the nerve transplant plays no part in the healing of the wound, so far as can be determined. It was our experience that storing of nerves in liquid petrolatum, as used by us, was much to be preferred to storing in vaseline as suggested by Dujarier and Francois. Homogenous nerves transplants stored in 50 per cent alcohol were used in a further series of experiments (Series No. 13). The suggestion for this series of experiments came quite indirectly from observations published by Nageotte.77 Nageotte had determined as a result of bilateral experimental operations on the sciatics of six dogs, in which on one side direct suture of the severed sciatic was made, while on the other side a 5 mm. long hetero-nerve transplant which had been stored in 50 per cent alcohol for some time was interposed between the severed ends of the cut sciatics and sutured in place, that better results could be reported in certain experiments for the side in which the short heterogenous nerve segment stored in alcohol was used. In Nageotte's experiments the heterogenous nerve was obtained from the slaughter house, placed in 50 per cent alcohol in sealed tubes, some of which were kept as long as 15 months. In our experiments the sciatics of full grown rabbits were removed under aseptic precautions and placed at once in 50 per cent alcohol, in sterile, wide-mouthed glass-stopped bottles, in which they were kept for periods varying from 7 days to 29 days. In the 50 per cent alcohol the nerve trunk becomes hardened, though not brittle, and of course can not be regarded as tissue retaining latent viability. Just before use as nerve transplants the nerve segments were taken from the alcohol and placed for 10 to 20 minutes in warmed, sterile, normal salt solution, in which, after a short stay, the nerve again becomes quite pliable. The nerve segments were taken from the normal salt solution, the sutures placed at requisite distance, the ends freshened by cutting with sharp scissors about 2 mm. beyond the suture lines, and NEUROSURGERY 1197 the operation completed by placing the alcoholized transplant between the resected sciatic stumps and sutured in place by making one central and one distal suture with fine silk thread waxed with sterile wax. The nerve seg- ments stored in alcohol, after a short stay in the saline solution, are of good consistency and lend themselves readily to operative technique; sutures pass easily; end-to-end approximation is easily made. In our experimental work, nerve segments were stored in 50 per cent alcohol for about four weeks and at room temperature; they were kept in a dark cabinet. We have no observa- tions indicating that nerve segments might not be stored in 50 per cent alcohol for a period of four months or more and then used as nerve transplants. This method of storing nerve transplants is so simple, the necessary precautions so easily met, that this method should commend itself as at least worthy of further experimental test. Protocols of experiments under Series No. 11, No. 12, and No. 13, homo-nerve transplants stored in vaseline,liquid petrolatum, and 50 per cent alcohol follow: PROTOCOLS Experiment No. 150.—Rabbit No. 97; large; full grown; 66 days. October 4, 1918, left sciatic exposed, internal popliteal bundle freed and resected 3 cm. For nerve transplant there was used the internal popliteal bundle of another rabbit, removed nine days previous and stored in sterile vaseline at a temperature of 3° C. Just before use as transplant, the nerve segment washed for some minutes in sterile rabbit's serum. One central and one distal waxed fine silk suture placed. Good central and distal approximation of nerve ends attained. Dry field. Wound closed. December 8, rabbit found dead in the morning. Wound well healed. On exposing left sciatic no material increase of connective tissue about nerve and transplant noted. Transplant found well in place. Indistinct central bulbous enlargement; no material enlargement of central end of distal internal popliteal stump. Xerve and transplant not adherent to muscle bed. Central and distal popliteal and trans- plant removed and fixed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.—Numerous down-growing neuraxes can be traced from the distal end of the central stump, through central wound to proximal end of transplant. Through this neuraxes can be traced in good number to and through distal wound to proximal end of the distal internal popliteal. In cross sections of the transplant neuraxes are found in small groups, separated by small areas containing vesicular cells and tissue detritus. Experiment No. 151/—Rabbit No. 97a; large; full grown; 66 days. October 4, 1918, right sciatic exposed, internal popliteal bundle freed and resected 3 cm. A nerve segment of equal length, taken from the sciatic of another rabbit, stored in sterile vaseline nine days at 3° C. temperature, washed in sterile rabbit's serum several minutes, used as transplant. One central and one distal waxed, fine silk suture placed; good nerve-end approximation attained. Dry field. Wound closed. December 8, rabbit found dead in the morning. Wound well healed. Small neurotrophic ulcer right heel. Right sciatic exposed. Transplant found well in place. Only indistinct central bulbous enlargement. No material increase of connective tissue about nerve and transplant. Nerve and transplant removed and fixed in 5 per cent neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grim. Microscopic findings.—Structurally considered, quite well defined central bulbous enlargement from the distal end of which many small nerve fibers nucleated, syncytial strands of protoplasm can be traced into the proximal end of the transplant and through this to the distal wound. Certain of the nerve fibers within the nerve transplants present thin myelin sheaths. The great majority of the new nerve fibers found within the trans- plant are arranged in the form of small bundles of narrow bands, here and there anastomos- ing, and separated by small areas or columns of vesicular cells and tissue detritus. The endoneural and perineural connective tissue not materially increased. \l\)S SURGERY Experiment No. 152.—Rabbit No. 99; medium size; full grown; s«. days. October 7, 191S left sciatic exposed, internal popliteal bundle freed and resected 3.0 cm. A nerve segment of equal length taken from the sciatic of another rabbit, stored 13 days in sterile vaseline, temperature 3° C, used as transplant. One central and one distal suture of waxed, fine silk thread placed. Good central and distal nerve-end approximation attained Dry field. Wound closed. January 4, 1919, rabbit found dead 1p.m.; living in the morning. Moderate emaciation; neurotrophic ulcer left heel. Wound well healed. Left sciatic exposed full length. External popliteal bundle found adherent along central wound. Trans- plant found well in place; small spindle-shaped central bulbous enlargement. Transplant found slightly adherent to underlying muscle; of light gray color and not quite as glistening as normal nerve. Distal wound not distinctly made out. Central and distal sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.—Good differential neuraxis staining attained. From the distal end of central bulbous enlargement which embraces central end of the transplant, numerous neuraxes are traced through the transplant, to and through the distal wound and into the proximal end of the distal popliteal stump in which for several centimeters well differentiated neuraxes are found in large numbers. In cross sections of the transplant, the new neuraxes present are found in the form of small funiculi separated by strands of endoneural connective tissue. Here and there small groups of vesicular cells, inclosing what appear to be lipoid globules, are noted. Distal internal popliteal well regenerated. Experiment No. 153.—Rabbit No. 99a; medium size; full grown; 89 days. October 7, 191S, right sciatic exposed, internal popliteal bundle freed; resected 3.2 cm. A segment of equal length taken from the sciatic of another rabbit, stored in sterile vaseline, at a tem- perature of 3° C. for 13 days, used as transplant. One central and one distal waxed, fine silk thread suture placed. Good central and distal approximation attained. Dry field; wound closed. January 4, 1919, rabbit found dead 1 p. m.; nerve removed at once. Mod- erately emaciated; slight neurotrophic ulcer right heel. Wound well healed. Right sciatic exposed full length. Transplant found well in place; clearly demarked by presence of central and distal suture. Small spindle-shaped, central, bulbous enlargement. External popliteal bundle not adherent to underlying muscle. No appreciable distal enlargement. Central and distal sciatic and transplant removed and fixed in 5 per cent neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht griin. Microscopic findings.—-Quite distinct central bulbous enlargement evidenced structur- ally, from the distal end of which many fine, myelinated nerve fibers and nucleated, proto- plasmic, syncytial strands pass through the transplant to the distal wound. In cross sections of the transplant about 1 cm. distal to central wound, one large funiculus and two small funiculi of the transplant almost completely filled with new nerve fibers with only here and there small areas of tissue detritus and vesicular cells evident. The perineural sheaths of the transplanted nerve funiculi well maintained and only slightly thickened. Apparent regener- ation through transplant; used histologic methods do not enable full determination of distal growth of new neuraxes. Experiment No. 154.—Rabbit No. 98; large; full grown; Belgian hare; 96 days. October 5, 1918, left sciatic exposed, internal popliteal freed; resected 2.5 cm. A segment of equal length, taken from the sciatic of another rabbit, stored in sterile vaseline, tem- perature 3° C, 11 days, used as nerve transplant. One central and one distal suture of waxed, fine silk thread placed. Only fair central and distal nerve-end approximation at- tained. Dry field; wound closed. January 9, 1919, killed. Rabbit much emaciated; "fungus" ears; severe neurotrophic ulcer left heel; on the whole quite active. Wound well healed. Left sciatic exposed full length. External popliteal bundle found quite free. Large spindle-shaped central bulbous enlargement noted on central internal popliteal stump; slight enlargement of the central end of distal stump. Transplant well in place; light gray color, not adherent to underlying muscle. Unoperated external popliteal bundle resected and removed. Calf muscles fully exposed; operated internal popliteal and transplant com- pletely freed from bed. On slowly cutting with scissors sciatic central to transplant doubtful, feeble contractions of calf muscles. On cutting internal popliteal lower level of popliteal space, feeble contraction of calf muscles; uncertain. Central and distal sciatic and trans- XEUROSURGERY 1199 plant and pieces of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.—Only fair silver differentiation attained; calf muscles silver staining good. Distinct central bulbous enlargement evidenced structurally from the distal end of which numerous new neuraxes pass through the transplant to the distal popliteal nerve. In sections of the calf muscles, numerous new neuraxes found in the larger muscular branches, relatively fewer in the smaller interfasicular branches and here and there single nerve fibers seem to pass to muscle fibers. Muscle fibers of small diameter, but show dis- tinct cross striations. Muscle capillaries very numerous and very tortuous. Regeneration of distal popliteal to muscular branches of the calf muscle, beginning recovery of motor function of these muscles. Experiment No. 155.—Rabbit No. 98a; large; full grown; Belgian hare; 96 days. October 5, 1918, right sciatic exposed; internal popliteal bundle freed; resection 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored 11 days in sterile vaseline at 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed; quite good approximation of nerve ends attained. Dry field; wound closed. January 9, 1919, killed. Rabbit much emaciated; "fungus" ears; severe neurotrophic ulcer right heel. Wound well healed. Right sciatic exposed full length. External popliteal bundle quite free; resected and removed. Operated internal popliteal bundle shows the transplant well in place, of good size and light gray color. Large, spindle-shaped central bulbous enlargement noted. After fully exposing the calf muscles and freeing the internal popliteal bundle from bed, on slowly cutting with scissors, the nerve central to transplant, no distinct twitching of calf muscles; the same on cutting distal to transplant. Operated nerve with transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation fair; calf muscles good. Microscopic findings.—Large central bulb evidenced structurally, from the distal end of which numerous new neuraxes may be traced through the transplant to the distal segment. In sections of calf muscles, numerous new neuraxes noted in the muscular nerves; a few of these may be traced between muscle fibers. Distal regeneration to and into the calf muscles. Experiment No. 156.—Rabbit No. 100; large; full grown; 155 days. October 8, 1918, left sciatic exposed; internal popliteal bundle freed and resected 3.0 cm. A segment of equal length taken from the sciatic of another rabbit, stored 12 days in sterile vaseline, temperature 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed. Good central and distal nerve-end approximation attained. Dry field; wound closed. March 12, 1919, killed. Rabbit in very good condition; neurotrophic ulcer healed; left foot appears normal; walks well, except now and then toe-drop; spreads toes of left foot on holding up by ears. Left sciatic exposed the whole length; external popliteal bundle free; resected and removed. Internal popliteal in operated region has the appearance of a normal nerve; scarcely any evidence of central bulb; no enlargement at the distal wound. Transplant not adherent; no material increase of connective tissue surrounding operated nerve. After exposing the calf muscles and removing skin to heel and completely freeing the operated nerve, on slowly cutting the nerve central to the transplant, vigorous and repeated contraction of calf muscles and apparently foot muscles; the same on cutting nerve distal to transplant. Operated nerve removed and fixed in ammoniated alcohol for pyridine-silver staining; portions of calf muscles removed for gold chloride method of stain- ing nerve terminations. Differential silver staining only of a portion of the nerve good. Microscopic findings.—Transplant well united to resected nerve ends; scarcely any evi- dence of central and distal wounds; these demarked by retained silk sutures. New neuraxes in great numbers pass through transplant to the distal nerve. For the transplanted nerve segment, the perineural sheaths of the funiculi well maintained. Within the funiculi the new neuraxes arranged in small groups, separated by endoneural connective tissue, much more extensive than in normal nerve. An attempt was made to endeavor to stain the motor nerve ending in gold chloride. This attempt not successful. In certain of the large muscular nerve bundles the neuraxes beautifully differentiated even into the smaller branches, but motor ending not differentiated. It seems clear that this is due to faults in the method, 4(>9!»7—27----7S 1200 SURGERY perhaps impurity of chemical used. Very complete regeneration of distal nerve through the transplanted nerve segment. Experiment No. 157.—Rabbit No. 100a; full grown; 155 days. October 8, 1918, right sciatic exposed; internal popliteal bundle freed and resected 3.0 cm. A segment of equal length taken from the sciatic of another rabbit, stored 12 days in sterile vaseline at 3° C. used as transplant. One central and distal suture of waxed, fine silk thread placed. Central suture nerve-end approximation good; distal not good. Slight manipulation caused this distal suture to give way. Another suture placed; slight traumatism of nerve end, otherwise approximation good. Fairly dry field; wound closed. March 12, 1919, killed. Rabbit very good condition; small neurotrophic ulcer right heel. Right foot otherwise normal; spreads toes on holding up by ears. Left sciatic exposed the full length. External popliteal free full length; resected; removed. Operated internal popliteal presents scarcely any evidence of central bulb; transplant well in place; good color; good size. After exposing fully the calf muscles and freeing internal popliteal, on slowly cutting nerve central to trans- plant, good contraction of calf muscles. Operated nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining; calf muscles removed for gold chloride staining. Silver differentiation of neuraxes fairly good. Microscopic findings.—Transplant well united to resected nerve ends; only slight struc- tural evidence of central bulbous enlargement. New neuraxes in large numbers traced through transplant to distal nerve. In the transplant these new neuraxes arranged in the form of small bundles separated by endoneural connective tissue. An attempt made to stain the motor endings in gold chloride not successful. Numerous neuraxes found in the larger and smaller nerve branches clearly differentiated, but not motor endings. The muscle fibers present the size and structure of normal muscle fibers. Very good regeneraton of distal nerve through the transplant. Experiment No. 158.—Rabbit No. 108; large; full grown; 1 hour. December 17, 1918, left sciatic exposed; internal popliteal bundle freed; resected 3.0 cm. A segment of equal length taken from the sciatic of another rabbit, stored seven days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal waxed fine silk thread suture placed; good approximation attained. Wound closed. As soon as wound was closed rabbit stopped breathing and could not be revived. Wound was reopened and the sciatic and transplant removed, about one hour after the operation was completed, and fixed in ammoniated alcohol for pyridine-silver staining. Experiment is recorded, since it enabled examining histologi- cally a nerve stored in liquid petrolatum immediately after it had been placed in the wound. Good differential silver staining. Microscopic findings.—The appearance presented in cross and longitudinal sections of the transplant, embedded in living tissue only about one hour, mav be regarded as essentially the same as that of a nerve stored in liquid petrolatum for a period and examined before transplantation. The sections obtained present in essentials the appearance presented by a fresh nerve fixed and stained after the pyridine-silver method. Especially is this true of cross sections. In longitudinal sections the neuraxes are seen as unsegmented strands of regular contour. The << Golgi-funnels" of the myelin, are distinctly evident though not quite so regular as in a fresh, normal nerve. The sheath cells were not differentiated. Experiment No. 159.-Rabbit No. 108a; large; full grown; 1 hour. December 17, 1918 right sciatic exposed; internal popliteal freed; resected 3.0 cm. A segment of equal ength removed from the sciatic of another rabbit, stored seven days in sterile liquid petrola- tum at 3 C. used as transplant. One central and one distal waxed, fine silk thread suture placed. Good approximation attained. Wound closed. Rabbit stopped breathing while this operation was being completed and could not be revived. About one hour after the operation was begun sciatic and the transplant removed and fixed in neutral formalin. stained in iron-hematoxylm and picro-fuchsin and in safranine and licht grim an,,.-¥^co^'c^^s--i 088 and longitudinal sections of the transplant present appear- lTZtltZTSTTy ^f ^f °f " n°rmal nerVG fixed and stained as above indicated. mentZ Z * n i ^+ ^^ the nerve fibers have not «> compact an arrange- "erve fibers iT iT, ^ ^ ^ themselv<* have the appearance of normal nerve fibers. In longitudinal sections, the fibers present a regular contour, the neuraxes even XEUROSURGERY 1201 borders and are not shrunken; the neurokeratin net of the myelin, very regular and distinct. The sheath nuclei present normal form and size and reaction to stains. Experiment No. 160.—Rabbit No. 105; full grown; Belgian hare; 2 days. November 8, 1918, left sciatic exposed; internal popliteal freed; resected 3.0 cm. A segment of equal length taken from the sciatic of another rabbit, stored 38 days in liquid petrolatum at 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed; good approximation attained. Wound closed. November 10, rabbit found dead in the morning. Wound clean; healing. Left sciatic exposed. Quite a large blood clot over nerve region of central wound. Nerve sutures in place. Ends of transplant and resected nerve ends not as yet united. Sciatic and transplant removed and fixed in neutral formalin. Stained in iron-hematoxylin, picro-fuchsin and safranine and licht grun. Microscopic findings.—In both cross and longitudinal sections of the transplant, it may be observed that the transplanted nerve fibers retain their form and structure very well. The neuraxes are not segmented, the myelin sheaths show clearly a neurokeratin net, the sheath nuclei distinctly evident and stain readily, though of more uniform color than normal nuclei. Experiment No. 161.—Rabbit No. 105a; full grown; Belgian hare; 2 days. Novem- ber 8, 1918, right sciatic exposed; internal popliteal freed; resected 2.8 cm. A segment of equal length taken from the sciatic of another rabbit, stored in liquid petrolatum 38 days at 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed; good approximation. Wound closed. November 10, rabbit found dead in the morning. Wound clean; healing. Right sciatic exposed. Nerve transplant found well in place, not adherent to resected nerve ends and surrounding tissues. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.—Silver staining not successful; no differentiation of neuraxes in normal central stump. In the transplanted nerve the neurolemma sheaths differentiated; These appear slightly thickened; other structures not clearly differentiated. Experiment No. 162.—Rabbit No. 106; full grown; 2 days. November 8, 191S, left sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored 38 days in liquid petrolatum at 3° C, used as transplant. Central and distal waxed, fine silk suture placed; good approximation. Wound closed. November 10, rabbit found dead in the morning. Sciatic and transplant removed and fixed in neutral formalin. Stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun. Microscopic findings.—Nerve fibers of the transplant very well preserved. No segmen- tation of the neuraxes of nerve fibers of the transplant noted. In many of the nerve fibers neurokeratin net of the myelin well stained, in others no longer evident. Sheath nuclei evident and well stained. Transplant loosely adherent to resected nerve ends. Centrally very little inwandering of leucocytes into the nerve transplant. Centrally and distally, hemor- rhage into resected nerve ends. As yet no evidence of degeneration of the nerve fibers of the distal nerves. Experiment No. 163.—Rabbit No. 106a; full grown; 2 days. November 8, 1918, right sciatic exposed; internal popliteal bundle freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored in liquid petrolatum 38 days at 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed; approximation good. Wound closed. November 10, rabbit found dead in the morning. Sciatic and trans- plant removed and fixed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.—In cross sections of the nerve transplant, neuraxes differentially stained though of paler color than in normal nerve; neurolemma sheaths stand out clearly and appear as if slightly thickened. Experiment No. 164.—Rabbit No. 102; full grown; 4 days. November 4, 1918, left sciatic exposed; internal popliteal freed; resected 2.8 cm. A segment of equal length taken from the sciatic of another rabbit, stored in sterile petrolatum 35 days at 3°C, used as trans- plant. One central and one distal waxed, fine silk thread suture placed; good approximation. Wound closed. November 8, rabbit found dead in the morning. Superficial wound clean and dry nearlv healed. Left sciatic exposed. Transplant found well in place; sutures show 1202 SURGERY clearly. Transplant presents a light yellow-white color; not adherent to underlying muscle; loosely united to the resected nerve ends. Resected nerve ends appear congested. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining- Fair differential silver staining attained. Microscopic findings.—In the transplanted nerve segment, both in cross and longitudinal sections, the neuraxes still evident, though staining very lightly, the majority not as yet frag- mented; certain ones showing a granular change. Neurolemma sheaths well maintained, and appear slightly thickened. Neurokeratin net and Golgi funnels not clearly seen. In the central end of the transplant are seen a number of distended capillaries, grown into the trans- plant from the central nerve stump. These capillaries have only endothelial walls and are distended with blood cells and have grown toward the periphery between the nerve fibers of the transplant. The distal segment presents evidence of early stages of nerve degeneration. Experiment No. 165.—Rabbit No. 102a; full grown; 4 days. November 4, 1918, right sciatic exposed; internal popliteal freed; resected 2.8 cm. A segment of equal length taken from the sciatic of another rabbit and stored in sterile liquid petrolatum 35 days at 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed; good approxi- mation. Wound closed. November 8, rabbit found dead in the morning. Superficial wound found clean and dry and nearly healed. Right sciatic exposed. Transplant found well in place, of yellow-white color, nonadherent and loosely united to the resected nerve ends. Sciatic and transplant removed and fixed in neutral formalin. Stained in iron-hematoxylin and picro-fuchsin; safranine and licht grim. Microscopic findings.—In cross and longitudinal sections of the nerve transplant, the nerve fibers found to be very well maintained; neuraxes present and not fragmented. The neurokeratin net of myelin only here and there clearly brought out. The neurolemma sheaths not collapsed, and of regular contour. Neuraxes of the transplant seen best preserved in the •immediate vicinity of the central and distal wounds; in these regions stain much more clearly than in the body of the transplant. Nerves of the distal segment show beginning stages of degeneration evidenced in fragmentation of the myelin. Experiment No. 166.—Rabbit No. 117; full grown; 4 days. December 27, 1918, left sciatic exposed; internal popliteal freed; resected 3.1 cm. A segment of equal length taken from the sciatic of another rabbit, stored 13 days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed; good approximation. Wound closed. December 31, rabbit found dead in the morning. Super- ficial wound healed. On removing skin over operated field, bloody exudate in subcutaneous tissue about wound and in deeper wound about transplant noted. Transplant found well in place; not adherent to surrounding tissue, loosely united to resected nerve ends. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. In part very good silver differentiation attained. Microscopic findings.—In longitudinal sections of the transplanted nerve segment, it may be observed that the neuraxes are undergoing changes; many appear fragmented into longer or shorter segments, of distinctly granular structure. The neurolemma sheaths well maintained, though in many fibers showing alternate slight distensions or constrictions. Capillaries coming from the central nerve stump extend nearly the whole length of the nerve transplant. Distal nerve shows earlv stages of degeneration. Experiment No. 167.-Rabbit No. 117a; full grown; 4 days. December 27, 1918, right sciatic exposed; internal popliteal freed; resected 3.2 cm. A segment of equal length taken from the sciatic of another rabbit, stored 13 days in sterile liquid petrolatum at 3° C. used as transplant. One central and one distal waxed, fine silk suture placed; good approxi- mation. Diameter of transplant smaller than that of the resected nerve. Wound closed. December 31, rabbit found dead in the morning. Superficial wound found healed. Right sciatic exposed. Transplant found well in place; but surrounded by a blood clot. Sciatic and transplant removed and fixed in neutral formalin. Stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun. Microscopic findings.-In cross and longitudinal sections of the transplanted nerve segment it is observed that the neuraxes are beginning to show a fragmentation. These fragments of neuraxes are found inclosed in myelin segments in which the neurokeratin net XEUROSURGERY 1203 is still evident, and are found within neurolemma sheaths. No evidence of proliferation of the sheath cells of the transplanted nerves ascertained. Capillaries containing blood cells, and extravasated blood cells found between the nerve fibers of the transplant. In the distal segment, beginning fragmentation of neuraxes and myelin; hypertrophy of the sheath cells noted; here and there these fill the neurolemma sheaths; as yet no distinct proliferation of the sheath cells observed. Experiment No. 168.—Rabbit No. 127; full grown; 5 days. March 4, 1919, left sciatic exposed; internal popliteal freed; resected 3.1 cm. A segment of equal length taken from the sciatic of another rabbit, stored twenty-one days in liquid petrolatum at 3° C, used as trans- plant. One central and one distal waxed, fine silk thread suture placed. Good central approximation attained; distal only fair. Wound closed. March 9, rabbit found dead in the morning. Transplant found well in place, easily demarked by sutures; united to resected nerve ends; not adherent to surrounding tissue. Sciatic and transplant removed and fixed in neutral formalin. Stained in safranine and licht grun. Microscopic findings.—In longitudinal sections of the transplanted nerve segments fragmentation of neuraxes noted; these fragments have a granular structure. The neuro- lemma sheaths well maintained but of irregular contour. Long, rod-shaped nuclei are found in relation with the nerve fibers. It is difficult to determine whether these nuclei are within the neurolemma sheaths or situated on their outer surface. The appearances presented in cross sections of the transplant enable the determination that the majority of these nuclei are situated between the nerve fibers, thus outside of the neurolemma sheaths and of connective tissue derivation. Numerous wandering leucocytes found between the nerve fibers of thf transplant in the immediate vicinity of both the central and distal wounds. Experiment No. 169.—Rabbit No. 112; full grown; 6 days. December 21, 191S, left sciatic exposed; internal popliteal freed; resected 2.3 cm. A segment of equal length taken from the sciatic of another rabbit, stored nine days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed. Central suture not good; removed and resutured; approximation fair; distal good. Wound closed. December 27, rabbit found dead in the morning. Superficial wound healed; deep wound, blood clot about transplant. Central suture not good. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. In part good silver differentia- tion attained. Microscopic findings.—New neuraxes budding from central stump; neuraxes can be traced into the central wound; these not as yet numerous. In the transplant, the neuraxes of the transplanted nerves found for the greater part in the form of short segments having wavy or spiral course. Neurolemma sheaths well maintained and of regular contour. Begin- ning stages of nerve degeneration noted in the distal segment. Experiment No. 170.—Rabbit No. 112a; full grown; 6 days. December 21, 1918, right sciatic exposed; internal popliteal freed; resected 2.6 cm. A segment of equal length taken from the sciatic of another rabbit, stored nine days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal waxed, fine silk suture placed; good approximation; small hematoma under fascial tissue in popliteal space. Wound closed. December 27, rabbit found dead in the morning. Wound well healed. On exposing sciatic, transplant found well in place and united to the resected nerve ends. Sciatic and transplant removed and fixed in neutral formalin. Stained in iron-hematoxylin and picro-fuchsin, safranine and licht grun. Microscopic findings.—In longitudinal sections of the transplanted nerve segment, the neuraxes of the transplanted nerves appear fragmented in short segments. These segments are here and there swollen and globular and for the most part inclosed in myelin in which a neurokeratin net is still evident. The neurolemma sheaths are well maintained. Within these sheaths are found the myelin segments and neuraxes segments shrunken in longi- tudinal direction leaving spaces in which a granular precipitate is seen. Sheath cells not evident. Capillaries course between the nerve fibers of the transplant. Distal segment found degenerating. Experiment No. 171.— Rabbit No. 109; full grown; Belgian hare; 12 days. December 18 1918 left sciatic exposed and internal popliteal bundle freed; resected 2.4 cm. A segment 1204 SURGERY of equal length taken from the sciatic of another rabbit, stored eight days in liquid petrolatum at 3° C, used as transplant. One central and one distal suture placed; approximation, both central and distal, only fair. Wound closed. December 30, rabbit found dead in the morn- ing. Wound well healed. Left sciatic exposed. Transplant found well in place and adherent to surrounding tissue which is discolored; bloody exudate. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation good; nuclei in part stained. Microscopic findings.—Early stages of central bulbous enlargement evidenced struc- turally. Central end of transplant well united to central stump; fibrous and cellular tissue constitutes central wound. Down-growing neuraxes from the central stump noted in passage through central wound. Certain of these have reached the central end of the transplant in which they have passed distally to the extent of approximately 2 mm. In the greater part of the nerve transplant no new neuraxes seen. Many remnants of old neuraxes evident, Fig. 228.-Cross section of homo-nerve transplant, stored in liquid petrolatum, at 3° C , 8 days ^rT^TTl^f^1'1^ N°- 171' 12 dayS after operation; Pyridine-silver prepara- hWindif? r r k TT" StrUCtUre °f the DerVe ^P^ted and the want of fibro- blastic differentiation about the nerve transplant as a whole he^lnd'^rf111^ ^Z^r °T °f Ughter C°l0r and granular structure- Sheath cells here and there evident Myelin not clearly differentiated. In the distal nerve segment nerve fibers in degeneration sheath cells proliferated; many nucleated, syncytial protoplasm bands; myelin ovoids and fragments of old neuraxes present oxopiasmic cem^lTT^ NV72:TRabbit No- IM*; full grown;" Belgian hare; 12 days. De- cember 18 1918, right sciatic exposed; internal popliteal bundle freed- resected 2 5 cm A segment of equal length taken from the sciatic of another rabbit str d e^ght daysTn z:^LT;:iutmx rc" rd as transpiant-one centrai ^ °- ^z:i ^^^^F^^-^r^^^attained- Dryw°und'w°undci°sed: December 30, rabbit found dead m the morning. Superficial wound well healed On re^IctT^e^rT^'iT1! ^ °f f°Cal infeCti°n ^ ^P "ou^taled surrounding rissuf The' JET* , \ d, ^ * ^ °nly moderately adherent to surrounding tissue. The sciatic and transplant removed and fixed in neutral formalin Stained in iron-hematoxylin and picro-fuchsin; safranine and lieht grim NEUROSURGERY 1205 Microscopic findings.—Transplant firmly united to central and distal ends of resected nerve by means of cellular fibrous tissue layer. Distinct central bulbous enlargement and slight distal enlargement. In longitudinal sections of the transplant, taken from its middle third, neurolemma sheaths of the transplanted nerve fibers well maintained and appear as slightly thickened. Myelin observed in the form of smaller and larger globules or segments, the larger of which inclose fragments of old neuraxes. Fibrous sheaths of the transplant invaded by wandering cells. Within the transplant many long nuclei with rounded ends. The majority of these appear to be situated between the nerve fibers; others appear to be within the neurolemma sheaths; their histogenesis uncertain. Distal segment of nerve found in degeneration. Experiment No. 173.—Rabbit No. 107; large; full grown; Belgian hare; 23 days. November 10, 1918, left sciatic exposed; internal popliteal bundle freed; resected 3.2 cm. A segment of equal length taken from the sciatic of another rabbit, stored thirty-nine days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal waxed, fine silk-thread suture placed; very good approximation attained. Dry field; wound closed. December 2, rabbit found dead in the morning. Wound well healed. Left sciatic exposed full length. External popliteal free and runs normal course. The nerve transplant found well in place. Material increase of connective tissue about the central and distal wounds. Transplant of yellow-white color and appears as if slightly congested. Transplant firmly united to resected nerve ends. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation centrally very good, distally not uniform. Microscopic findings.—A distinct central bulb evidenced structurally. From the distal end of this bulb numerous neuraxes pass to and through the central wound into central end of transplant, in which they may be traced to the neighborhood of the distal wound. The distal wound appears not to have been penetrated by down-growing neuraxes nor are any new neuraxes to be found in the central end of the distal nerve. In cross sections of the nerve transplant, about 1 cm. distal to the central wound, new neuraxes found in all parts of the transplanted nerve. In many regions small groups of new neuraxes appear to pass distally within one old neurolomma sheath; certain neuraxes observed between or out- side of neurolemma sheaths. Perineural sheaths of the transplanted nerve funiculi not materially thickened. Experiment No. 174.—Rabbit No. 107a; large, full grown; Belgian hare; 23 days. November 9, 1918, right sciatic exposed; internal popliteal freed; resected 3.2 cm. A segment of equal length taken from the sciatic of another rabbit, stored 39 days in sterile liquid petrolatum at 3° C, used as transplant. One central ajp.d one distal waxed, fine silk-thread suture placed; good approximation; dry field; wound closed. December 2, rabbit found dead in the morning. Wound healed. Cold abscess over right gluteal region; not related to wound. The right sciatic exposed full length. Transplant found well in place and firmly united to the resected nerve ends; quite adherent to surrounding tissue; of yellow- white color. Quite well developed central bulbous enlargement. Sciatic and transplant removed and fixed in neutral formalin, stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun. Microscopic findings.—Fibrocellular central wound into which extend nucleated proto- plasmic bands. In longitudinal sections of the transplant, from about its middle third, myelin of the transplanted nerve segments in the form of larger and smaller globules, certain of which are found to contain fragments of the old neuraxes. Numerous, relatively large round or oval nuclei found within the old neurolemma sheaths. Histogenesis of these is uncertain. The neurolemma sheaths well maintained and appear slightly thickened. Distal nerve not sectioned. Experiment No. 175.—Rabbit No. 133; large; old; Belgain hare; 82 days. March 15, 1919 left sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored seven days in sterile liquid petrolatum at 3° C used as transplant. One central and one distal waxed, fine silk-thread suture placed; good approximation attained. Wound not quite dry; wound closed. June 5, killed. For several clays had not eaten well; much emaciated; moribund when killed. Severe neuro- 1206 SUHGERY trophic ulcer left heel. Wound well healed. Left sciatic exposed full length. External popliteal found free from operated internal popliteal. The transplant found well in place; no material increase of connective tissue about transplant. Large, spindle-shaped central bulbous enlargement. Distal suture clearly seen. Calf muscles exposed; these are atrophic and of pale-red color; appearance of degenerated muscles. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation not uni- form throughout. ^'^r^T^^^^1^-8101^ iD liQUid petrolatum at 3° C. for 39 days before use, Experi- ment No 1,4 removed 23 days after operation; pyridine-silver preparation. Attention is called to the distinct ."nerve ^^ "' ^ ^ ^ ^ BnaU am°UDt °f flbrous ^ development sLunding ppntr"lZTPlC fin]din9S:~^ down-growing neuraxes can be traced from distal end of central bulbous enlargement to and into transplant and in this to and through the distal Zraxel have" i °f , ' ^ ^ 8e8ment- WitWn the *™*^ these new neuraxes have a very regular, longitudinal course and appear to pass distally within and outside of old neurolemma sheaths. Areas of degenerated or fragmented myelin o^betean* Experiment No. l.b.-Rabbit No. 131; large; full grown; 82 davs. March 12 919 left sciatic exposed; mternal popliteal bundle freed; resected 2.9 cm/ A segment of' equal NEUROSURGERY 120; length taken from the sciatic of another rabbit, stored in sterile liquid petrolatum 23 days at 3° C, used as transplant. One central and one distal suture of waxed, fine silk thread placed. Central suture pulled out; resutured, a little traumatism to central resected stump resulted; central approximation only fair; distal good. Wound closed. June 2, rabbit found dead in the morning. Slightly emaciated; neurotrophic ulcer left heel. Wound well healed. Left sciatic exposed full length. No material increase of connective tissue about nerve. External adherent to side of operated internal popliteal. Transplant well in place; of light reddish-brown color; not adherent to surrounding tissue. Sciatic and transplant Fk; 230 —Cross section of homo-nerve transplant stored in liquid petrolatum 39 days at 3° C. before use; Experiment ' Xo. 174. Experiment terminated 23 days after operation. Higher magnification of portion of the larger funiculus shown in Figure 229. Note the new neuraxes seen in cross section as fine black dots, many of which are found within neurolemma sheaths of the transplanted nerve fibers removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentia- tion only partially successful; tissue not well embedded and difficult to cut; sections torn. Microscopic findings.—Numerous new neuraxes can be traced from the central stump to and through the distal wound. The differential staining of the distal nerve not successful, thus can not clearly determine whether new neuraxes have reached the distal popliteal. Experiment No. 177.—Rabbit No. 129; full grown; 112 days. March 7, 1919, left sciatic exposed; internal popliteal freed; resected 2.9 cm. A segment of equal length taken from the sciatic of another rabbit, stored in sterile liquid petrolatum 17 days at 3° C, used as 120* SURGERY transplant. One central and one distal waxed, fine silk thread suture placed; good approxi- mation. Wound closed. June 27, killed. Rabbit much emaciated; not well; severe neuro- trophic ulcer left heel. Wound well healed. Left sciatic exposed full length. External popliteal adherent to operated internal popliteal; both bundles surrounded by a dense fibrous tissue sheath and adherent to underlying muscle. Transplant found well in place and of good size. Calf muscles fully exposed; are atrophic and of pale red color. Sciatic com- pletely freed from bed. On slowly cutting with scissors, sciatic central to transplant, vigorous contraction of the foot flexors supplied by the external popliteal, unoperated, but only very feeble and doubtful twitching of calf muscles supplied by operated internal popliteal. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fair differential silver staining throughout the series of sections attained. Microscopic findings.—-Large, spindle-shaped central bulbous enlargement evidenced structurally, from the distal end of which new, down-growing neuraxes may be traced through the transplant, to and through the distal wound and in good numbers into the central end of the distal popliteal, in which they may be traced to the lower level of the popliteal space. Unfortunately the calf muscles were not removed for microscopic examination; it is thus not possible to report on the presence or absence of new neuraxes in the calf muscles. Micro- scopic -findings indicate partial regeneration of the distal nerve segment through the nerve transplant. Experiment No. 178.—Rabbit No. 104; full grown; 117 days. November 7, 1918, left sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored 38 days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal waxed, fine silk thread suture placed; good central approximation, distal fair. Wound closed. March 4, 1919, killed. Rabbit found nearly moribund; "fungus" ears; eyes infected; much emaciated; wound well healed; neurotrophic ulcer left heel. On exposing the left sciatic, transplant found well in place, of small diameter, adherent to underlying muscle. Large, spindle-shaped central bulb. Calf muscles fully exposed; these appear atrophic and of pale red color and do not respond distinctly on cutting the sciatic central to the transplant. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Not complete and uniform silver differentiation. Microscopic findings.—Sections show sufficient silver differentiation of neuraxes to determine the observation that neuraxes growing from the central bulb enter the transplant and pass through this to and through distal wound into the central end of distal popliteal, in which region the staining is better; here numerous new neuraxes are differentiated. Regen- eration through transplant of central end of distal popliteal. Experiment No. 179.—Rabbit No. 104a; full grown; 117 days. November 7, 1918, right sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored 38 days in sterile liquid petrolatum at 3° C, used as transplant. One central and distal waxed, fine silk thread suture placed; good ap- proximation. Wound closed. March 4, 1919, killed. Rabbit found nearly moribund; only slight neurotrophic ulcer right heel. On exposing right sciatic, transplant is found well in place, of good size and only slightly adherent to the underlying muscle. Large central bulb. No record of test of muscles. Sciatic and the transplant removed and fixed in am- moniated alcohol for pyridine-silver staining. Silver differentiation very unsatisfactory and imperfect. Microscopic findings.—Transplant well united to resected nerve end. New neuraxes appear to be present in the transplant; this can not be determined definitely since silver differential staining is unsuccessful. Experiment not conclusive. Experiment No. 180.—Rabbit No. 130; full grown; 120 days. March 10, 1919, left sciatic exposed; internal popliteal bundle freed; resected 3.4 cm. A segment of equal length taken from another rabbit, stored 20 days in sterile liquid petrolatum at 3° C, used as trans- plant, One central and one distal waxed, fine silk thread suture placed; centrally, good approximation; distally only fair. Wound closed. July 8, rabbit found dead in the morning; examined soon after death. Neurotrophic ulcer left heel noted. On exposing left sciatic, the nerve transplant found well in place, of good size and dull-white color and only moderately adherent to underlying muscle. Small, spindle-shaped central bulb, and slight enlargement NEUROSURGERY 1209 of central end of distal stump noted. Calf muscles fully exposed; these appear as if partly recovered; good color though not full size. Muscles could not be tested as regards functional return, because animal had been dead some time before it was examined. Sciatic and trans- plant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation attained. Microscopic findings.—In alternate cross and longitudinal sections of the operated nerve, numerous new neuraxes coming from the central stump may be traced through the trans- plant to the distal popliteal. In cross sections of the transplant near the central and distal wounds, there may be observed an increase of the endoneural connective tissue but no mate- rial thickening of the perineural sheaths of the funiculi. The new neuraxes are found in small groups, separated by endoneural connective tissue and are equally distributed through all parts of the transplant. Experiment No. 181.—Rabbit No. 114; full grown; 145 days. December 24, 1918, left sciatic exposed; internal popliteal freed; resected 2.1 cm. A segment of equal length taken from the sciatic of another rabbit, stored 11 days in sterile liquid petrolatum at 3° C, used as transplant. Only fair central and distal approximation attained. Wound closed. May 18, 1919, rabbit found dead in the morning. Emaciated; "fungus" ears, neurotrophic ulcer left heel, which seemed to be healing; wound well healed. On exposing left sciatic, transplant found well in place, no material increase of connective tissue about operated nerve not adherent to underlying muscle. Quite distinct central bulb noted. Distal nerve presents the appearance of a normal nerve. Calf muscles fully exposed, have the appear- ance of regenerating muscle, though not fully recovered. Could not be tested as to func- tional return—animal dead. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining; silver staining faint but differential. Microscopic findings.—Neuraxes in very good numbers pass from the distal end of the central stump, through the transplant to the distal nerve, in which they are distributed in good numbers in all of the funiculi. In cross sections of the transplant, the new neuraxes found mostly in small groups, separated by strands of endoneural tissue; quite evenly dis- tributed over the entire transplant. Here and there small areas or columns of myelin globules and detritus, derived from the myelin sheaths of the transplanted nerve fibers, are to be found. Such areas not generally traversed by neuraxes. Very complete regeneration of the distal nerve, through the transplant, evidenced structurally. Experiment No. 182.—Rabbit No. 114a; full grown; 145 days. December 24, 1918, right sciatic exposed; internal popliteal bundle freed; resected 2.9 cm. A segment of equal length taken from the sciatic of another rabbit, stored 11 days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal waxed, silk thread suture placed. Good central, only fair distal approximation attained. Wound closed. May 18, 1919, rabbit found dead in the morning. Large neurotrophic ulcer right heel; apparently healing. On exposing right sciatic, transplant found well in place; external popliteal looped over it, though not adherent; no material increase of connective tissue about nerves. Distinct spindle-shaped central bulb, only indistinct enlargement of central end of distal stump. Distal nerve has the appearance of normal nerve. Calf muscles exposed; not fully recov- ered, though present the appearance of regenerating muscle. Could not be tested as to functional return. Sciatic and transplant removed and fixed in neutral formalin. While tissues were being prepared for embedding and serial section, preparatory to staining in iron-hematoxylin and picro-fuchsin, it was accidentally thrown out, thus not available for report as to microscopic findings. Experiment No. 183.—Rabbit No. 128; full grown; Belgian hare; 138 days. March 5, 1919 left sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored 22 days in sterile liquid petro- latum at 3° C, used as transplant. One central and distal waxed, fine silk-thread suture placed. Good approximation attained. Wound closed. July 21, rabbit found dead in the morning* much emaciated. Severe neurotrophic ulcer left heel. On exposing the left sciatic, transplant found well in place, of good size and of an appearance similar to resected nerve. Moderately large central bulb noted. Calf muscles still appear somewhat atrophic and of pale red color. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine- silver staining. Good differential silver staining attained. 1210 SURGERY Microscopic findings.— Large numbers of neuraxes pass from distal end of central .tump through central wound and transplant, through distal wound into distal popliteal. Certain of the neuraxes passing through the transplant have acquired a myelin sheath. Spindle-shaped areas of myelin globules and granular detritus noted in longitudinal sections of the transplant, These lie between bundles of descending neuraxes. Endoneural con- nective tissue not materially increased; while the perineural sheaths are materially thickened. Numerous new neuraxes in the distal popliteal in all of the funiculi. Regeneration of the distal nerve evidenced structurally. Experiment No. 184.—Rabbit No. 101; full grown; 155 days. October 8, 1918, left sciatic exposed; the internal popliteal freed; resected 3.5 cm. External popliteal bundle accidently cut while separating it from the internal popliteal; disregarded. A segment of equal length taken from the sciatic of another rabbit, stored nine days in sterile liquid petro- latum at 3°C, used as transplant. One central and one distal waxed, silk thread suture placed. Approximation of central ends fair; distally good direction, but suture not well placed, not good approximation attained. Muscle torn in exposing nerve; oozing, not fully controlled. Wound closed. March 12, 1919, killed. Rabbit in very good condition. One toe left foot missing; neurotrophic ulcer of left heel practically healed; does not spread toes of left foot on lifting up rabbit by ears. On exposing the left sciatic, transplant found well in place, of good size; quite material increase of connective tissue about operated nerve. Only indistinct central bulb. External popliteal accidently cut and not sutured, found united, slight bulbous enlargement at the place of cutting. Calf muscles and other Teg muscles fully exposed, and internal popliteal and transplant completely freed from bed. On slowly cutting internal popliteal bundle central to transplant, vigorous contraction of calf muscles; same on cutting distal to transplant; no distinct response from plantar foot muscles. Plantar foot muscles have nearly recovered normal size and are of pale red color. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining; por- tions of calf muscles removed for gold chloride staining. Good differential silver staining attained. Microscopic findings.—Numerous new fibers, both myelinated and nonmyelinated, pass through transplant to the distal stump. Scarcely any myelin globules, remains of myelin of transplanted nerve, to be found in the transplant. In cross sections of the transplant near both central and distal wounds, numerous neuraxes, evenly distributed over transplant, to be seen. Very little increase of endoneural connective tissue to be noted; perineural tissue not materially increased. Numerous new neuraxes in distal popliteal in all of the funiculi. In the calf muscles stained after the gold chloride method, the neuraxes of the nerve fibers of the larger muscular bundles well stained, as also in certain smaller muscular branches. Motor endings nowhere stained. This is regarded as inconclusive, and appears to be due to im- perfect differentiation, since the teased muscle fibers appear to present normal structure. Regeneration and return of motor function in calf muscle, though this latter is not fully checked by histologic findings. Experiment No. 185—Rabbit No. 101a; full grown; 154 days. October 9, 1918, right sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored nine days in sterile liquid petrolatum, at 3°C, used as transplant. One central and one distal waxed, fine silk thread suture placed; good approximation attained. Wound closed. March 12, 1919, killed. Rabbit in very good condition, healed neurotrophic ulcer right heel; spread toes of right foot on elevating rabbit by ears. On fully exposing right sciatic and calf muscles, transplant found well in place with only slight increase of connective tissue about operated nerve. Transplant of good size and good color. Only slight bulbous enlargement of central stump noted. After com- pletely freeing the operated internal popliteal and transplant, cutting the same central to the transplant, good contraction of calf muscles, contraction of foot muscles somewhat uncertain. Operated nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining; portions of calf muscles for gold chloride staining. Good silver differentiation attained. Microscopic findings.—Numerous, both myelinated and nonmyelinated neuraxes to be traced from the distal end of the central stump to and through transplant, to distal popliteal. NEUROSURGERY 1211 In cross sections of the transplant, neuraxes seem to be evenly distributed over transplant. Narrow streaks of myelin remains, with these certain large vesicular cells, found between bundles of new neuraxes; these remains not numerous. Endoneural connective tissue not materially increased. In the gold chloride stained pieces of muscle, neuraxes well stained in the larger and smaller muscular nerves. The motor endings not differentiated; apparently due to faulty differential staining; muscle fibers present a normal structure. Regeneration of distal popliteal through transplant. Experiment No. 186.—Rabbit No. Ill; full grown; 196 days. December 20, 1918, left sciatic exposed; internal popliteal bundle freed; resected 3.0 cm. A segment of equal length taken from the sciatic of another rabbit, stored 10 days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal suture placed, waxed, fine silk thread used. Good approximation attained. Dry field; wound closed. July 4, 1919, rabbit found dead in the morning; seemed in fairly good condition the day before; severe neuro- trophic ulcer left heel; healing. On exposing the left sciatic, transplant found well in place and presents the appearance of a normal nerve; no material increase of connective tissue about it. Large oval-shaped central bulb; central end of distal stump not materially in- creased. Distal nerve presents the appearance of a normal nerve trunk. The calf muscles exposed; they present a pale red color and are still slightly atrophic. Could not be tested as to functional return. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation not wholly satisfactory. Microscopic findings.—In cross and longitudinal sections, sufficient differential silver staining of neuraxes found to determine the fact that numerous, both myelinated and non- myelinated neuraxes, extend through the transplant from the central to the distal stump. Columns and spindle-shaped areas of myelin globules and detritus, are here and there noted in the longitudinal sections of the transplant; these show as round or oval areas in cross sections of the transplant. Apparent regeneration of the distal nerve through the transplant. Experiment No. 187.—Rabbit No. Ilia; full grown; 196 days. December 20, 1918, right sciatic exposed; internal popliteal freed; resected 2.6 cm. A segment of equal length taken from the sciatic of another rabbit, stored 10 days in sterile liquid petrolatum at 3°, C. used as transplant. One central and one distal waxed, fine silk thread suture placed; good approximation attained. Dry field; wound closed. July 4, 1919, rabbit found dead in the morning. Seemed in fairly good condition the day before; healing neurotrophic ulcer right heel. On exposing the right sciatic, it is found that the transplant is well in place of good size and color and not adherent to underlying muscle. Small, oval-shaped central bulb noted. Distal nerve presents the appearance of normal nerve trunk. Notes do not record the appearance and condition of the calf muscles. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation not wholly satisfactory. Microscopic findings.—In cross and longitudinal sections, sufficient differentiation of neuraxes to enable determining the fact that numerous neuraxes, both myelinated and non- myelinated, pass from the central stump through the transplant to the distal internal popli- teal. Scarcely any remains of the myelin of the transplanted nerve noted. Apparent re- generation of the distal popliteal through the transplant. Experiment No. 188—Rabbit No. 116; full grown; 223 days. December 27, 1918, left sciatic exposed; internal popliteal freed; resected 3.1 cm. A segment of equal length taken from the sciatic of another rabbit, stored 13 days in sterile liquid petrolatum at 3° C, used as transplant. One central and distal suture placed; good approximation attained. Slight oozing of blood from distal stump into distal wound; not fully controlled. Wound closed. August 7, 1919, rabbit found dead in the morning; seemed in good condition, "fun- gus" ears; neurotrophic ulcer left heel, seems to be healing. On exposing the left sciatic, transplant found well in place; of good size and color; presents the appearance of normal nerve; not materially adherent to underlying muscle. Calf muscle exposed, of nearly normal size, of yellow-red color, streaked with narrow yellow stripes. Sciatic and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good silver differentiation attained throughout whole length of nerve. Microscopic findings.—Well-developed central bulbous enlargement evidenced structur- ally from the distal end of which numerous myelinated and nonmyelinated neuraxes can be 1212 SURGERY traced through the transplant to the distal popliteal. Scarcely any neuraxes in the connec- tive tissue, surrounding the transplant, found. In cross sections of the transplant, it may be observed that the down-growing neuraxes pass through and between the old neurolemma sheaths. Endoneural and perineural connective tissue not found materially increased. Numerous new neuraxes found in all the funiculi of the distal popliteal cut at the lower level of the popliteal space. In longitudinal and cross sections of pieces of calf muscle, silver stained, new neuraxes observed in the larger muscular nerve branches, in the smaller inter- fascicular nerve branches and as single fibers between the muscle fibers; here and there evidence of motor nerve-endings noted. Regeneration of distal popliteal through the trans- plant, recovery of motor function in calf muscles, as evidenced structurally, obtained. Experiment No. 189—Rabbit No. 116a; full grown; 223 days. December 27, 1918, right sciatic exposed; internal popliteal freed; resected 3 cm. A segment taken from the sciatic of another rabbit, stored 13 days in sterile liquid petrolatum at 3° C, used as trans- plant. One central and distal waxed, fine silk thread suture placed; good approximation. Oozing in deep popliteal space, not fully controlled. Wound closed. August 7, 1919, rabbit found dead in the morning; seemed in good condition, "fungus" ears; severe neuro- trophic ulcer right heel; apparently healing. On exposing right sciatic, transplant found well in place; of good size and color; surrounded by relatively dense connective tissue, ad- herent to underlying muscle. Calf muscles fully exposed; are of good size, yellow-red color, with narrow yellow streaks evident. Sciatic and transplant, with portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining throughout. Microscopic findings.—Distinct, large spindle-shaped central bulb, from the distal end of which numerous new neuraxes pass through the transplant to the distal popliteal. Scarcely any neuraxes course in the connective tissue outside of the perineural sheaths of the trans- planted nerve. In cross sections of the transplanted nerve it may be observed that new neuraxes are distributed quite evenly over the entire transplant. In the distal popliteal lower level of the popliteal space, numerous neuraxes, both myelinated and nonmyelinated, found in all of the funiculi. In sections of the calf muscles, both in cross and longitudinal sections, new down-growing neuraxes found in the larger and smaller muscular branches and as single terminal nerve fibers on and between the muscle fibers. Regeneration of the distal popliteal through transplant and recovery of the motor fibers in the calf muscle. Experiment No. 190— Rabbit No. 115; full grown; 235 days. December 26, 1918, left sciatic exposed; internal popliteal freed; resected 2.9 cm. A segment of equal length taken from the sciatic of another rabbit, stored 13 days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal suture placed, waxed, fine silk thread suture; approximation good. Dry field; wound healed. August 18, 1919, killed. Rabbit in good condition; holds head to left side; when attempting to walk forward rolls over; some semi- circular canal condition not pertinent to experiment. On exposing the left sciatic, trans- plant found well in place; presents appearance of normal nerve, though not as distinctly bounded; only moderate increase of connective tissue about transplant. Distinct central bulb; only slight enlargement of central end of distal stump. External popliteal adherent to operated internal popliteal; cut and in part resected. Calf muscles fully exposed; these present nearly normal size and color. After completely freeing operated internal popliteal and transplant from bed and slowly cutting with scissors internal popliteal central to the trans- plant, vigorous contraction of the muscles and movement of toes; the same on cutting distal to the transplant. Sciatic nerve and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Only in part good silver differenti- ation attained. Microscopic findings.-L&rge spindle-shaped bulb, to which is adherent the external popliteal. From the distal end of the central bulbous enlargement on the internal popliteal, numerous myelinated and nonmyelinated neuraxes can be traced through the transplant to the distal popliteal. A few small funiculi of nerve fibers found in the connective tissue outside of the perineural sheaths of the transplanted nerves, on the side toward the adherent external popliteal. In the distal popliteal, new neuraxes in large numbers in all of the funiculi. In sections of the calf muscles, neuraxes noted in the larger and smaller intramuscular branches. NEUROSURGERY 1213 Regeneration of the distal popliteal through the transplant with regeneration of motor nerves to the calf muscles. Interossei not removed and studied. Experiment No. 1919—Rabbit No. 115a; full grown; 235 days. December 26, 1918, right sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored 13 days in sterile liquid petrolatum at 3° C, used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Dry field; wound closed. August 18, 1919, killed. Good general con- dition; holds head to left side; when attempting to walk, falls to side. On exposing the right sciatic, transplant found well in place; presents the appearance of a normal nerve; external popliteal adherent. Large central bulb; central end of distal segment distinctly enlarged. On exposing calf muscles, which are nearly of normal size and color, and completely freeing the internal popliteal and transplant from its bed, slowly cutting with scissors the internal popliteal central to the transplant, causes feeble contraction of calf muscles; more vigorous contraction on cutting distal to the transplant; contraction and movement of toes doubtful. Sciatic and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Only in part good differential silver staining attained. Microscopic findings.—Large central bulb, which tapers into transplant. From the distal end of bulb, numerous myelinated and nonmyelinated neuraxes traced through the transplant to the distal popliteal. Scarcely any neuraxes found in the connective tissue outside of the perineural sheaths of the transplanted nerve. These perineural sheaths found quite distinctly thickened. All of the funiculi of the distal popliteal nerve possess numerous new neuraxes, many of which are myelinated. In sections of the calf muscles, new neuraxes found in the intramuscular branches and as single terminal branches on the muscular fibers. Regeneration of distal popliteal through the transplant, also motor nerves in the calf muscles. Experiment No. 192.—Rabbit No. 113; full grown; 238 days. December 23, 1918, left sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored 11 days in sterile liquid petrolatum at 3° O, used as transplant. One central and distal waxed, silk thread suture placed; approxi- mation central good; distal good direction, but transplant twisted one-half spiral. Field not quite dry; wound closed. August 18, 1918, killed. Rabbit not in good condition; "fungus" ears; emaciated; neurotrophic ulcer left heel, not completely healed. On ex- posing left sciatic, it is noted that muscles of thigh look pale and flabby. Transplant found well in place; good size and color; no material increase of connective tissue about it; well- developed central bulb; quite distinct enlargement of central end of distal stump. Calf muscles fully exposed; these are small and of pale color. After freeing nerve and transplant from bed and on cutting slowly with scissors nerve central to transplant, feeble but distinct contraction of calf muscles and movement of toes noted; also on cutting distal to transplant. Sciatic and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Differential silver staining very good in part; granular deposit obscures in part. Microscopic findings.—Large central bulb from the distal end of which numerous new neuraxes can be traced to distal popliteal, in which to the level of entrance of branches into the calf muscles new neuraxes are found in large numbers in all of the funiculi. Scarcely any neuraxes found in the connective tissue outside of the perineural sheaths of the trans- planted nerves. Portions of calf muscle, in this experiment, were accidently lost. Regenera- tion of distal popliteal to level of calf muscles through the transplant. Experiment No. 193.—Rabbit No. 113a; full grown; 238 days. December 23,1918, right sciatic exposed; internal popliteal bundle freed; resected 2.4 cm. A segment of equal length taken from the sciatic of another rabbit, stored 11 days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal suture of waxed, fine silk thread placed; good approximation. Dry field; wound closed. August 18, 1919, killed. Rabbit not in good condition; much emaciated; neurotrophic ulcer right heel; not completely healed. On exposing the right sciatic, external popliteal found free; transplant well in place; good size and color- connective tissue not materially increased about it. Calf muscles fully exposed; these appear small and of pale red color. After freeing nerve and transplant completely, on slowly cutting nerve with scissors central to the transplant, good contraction of the calf 1214 SURGERY muscles and distinct movement of the toes noted, the same on cutting distal to the transplant. Sciatic and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation only in part successful. Microscopic findings.—From the distal end of a long, spindle-shaped central enlargement embracing the central wound, numerous myelinated and nonmyelinated neuraxes traced through the transplant to the distal popliteal, in which new neuraxes are found in large numbers in all of the funiculi. Scarcely any neuraxes found in the connective tissue surround- ing the transplant. Pieces of calf muscle accidently lost. Regeneration of distal popliteal through transplant. Experiment No. 194.—Rabbit No. 110; full grown; 242 days. December 19, 1918, left sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored eight days in sterile liquid petrolatum at 3° C, used as transplant. One central and one distal suture of waxed, fine silk thread used; good approximation; dry field; wound closed. August 18, 1919, killed. Rabbit in good condition; walks well; neurotrophic ulcer left heel very nearly healed. On exposing the left sciatic, the external popliteal found in very close approximation to operated internal popliteal. The transplant found well in place; good size and color, no material increase of connective tissue about the operated nerve. Distinct central bulb and distinct enlargement of central end of distal popliteal. Calf muscles and plantar foot muscles fully exposed; these of normal size and color. After completely freeing the operated nerve from bed, slowly cutting the nerve central to transplant, continued and vigorous contraction of calf and plantar foot muscles; the latter exposed so that contraction was directly observed. Sciatic and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Fair silver differentiation attained. Microscopic findings.—From distinct bulbous enlargement of the central stump, numer- ous myelinated and nonmyelinated neuraxes traced through the transplant to the distal popliteal, through which they are traced to the level of entrance to calf muscles. Scarcely any neuraxes in the connective tissue surrounding the transplanted nerve segments. Nu- merous neuraxes noted in the intramuscular branches in the sections of the calf muscles. Regeneration of distal popliteal through the transplant, recovery of calf muscles. Experiment No. 195.—Rabbit No. 110a; full grown; 242 days. December 19, 1918, right sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored in liquid petrolatum eight days at 3° C, used as transplant. One central and distal suture of waxed, fine silk thread used; good approxi- mation; field not quite dry; wound closed. August 18, 1919, killed. Rabbit in very good condition; uses right hind foot well; neurotrophic ulcer on right heel very nearly healed. On exposing right sciatic, external popliteal quite free, resected. The transplant found well in place; good size and color, no material increase of connective tissue about it. Distinct central bulb and quite distinct enlargement of central end of distal popliteal. Calf muscles and plantar foot muscles fully exposed; these of normal size and color. After freeing trans- plant and nerve from bed, on slowly cutting with scissors central to the transplant, good con- traction of foot and calf muscles noted. Sciatic and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Only partially successful silver differentiation attained. This owing to fact that while this and several other series were being embedded in paraffin, steam escaped into chamber containing paraffin dishes with tissues. Sufficient silver differentiation obtained to enable determination of the neuraxes, though these are not distinctly stained. Microscopic findings.-Large spindle-shaped central bulb, from the distal end of which numerous neuraxes, myelinated and nonmyelinated, can be traced through the transplant to the distal popliteal, in which neuraxes in large numbers are found in all of the funiculi. in sections of the calf muscles, neuraxes noted in the larger and smaller calf muscles and as single terminal nerve branches between and on the muscle fibers. Regeneration of distal popliteal through the transplant, and recovery of motor nerves in calf muscles Experiment No 196.-Rabbit No. 103; large; full grown; Belgian hare; 286 days. November 5 1918, left sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored 36 davs in sterile liquid petro- NEUROSURGERY 1215 latum at 3° C, used as transplant. One central and one distal waxed, fine silk-thread suture placed. Centrally one funiculus of central stump not in good approximation; distally good approximation attained. Dry field; wound closed. August 18, 1919, killed. Rabbit in good condition; walks well; neurotrophic ulcer left heel very nearly healed. On exposing left sciatic, external popliteal found in close apposition to operated internal popliteal. Trans- plant found well in place; good size and color, very little connective tissue increase about it. Only small, indistinct central bulbous enlargement noted, distally scarcely any enlargement. Calf muscles fully exposed; these have the appearance of normal muscle. After completely freeing transplant and nerve, on slowly cutting nerve with scissors central to transplant, vigorous contraction of calf muscles and movement of toes noted. Sciatic and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Only partially successful silver differentiation attained. Microscopic findings.—Not well marked central bulbous enlargement noted, in the center of which an accumulation of small cells, not clearly defined in silver stain, but presenting the appearance of a small localized pus pocket, is noted. From the distal end of this bulbous enlargement, numerous neuraxes, both myelinated and nonmyelinated, can be traced through the transplant to the distal popliteal. In cross sections of the transplant, approximately 1 cm. from the central wound, an accumulation of small cells under the perineural sheath is noted; possibly a small focus of pus cells. Perineural and endoneural connective tissue of the transplant found materially increased. Numerous small nerve bundles in the connective tissue outside of perineural sheaths observed. Muscle pieces came in contact with water while in paraffin; silver differentiation unsuccessful. Regeneration through transplant, although this gives evidence of having been slightly infected, of the distal popliteal to the level of muscular branches to calf muscles, more distally not controlled histologically. Experiment No. 197.—Rabbit No. 103a; large; full grown; 286 days. November 5, 1918, right sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored 36 days in liquid petrolatum at 3° C, used as transplant. One central and distal waxed, fine silk-thread suture placed; good ap- proximation; dry field; wound closed. August 18, 1919, killed. Rabbit in very good condi- tion; small healing neurotrophic ulcer left heel. On exposing the right sciatic, external popliteal found in close apposition to operated internal popliteal. Transplant found well in place, good size and color; very little increase of connective tissue about it. Only small central bulbous enlargement noted. Observations necessarily and unavoidably interrupted at this point; before they could be resumed sufficient time had elapsed to make it impossible to obtain contraction of muscles supplied by unoperated external popliteal. Calf muscles presented the appearance of normal muscles, both as to size and color; return of function could not be tested. Sciatic and portions of calf muscles removed, fixed in ammoniated alcohol for pyridine-silver staining. Only partial silver differentiation attained. Microscopic findings.—Silver differentiation sufficient to determine the fact that neuraxes, both myelinated and nonmyelinated, pass through the transplant to the distal popliteal, where they were traced to and into the muscular branches of the calf muscles. In cross sections of the transplant it is observed that very few neuraxes pass distally in the connective tissue surrounding the transplanted nerve segment. In cross sections of the distal popliteal, numerous neuraxes to be observed in all of its funiculi. Regeneration of distal popliteal through the transplant to the calf muscles. Experiment No. 198.—Rabbit No. 120; full grown; 2 days. January 10, 1919, left sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, and stored 11 days at room temperature in sterile 50 per cent alcohol, used as transplant. Before use, nerve was taken from alcohol and placed for 15 minutes in warm, sterile saline solution. One central and distal waxed fine silk thread suture placed; good approximation; slight oozing from central stump, not fully controlled; wound closed. January 12, rabbit found dead in the morning. On exposing sciatic, dry field noted. Transplant found well in place, of dull gray-green color; sutures in place. Ends of resected nerve found congested. Sciatic with transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver staining very pale. 4C)!I97- 27----7!) 1216 SURGERY Microscopic findings.—In longitudinal sections of the transplanted nerve segment the neurolemma sheaths of the nerve fibers distinctly made out; in myelin in many places traces of Golgi funnels; neuraxes not found segmented but staining very lightly, having even borders and of approximately normal size. In cross sections outline of nerve fibers well maintained, distinctly bounded by neurolemma sheaths; myelin scarcely stained; neuraxes centrally placed in fibers and staining very lightly. Experiment No. 199— Rabbit No. 120a; full grown; 2 days. January 10, 1919, right sciatic exposed; internal popliteal freed; resected 3.3 cm. A segment of equal length taken from the sciatic of another rabbit, stored 11 days at room temperature in sterile 50 per cent alcohol, used as transplant. Before use, placed in warm, sterile saline solution for one hour. One central and distal waxed fine silk thread suture placed; good approximation. Wound closed. January 12, rabbit found dead in the morning. On exposing right sciatic, trans- plant found well in place, sutures evident. Transplant of dull gray-green color, and found not adherent to surrounding tissues. Nerve and transplant removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun. Microscopic findings.^In longitudinal sections of the transplant, the neurolemma sheaths of the nerve fibers found well maintained; neurokeratin net of myelin only faintly stained. Neuraxes found not segmented. In longitudinal sections embracing the central and distal wounds, respectively, inwandered leucocytes in ends of the transplant distinctly observed. These inwandered cells extend for a distance of about 2 mm., both at the central and distal ends of the transplant, mainly between the nerve fibers, certain few within the neurolemma sheaths of the transplanted nerve fibers. No neurolemma sheath cells of trans- planted nerves clearly made out. Experiment No. 200.—Rabbit No. 123; full grown; 23 days. January 18, 1919, left sciatic exposed; internal popliteal freed; resected 2.8 cm. A segment of equal length taken from the sciatic of another rabbit, stored 17 days at room temperature in sterile ">() per cent alcohol, used as transplant. Before use, placed in sterile, warm saline solution 10 minutes. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. February 10. Died, nerve taken out just after death of rabbit; still warm; beginning neurotrophic ulcer left heel. Wound well healed. On expos- ing the left sciatic, transplant found well in place, united to resected nerve ends; of slightly smaller diameter in middle portion than at ends; no material increase of connective tissue about transplant. Distinct, central bulbous enlargement noted. The nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver staining differential but faint. Microscopic findings.—Numerous neuraxes extend from distal end of the central stump, through central wound into the central end of the nerve transplant, in which they may be traced distally for a distance of approximately 2 cm. In cross sections of the middle of the transplant small groups of neuraxes found within as well as outside of the neurolemma sheaths are to be observed. Neurolemma sheaths in certain regions widely distended or broken down. In such regions myelin globules, granular detritus, and large vesicular cells enclosing what appears to be lipoid globules encountered. Perineural sheaths of transplant well maintained, not materially thickened. No neuraxes found in the connective tissue out- side of this sheath. New neuraxes have not reached the distal stump; this shows nerve fibers in process of degeneration. Experiment No. 201.—Rabbit No. 123a; full grown; 23 days. January 18, 1919, right sciatic exposed; internal popliteal freed; resected approximately 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored 17 days in 50 per cent alcohol at room temperature, used as transplant. One central and one distal suture placed. While manipulating transplant, central suture pulled out; transplant resected and resutured, final length approximately 2 cm.; good approximation. Wound closed. February 10, died. Nerve taken out just after death; still warm. Wound well healed. On exposing the right sciatic, transplant found well in place; united to resected nerve ends, of good size and dull gray-green color. Distinct central bulbous enlargement noted. Nerve and transplant removed and fixed in neutral formalin. Sections stained in safranine and licht grun. NEUROSURGERY 1217 Microscopic findings.—Transplant found well united to central and distal resected ends of internal popliteal; only narrow connective tissue wounds evident. In longitudinal sections of the transplanted nerve segment, strands of syncytial nucleated protoplasmic bands, apparently extending from the distal end of the central stump into the transplant, are found separated by narrow areas or columns of myelin globules, granular detritus, and vesicular cells with lipoid globules, the remains of the myelin of the transplanted nerve fibers. This structure extends to the distal end of the transplant, where, near the distal wound, the protoplasmic bands are more widely separated and less numerous, the intervening spaces wider. The central end of the distal stump presents the appearance of a nerve in degeneration. Experiment No. 202.—Rabbit No. 118; full grown; 42 days. December 28, 1918, left sciatic exposed; the internal popliteal bundle freed; resected 2.4 cm. A segment of equal length taken from the sciatic of another rabbit, stored seven days at room temperature in sterile 50 per cent alcohol, used as transplant. Before use, nerve placed in sterile, warmed saline solution ten minutes. One central and one distal waxed, fine silk thread suture placed. Good approximation attained, though the transplanted nerve segment is of distinctly smaller diameter than the resected nerve. Wound closed. February 8, 1919, killed. Rabbit not in good condition; "fungus" ears; emaciated; neurotrophic ulcer left heel. Wound well healed. On exposing the left sciatic, the external popliteal found adherent to operated internal popliteal. Transplant found well in place; of yellow-white color; adherent to under- lying muscle. Large central bulbous enlargement. Distal nerve presents the appearance of a degenerated nerve. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining throughout. Microscopic findings.—In longitudinal sections of central and distal wounds, the trans- plant well united to resected nerve ends, little connective tissue intervening. From the distal end of the central bulb, numerous neuraxes may be traced into the central end of the transplant, in which they end distally, grouped mainly to one side in the transplant, along the inner surface of its perineural sheath; only a few scattered bundles of neuraxes in the substance of the transplant. In the transplant areas and columns of myelin globules, gran- ular detritus and masses of large vesicular cells, with lipoid globules. The downgrowing neuraxes traced to and through the distal wound, only a few having reached the central end of the distal popliteal, in which they may be traced distally for a distance of about 1 cm. Experiment No. 203.—Rabbit No. 118a; full grown; 42 days. December 28, 1918, right sciatic exposed; the internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored seven days in sterile 50 per cent alcohol at room temperature, used as transplant. One central and distal waxed, fine silk thread suture placed. Good central approximation attained, distal good direction, end of trans- plant twisted one half turn. Wound closed. February 8, 1919, killed. Rabbit not in good condition; "fungus" ears; emaciated; neurotrophic ulcer right heel. Wound well healed. Right sciatic exposed. External popliteal found adherent. Transplant found well in place; of yellow-white color, clearly demarked; adherent to underlying muscle. Large central bulb. Nerve and transplant removed and fixed in neutral formalin. Sections stained in safranine and licht grun. Microscopic findings.—In longitudinal sections of central and distal wounds, the trans- plant found well united to resected nerve ends. New nerve fibers and nucleated, syncytial protoplasmic bands extend from distal end of the central stump into the transplant. In longitudinal sections of the transplant, larger and smaller bundles of syncytial protoplasmic bands, having in the main a longitudinal direction, but here and there anastomosing, and separated by areas and columns of large vesicular cells, are to be observed. In cross sec- tions of the'transplant about 1 cm. distal to central wound, one relatively large bundle of syncytial protoplasmic bands, placed largely to one side, but extending into the middle of the transplant, is recognized. Fewer of these nucleated protoplasmic bands seen in the distal part of the transplant, but may be traced to and into the distal wound. The distal nerve presents the appearance of a degenerated nerve. Experiment No. 204.—Rabbit No. 121; full grown; 70 days. January 14, 1919, left sciatic exposed; internal popliteal freed; resected 3.2 cm. A segment of eoual length taken 1218 SURGERY from the sciatic of another rabbit, stored 14 days in sterile 50 per cent alcohol at room tempera- ture, used as transplant. Before use, the nerve placed for eight minutes in sterile, warmed saline solution. One central and distal waxed, fine silk thread suture placed. Central approximation recorded as good, distal "fair." Wound closed. March 25, rabbit found dead in the morning. Had had convulsions previous day; much emaciated; severe neurotrophic ulcer left heel. Wound well healed. On exposing the left sciatic, transplant found well in place, of light yellow-white color, of smaller size than when used; no material increase of con- nective tissue about it. Relatively large central bulb noted. The nerve and the transplant removed and fixed in neutral formalin. Sections stained in safranine and licht grun. Microscopic findings.—No distinct central bulb evidenced structurally. New nerve fibers and syncytial protoplasmic strands extend from the distal end of the central stump into the nerve transplant, in the proximal half of which these are arranged in small bundles, within the perineural sheaths of the nerve transplant, with relatively few myelin globules and vesicular cells separating such bundles. In the distal half of the transplant these small bundles of nucleated protoplasmic bands are separated by larger and smaller areas or columns of vesicular cells and myelin globules. Many of the nucleated protoplasmic bands reach and penetrate the distal wound. The distal popliteal found degenerated; numerous nucleated, syncytial protoplasmic strands noted; relatively few myelin globules are evident. Experiment No. 205.—Rabbit No. 121a; full grown; 70 days. January 14, 1919, right sciatic exposed; internal popliteal freed; resected 3.3 cm. A segment of equal length taken from the sciatic of another rabbit, stored 14 days in sterile 50 per cent alcohol at room temper- ature, used as transplant, Nerve placed in sterile, warmed saline solution forty-five minutes before use. One central and distal waxed, fine silk thread suture placed; good approxima- tion. Wound closed. March 25, rabbit found dead in the morning; much emaciated; severe neurotrophic ulcer right heel. Wound well healed. On exposing the right sciatic, trans- plant found well in place, of light yellow-white color, much smaller diameter than when used; not adherent. Large central bulb. Nerve and transplant removed and fixed in neutral formalin. Sections stained in safranine and licht grun. Microscopic findings.—-Transplant well united to resected nerve ends. Distinct central bulb evidenced structurally, from the distal end of which numerous new nerve fibers and nucleated, syncytial strands extend into the transplant, extending to and into the distal wound. In the distal end of the transplant, areas and columns of large vesicular cells found between protoplasmic strands. The distal nerve presents the appearance of a degenerated nerve. Experiment No. 206.—Rabbit No. 119; full grown; 62 days. January 9, 1919, left sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored 10 days at room temperature in sterile 50 per cent alcohol, used as transplant. Nerve, before use, placed fifteen minutes in sterile, warmed saline solution. One central and distal suture of waxed, fine silk thread placed; good approxi- mation. Field not quite dry; wound closed. March 12, rabbit found dead in the morning. Not much emaciated; severe neurotrophic ulcer left heel. Wound well healed. On exposing the left sciatic, external popliteal found closely adherent to operated internal popliteal. Transplant found well in place, in part of light pink color in part dull white color; no material increase in connective tissue surrounding operated nerve. Large central bulbous enlarge- ment, adherent to underlying muscle. Nerve and transplant removed and fixed in ammoni- ated alcohol for pyridine-silver staining. Throughout, good differential neuraxis staining attained. Microscopic findings.—The transplant found well united to resected nerve ends. From the distal end of the central bulb, numerous down-growing neuraxes found growing distallv through central wound to central end of transplant. In cross sections of the transplant about 1 cm. distal to central wound, numerous small bundles of neuraxes, separated bv endoneural connective tissue are to be found. In cross sections taken near the distal wound, essentially the same structural appearance observed for the greater part of the transplant; to one side, within perineural sheath, a relatively large area, containing large vesicular cells and granular detritus noted. In this field no neuraxes observed. New neuraxes traced through the distal wound into the distal nerve segment, in which they may be traced in good numbers for a NEUROSURGERY 1219 distance of about 2 cm. Regeneration of proximal end of distal nerve through the nerve transplant. Experiment No. 207.—Rabbit No. 119a; full grown; 62 days. January 9, 1919, right sciatic exposed; internal popliteal bundle freed; resected 2.2 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature in sterile 50 per cent Fig. 231.—From a longitudinal section of homo-nerve transplant, stored in 50 per cent alcohol for 10 days before use as transplant; Experiment No. 206. Xerve removed 62 days after operation. Note the regular course of the new neuraxes, evident as black lines, as they pass distally within the neurolemma sheaths of the transplanted nerve fibers alcohol for a period of 10 days, used as transplant, Nerve placed in sterile, warmed saline solution one hour and ten minutes before use. One central and distal waxed, fine silk thread suture placed. Central suture torn out; resected and resutured; approximation good. Field not quite dry; wound closed. March 12, rabbit found dead in the morning; not much emaciated; severe neurotrophic ulcer right heel. Wound well healed. On exposing the right 1220 SURGERY sciatic, external popliteal found closely adherent to operated internal popliteal The trans- plant found well in place; relatively small diameter; not adherent to underlying muscle Central end of transplant of dull white color; distal of light pink color. Large oval-shaped central bulb. Nerve and transplant removed and fixed in neutral formalin, .sections stained in safranine and licht grun. Microscopic findings.—Transplant found well united to the resected nerve ends; narrow connective tissue wounds. From the distinct central bulb, new small nerve fibers and Kig. 232.—From a cross section of homo-nerve transplant, stored in 50 per cent alcohol for 10 days before use as trans- plant; Experiment No. 206. Nerve removed 62 days after operation. Section made approximately 15 mm. distal to the central wound. Note the numerous central neuraxes seen in cross section, showing as fine darkly stained points, very evenly distributed through the field. There is here evident excellent neurotization of the trans- planted nerve segment nucleated, protoplasmic bands extend into the transplant in which they may be traced to and through the distal wound. Especially in the longitudinal sections taken from the distal half of the transplant, irregular columns and areas of large vesicular cells and cell detritus, separating bundles of new nerve fibers, are to be noted. Experiment No. 208.—Rabbit No. 135; large; old; Belgian hare; 67 days. March is. 1919, left sciatic exposed; internal popliteal freed; resected 3.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature for 28 days in sterile 50 per cent alcohol, used as transplant. Nerve placed in sterile saline solution 15 NEUROSURGERY 1221 minutes before use. One central and distal waxed, fine silk thread suture placed; good approximation. Dry field; wound closed. May 24, rabbit found dead in the morning; not much emaciated; severe neurotrophic ulcer left heel. Wound well healed. On exposing the left sciatic, external popliteal found free. Transplant well in place, found only moderately adherent to underlying muscle; of yellow-white color, tinged here and there a brown color. Distinct central bulb; central end of distal nerve enlarged. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation not successful throughout. Microscopic findings.—Transplant well united to resected nerve ends. The silver differ- entiation of sufficient clearness to determine the fact that many new neuraxes coining from the distal end of the central bulb pass to and through the transplant. These are seen to descend mainly along the inner surface of the perineural sheath and peripheral part of the main funiculus, the core of which is occupied by a relatively large area containing large vesicular cells and granular detritus. Few, if any, of the down-growing neuraxes appear to have reached the distal segment of the resected nerve, which presents the appearance of a degenerated nerve. Experiment No. 209.—Rabbit No. 122; full grown; 144 days. January 16, 1919, left sciatic exposed; internal popliteal bundle freed; resected 3.0 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature for a period of 15 days in sterile 50 per cent alcohol, used as transplant. Before use placed in warmed, sterile saline solution 15 minutes. One central and distal waxed, fine silk thread suture placed; good approximation attained. Wound closed. June 9, rabbit found dead in the morning; not much emaciated; small neurotrophic ulcer left heel. Nerve and transplant removed, fixed in ammoniated alcohol for pyridine-silver staining. Fair silver differentiation attained; not well embedded, sections torn. Microscopic findings.—Transplant found well united to the resected nerve ends. From the distal end of the central bulb, numerous neuraxes are found to pass to the transplant in which they are arranged in small bundles separated by endoneural connective tissue, present in much greater amount than in a normal nerve trunk. To one side of transplant, remains of the transplanted nerve fibers noted particularly in cross sections. Neuraxes of the transplant pass to and through the distal wound and are found in good numbers in the distal nerve. Regeneration of the central end of the distal segment through the transplant. Experiment No. 210.—Rabbit No. 122a; full grown; 144 days. January 16, 1919, right sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature for 15 days in sterile 50 per cent alcohol, used as transplant. Before use, nerve placed for one hour in warmed, sterile saline solution. One central and distal waxed, fine silk thread suture placed; distal resutured, first very unsatisfactory; good approximation attained. Small blood clot in the connective tissue near distal wound. Wound closed. June 9, rabbit found dead in the morning; not much emaciated; moderately large neurotrophic ulcer right heel. On exposing the right sciatic, external popliteal found free. Transplant found well in place; of good size; only moderately adherent to underlying muscle. Large central bulb. The nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Fair silver differentiation attained; tissue not well embedded, sections torn. Microscopic findings.—Neuraxes coming from the distal end of the central bulbous enlargement can be traced through the transplant into the distal segment of the resected nerve in which they are present in large numbers. Within the transplant, these down- growing neuraxes are arranged in small bundles, separated by endoneural connective tissue, present in larger amount than in a normal nerve trunk. Regeneration of the distal nerve segment through the nerve transplant attained. Experiment No. 211.—Rabbit No. 137; small rabbit; seemed full grown; 152 days. March 19 1919, left sciatic exposed; internal popliteal freed; resected 2.5 cm. A segment of equal length taken from the sciatic of another rabbit, stored for a period of 29 days at room temperature in sterile 50 per cent alcohol, used as transplant. Before use, nerve placed for 10 minutes in warmed, sterile saline solution. One central and distal waxed, fine silk thread suture placed. Good central approximation attained; a small amount of 1222 SURGERY clotted blood in central wound; distally, good direction, but distal end of transplant twisted one half turn. Wound closed. August 18, killed. Rabbit in good condition; not large, but appears well fed; neurotrophic ulcer left heel, which appears to be healing. On exposing the left sciatic, external popliteal found in close approximation to the operated internal popli- teal. Transplant found well in place, of good size; has the appearance of a normal nerve, though of slightly brown color. No distinct central bulbous enlargement noted. Calf muscles fully exposed, these present a pale red color but have not fully recovered their nor- mal size. The external popliteal cut central and distal to the region of the transplant and the internal popliteal and transplant completely freed from bed. On slowly cutting the sciatic central to the transplant good contraction of the calf muscles and slight movement of the toes noted; the same cutting distal to the transplant. The nerve and the transplant and portions of the calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation not good for distal portion of nerve. Microscopic findings.—Numerous new neuraxes traced through the transplant into the distal portion of resected nerve to level of calf muscles. In the transplant these neuraxes in the form of small bundles separated by endoneural connective tissue. Very little detritus derived from the transplanted nerves noted. In sections of the calf muscles, numerous neuraxes observed in the intrafascicular nerve bundles and as single nerve fibers, between and on muscle fibers; a few motor nerve endings noted. In sections of the posterior tibial nerve, not successful silver differentiation. Regeneration of distal popliteal including motor branches and endings in the calf muscles attained. Experiment No. 212.—Rabbit No. 134; full grown; not large; 154 days. March 17, 1919, left sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature in sterile 50 per cent alcohol for a period of 27 days, used as transplant. Before use, nerve placed for 15 minutes in warmed, sterile saline solution. One central and distal nerve suture placed; good approximation. Wound closed. August 18, killed. Rabbit in good condition; neurotrophic ulcer left heel nearly healed. On exposing the left sciatic, the external popliteal found in close apposition to the operated internal popliteal. Transplant found well in place; of small diameter; but presents the appearance of a normal nerve; only moderately adherent to the underlying muscle. Distinct central bulb noted. Distal nerve presents the appear- ance of a normal nerve. Calf muscles fully exposed; these still somewhat atrophic and of pale-red color. Nerve and transplant completely freed from the bed. On cutting slowly with scissors central to the transplant, indistinct contractions—"feeble contractions"—of calf muscles noted. Nerve and transplant and portions of the calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining for central part of nerve, but not for distal part, attained. Microscopic findings.—Numerous neuraxes can be traced from the distal end of the central stump through the transplant to the distal nerve. Silver staining of pieces of calf muscles not satisfactory—no neuraxes stained. Regeneration of distal nerve through trans- plant, recovery of calf muscles not confirmed by microscopic findings. Experiment No. 213.—Rabbit No. 125; full grown; 208 days. January 22, 1919, left sciatic exposed; internal popliteal freed; resected 2.9 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature for 21 days in sterile 50 per cent alcohol, used as transplant. Nerve placed in sterile saline solution for 15 minutes before use. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. August 18, killed. Rabbit in fairly good condition; healing neurotrophic ulcer left heel; walks on heel and does not bring foot down to floor. On exposing left sciatic external popliteal found free; transplant well in place; of small diameter; only slightly adherent to underlying muscle. Large and distinct central bulb noted; evident enlargement of the central end of distal nerve. Calf muscles fully exposed; these still slightly atrophic, of pale red color, streaked with light yellow bands. External popliteal resected, operated internal popliteal and transplant completely freed from bed. On slowly cutting nerve with scissors central to the transplant, feeble but distinct contraction of calf muscles noted; the same on cutting distal to transplant. No distinct movement of the toes observed. Nerve and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good differential silver staining attained. NEUROSURGERY 1223 Microscopic findings.—The distinct central bulb evidenced structurally, from the distal end of which numerous new neuraxes can be traced through the transplant to the distal nerve. Within the transplant the neuraxes arranged in the form of small funiculi separated by endoneural connective tissue. New neuraxes traced into the calf muscles in which they are found in the intrafascicular nerves and as separate nerve fibers between and on the muscle fibers. Regeneration of distal nerve through transplant, partial return of motor function in calf muscles. Experiment No. 214.—Rabbit No. 125a; full grown; 203 days. January 27, 1919, right sciatic exposed; the internal popliteal bundle freed; resected 2.9 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature in sterile 50 per cent alcohol for 21 days, used as transplant. Before use, nerve kept in sterile saline solution for 50 minutes. One central and distal waxed, fine silk suture placed; good approxi- mation. Wound closed. August 18, killed. Rabbit in fairly good condition; healing neuro- trophic ulcer right heel. On exposing the right sciatic, it is found that the external popliteal is closely adherent to operated internal popliteal. The transplant found well in place and about one-half the diameter as when used; only moderately adherent to underlying muscle. Relatively large central bulb; central end of distal nerve found only slightly enlarged. Calf muscles fully exposed; these have not fully recovered size; pale red color. The nerve and the transplant completely freed and external popliteal cut in popliteal space; on slowly cutting with scissors, the nerve central to the transplant, distinct but feeble contractions of the calf muscles noted; the same on cutting distal to the transplant; no toe movement noted. Nerve and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—From the large central bulb, numerous new neuraxes can be traced through the transplant to the distal nerve and through the muscular branches to the calf muscles. Very good regeneration of motor fibers in calf muscles noted. Regeneration of distal nerve through the transplant including muscular branches to calf muscles. Experiment No. 215.—Rabbit No. 126; full grown; 208 days. January 22, 1919, left sciatic exposed; internal popliteal freed; resected 2.6 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature in sterile 50 per cent alcohol for 22 days, used as transplant. Before use, nerve placed in warmed, sterile saline solution for 15 minutes. One central and distal waxed, fine silk-thread suture placed; central approximation not quite end to end, distal good. Wound closed. August IS, killed. Rabbit in good condition; small healing neurotrophic ulcer left heel; not full use of foot. On ex- posing the left sciatic, it is found that external popliteal is in close approximation to operated internal popliteal. Transplant found well in place; nearly of same size as when used. Dis- tinct central bulb noted; moderate enlargement of central end of distal nerve. Calf muscles fully exposed; these have not fully recovered size. Nerve and the transplant completely freed from bed. On slowly cutting nerve central to transplant, contraction of the calf muscles noted, as also slight movement of the toes; same on cutting distal to the transplant. Nerve and transplant and portions of calf muscles removed and fixed in ammoniated alcohol for pyridine-silver staining. Fairly good differential silver staining attained; pale. Microscopic findings.—Transplant firmly united to resected nerve ends. Well-developed central bulb evidenced structurally, from the distal end of which numerous myelinated nerve fibers can be traced through the transplant to the distal nerve. In cross sections of the transplant made about 1.5 cm. distal to the central wound, it may be observed that the perineural sheaths of the transplanted nerve segment are intact and only moderately thick- ened, while the endoneural tissue is distinctly increased in amount. The neuraxes are found in small groups separated by endoneural tissue. In sections of the calf muscles new, neuraxes are found in the interfascicular nerve bundles, and here and there as single fibers passing to the muscle fibers. Good regeneration of distal internal popliteal through the nerve trans- plant attained. Experiment No. 216.—Rabbit No. 126a; full grown; 208 days. January 22, 1919, right sciatic exposed; internal popliteal freed; resected 2.9 cm. A segment of equal length taken from the sciatic of another rabbit, stored at room temperature in sterile 50 per cent cent alcohol for 22 days, used as a transplant. Before use, nerve placed in warmed, sterile 1224 SURGERY saline solution for one hour. One central and distal waxed, fine silk-thread suture placed; good approximation. Wound closed. August 18, killed. Rabbit in good condition; heal- ing neurotrophic ulcer right heel. On exposing the right sciatic, external popliteal found close- ly adherent to operated internal popliteal. Transplant found well in place; of good size; of dull white color and only moderately adherent to underlying muscle. Large central bulb noted; central end of distal nerve only slightly enlarged. Calf muscles fully exposed; these appear to have nearly recovered size and color. The nerve and the transplant completely freed from bed and external popliteal cut in popliteal space. On slowly cutting with scissors the nerve central to the transplant, good contraction of the calf muscles observed. Nerve and transplant and portions of the calf muscles removed for pyridine-silver staining. Pale, but fairly good differential silver staining attained. Microscopic findings.—Transplant found well in place and firmly united to the resected nerve ends; line of suture hardly evident. From the central bulb numerous neuraxes traced into proximal end of the transplant, relatively few traced into the connective tissue sur- rounding the transplant. In cross sections of the transplant taken about 1.5 cm. distal to the central wound, the epineural sheaths found materially thickened and there is noted a marked increase of the endoneural connective tissue. Within the transplant, nerve fibers, both myelinated and nonmyelinated, observed in small bundles, separated by varying amounts of endoneural connective tissue. These neuraxes can be traced through the transplant to the distal nerve within which they are present in large numbers, both myelinated and nonmyelinated fibers, and are found quite evenly distributed in the several funiculi. In sec- tions of the calf muscles, neuraxes observed in the interfascicular nerve branches and as single nerve fibers on and between muscle fibers. Structurally considered, the muscles ap- pear as regenerated. Fairly complete regeneration of the distal nerve through the transplant, including nerves to calf muscles, attained. The end results of the experimental observations on stored, homo-nerve transplants are on the whole very satisfactory. Functional return is recorded for all of the experiments of longer duration. Stored homo-nerve transplants seem to serve the purpose of nerve bridge quite as well as fresh homo-nerve transplants, thus obviating in a large measure certain difficulties connected with the use of homo-nerve transplants in human surgery. If nerves obtained at amputations can be stored for weeks, to be at hand when required, with promise of favorable results on use, stored homo-nerve transplant deserves con- sideration in human surgery. It is our belief that smaller nerve bundles, used if necessary as cable or multiple nerve transplants, should give promise of more favorable end results than the use of one large nerve, such as the sciatic or its main branches used as a nerve bridge. In all of the experiments (No. 150 to No. 157) in which a homogenous nerve bridge of nerve stored in vaseline was made there was noted relatively little increase in the connective tissue surrounding the nerve transplant at the time when the nerve was exposed for study of functional return. The transplant presented the appearance of a normal nerve. In all of these experiments down-growing neuraxes derived from the central stump neuraxes were traced through the central wound into the transplant, and through the transplant to and through the distal wound into the distal stump. In the cross sections of the transplants the down-growing neuraxes encountered are many of them found within what appear to be neurolemma sheaths remains of transplanted nerve fibers. Tissue detritus and large vesicular phagocytic cells, unlike the end results of Wallerian degeneration, are met with within the nerve funiculi. In the experiments of about two months' duration (No 154 and No. 155) feeble muscle contraction was noted and interfascicular, muscular XEUROSURGERY 1225 nerve bundles with new neuraxes were noted in the sections of the calf muscles; and in experiments of nearly five months' duration (No. 156 and No. 157) regeneration of the distal segment of the nerve with down-growing neuraxes was quite complete. On the whole, very satisfactory neurotization of the degenerated distal segment was obtained in experiments dealing with homo- nerve transplants, stored in vaseline, following in the main the method of procedure suggested by Dujarier and Francois.76 The much larger series of homogenous-nerve transplants stored in liquid petrolatum (No. 158 to No. 197) included 14 experiments of relatively short duration (1 hour to 12 days) in wliich the behavior of the transplant soon after it was placed as a nerve bridge could be studied. A nerve stored in liquid petrolatum at 3° C. retains its microscopic structure quite completely and will stain differentially by the pyridine-silver method. Two days and even four days after such a transplant is placed the neuraxes of the nerve fibers as seen in the pyridine-silver prepara- tions are not fragmented. From 6 days to 12 days after transplantation the neuraxes are found segmented and show a granular change. The myelin shows fragmentation, but there is no evidence of proliferation of sheath cells. At the end of 12 days there are still found fragments of old neuraxes in the transplanted nerve segment. In the central wound region down-growing central neuraxes have penetrated the wound region and certain ones have extended into the transplant for a distance of about 2 mm. Experiments Nos. 173 and 174 deserve special consideration. A homogenous-nerve trans- plant stored 39 days in liquid petrolatum was used to bridge a nerve defect. The animal died 23 days after the operation but was used for histologic study. In cross sections of the transplants, made about 1 cm. distal to the central wound, new neuraxes were found in all parts of the transplant. In many parts of the field more than one neuraxis was found in one neurolemma sheath, while other neuraxes are found outside of the neurolemma sheaths. Extensive neurotization of the transplant had taken place, by downward growth of central neuraxes, at the end of 23 days after the operation. Of the experiments of this series 20 were carried on for a period of 3 months or longer; the longest for a period of nearly 7 months. In all of these experiments, where functional tests could be made, return of functions in the calf muscles is recorded, and in certain of the longer time experiments return of function in the foot interossei was observed. All of the experiments were controlled by histologic study of practically the whole sciatic nerve, and in all of the experiments could central neuraxes be traced through the transplant into the distal popliteal nerve and thence into the calf muscles. In cross sections of the transplanted nerves in the respective experiments, stained by the pyridine-silver method, it could be determined in nearly every experiment that the down-growing central neuraxes made use of the neurolemma sheaths of the transplanted nerve fibers in their course through the transplant. In all of these experiments relatively few nerve fibers are found in the connective tissue surrounding the perineural sheaths of the funiculi of the nerve transplant, interpreted as meaning that in this series the nerve transplant is the main avenue along which the down- ^rowino- neuraxes reach the distal stump. The experimental observations dealing with homogenous-nerve transplants stored in liquid petrolatum seem 1226 SURGERY to us to warrant the deduction that human nerves obtained from amputated members and stored in liquid petrolatum as here directed and, on need, used for bridging nerve defects, deserve serious consideration as a surgical procedure. We were agreeably surprised at the favorable results attained on use of homog- enous-nerve transplants stored in 50 per cent alcohol for purpose of nerve bridge. In this series of 18 experiments (No. 198 to No. 216) relatively few- were of short duration. In Experiments No. 198 and No. 199 the rabbit was found dead 2 days after operation. In sections of the transplant stained by the pyridine-silver method the neuraxes were found to stain very lightly, but were found unsegmented. Inwandered leucocytes were found in the ends oi the transplant at the central and distal wounds, both within the neuro- lemma sheaths and between the nerve fibers. In Experiments No. 200 and No. 201 (compare Experiments No. 173 and No. 174) the rabbit had died 23 days after the operation but the tissue was used for histologic study. In preparations stained after the pyridine-silver method down-growing central neuraxes can be traced through the central wound and for a distance of about 2 cm. into the transplant. In cross sections of the transplant the down-growing neuraxes are found within as well as without the neurolemma sheaths, but practically no nerve fibers are found in the connective tissue surrounding the transplant, outside of the perineural sheaths. By the end of 42 days, more clearly 2 months after the operation, down-growing neuraxes were traced through the transplant to the distal wound and through this into the central end of the distal popliteal, the down-growing neuraxes decreasing in number the farther distal the observation is made. In the experiments of longer duration, 8 in number, in which the observations were carried on to from 4 months to nearly 6 months after the operation, functional return was noted in the experiments in which this could be tested and histologically new neuraxes were found in the distal nerve, conveyed there through the transplant. In several experiments new neuraxes were found in the interfascicular and intrafascicular nerve bundles of the calf muscles. By way of summary it may here be added that very good neurotization was attained through homogenous nerve bridges which had been stored in 50 per cent alcohol. The supposition is permissible that in nerves stored in sterile vaseline and liquid petrolatum at a temperature of 3° C. there may be some degree of viability of certain tissue elements—sheath cells or con- nective tissue cells—even though there is no satisfactory evidence of the pro- liferation of the sheath cells of transplanted nerve fibers, nor of the participation of the sheath cells of the nerve transplant, direct or indirect, in the down growth of the central neuraxes. In case of nerves stored in alcohol, it can not be supposed that any viability is retained by the tissue elements or cells of the nerves transplanted. There is no evidence of sheath cell participation and no evidence that they proliferate. The fragmentation of the myelin and neuraxes of the transplanted nerves after storage in vaseline, liquid petrolatum, and alcohol is a necrobiotic change and not a secondary degeneration-Wal- lenan degeneration—as observed in the distal segment. NEUROSURGERY 1227 STORED HETERO-NERVE TRANSPLANTS SERIES NO. 14 HETERO-NERVE TRANSPLANTS STORED IX LIQUID PETROLATUM SERIES NO. 15 HETERO-NERVE TRANSPLANTS STORED IX 50 PER CENT ALCOHOL In the discussion of Series No. 11, No. 12 and No. 13, stored homogenous transplants, consideration was given to the fact that little if any viability is retained by any of the tissue elements of nerves stored for stated periods before use as a transplant, especially so when stored in 50 per cent alcohol. Therefore, it was thought that the sheath cells of the stored, transplanted nerves take no active part in the fragmentation of the neuraxes and myelin sheaths of the transplanted nerves and, so far as can be determined, are not causally related to the downgrowth of the central neuraxes, in their passage through the trans- plant to reach the distal segment of the resected nerve. The conviction seems warranted that the neurolemma sheaths of the stored, transplanted nerve fibers, which do not fragment with the neuraxes and myelin sheaths, act in a purely mechanical way in serving as conduits through which the down-growing neuraxes are conveyed through the transplant to the distal nerve segment. Therefore, the supposition seemed justified that a hetero-nerve transplant, stored in liquid petrolatum and especially in alcohol, would prove more satifactory as a nerve- bridge than a fresh heterogenous nerve transplant. Series No. 14 and No. 15 were undertaken to test this hypothesis. In Series No. 14, the internal popli- teal or ulnar nerve of dogs was removed under aseptic precautions and stored in liquid petrolatum, as described under Series No. 12, for periods varying for from 12 days to 25 days and were then used to bridge nerve defects caused by resecting the sciatic nerve of rabbits. One central and one distal fine waxed silk suture was placed to fix the transplant to the resected nerve ends. In Series No. 15, segments, taken from the internal popliteal and ulnar nerves of dogs and stored for periods varying from 5 days to 7 days in 50 per cent alcohol, were used to bridge nerve defects in the sciatic of rabbits caused by resection and sutured in place by fine waxed silk sutures. The protocols of the experiments of Series No. 14 and No. 15, stored heterogenous nerve-transplants, are as follows: PROTOCOLS Experiment No. 217.—Rabbit No. 127a; full grown; 5 days. March 4, 1919, the right sciatic exposed; internal popliteal freed; resected 3.1 cm. A segment of equal length taken from the internal popliteal of a dog, stored for 10 days in sterile liquid petrolatum at 3° C, used as transplant. The transplant of dull white color and of larger diameter than the resected nerve. One central and distal suture of waxed, fine silk thread placed; good approxi- mation. Dry field; wound closed. March 9, rabbit found dead in the morning. Super- ficial wound healed. On exposing the right sciatic, transplant is found well in place; loosely united to resected nerve ends; not adherent to surrounding muscle. Nerve and transplant removed and fixed in neutral formalin. Sections stained in safranine and licht grun. Microscopic findings.—Longitudinal sections, embracing central and distal wounds, show verv good approximation; a few extravasated blood cells found in the intervening connective 122N SURGERY ti.ssue. Leucocytes noted in the central and distal ends of the transplant for a distance of about s mm. The great majority of these found between the nerve fibers. Leucocytes have wandered in less number and for a shorter distance into the resected nerve ends. In cross and longitudinal sections of the transplant taken from its middle third, the contained nerve fibers appear as very well preserved; the neuraxes staining pale, though readily made out, and not fragmented; the myelin sheaths not fragmented; the neurolemma sheaths clearly seen. The few sheath cell nuclei here and there seen, appear in form and staining reaction much as do similar nuclei in normal nerves. The perineural sheaths present the characteristic appearance of this structure. Experiment No. 218.—Rabbit No. 133a; large; old; Belgian hare; 82 days. March 15, 1919, right sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the left ulnar of a dog, stored 25 days in sterile liquid petrolatum at 3° C, used as transplant, One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. June 5, killed. For several days rabbit had not been well; emaciated; nearly moribund, when killed; right heel swollen and red, no ulcer. On exposing the right sciatic, external popliteal found free. Transplant found well in place and firmly united to resected nerve ends; seemed of smaller diameter than when used; of distinct light yellow color; only moderately adherent to the underlying muscle. Large central bulb, which tapers toward the transplant; slight enlargement of central end of distal nerve noted. Calf muscles very atrophic; no response on cutting nerves. Nerve and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—In longitudinal sections, the large central bulb clearly demarked from the transplant. In the portion of the bulb developed from the distal end of the central stump the light yellow coloring, differential staining of neuraxes characteristic for pyridine silver methods, is to be observed. The sections of the transplant throughout, present a jet-black, nontransparent coloration, by reason of which structural differentiation can not be made out. By reason of this silver reaction, it is not possible to de- termine whether neuraxes coming from the central stump penetrate the transplant. In cross sections of the transplant, its connective tissue sheaths present a brown-yeUow color. In close relation with this sheath new neuraxes are observed. Within the sheaths, the portions containing the nerve fibers of the funiculi colored jet-black. The distal internal popliteal stump completely degenerated. Experiment No. 219.—Rabbit No. 131a; large; full grown; 82 davs. March 12 191(1 right sciatic exposed; internal popliteal freed; resected 2.8 cm. A segment of equal length taken from the right ulnar of a dog, stored in sterile liquid petrolatum at 3° C. for a period of 20 days, used as transplant. One central and distal waxed, fine silk thread suture placed Good central approximation attained; at the distal wound, thread through transplant verv nearly cut through. Wound closed. June 2, rabbit found dead in the morning; moderate emaciation; severe neurotrophic ulcer right heel. On exposing the right sciatic, it is noted that the transplant is united to central end of resected nerve, but pulled free from the distal segment, the transplant ending free 1.5 cm. distal to central wound; remaining transplant segment yellow-white color; large central bulb. The central and distal segments of the resected nerve and remains of transplant removed and placed in ammoniated alcohol for pyridine-silver staining. Microscopic findings.-Numerous neuraxes can be traced from the distal end of the central bulb along the side of the transplanted nerve segment, but do not appear to have bWWnlo \ Sam£- transplanted nerve segment clearly demarked bv reason of its jet- black coloration. Distal nerve completely degenerated " Experiment No. 220.-Rabbit No. 129a; full grown; 112 davs. March 7 1919 right Trom thXTinte1:16:,"1 Tt ^K ^ T^ ^ Cm" A Segment °f e0ual length'taken from the ^internal popliteal bundle of a dog, stored 14 days in sterile liquid petrolatum at 3 C, used as transplant. One central and distal waxed, fine silk thread suture placed" T^Tne^T Dry field- ^T /* T r^^ "°mewhat ^ ^^oTtt resected nerve. Dry field; wound closed. June 27, killed. Rabbit not well for several days; neurotrophic ulcer right heel. On exposing right sciatic, external popliteal found free NEUROSURGERY 1229 Transplant found well in place and firmly united to resected nerve ends; seems of slightly larger diameter than when used; distinct yellow-white color, which enables demarking it clearly. Moderately large central bulb. Calf muscles atrophic. No response on cutting nerve central and distal to the transplant. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—Distinct central bulb evidenced structurally, from the distal end of which new neuraxes pass to the side of the transplant. The transplant itself is stained a deep black color, admitting no determination of structural details. In cross and longi- tudinal sections of the transplant, it is not possible to differentiate any neuraxes within the perineural sheaths of the transplant; this by reason of the dark silver reaction. In cross and longitudinal sections of the internal popliteal distal to the transplant a goodly number of new neuraxes are to be observed. In a series of longitudinal sections embracing the distal wound and adjacent nerve ends, neuraxes are to be observed entering the field of the distal wound to one side of the distal end of the transplant, It would appear, though by reason of the peculiar staining of the transplant this can not be determined conclusively, regenera- tion in the distal stump is attained through neuraxes that pass distally outside of the trans- plant. Experiment No. 221.—Rabbit No. 130a; full grown; 121 days. March 10, 1919, right sciatic exposed; internal popliteal freed; resected 3.2 cm. A segment of equal length taken from the right ulnar of a dog, stored in sterile liquid petrolatum 17 days at 3° C, used as transplant. One central and distal suture waxed, fine silk thread placed; good approxi- mation. The diameter of the transplant greater than that of the resected nerve. Wound closed. July S, rabbit found dead in the morning; moderately emaciated; severe neuro- trophic ulcer right heel. On exposing the right sciatic, external popliteal found free; trans- plant well in place; clearly demarked by reason of its light yellow color; no material increase of connective tissue about it. Large central bulb, adherent to underlying muscle, noted. Calf muscles still atrophic, present the appearance of degenerated muscle. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good silver differentiation attained. Microscopic findings.—From the distal end of the central bulb new neuraxes can be traced mainly to one side of the transplant; some few appear to enter the transplant, but by reason of the dark, nontransparent coloration they can not be traced any distance in the transplant. No neuraxes appear to have reached the distal internal popliteal, which structurally considered has the appearance of a completely degenerated nerve. Experiment No. 222.—Rabbit No. 129a; full grown; Belgian hare; 138 days. March 5, 1919, right sciatic exposed; internal popliteal freed; resected 3.2 cm. A segment of equal length taken from the internal popliteal of the right sciatic of a dog, stored in sterile liquid petrolatum for 11 days at 3° C, used as transplant. One central and distal waxed, fine silk thread suture placed; good approximation. Wound closed. July 21, rabbit found dead in the morning; much emaciated; severe neurotrophic ulcer right heel. On exposing the right sciatic, external popliteal found closely adherent to operated internal popliteal. Transplant found well in place; of distinct yellow-white color, thus clearly demarked. Large spindle-shaped central bulb. Calf muscles atrophic; present the appearance of degenerated muscle. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation not good in all parts of the series. Microscopic findings.—From the distal end of the very well developed central bulb, numerous neuraxes passing mainly to one side of the transplanted nerve segment noted. In cross and longitudinal sections of the nerve transplant, the appearance presented in sec- tions warrants conjecture that the chemical state of the transplanted nerve segment, which may be correlated with the peculiar jet-black coloration noted on staining with the pyri- dine-silver method, is undergoing a change in that the outer portion of the transplant no longer presents this peculiar coloration, only the core or central portion being thus colored. No neuraxes are to be observed within the transplant nor in the distal stump, which presents the appearance of a completely degenerated nerve. Experiment No. 223.—Rabbit No. 135a; old; Belgian hare; 07 days. March 18, 1919 right sciatic exposed; the internal popliteal freed; resected 3.3 cm. A segment of equal ,9oq SURGERY lenrfh taken from the right ulnar of a dog, stored at room temperature in sterile 50 per cent Sol for 6 d~s, used as transplant. Before use, the nerve was placed in warm, stenk !S Liution for 5 minutes. One central and distal waxed, fine silk thread suture placed. Wound keu~. Mav 24, rabbit found dead in the morning; moderate emaciation severe Neurotrophic.ulcer right heel. On exposing the right sciatic, the external popliteal found re" Transplant found well in place, united to resected nerve ends clearly demarked by ts yellow -olor; no material increase of connective tissue about it. Large spindle-shaped bulb noted, dlf muscles atrophic and flabby. Nerve transplant and nerve removed and fixed in ammoniated alcohol for pyridine-silver staining. Good neuraxes differentiation attained; tissue blocks not well embedded, sections in part torn Miroseopic findings.-In longitudinal sections embracing the central wound, scatlered neuraxes traced from the central nerve stump into central end of the transplant. In cross sections of the transplant, approximately 1.5 cm. distal to the central wound the perineural sheath of the transplanted nerve segment is found very materially thickened; within this there is found a detritus, the remains of the transplanted nerves. In it no definite tissue can be recognized; even the neurolemma sheaths of the transplanted nerves have disappeared. No new neuraxes are to be recognized. In longitudinal sections of the transplant the same general appearances are presented, except that here and there short fragments of old neu- raxes, having no definite arrangement, are found scattered through the detritus. Distal nerve completely degenerated. Experiment No. 224.—Rabbit No. 137a; small; full grown; 152 days. March 19, 1919 right sciatic exposed; internal popliteal freed; resected 3 cm. A segment of equal length taken from the left ulnar of a dog, stored at room temperature in sterile 50 per cent alcohol for 7 days, used as a transplant. Before use, the nerve was placed for 15 minutes in a sterile saline solution. One central and distal waxed, fine silk thread suture placed; very good approximation of nerve ends. Wound closed. August 18, killed. Rabbit in good condition; small neurotrophic ulcer of the left heel. On exposing the right sciatic, external popliteal found free. Transplant found well in place; clearly demarked by its yellow-white color; good size and firmly united to resected nerve ends. Calf muscles ex- posed; atrophic and of a pale yellow-red color. Nerve and transplant freed from bed, on slowly cutting the nerve central to the transplant, no response of calf muscles noted; no evidence of contraction. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation only in part successful. Resulting sec- tions somewhat torn. Microscopic findings.—In longitudinal sections of the central wound region, it is to be observed that neuraxes passing from the distal end of the central bulb, pass to the region of the central wound, which they do not penetrate for any distance; certain of them turn- ing centralward. In the central end of the transplant, near the central wound and for several millimeters distal, quite long fragments of the old neuraxes of the transplanted nerves, differentially stained in silver, may be observed; distal to this region, such neuraxes remains no longer observed. In cross and longitudinal section of the transplant 1.5 cm. to 2 cm. and 3 cm. distal to the central wound, no new neuraxes observed within the transplanted nerve segment. The nerve fibers of the transplant in part completely broken down, in part the old neurolemma sheaths found persisting, filled with detritus and leucocytes filled with lipoid globules. Just central to the distal wound, new neuraxes recognized in the transplant, passing through the distal wound into the distal popliteal in which they may be traced to the level of the calf muscles. Apparent regeneration of the distal nerve, down- growing neuraxes appearing to pass distally mainly outside of the transplant is concluded. Experiment No. 225.—Rabbit No. 134a; full grown; 154 days. March 17, 1919, right sciatic exposed; internal popliteal freed; resected 3.0 cm. A segment of equal length taken from the external popliteal bundle of the left sciatic of a dog, stored in sterile 50 per cent alcohol at room temperature for 5 days, used as a transplant. Before use, nerve placed 15 minutes in warmed, sterile saline solution. One central and distal waxed, fine silk thread suture placed; good approximation. Clean, dry field; wound closed. August 18, killed. Rabbit in good condition; neurotrophic ulcer on right heel nearly healed; does not use right hind leg and foot normally. On exposing the right sciatic, the external popliteal found NEUROSURGERY 1231 quite free. Transplant found well in place; demarked by light yellow color; united to re- sected nerve ends. Spindle-shaped central bulb noted. Calf muscles atrophic and of pale red color. Section of nerve causes no contraction of the calf muscles. Nerve and trans- plant removed and fixed in ammoniated alcohol for pyridine-silver staining. Yery good silver differentiation attained. Microscopic findings.—In longitudinal sections embracing the central wound, new neuraxes can be traced from the distal end of the central stump into the central end of the transplant, either as single neuraxes or as small groups of such, which course distally in collapsed neurolemma sheaths. In cross sections of the transplant approximately 1.5 cm. distal to the central wound, it may be observed that mainly to one side many new neuraxes are found within the perineural sheath of the transplant, in part within this sheath, as also in the detritus, derived from the transplanted nerve fibers. Within and between the per- sisting neurolemma sheaths, numerous leucocytes greatly distended with lipoid globules are to be observed. Certain of the neuraxes which are found in the transplant and its sheath are to be traced to and through the distal wound into the distal popliteal through the trans- plant attained. The end results of the experiments on stored hetero-nerve transplants are, on the whole, unsatisfactory. As concerns Series No. 14, heterogenous nerve transplants stored in liquid petrolatum, in none of the experiments of longer duration was regeneration of the distal segment of the resected and bridged nerve attained through the heterogenous transplant. The nerve segment was found firmly united to the central and distal nerve stump. On staining after the pyridine-silver method, the stored, heterogenous nerve transplant presented a peculiar reaction toward the silver nitrate in that the silver appeared to be reduced en masse, so that no differentiation of elements was possible within the perineural sheath of the funiculi transplanted. This made a close histologic study of the behavior of the transplanted nerve segments in these experiments difficult and in the main unsatisfactory, in that it could not be determined with certainty whether down-growing neuraxes of central origin passed through the transplant to reach the distal segment of the nerve. Down-growing neuraxes were found in the central nerve bulb and from this could be traced in the general direction of the central end of the nerve transplant, but also into the connective tissue surrounding the transplant and in this connective tissue to the level of the distal wound. In none of the experiments was neurotization of the distal segment attained. In the experiments of Series No. 15, in which heterogenous nerve transplants stored in 50 per cent alcohol were used, the end results at- tained are much less satisfactory than in the series in which homogenous nerve transplants were used (Series No. 13). The several animals were under ob- servation for from 64 days to 154 days, thus for a time of sufficient length to admit of regeneration through the transplant, under favorable conditions. It may be noted on study of the protocols that to a limited extent downgrowth of central neuraxes through the transplants was observed; our results thus con- firming Nao-eotte.77 The long persistence of fragments of the neuraxes of the transplanted nerves is to be noted, especially in Experiment No. 224, terminated 152 days after the operation. In the central portion of the transplant near the central wound and for several millimeters distal, quite long fragments of old neuraxes stained differentially by the pyridine-silver method are to be found. Distal to this region they have disappeared from the remains of the transplanted 46997—27----SO 1232 SURGERY nerve fibers. Judging from the limited number of experiments here presented (3), testing the value of heterogenous nerve transplants stored in 50 per cent alcohol, it seems clear that this form of nerve bridge is not to be advocated as worthy of consideration in human surgery. The experiments of this series in so far as they can be compared with the series in which homogenous nerve transplants stored in 50 per cent alcohol (Series No. 13) were tested, indicate that there is distinct difference as regards serviceability between homogenous and heterogenous nerve transplants stored in 50 per cent alcohol and in favor of the alcoholized homogenous nerve transplants. AUTO-NERVE TRANSPLANTS WRAPPED IN PROTECTIVE MATERIAL SERIES NO. 16 AUTO-XERVE TRAXSPLANTS WRAPPED IN CARGILE MEMBRANE In this and the following several series (Series No. 16, No. 17, No. 18, and No. 19) we have attempted to test the merits of certain membranous structures which had been recommended for use in surgical practice, as a covering for suture lines in operations of nerve suture or as a wrapping about a nerve transplant and the suture lines or in other operative procedures in peripheral nerve repair. Incidental references are found in surgical literature to a num- ber of membranous structures used for wrapping nerves or tendons after operative procedure. Our list of experiments might have been extended had cognizance been given to all of the materials used for this purpose. Refer- ences to the use of Cargile membrane are not infrequent. It seemed to be used sufficiently frequently to warrant renewed experimental inquiry Mor- ris 7* states that he had received from Dr. Charles H. Cargile, of Arkansas sterilized animal membrane" (dried and sterilized peritoneum of the ox) with the request that he test its use and value in surgical practice, especially as a means of preventing adhesions in certain cases of abdominal surgery. Twelve experiments on rabbits were made. Morris found that the membrane esisted absorption for more than 10 days but less than 30 days when placed in the peritoneal space. Craig and Ellis » undertook a series of experiments on dogs usmg both chromatid and unchromatized Cargile membrane to wrap "edTndl T^V ^ "^^ ^ —1-on that both the llZl tized and the unchromatized membrane are of value in preventing adhesions brands abso b d 'T ^T™^ ^ eSpeCia11^ achromatized Cargile mem- brane is absorbed relatively quickly m the tissues; macroscopicallv within 5 days, microscopically within 14 days. The membrane appears^^ be dl troyed by a lytic substance contained in the body fluids, phagocytes CS as of less importance m this process of disintegratioia^dLo ption 'SWn ' witn nerve suture and nerve transplantation. Other writers refer to thp ,,«p ionto and 5 cm. vide, cut from rubber gloves and wrapped spirally NEUROSURGERY 1233 about the nerve, at the seat of injury. This teclmique was used in 100 cases and in 93 without unfavorable reaction. In experiments of Scries No. 16, the sciatic nerve of a dog was resected to tlie extent of approximately 4 cm. and the defect bridged by a segment of necessary length removed from the ulnar of the opposite side of the same dog. After the nerve transplant had been completed with the necessary sutures placed, one or several layers of Cargile membrane of sufficient length to extend about 1 cm. beyond the central and distal suture lines were wrapped about the nerve transplant and the ends of the central and distal stumps as closely and as evenly as could be. The Cargile membrane used was that made by Johnston and Johnston and was designated as " medium hard chromic." Pieces of requisite size, either of one layer or of several layers, were cut from pieces found within the several envelopes, as found in the market, and used at once as wrap- ping for the operated nerve, after which the wound was closed. An attempt was made to sterilize the portion of the Cargile membrane not used at any one operation, until it occurred to us to place the unused portion of any membrane in 70 per cent or 95 per cent alcohol, in which the membrane fragments were kept until further used. Before actual use, the membrane piece to be used was placed in absolute alcohol for several hours or perhaps a day. From the abso- lute alcohol the membrane was placed, just before use, on a dry, sterile towel so as to enable the absolute alcohol to evaporate. In this dry state, after the evaporation of the alcohol, the membrane was used as a wrapping for an operated nerve. As will be noted on reading the protocols, Cargile membrane thus stored in absolute alcohol reacts very differently toward tissues than Cargile membrane not stored in alcohol. In our discussion we shall use the term "alcoholized Cargile membrane" meaning thereby Cargile membrane, either chromatized or unchromatized, which had for a time been kept in alcohol. The characteristics of an alcoholized Cargile membrane were discovered quite by accident. Our own observations pertain to the use of such a membrane as a wrapping for an operated nerve; its wider application in surgery has not been considered. The protocols of experiments under Series No. 16, auto-nerve transplants with a wrapping of li Cargile membrane" and " alcoholized Cargile membrane," are as follows: PROTOCOLS Experiment No. 226.—Dog No. 34; medium size; full grown; 20 hours. May 28, 1918, left sciatic exposed and internal popliteal freed. Right ulnar exposed. A segment 4.6 cm. length of right ulnar transplanted to the resected internal popliteal; one central and distal fine silk thread suture used; distally a second epineural suture placed. Good approximation attained. A single layer of Cargile membrane, cut long enough to overlap suture lines 5 mm., wrapped about nerve; well applied, forms close-fitting tube. Both wounds closed. May 29, dog found dead next morning; distemper. Wound reopened, and sciatic exposed. Resected nerve ends appear slightly congested. Transplant and Car- gile membrane found well in place; a small amount of fluid noted within membrane; mem- brane loosely adherent to surrounding tissues; adhesions easily broken down. Nerve and transplant surrounded by Cargile membrane removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.—In cross and longitudinal sections, Cargile membrane presents the appearance of a thin layer of dense collagenous connective tissue. Numerous leucocytes 1234 SURGERY between membrane and epineural sheath of the transplant Coagulum and numerous ^eucocy es on outer surface of membrane. At the central wound beginning degeneration of dlstalend of central nerve fibers noted; leucocytes and extravasated red blood cells between the e fibers. In central end of transplant, for a distance of about mm., myelin degenera- tion noted; here leucocytes in and between neurolemma sheaths of fibers. More distal m the transplant, few leucocytes observed. Experiment No. 227.-Dog No. 33; half grown; medium size, 3 days^ May 2, 1918 left sciatic exposed and the internal popliteal freed. Right ulnar exposed and freed V segment of 5 cm. length of right ulnar transplanted to left internal popliteal. One central and distal silk suture placed. Distal suture gave way; in resuturing this central suture gave wav; central resutured. Fair approximation attained. A single layer of Cargile membrane wrapped about transplant and suture lines; wel applied \\ounds closed. Mav 30 dog found dead in the morning; distemper. Superficial wounds healed On expos- ing sciatic, slight infection of deep wound noted. The Cargile membrane evident; small amount of exudate within the membrane. Resected nerve and transplant with Cargile membrane removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.-In sections, Cargile membrane is found well in place. Coagulum, leucocytes, extravasated blood observed within membrane and about its outer surface. Beginning degeneration of distal end of central stump and central end of the transplant to be observed. Central end of transplant and distal end of central stump united; fibrin, coagulum, leucocytes, extravasated red blood cells intervening. Leucocytes observed in and between neurolemma sheaths of the transplanted nerves. Experiment No. 228.—Dog No. 3; medium size; full grown; 56 days. June 11, 1918, right sciatic exposed and the internal popliteal freed. The left ulnar exposed. A segment 2 cm. length of left ulnar transplanted to the right internal popliteal. One central and distal fine silk thread suture placed; good approximation. Two layers of Cargile mem- brane wrapped about transplant and the resected nerve ends; well applied, forming close- fitting tube. Slight oozing from resected nerve ends, not controlled. Both wounds closed. August 6, killed. Dog in good condition; active; no neurotrophic ulcer right foot. Wound well healed. On exposing the right sciatic, transplant is found well in place; no trace of Cargile membranes evident. Quite a little increase of connective tissue about the transplant and suture lines noted; adherent to underlying muscles. No distinct central bulb noted. No contraction of the calf muscles on cutting the nerve. Resected nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Differ- ential neuraxis silver staining not entirely satisfactory. Microscopic findings.—In both cross and longitudinal sections of the region of the transplanted nerve segment no trace of the Cargile membranes observed. Distinct thick- ening of the epineural sheath of the transplant observed. New neuraxes can be traced from the distal end of the central stump, through the central wound into the transplant, and through the transplant into the central end of the distal popliteal; relatively few neuraxes have passed the distal wound. Remains of degenerated myelin observed in the transplant. Many small myelin ovoids seen in the distal popliteal, as also numerous nucleated syncytial bands in which no neuraxes are differentiated observed. Experiment No. 229.—Dog No. 30; large; full grown; 129 days. May 22, 1918, two segments of the right ulnar of 2.3 cm. length transplanted to the resected left sciatic. Each segment sutured separately, centrally, and distally, using fine Chinese silk sutures. Fair approximation attained. The transplants and the resected nerve ends, for a distance of 8 mm., wrapped in a single layer of Cargile membrane well applied. Both wounds closed. September 2S, dog found dead in the morning. Seemed fairly well day previous; moderate emaciation; skin disease; no neurotrophic changes left foot. On removing skin over operated nerve a small encapsuled stitch abscess noted; does not extend to deeper tissues. On exposing the left sciatic, no material increase of connective tissue noted. Transplants found well in place, demarked by presence of sutures. Transplant presents the appearance of a normal nerve. No trace of Cargile membrane observed. No distinct central bulb noted. Calf muscles of good size and color. Left sciatic and transplant, posterior tibial and external popliteal removed and fixed in ammoniated alcohol for pyridine-silver staining. NEUROSURGERY 1235 Microscopic findings.—No trace of Cargile membrane observed in sections. In cross sections of the transplant about 1 cm. distal to the central wound, the funicular structure of both of the transplanted ulnar segments preserved, and are surrounded by common fibrous tissue sheath. All of the funiculi on the transplanted ulnar segments contain new neuraxes, certain of these are myelinated, the majority not. Numerous small bundles of nerves observed in the connective tissue intervening between the two nerve segments transplanted. Numerous neuraxes can be traced from the transplants through the distal wound into the distal sciatic segment, all of the funiculi containing them. New neuraxes in good number observed in the posterior tibial and the external popliteal. Experiment No. 230.—Dog No. 2; medium size; full grown; 342 days. June 12, 1918, right sciatic exposed and the internal popliteal bundle freed. The left ulnar exposed and freed. A segment of 2 cm. length of the left ulnar transplanted to the right internal popliteal. One central and one distal fine silk thread suture placed; good approximation. A double layer of Cargile membrane wrapped about transplant and resected nerve ends; well applied. Both wounds closed. May 20, 1919, killed. Dog in very good condition; uses right foot well as normal dog. On exposing the right sciatic, external popliteal bundle found free. Distinct central bulb, which tapers toward the transplant, noted. Transplant has the appear- ance of normal nerve, though surrounded by quite dense connective tissue and adherent to underlying muscle. No trace of Cargile membrane. Calf muscles exposed; these have the appearance of normal muscle. Nerve and transplant completely freed. On slowly cutting nerve with scissors central to the transplant, vigorous contraction of calf and plantar foot muscles. Nerve and the transplant removed and fixed in ammoniated alcohol for pyridine- silver staining. Neuraxes only very lightly stained. Microscopic findings.—Numerous myelinated and nonmyelinated nerves traced from central bulbous enlargement to the distal popliteal. In cross sections of the transplant funiculi are found to be well maintained, with only moderate increase of connective tissue about the transplant. Calf and plantar muscle not studied in this experiment. Experiment No. 231.—Dog No. 35; small dog; full grown; 350 days. June 1, 1918, left sciatic exposed; internal popliteal bundle freed. Right ulnar exposed. A segment 3.4 cm. length taken from the right ulnar and transplanted to the resected left internal popliteal. One central suture of vessel silk; vessel silk suture attempted for distal suture, broken twice; finally Chinese silk suture used. Good central approximation attained, distal "fair." Dou- ble layer of Cargile membrane wrapped about transplant and the resected nerve ends; well applied; formed close fitting tube. Both wounds closed. May 16, 1919, killed. Dog in very good condition; active; no neurotrophic changes on left hind foot. On exposing the left sciatic, external popliteal bundle found free. Operated internal popliteal presents appearance of a normal nerve, except that region of the transplanted nerve appears slightly smaller than resected nerve. No trace of Cargile membrane, only very moderate increase of connective tissue about the transplant. Small spindle-shaped central bulb noted. Calf muscles exposed; these have the appearance of normal muscle. External popliteal resected and internal popliteal freed from bed. On cutting nerve slowly with scissors central to the transplant, vigorous contraction of calf and plantar muscles observed. Resected nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Silver differentiation faint. Microscopic findings.—In longitudinal sections embracing central wound, line of central wound is indistinct. Numerous myelinated and nonmyelinated nerve fibers can be traced from central stump through the transplant to the distal nerve. In cross sections made about middle of the transplant, many myelinated and nonmyelinated fibers observed within the transplant, the funiculi of which are well maintained. Outside of perineural sheath, but within the denser connective tissue surrounding the transplant, many small funiculi of nerve fibers observed. Many new nerve fibers, both myelinated and nonmyelinated, noted in the distal popliteal. No trace of Cargile membrane observed in any of the sections. Experiment No. 232.—Dog No. 32; medium size dog; full grown; 358 days. May 24 1918 left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment of 3 cm. length taken from the right ulnar transplanted to the left internal popliteal. Three epineural sutures placed distally; good approximation. A single layer of Cargile 1236 SURGERY membrane wrapped about transplant and resected nerve ends; well applied. Both wounds closed. May 19, 1010, killed. Dog in very good condition; walks well. No neurotrophic changes left hind foot. On exposing the left sciatic external popliteal found free. Operated internal popliteal presents a small spindle-shaped central bulb; otherwise the appearance of a normal nerve. No trace of Cargile membrane. No material increase of connective tissue about the transplant noted. Calf muscles exposed; these of normal size and appearance. The internal popliteal and transplant freed from the bed. On slowly cutting the nerve with scissors central to the transplant, good contraction of the calf and plantar muscles observed. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine- silver staining. Fairly good differential silver staining attained. Microscopic findings.—In longitudinal sections of the central wound region, the central wound not easily located. Numerous myelinated and nonmyelinated nerves pass from distal end of the central bulb to and through the transplant to the distal nerve. In cross sections of the transplant taken near the central wound, many new nerve fibers found within the trans- plant. Funiculi and perineural sheaths maintained. Many small nerve funiculi in the connective tissue surrounding the transplant. In cross sections through the distal part of the transplant, perineural sheaths of transplant not so distinct. Numerous smaller and larger funiculi in the connective tissue outside of the transplant, in distribution more or less clearly bounded by an outer fairly dense connective tissue sheath, probably connective tissue replacing the Cargile membrane. Many new nerve fibers, nearly as many as seen in a normal nerve, traced through the distal wound into the distal popliteal. Very complete regeneration through the transplanted nerve segment. Experiment No. 233.—Dog No. 31; large; full grown; 359 days. May 23, 1918, left sciatic exposed and freed. Right ulnar exposed and freed. A segment of 2.9 cm. length taken from the right ulnar transplanted to the left sciatic. One central and distal fine silk thread suture placed; fairly good approximation attained. One layer of Cargile membrane wrapped about the transplant and resected nerve ends; well applied, forming closely fitting tube. Both wounds closed. May 19, 1919, killed. Dog very good condition; uses left hind leg well; no neurotrophic changes left hind foot. On exposing the left sciatic, the region of the nerve transplant is located by reason of the distinct central bulbous enlargement. Transplant has the appearance of a normal nerve; no material increase of connective tissue about it. No trace of Cargile membrane. Calf muscles exposed; these have the appear- ance of normal muscle. After freeing nerve and transplant from the bed, on slowly cutting nerve central to transplant, vigorous contraction of calf and the plantar foot muscle noted. Sciatic and the transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—In longitudinal sections through the central wound, central bulb distinctly evidenced by crisscrossing and tangling of the neuraxes of this region; line of central wound not clearly demarked. Numerous neuraxes pass from central bulb to and through the transplant. In cross sections of the transplanted nerve funicular structure and sheaths clearly are maintained. Numerous new nerve fibers observed with the transplant. Nearly all of the neuraxes observed in cross sections of the transplant found within its sheaths; only a few small scattered nerve funiculi found in the connective tissue surrounding the transplant. Numerous nerve fibers, myelinated and nonmyelinated, can be traced to the distal sciatic in which they are found in all of its several funiculi about equally distributed Experiment No. 234.-Dog No. 30; large; full grown; 44 davs. August 15 1918 right sciatic exposed and internal popliteal bundle freed. Left ulnar exposed and freed A segment 2.1 cm length taken from the left ulnar transplanted to the right internal popliteal. One central and one distal waxed, fine silk thread suture placed; good approximation. Two avers of Cargile membrane which had been stored several days in 70 per cent alcohol, then for 24 hours in absolute alcohol and before use spread on a dry, sterile towel until dry, wrapped about the nerve and the resected nerve ends. (Cargile membrane thus treated is in subse- Sed^T^ " "k r * 1 al '■ w' 4_r • tg$*r isriastst,?^ta,Bi aut°-fasciai sheath'Experiment n°- ^^- ulnar nerves M ^^^^^^T^^^ ^^ Note the fUnlCUlar Structure of the *™ materially increased traDSPlaDtS- The tube of fascla » clearly evident in the figure. Epineural fibrous tissue is s=='»HS=_Hss=F~r = ri;_;vsiSL-Sh=ti-ii ssSSSJS NEUROSURGERY 1245 formed connective tissue; adherent to the surrounding tissue and the underlying muscle. Fascial sheath presents a glistening white appearance. Deep wound not congested; no distinct evidence of infection noted. Sciatic and transplant and fascial sheath removed and fixed in neutral formalin. Serial sections stained in iron-hematoxylin and picro-fuchsin. Microscopic findings.—In longitudinal sections of the central and distal wound areas, it is noted that the distal end of the central stump and the central end of the distal stump present early degenerative changes of the nerve fibers. In cross sections of the transplant and the fascial sheath, the outer surface of the fascial sheath is seen to be covered with coagulum, extravasated red blood cells, numerous leucocytes and newly formed connective tissue. The cross cut transplanted nerves are clearly demarked; their perineural sheaths appear as thickened. Between the inner surface of the fascial sheath and the nerve trans- plants, newly formed connective tissue, containing many leucocytes and phagocytic cells, Fig. 236.—Cross section of auto-nerve transplant wrapped in auto-Iascial sheath, Experiment No. 241, terminated 15 days after operation; formalin fixation, iron-haematoxylin staining. The very complete auto-fascial tube formed is evident in the section. Connective tissue proliferation is clearly recognized but is not excessive observed. The nerve fibers of the nerve transplant do not present the same type of degenera- tion as do the nerve fibers of the distal sciatic; fragmentation of the myelin not so far advanced. Experiment No. 241.—Dog No. 17; medium size; full grown; 15 days. August 13, 1918, right sciatic exposed and freed. Left ulnar exposed and freed. A segment of 3.6 cm. length taken from the left ulnar transplanted to the resected sciatic. One central and dis- tal waxed, fine silk thread suture placed; good approximation. A portion of the fascia lata taken from the right leg of the same dog wrapped about the transplant and resected nerve ends. Three half mattress sutures placed. Good fascial tube formed. The three wounds closed. August 28, killed. Dog not well since operation. All three wounds in part open; superficial skin wounds, deep wounds healed. On exposing the right sciatic, deep wound found healed; appears not to be infected. Fascial sheath and transplant found well in place. Fascial sheath surrounded by newly formed connective tissue; adherent to sur- rounding tissue; evidence of sanguineous fluid within the fascial sheath. Sciatic and trans. 1246 SURGERY plant and fascial sheath removed and fixed in neutral formalin. Sections stained in iron- hematoxylin and picro-fuchsin; safranine and licht grim. Microscopic findings.—In cross sections of the transplant and the fascial sheath, trans- planted nerve found clearly demarked, its perineural sheaths appear thickened. On both surfaces of the fascial sheath newly formed connective tissue, containing leucocytes, extrav- asated red blood cells, and coagulum. The tendon cells of the transplanted fascial sheath present normal shape and staining reaction. Experiment No. 242.—Dog No. 40; medium size; not quite full grown; 22 days. August 19, 1918, right sciatic exposed and internal popliteal freed. Left ulnar exposed and freed. A segment of 3 cm. length taken from the left ulnar transplanted to the right internal popliteal. One central and distal waxed, fine silk thread suture placed; approximation not good. Central and distal epineural suture improves approximation. An auto-fascial sheath taken from the right fascia lata of the same dog, wrapped about the transplant and resected nerve ends. One central and distal stay sutures and three intervening half mat- tress silk sutures placed. Good fascial tube formed. The three wounds closed. Septem- ber 10, killed. Much emaciated; severe skin disease; trophic ulcer over right hip. Sciatic wound not completely healed, several stitches had given away; deep wound seemed healed. On exposing the right sciatic, slight evidence of infection of deep wound noted; parts con- gested. Transplant and fascial sheath found well in place, surrounded by connective tissue and adherent to underlying muscle. External popliteal found adherent to side of fascial sheath. Sciatic, transplant, and fascial sheath removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grim. Microscopic findings.—In cross sections of the transplant and fascial sheath, fascial sheath found surrounded by newly formed connective tissues containing numerous leucocytes. Between transplanted nerve and fascial sheath newly formed connective tissue, numerous leucocytes, and extravasated blood cells observed. In longitudinal sections of the central and distal wound areas, leucocytes and phagocytic cells especially numerous in the region of central and distal wounds. Distal nerve in process of degeneration. Fragmentation of myelin and breaking down of the nerve fibers of the transplanted nerves not of the same nature as in distal popliteal; proliferation of sheath cells not noted. Experiment No. 243.—Dog No. 57; small dog; full grown; 46 days. July 25, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment 3.2 cm. length taken from the right ulnar transplanted to the resected left internal popliteal. Centrally one through-and-through suture and one epineural suture, distally one suture of waxed, fine silk thread placed; approximation good. Adrenalin used; dry field. Fascial sheath taken from the fascia lata of the left leg of the same dog wrapped about transplant and resected nerve ends. Central and distal stay sutures and three intervening half mattress sutures placed. Good, even fascial tube formed. The three wounds closed. Toward the end of July developed skin disease; had not been well some weeks. September 9, the dog found dead in the morning. On exposing the left sciatic, external popliteal found free. Mod- erate increase of connective tissue about sheath. Distinct central bulb showing through central end of the fascial tube. Sciatic, transplant, and fascial sheath removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grim. Microscopic findings.—In cross sections through the transplant and the fascial sheath there is noted a fairly dense layer of fibrous tissue surrounding the fascial sheath. Sheath in close relation to perineural sheath of transplanted nerve segment, very little connective tissue intervening. Neurolemma sheaths of transplanted nerve segment evident; appear thickened. Certain ones contain ovoids of myelin and phagocytes filled with lipoid gran- ules; others contain syncytial protoplasmic bands; these also observed outside of neuro- lemma sheaths Distinct central bulb evidenced structurally. Fascial sheath extends over the central bulb. Experiment Nc> 244.-Dog No. 55; large, full grown; 47 days. July 22, 1918, left sciatic exposed and the internal popliteal freed. The right ulnar exposed and freed A segment of 3 cm length taken from the right ulnar transplanted to the left internal popliteal. One central and distal waxed, fine silk thread suture placed; fairly good approximation NEUROSURGERY 1247 attained. A fascial sheath taken from the facsia lata of the left leg of the same dog wrapped about the transplant and resected nerve ends. One central and distal stay sutures and two intervening half mattress sutures placed. Good tube formed. Dry field. The three wounds closed. September 8, dog found dead in the morning; much emaciated; skin disease. On exposing the left sciatic external popliteal found moderately adherent to the operated internal popliteal; easily dissected. Fascial sheath found well in place, distinct increase of connective tissue about it; adherent to underlying muscle. Distal internal popliteal presents a distinct, light-yellow color. Nerve and transplant and the facial sheath removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun. Microscopic findings.—In cross sections of transplanted nerve and sheath, it is observed" that a relatively thick layer of fibrous tissue surrounds fascial sheath. Between the fascial sheath and the transplanted nerve, and blending with the perineural sheath of the same, distinct layer of fairly dense fibrous tissue. In longitudinal sections embracing central and distal wounds, numerous leucocytes observed within the fascial sheath. In cross sections of the nerve transplant, increase in the amount of endoneural connective tissue noted. Within the old neurolemma sheaths, in many instances, one, two, three, or four small medullated fibers observed; other neurolemma sheaths distended with detritus derived from breaking down nerve fibers. Numerous nucleated, syncytial protoplasmic strands noted within the transplant in longitudinal sections of the same. Experiment No. 245.—Dog No. 38; medium size; full grown; 61 days. June 21, 1918, left sciatic exposed; internal popliteal freed. The right ulnar exposed and freed. A segment of 2.5 cm. length taken from the right ulnar transplanted to the left internal popliteal. One central and distal waxed, fine silk thread suture placed; good approximation. Fascial sheath taken from the fascia lata of the left leg of the same dog wrapped about the transplant and resected nerve ends. One central and distal stay suture and one half mattress suture placed. Adrenalin used to control oozing. The three wounds closed. August 22, dog used in the morning for another operation; found dead 1.30 p. m.; did not recover from second operation. Dog in good condition; slight toe-drop left hind foot; neurotrophic ulcer dorsum of left foot. Sciatic and other wounds well healed. On exposing the left sciatic, the external popliteal found firmly adherent to the fascial sheath about operated internal popliteal. Fascial sheath clearly demarked; marked increase of connective tissue about it. Distinct central bulb evident through proximal end of the fascial sheath. Calf muscles found very atrophic. Nerve and the fascial sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Quite good differential silver staining attained. Microscopic findings.—In cross sections of the transplant and the fascial sheath, sheath found in close relation to the transplanted nerve segment; a thin layer of fibrous tissue surrounds the sheath. Endoneural connective tissue of the transplant distinctly increased. New neuraxes, which in longitudinal sections of the central wound can be traced from the distal end of the bulbous enlargment into the transplant, in cross sections are found arranged in the form of numerous very small nerve funiculi, often containing only a few nerve fibers, and without special fibrous sheath, but separated by endoneural connective tissue. New neuraxes traced through the transplant and through distal wound into the distal stump. In cross sections of the distal popliteal, scattered neuraxes found in all of its funiculi, in many instances more than one in old neurolemma sheath. Beginning regeneration of distal popliteal through transplant attained. Experiment No. 246.—Dog No. 41; small dog; full grown; 31 days. July 28, 191S, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment of the right ulnar of 3.5 cm. length transplanted to the resected left internal popliteal. One central and distal waxed, fine silk thread suture placed. Good central approximation; distal partly pulled out as the sheath was being applied, a fascial sheath taken from the left fascia lata of the same dog wrapped about the transplant and resected nerve ends. One central and distal stay suture and one half mattress suture applied. Good fascial tube formed. '.Younds clean and dry. All three wounds closed. August 28, dog found dead in the morning; had not been well for some time; much emaciated; small neurotrophic 4(i!)!)7—27----SI 124N SURGERY ulcer on dorsum of left foot. On exposing the left sciatic, external popliteal found quite adherent to fascial sheath. Fascial sheath well in place; moderate increase of connective tissue about it noted. Found loosely adherent to underlying muscle. Sciatic and trans- plant with fascial sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Only fair differential neuraxis staining attained. Tissues not well embedded; sections much torn. Microscopic findings.—In cross sections of the transplant and the fascial sheath, it is found that the sheath is surrounded by dense layers of fibrous tissue. Sheath in close relation to nerve transplant, very little connective tissue intervening. The transplanted nerve pre- sents areas in which the old neurolemma sheaths are either broken down or distended with detritus and phagocytic cells with lipoid globules. Only a few neuraxes can be traced from the distal end of the central stump, through the transplant, to the distal popliteal. This is no doubt in part accounted for by the imperfect differentiation of neuraxes attained in the pyridine-silver staining. Experiment No. 247.—Dog No. 4; medium size; full grown; 66 days. June 13, 191N. right sciatic exposed; internal popliteal freed. Left ulnar exposed and freed. A segment of 2.5 cm. length taken from the left ulnar transplanted to the resected right internal popliteal. One central and distal waxed, fine silk thread suture placed; good approximation. A fascial sheath taken from the right fascia lata of the same dog wrapped about the transplant and the resected nerve ends. One central and distal stay suture and three intervening sutures placed. Wound not quite dry, slight oozing, which was not fully controlled. The three wounds closed. August IS, killed. Much emaciated; had not been active for several days; no neurotrophic changes right hind foot. On exposing the right sciatic, the external popliteal is found adherent to the fascial sheath. Fascial sheath found well in place; forms closely fitting tube, surrounded by fibrous tissue; only moderately adherent to underlying muscle. Quite distinct central bulb, evident through the transplant. Sciatic and transplant witli fascial sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Distal posterior tibial fixed in neutral formalin. Good differential neuraxis staining attained. Tissues not well embedded; sections torn. Microscopic findings.—In cross sections of the nerve transplant and the fascial sheath, it may be observed that the sheath is surrounded by a relatively thick layer of fairly dense fibrous tissue. In alternate cross and longitudinal sections of operated nerve, it may be seen that neuraxes pass from the distal end of the central bulb, through the transplant into the distal popliteal. Experiment No. 24S.—Dog No. 40; medium size; dog not quite full grown; 65 days. July 7, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment of 3.0 cm. length taken from the right ulnar transplanted to the resected left internal popliteal. One central and distal suture of No. 00 catgut placed. Approximation not satisfactory; not as good as when waxed, fine silk thread is used for suture. A fascial sheath taken from the left fascia lata of the same dog wrapped about the transplant and resected nerve ends. Central and distal stay sutures and one intervening suture all of fine silk thread placed. Good fascial tube formed. Dry wound. The three wounds closed. September 10, killed. Dog much emaciated, severe skin disease. On exposing the left sciatic, external popliteal found adherent along side of the fascial sheath. Fascial sheath found well in place; its proximal and distal ends not clearly demarked; moderate increase of connective tissue about it; adherent to underlying muscle. No distinct central bulb made out. Calf muscles exposed; atrophic; do not respond when nerve is cut, Sciatic and the transplant with the fascial sheath removed and fixed in ammoniated alcohol for pyridine- silver staining. Yery good differential neuraxes staining attained. Microscopic findings.—Only indistinct central bulb evidenced structurally. In cross sections of the transplant and sheath, sheath is found surrounded by a relatively loose layer of fibrous tissue. The transplanted nerve clearly demarked, its perineural sheath not mate- rially thickened, between these perineural sheaths and the inner surface of the fascial sheath a layer of loose fibrous tissue. In the transplanted nerve many new neuraxes, singly or in small bundles, observed; endoneural connective tissue only moderately increased. These XEUROSURGERY 1249 new neuraxes can be traced through the transplant and distal wound into the distal popliteal to the level of the calf muscles. Partial regeneration of the distal popliteal attained. Experiment No. 249.—Dog No. 17; medium size, full grown; 106 days. May 14, 191S, left sciatic exposed. Right ulnar exposed. Two segments, each measuring 1.6 cm. taken from the right ulnar transplanted to the resected right sciatic. One central and distal suture of fine Chinese silk for each segment placed; only fair approximation attained. A fascial sheath taken from the fascia lata of the left side of the same dog wrapped about the transplants and the resected nerve ends. One central and distal stay suture and con- tinuous over and over suture between, placed. The three wounds closed. All wounds healed well. August 28, killed. Dog had not been well for some time; nearly moribund when killed. On exposing the left sciatic, moderate increase of connective tissue about the transplant is found; adherent to underlying muscle. Fascial sheath distinctly evident; its central and distal limits not distinctly made out. Nerve distal to transplant presents the appearance of normal nerve. On exposure, the calf muscles seem still somewhat atrophic and are of pale red color. On slowly cutting the sciatic central to sheath and transplant, no contraction of calf muscles; this may in part be accounted for by condition of dog when killed. Sciatic with the transplant and sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential neuraxis staining attained. Microscopic findings.—Distinct central bulb evidenced structurally. In cross sections of the transplants and sheath, the fascial sheath appears not to have been reduced in thickness and is found surrounded by a layer of relatively dense fibrous tissue. The two transplanted ulnar segments clearly demarked within the fascial tube. Their perineural sheath relatively thick, but the funicular structure is not lost. Yery little connective tissue found between the perineural sheaths and the fascial sheath. Each of the transplant nerve segments, as seen in cross sections, contains numerous new neuraxes; in about equal number in two nerve segments. These neuraxes can, in sections, be traced through the distal wound to the distal sciatic, found approximately equally distributed through its several funiculi. Regeneration of the central end of distal sciatic attained. Experiment No. 250.—Dog No. 42; large dog; full grown; 268 days. August 21, 1918, right sciatic exposed; internal popliteal freed. Left ulnar exposed and freed. A segment of 3 cm. length taken from the left ulnar transplanted to the right internal popliteal. One central and distal waxed, fine silk thread suture placed. Centrally good approximation; distally a second, an epineural, suture placed; approximation fair. Fascial sheath taken from the fascia lata of the right side of the same dog, wrapped about transplant and the resected nerve ends. Central and distal stay sutures and five intervening half mattress sutures placed. Good tube formed. The three wounds closed. May 16, 1919, killed. Dog in good condition; walks well, but does not climb stairs as easily as normal dog; no neurotrophic changes right hind foot. On exposing the right sciatic external popliteal bundle found free. Quite marked increase of connective tissue about the transplant noted, so that fascial sheath is not clearly made out. Calf muscles exposed; these have the appearance and size and color of normal muscle. Cutting of nerve central to transplant causes good contraction of calf muscles; movement of toes feeble and indistinct. Nerve and transplant with sheath fixed in ammoniated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—In cross sections of the transplant and sheath, fascial sheath is clearly demarked; does not appear to have been reduced in thickness by absorption; surrounded by a relatively dense layer of fibrous tissue, containing here and there small lobules of adipose tissue. The transplanted ulnar segment presents a funicular structure with perineural sheaths thickened, and endoneural connective tissue materially increased. A loose connective tissue intervenes between perineural sheaths and fascial sheath; in this there may be observed numerous small funiculi of nerve fibers delimited peripherally by the fascial sheath. The funiculi of the transplanted nerve contain numerous new neuraxes scattered or in small bundles. In series of alternate cross and longitudinal sections, new neuraxes can be traced to the distal popliteal in which, in each of the several funiculi, there may be observed numerous both myelinated and nonmyelinated nerve fibers. Yery complete regeneration of the distal popliteal through the transplant attained. 1250 SURGERY Expekimkxt No. 251.—Dog No. 39; medium size; full grown; 27<» days. August 14, 191S, right sciatic exposed; internal popliteal freed. Left ulnar exposed and freed. A segment of 3.5 cm. length taken from the left ulnar transplanted to the resected right internal popliteal. One central and distal waxed, fine silk thread suture placed; good approximation. Fascial sheath taken from the right fascia lata of the same dog wrapped about the transplant and the resected nerve ends. The piece of fascia cut a little too narrow at one end so that complete fascial tube could not be made. Central and distal stay sutures and two interven- ing half mattress sutures placed. Three wounds closed. May 16, 1919, killed. Dog in very good condition; used right hind leg and foot well; no neurotrophic changes. On exposing the right sciatic, the external popliteal found free. Operated internal popliteal in ^^aftJr^olr^n11 K aut°;nerVertrafn!Plant; wraPPed * auto-fascial sheath, Experiment No. 250, terminated 268 days evMPnfsornPwhr„vP ,i'Ve fU™U ° ^ "* maintained and fully neurotized. Auto-fascial sheath still distinctly e\ ment somewhat over six months after operation the region of the transplant and sheath surrounded by quite dense connective tissue and adherent to the underlying muscle. Fascial sheath not clearly made out. Calf muscles exposed; these have appearance, both as to size and color, of normal muscle. Sciatic freed from bed and external popliteal resected. On slowly cutting with scissors nerve central to the transplant, good contraction of calf and foot muscles noted. Sciatic, transplant and sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differen- tial neuraxis staining attained.. Microscopic findings.-In cross sections of the transplant and sheath, the fascial sheath L2r n^ I1" plaCe;fPP?ars not to have bee* educed in thickness by absorption; presents essentially the same structure as in short-time experiments of this series; surrounded by a XEUROSURGERY 1251 distinct layer of fibrous tissue in which many fat cells are seen. The transplanted nerve segment is clearly demarked, having retained its funicular structure. The perineural sheaths of transplant found thickened and for nearly the whole circumference in relation with inner surface of the fascial sheath; very little connective tissue intervening. New neuraxes traced from central stump through the transplant into distal popliteal in which are found numerous myelinated and nonmyelinated nerve fibers arranged singly or in small bundles and separated by endoneural connective tissue which is distinctly increased in amount. Almost complete regeneration of the distal popliteal through the transplant attained. Experiment No. 252.—Dog No. 42; large dog; full grown; 318 days. July 2, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment of 3.6 cm. length of right ulnar transplanted to the resected left internal popliteal. One central and distal waxed, fine silk thread suture placed; good approximation. Fascial sheath taken from the left fascia lata of the same dog wrapped about transplant and the resected nerve ends. One central and distal stay suture, no intervening sutures placed. Good tube formed. Field not quite dry; oozing controlled by use of adrenalin. The three wounds closed. May 16, 1919, killed. Dog in very good condition, walks well but does not climb stairs as easily as normal dog; no neurotrophic changes left hind foot. Left sciatic exposed; skin adherent along wound line. External popliteal found free. Operated internal popliteal, transplant and sheath surrounded by quite dense layer of connective tissue and adherent to underlying muscle. Fascial sheath not clearly made out. Calf muscles exposed; these have the ap- pearance and size of normal muscle. Cutting of sciatic, after removing external popliteal and removing nerve from bed, central to the transplant, calls forth good contraction of calf and foot muscles. Sciatic, transplant and sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential neuraxis staining attained. Microscopic findings.—-Structural evidence of well-developed central bulb. Down- growing central neuraxes cross and recross distal part of the bulbous enlargement; evidence of resistance spiral noted. Many neuraxes observed as passing to central end of transplant. In cross sections of the transplant and sheath, fascial sheath is clearly made out for the greater part of the circumference, to one side, it would appear that the lip of the fascial sheath sepa- rated, admitting an ingrowth of connective tissue. The transplanted nerve segment clearly demarked, with funicular structure retained. Fairly dense connective tissue intervenes be- tween the several funiculi and the inner surface of the fascial sheath. Numerous myelinated and nonmyelinated neuraxes are transmitted by the transplant to the distal popliteal, cross and longitudinal sections of which present an appearance which resembles that of a nearly completely regenerated nerve. Experiment No. 253.—Dog. No. 39; medium size; full grown; 326 days. June 24, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A seg- ment of 3.2 cm. length of the right ulnar transplanted to the left internal popliteal. One central and distal waxed, fine silk thread suture placed; good approximation. Fascial sheath taken from the left fascia lata of the same dog wrapped about transplant and the resected nerve ends. One central and distal and two intervening half mattress sutures placed. Good tube formed. Wound not quite dry; oozing controlled by use of adrenalin. The three wounds closed. May 16, 1919, killed. Dog in very good condition; uses left leg well; no neurotrophic changes. On exposing left sciatic, external popliteal found free. Operated internal popliteal surrounded by relatively dense layer of fibrous tissue, adherent to underlying muscle. Distal nerve has the appearance of normal nerve. Calf muscles exposed; these have the appearence of normal muscle. After freeing sciatic from bed and cutting the external popliteal, slowly cutting with scissors the sciatic central to trans- plant, calls forth good contraction of calf and foot muscles. Nerve, transplant and sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Good differential neuraxes staining attained. Microscopic findings.—Central neuraxes pass without special line of demarcation to trans- plant. In cross sections of transplant and sheath, fascial sheath found well in place and not materially reduced in thickness through absorption; covered on its outer surface by distinct layer of fibrous tissue. The transplanted nerve segment clearly demarked; perineural sheaths thickened, these in close relation to inner surface of the fascial sheath. Numerous small 1252 SURGERY funiculi of nerve fibers in the connective tissue within the fascial sheath, but outside of perineural sheath, observed; especially to one side. Numerous neuraxes, both myelinated and nonmyelinated, transmitted by the transplant to the distal popliteal, wliich in cross and longitudinal sections presents the appearance of a nearly completely regenerated nerve. The experiments of Series No. 17, 14 in number, are sufficiently varied as to time under observation and sufficiently numerous to admit of formulating certain general deductions relative to auto-fascial sheaths. Experiments Xo. 250 to No. 253 were under observation for periods varying, respectively, from somewhat over 8 months to nearly 11 months, and in each of these experi- ments it is noted that the fascial sheath could be clearly made out in micro- scopic sections of the transplant region. These four experiments were studied chiefly with reference to the behavior of the down-growing neuraxes, which were thus fixed for pyridine-silver staining. In preparations stained after this method the fascicular structure of the transplanted fascial sheaths could be clearly made out, the cellular elements were not clearly differentiated. There- fore it can not be stated whether the fixed connective tissue cells—tendon cells—of the fascial sheaths were maintained after transplantation. Lewis and Davis 87 have shown that a fascial tube remains patent for an extended period. In a case in which a fascial tube was used in tendon repair, the sheath was evident 255 days after the operation. In these experiments of long duration there is no distinct evidence of a secondary contraction of the fascial tube. There is found a layer of areolar tissue between the inner surface of the fascial sheath and the perineural sheaths of the funiculi of the transplanted nerve segments. This varies in thickness in the several experiments and also in different regions of the same experiment. The newly formed nerve fibers found within the funiculi of the nerve transplant are of normal appearance and were especially numerous in Experiment No. 253, terminated 326 days after the operation at which the fascial sheath was placed. In this experiment the fascial sheath was well maintained and there was found relatively little loose areolar tissue within the fascial sheath. The contraction noted by Kredel85 in the case of neurolysis of the tibialis in which the fascial sheath was found con- tracted 24 days later is not conclusive. It may be asked whether the correct operative procedure was undertaken in the first place. It may be repeated that these experiments seem to indicate that there is relatively little secondary contraction of a fascial sheath. From the experiments here reported it is evident that an auto-fascial sheath of fascia lata does incite connective tissue proliferation even in an aseptic wound in healthy tissue, a wound passing in the main through intermuscular planes. It seems quite impossible to remove a piece of fascia lata without having extravasated blood cells and tissue fragments adhere especially to its outer surface, the more so if a layer of subcutaneous fat is removed with the fascia, as has been recommended. The inner surface is quite smooth if the portion removed is correctly oriented. In all of our experi- ments a distinct development of fibrous tissue is noted surrounding the fascial sheath This layer is quite cellular in the experiments of short duration and in it there are found many leucocytes and extravasated red blood cells In certain of the experiments the fascial sheath was found adherent to the muscle bed, to the extent necessitating dissection; this shows connective tissue pro- NEUROSURGERY 1253 liferation. This newly formed connective tissue surrounding the fascial sheaths, even in aseptic wounds in healthy tissue, on subsequent contraction and cicat- rization may be regarded as having deleterious effect on the structural and functional regeneration of an injured nerve, sheathed by fascial sheath, rather than the secondary contraction of the fascial sheath itself. While thus inciting connective tissue growth, the fascial sheath does appear to retard the growth of connective tissue into the central and distal wound and the immediate environs of a nerve transplant. Experiment No. 252 bears on this indirectly. In this experiment, studied 318 days after the primary operation, the fascial tube appears to have opened along the side. There was an ingrowth of con- nective tissue through this cleft, to the extent that a fairly dense layer of con- nective tissue intervenes between the nerve funiculi and the inner surface of the fascial sheath, much more so than when the fascial sheath remained closed in tube form as in the majority of the experiments. However, even in this experiment there was found good neurotization of the distal segment through the nerve transplant. The general conclusion seems warranted that an auto-fascial sheath is very slowly absorbed, evidence of its persistence having been noted nearlv a year after it was placed at operation in the wound in healthy tissue. However, even in aseptic wounds in healthy tissue there is noted a distinct proliferation of the surrounding connective tissue, which would prejudice against the use of fascial sheaths in connection with operations of nerve repair, especially where such operations pass through cicatricial tissue. It would appear that auto-fascial sheaths incite more connective tissue proliferation than does alcoholized Cargile membrane, the application of which is technically much simpler and serves every purpose that could be gained on use of a fascial sheath. SERIES NO. is AUTO-NERVE TRANSPLANTS WRAPPED IX FORMALIZED ARTERIAL SHEATHS This short series of experiments was suggested through records of clinical and experimental observations in which arteries or veins, used either fresh or after fixation and taken as auto-, homo-, or heterogenous vessels were placed as a wrapping or as a tube to ensheath the suture lines in operations for repair of peripheral nerves. To review- in extenso the literature involved is not here justi- fiable. The brief experimental observations of Foramitti,88 have influenced later operators and experimenters and may thus be given brief consideration here, the more so since wre have followed his method of preparing arterial tubes. though Biingner 27 some years earlier had used a segment of a sterilized human brachial artery to bridge a nerve section. We shall consider ''tubular sutures" under Series Xo. 20, in connection with which series the bridging of nerve defects bv means of tubular structures will be considered. Ensheathing a nerve suture after severance, or a nerve transplant with a tubular structure is not a "tubular suture" in the correct use of this term. Three animals were operated by Fora- mitti. Both fresh and hardened arteries were used, either applied to a liberated nerve, bv cutting the vessel wall longitudinally and slipping the vessel wall over one end of a resected nerve, making a central nerve flap and moving the arterial 1254 SUR.iERY segment so as to cover the field of operation; or. as a tubular suture. The longest observation, that of tubular suture, extended only six weeks. Foramitti found that on use of both fresh and hardened arteries, the inclosed peripheral nerve tissues was only lightly adherent to the wall of the artery. The experi- ments of Foramitti are not conclusive and leave further doubt when he states ''die physiologische Function des Nerven war hergestellt," in speaking of a section and sutured sciatic of the dog studied three weeks after operation. We have used in this series only prepared arterial wTalls, taken from the carotid of large dogs, and used for the purpose of making a tubular sheath after nerve transplantation. The arteries used were prepared as follows: The carotids of large dogs were stretched over glass tubes of suitable size, were then fixed in 5 per cent to 10 per cent formalin solution for 48 hours, washed in water for 24 hours, boiled in distilled water for 20 minutes, and then stored in 70 per cent to 95 per cent alcohol. They were stored on glass rods in the alcohol in wide mouthed, glass-stoppered bottles, for several days to several weeks depending on the time when they were used at operation. Before use at operation an arterial segment of required length was slipped from the glass rod, cut longitudi- nally along a line and placed in sterile salt solution for about 30 minutes. The arterial sheath thus prepared was then wrapped about the nerve transplant, sutured in place and allowed to extend 5 mm. to 8 mm. over the central and divided suture lines, and was fixed in place by central and distal stay sutures and intervening half mattress sutures, using for suture fine, waxed silk thread. Experiments with fresh arteries or veins used as sheaths were not made: neither have we tested autogenous nor heterogenous vessels. Foramitti recommended the use of formalized arteries of the calf. With the treatment given the tissue, namely, formalin fixation, boiling for 20 minutes and storage in 95 per cent alcohol, it is to be questioned whether homogenous vessels obtained from amputations or even at autopsy (in selected cases) could not be used for en- sheathing operated nerves in human surgery. The experiments of Eden88 of inserting the central and distal ends of the resected anterior crural through fine slits into the femoral artery or vein, with the circulation maintained, did not seem to us worthy of repetition. The protocols of experiments on the use of formalized arterial walls for the purpose of ensheathing nerve transplants are as follows: PROTOCOLS Experiment Ao. 254.-Dog No. 50; large dog; full grown; 6 days. July 17, 1918 left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed, "a segmeni of 3 cm length transplanted to the resected left internal popliteal. One central and dTsta A segment of formahzed artery of a dog, split longitudinally along one side, placed so as to surround the transplant and the resected nerve ends. A central and distasSy suture Ld three intervening half mattress sutures placed. Adrenalin used to obtain dry field Woundt closed. July 23, dog found dead in the morning. The superficial wound seemedTealed On reopening wound, evidence of infection noted in deep wound; parts congested Trant plant and tube surrounded by sanguineous exudate. Arterial sneath found well'in plac The nerve transplant and the arterial sheath removed and fixed in neutraWo^n Sec turns stained in iron-hematoxylin and picro-fuchsin; safranine and licht grun NEUROSURGERY 1255 Microscopic findings.—As seen in cross sections of the transplant and sheath, arterial sheath forms a well-closed tube with edges overlapping. About the sheath blood coagulum, tissue detritus, numerous wandering leucocytes and phagocytes. Within the sheath rela- tively few leucocytes. In longitudinal sections of the region of the central and distal wounds leucocytes have penetrated for a distance into the central and distal stump, and central and distal ends of the transplant, where they are found between the nerve fibers as also within the neurolemma sheaths. The nerve fibers of the transplanted nerve segment present little evidence of beginning degeneration. Their myelin sheaths stain pale, but as yet no distinct evidence of myelin fragmentation. Proliferation of sheath cell nuclei not observed. Experiment No. 255.—Dog No. 48; medium size; full grown; 57 days. July 15, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment of 2.5 cm. length of right ulnar transplanted to the resected left internal popliteal. One central and distal waxed, fine silk thread suture placed; good approximation. An arterial sheath, formed by cutting longitudinally a segment of formalized carotid artery of a dog and wrapped about transplant and resected nerve ends placed. One central and distal stay suture and two intervening half mattress sutures used. Good tube formed. Dry field after using adrenalin. Wounds closed. September 10, dog found dead in the morn- ing; much emaciated. On exposing the left sciatic, arterial sheath is found well in place. Proximal and distal ends of sheath covered with connective tissue and adherent to epineural sheath of the resected nerve. No material increase of connective tissue about sheath. Nerve, transplant and sheath fixed in neutral formalin. Sections stained in iron-hema- toxylin and picro-fuchsin; safranine and licht grun. Microscopic findings.—In cross sections of sheath and transplant, arterial sheath clearly recognized in sections; centrally the lips of the arterial sheath have rolled in so that to one side of the transplanted nerve a segment is exposed; distally arterial sheath forms a tube completely inclosing transplant. In section it may be observed that the elastic tissue of the intima and media, and the fibrous tissue of the adventitia are best preserved; the in- voluntary muscle of the media still recognizable, though many muscle cells appear frag- mented. Only a thin layer of fibrous tissue surrounds the arterial sheath. The trans- planted nerve segment has retained its funicular structure, with perineural sheaths mate- rially thickened. Dense fibrous tissue intervenes between nerve and arterial sheath, especially centrally, where sheath is incomplete. Many small medullated fibers found within the transplant. Experiment No. 256.—Dog No. 45; small dog; full grown; 63 days. July 12, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment of the right ulnar of 3 cm. length transplanted to the resected left internal popliteal. One cen- tral and distal waxed, fine silk thread suture placed. Centrally fair, distally good approxi- mation attained. An arterial tubular sheath formed by splitting longitudinally a segment of formalized carotid artery of a dog, and wrapping the same about the transplant and the resected nerve ends. Stay sutures and two intervening half mattress sutures placed. Good tube formed. Wounds closed. September 13, dog nearly moribund; killed. Much ema- ciated; severe skin disease. On exposing left sciatic, arterial sheath is found well in place. The two half mattress sutures appear to have given away, since a slit can be recognized along one side of "tube," for nearly its whole length. No material increase of connective tissue about the sheath. Nerve, transplant, and arterial sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Only faint silver staining attained; especially in the region of the transplant. Microscopic findings.—In cross sections, it may be observed that the arterial sheath forms a closely fitting tube surrounding the transplant. A very thin fibrous tissue sheath surrounds tlie arterial sheath. Arterial wall not so clearly defined in silver-stained prepara- tions as when other fixatives and certain other staining methods are used. However, in the silver preparation it is possible to differentiate the arterial wall and especially its elastic tissue. The perineural sheath of the transplanted nerve segment in close relation to the inner surface of the arterial sheath, very little connective tissue intervening. In series of longitudinal and cross sections, it is possible to trace numerous neuraxes from the central 1256 SURGERY stump through the transplant and distal wound to the distal popliteal in which a few scattered neuraxes can be traced distally for a distance of about 2 cm. Experiment No. 257.—Dog No. 49; medium size; full grown; 117 days. July 16, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment of the right ulnar of 3.5 cm. length transplanted to the resected left internal popliteal. One central and distal waxed, fine silk thread suture placed; good approximation. An arterial sheath made by cutting longitudinally along one side, a segment of a formalized carotid artery of a dog and wrapping same about transplant and resected nerve ends. Stay sutures and three half mattress sutures placed. Good tube formed. Dry field obtained after using adrenalin. Wounds closed. November 10, dog found dead in the morning, much emaciated; severe skin disease. On exposing the left sciatic, arterial sheath found well in place; no material increase of connective tissue about sheath. No distinct central bulb noted. Con- dition of calf muscles not recorded. Nerve, transplant, and sheath removed and fixed in ammoniated alcohol for pyridine-silver staining. Faint but fairly good differential neuraxis staining attained. Microscopic findings.—In cross sections of the transplant and sheath, it is observed that arterial sheath forms complete tube about transplanted nerve segment and is surrounded by only a thin layer of fibrous tissue. Sheath in close relation with the perineural sheaths of the transplanted nerve segment, the funicular structure of which is retained; the endoneural connective tissue of the funiculi materially increased. In alternate cross and longitudinal sections, numerous new neuraxes may be traced from the central stump through the trans- plant to the distal popliteal. Experiment No. 258.—Dog No. 43; small dog; full grown; 130 days. July 11, 1918, left sciatic freed. Right ulnar freed. A segment of the right ulnar of approximately 3 cm. length transplanted to the resected left sciatic. One central and distal waxed, fine silk thread suture placed. Approximation fair; a small amount of blood exudate in central nerve wound. An arterial sheath made by splitting longitudinally a segment of a formalized carotid artery of a dog and wrapping same about the transplant and the resected nerve ends. Stay sutures and several mattress sutures placed. Good tube formed. Wounds closed. November 18, dog seemed fairly well in the morning; found dead 4 p. m.; seemed in good condition; well nourished; no neurotrophic changes on left foot. On exposing the left sciatic, arterial sheath found well in place, moderate increase of connective tissue about it. No distinct central bulb, only slight enlargement noted. Calf muscles exposed; these slightly atrophic, but of good color. Nerve, transplant, and sheath removed and fixed in ammo- niated alcohol for pyridine-silver staining. Good differential silver staining attained. Microscopic findings.—In cross sections of the transplant and sheath, arterial sheath is found to have been well maintained; forming closely fitting tube about the transplant; with scarcely any connective tissue between transplanted nerve segment and inner surface of sheath and only a thin layer of fibrous tissue surrounding it. In cross and longitudinal sections, it is to be observed that new neuraxes in large numbers may be traced from the central stump through the transplant to the distal popliteal in which numerous neuraxes are found in its peripheral distribution, namely, to the posterior tibial several centimeters above the heel and into the small interfascicular nerve branches in the calf muscles. Regeneration of distal popliteal through the transplant attained. Experiment No. 259.-Dog No. 44; small dog; full grown; 243 days. July 12, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A segment of the right ulnar of 3 cm. length transplanted to the resected left internal popliteal. One one thto^ht ffrZ™ I I ^ "^ ^^ Pl&Ce± Central suture ^ave ^i sutured, Zd An T : ,°"glSUture and 0ne epineural «*ure; central approximation fair, distal TotMalrv 7 H ^^ b3' SPlItting k^dinally a ^gment of the formalized ends Two t & f°g and7™pPlne the sa™ about the transplant and the resected nerve £m ■« * S^tUreS1.and three half ^ttres* sutures placed. Good tube formed. Drv field after use of adrenalin. Wounds closed. March 12, 1919, killed. Dog in good condi- tion; no neurotrophic changes left foot; uses left hind foot and leg well. On exposing the n, H^U?0 T'r00^0 GVidenCe °f ^^ Sheath f0Und- No Serial incrase of con- nect e tissue about operated internal popliteal; nerve only moderately adherent to under- NEUROSURGERY 1257 lying muscle. Only small central bulb noted. Calf muscles exposed; these present the appearance of normal muscle. After freeing the operated nerve from bed and slowly cutting with scissors central to the transplant good contraction of calf muscles observed, but only feeble and indistinct movement of the toes noted. Nerve and transplant removed and fixed in am- moniated alcohol for pyridine-silver staining. Good differential neuraxis staining attained. Microscopic findings.—Scarcely any structural evidence of a central bulb noted. In longitudinal sections of the central and distal wound region and in cross and longitudinal sections of the transplant no distinct structural evidence of the arterial sheath noted. In the silver stained preparations the presence or absence of the sheath is not readily determined. The transplant and regions of the nerve wounds surrounded by a relatively thin layer of fibrous tissue in which no clear determination of the elastic tissue of the arterial sheath could be gained. In cross sections of the transplant it is to be observed that the endoneural con- nective tissue is very materially increased. The numerous neuraxes, which can be traced from the central stump through the transplant, within the transplant are found arranged in small funiculi, separated by endoneural connective tissue. These neuraxes can be traced to the distal popliteal, in which they are found in large numbers. Very complete regeneration of the distal popliteal through the transplant attained. This series of experiments is unsatisfactory to the extent that such a large per cent of the experimental animals died from intercurrent disease not related to the experiments, that a function test could not be made in certain of the experiments in which such test would have been desirable. The whole series could be and was used to determine morphology. It was found, con- firming Foramitti, that a formalized arterial tube incites relatively little con- nective tissue proliferation when placed in normal tissue in aseptic wounds. In the experiments of long standing, the arterial tube was found surrounded by only a relatively thin layer of fibrous tissue which was only loosely adherent to adjacent connective tissue. Between the perineural sheath of the funiculi of the transplanted nerve segment and the inner surface of the arterial sheath there was found only a relatively small amount of areolar tissue. The arterial sheath was clearly made out macroscopically in Experiment No. 258 somewhat over four months after it was placed about the operated nerve. It is more particularly the elastic tissue of the vessel wall that resists absorption, forming a compact tubular structure easily recognized in cross sections of the transplant. There is no evidence of a secondary contraction of the vessel wall after it is placed in the tissue. It is recognized, of course, that a tubular structure which persists for a period of approximately 4 months has fulfilled any useful purpose which may be hypothecated to it, when considered in connection with the wound region in a peripheral nerve. In Experiment No. 259, of nearly 8 months' duration, the arterial sheath used at the operation could not be made out macroscopically nor was it recognized in sections, stained after the pyridine- silver method. The neurotization of the distal segment was very satisfactory m all of the experiments in which an auto-nerve transplant wTas ensheathed in a formalized arterial tube, especially so in experiments observed for a time sufficient to admit of downgrowth of central neuraxes. Attention is particu- larly called to the protocols of Experiments Nos. 258 and 259 in this regard. Since formalized arterial sheaths are so easily prepared and may be kept on liand in 70 per cent to 95 per cent alcohol, ready for use on need, the method deserves consideration in surgical practice when sheathing of the suture line in nerve suture or of a nerve transplant after bridging a nerve defect is deemed 125S .SURGERY necessary. However, this typo of sheathing presents no advantage over a sheath or tube formed with a double or triple layer of an alcoholized Cargile membrane, which is more easily prepared and applied. A formalized arterial wall used as sheath or tube appears to incite less connective' tissue proliferation than does an auto-fascial sheath or tube as judged by the experimental evidence presented. 1 SERIES NO. 19 AUTO-NERVE TRANSPLANTS WRAPPED IN AUTOGENOUS-FAT FLAP Relatively frequent reference is made in literature to the use of pedicled or nonpedicleii fat sheaths or flaps in connection with operation for the repair of peripheral nerves or of neurolysis. This method of sheathing an operated nerve was for a time especially recommended in case the nerve repair or libera- tion was undertaken in the presence of scar tissue. The behavior of a fat flap or sheath, either pedicled or nonpedicled, lias not been considered experimentally so far as we are able to ascertain. It has been the intention to extend this series of experiments but for various reasons further experiments were not undertaken. In one of the two experiments, the fat membrane was taken in the region of fascia lata through a skin wound made for this purpose; in the other tlie fat membrane was taken through the wound exposing the sciatic. The fat membrane was thus taken from subcutaneous tissue. There is of necessity free oozing of blood on liberating a fat layer, with consequent adher- ence of blood coagulum to the tissue removed. The fat membrane, which had an average thickness of 5 mm., was rinsed in sterile salt solution before it was wrapped about the nerve transplant. It was held in place by several stay sutures made with fine, waxed silk thread. The fat sheath thus made was without pedicle and was autogenous tissue, slightly cooled during manipulation and rinsing in the saline solution. The protocols of the two experiments under this series are as follows: PROTOCOLS Experiment No. 260.—Dog No. 54; large dog; not full grown; 4 days. July 22, 1918, left sciatic exposed and the internal popliteal freed. The right ulnar exposed and freed. A segment of the right ulnar of 3.8 cm. length transplanted to the resected left internal popliteal. One central and distal waxed, fine silk thread suture placed; good approximation. A layer of subcutaneous fat removed from the region of the fascia lata of the left leg of the same dog, trimmed to proper size and rinsed in warm, sterile saline solution to remove the adherent blood, was placed under the transplant and the resected nerve ends and folded over so as to form a fat sheath. Two proximal and two distal stay sutures and three intervening sutures placed; fairly even fat sheath formed. Wounds closed. July 26, dog found dead in the morning. Sciatic wound found open in part; field congested: a small amount of pus noted. Fat sheath of yellow-brown color; soft and pliable. Nerve transplant and fat sheath removed and fixed in neutral formalin. Sections stained in iron-hematoxylin and picro-fuchsin; safranine and licht grim. Microscopic findings.—In cross sections of the transplant and fat sheath, it may be observed that the nerve transplant is necrotic and as seen in longitudinal sections of the central wound, had torn free from the central stump. The fat sheath is found to have been penetrated from all sides and through its entire thickness bv numerous leucocytes and phagocytes. Many of the fat cells appear collapsed and empty of fat globule; others partially so. The interlobular connective tissue of the fat sheath presents evidence of begin- NEUROSURGERY 1259 ning necrosis, evidenced by fragmentation and curling of fiber bundles, especially of elastic tissue. Experiment No. 261.—Dog No. 47; medium size; full grown; 240 days. July 15, 1918, left sciatic exposed; internal popliteal freed. Right ulnar exposed and freed. A seg- ment 2.5 cm. length from the right ulnar transplanted to the resected left internal popliteal. One central and distal suture of waxed, fine silk thread placed; good approximation. A layer of subcutaneous fat removed from the region of the wound, trimmed and washed in warmed, sterile saline solution, placed under nerve and transplant and folded over to form a tube; central and distal stay sutures and several intervening sutures placed. 'Wounds closed. Sciatic wound healed slowly; stitches did not give away, but small droplets of liquid fat appeared to escape from wound; no infection. March 12, 1919, killed. Dog in good con- dition; no neurotrophic changes left hind foot. On exposing left sciatic dense, fibrous tissue was found in the line of the wound, and dense fibrous tissue surrounded the operated nternal popliteal. No evidence of fat sheath noted; this replaced by dense fibrous tissue. Large central bulb observed. Nerve in region of transplant of smaller diameter than resected nerve; distal popliteal has the appearance of a normal nerve. Calf muscles exposed; these have nearlv recovered full size, are of pale yellow color streaked with light yellow lines. On cutting nerve central to the transplant, distinct though not vigorous contraction of calf muscles observed; feeble toe movements noted. Nerve and transplant removed and fixed in ammoniated alcohol for pyridine-silver staining. Very good silver differentiation attained. Microscopic findings.—Neither in cross nor longitudinal sections is there observed any evidence of the fat sheath. In the region of central and distal wounds and the intervening transplant, distinct increase of dense fibrous tissue about the nerve. In cross sections of the nerve transplant, distinct increase of the endoneural connective tissue observed. New neuraxes traced from the central stump through the transplant are within the transplant found arranged in small bundles, spaced by intervening connective tissue. New neuraxes found in abundance in the distal internal popliteal in all of its funiculi, traced in peripheral distribution in alternate cross and longitudinal sections. Regeneration of distal popliteal through the transplant with great increase of connective tissue in the field of operation attained. Experiment No. 260 loses in value by reason of the slight infection of the wound region and the early termination of the experiment by reason of the death of the animal. Attention is called to the relatively early disappearance of the fat from certain of the transplanted fat cells, so that many of these cells appear collapsed, shriveled, and shrunken. There was noted marked leuco- cyte invasion into the fat flap, perhaps in part to be ascribed to the infection present. It was noted in this experiment and in Experiment No. 261 for a few days after the operation that tliere was taking place a slight oozing of a lipoid fluid from the wound. It was observed in connection with Experi- ment No. 261 that the wound healed relatively slowly, though infection was not evident. In this experiment the dog was in good condition throughout the time he was under observation, was active, and was kept nearly eight months after the operation. On exposing the sciatic nerve at the termination of the experiment there was found very marked increase of fibrous tissue in the region of the wound and operated sciatic. This fibrous mass was more dense and more extensive than found after any of the other operations in which the nerve transplant w^as sheathed. The nerve and the nerve transplant, through which neurotization of the distal segment had taken place, were found embedded in the deeper portion of this fibrous tissue, which was adherent superficially to the skin. 1260 SURGERY V -eneral deduction seems hardly justifiable on the basis of a single experiment. However, the results here presented argue against the use of a completely detached, autogenous-fat sheath or flap, in connection with operated or liberated peripheral nerves, since the fat membrane appears to bo replaced . bv dense fibrous tissue, persisting only a relatively short time as a fat layer. It is to be questioned whether a pedicled fat layer used as a sheath for wrap- ping an operated nerve would be maintained for a longer time as a fat layer and thus serve the purpose hypothecated to it. NERVE SUTURE SERIES NO. 20 TUBULAR SUTURE WITH USE OF FORMALIZED ARTERY Tubular suture in the repair of peripheral nerves with loss of substance has been given extensive consideration and came into use relatively early in the development of operative technique as regards peripheral nerve repair. The term "tubular suture'' as here employed recognizes the union of severed nerve ends by means of a tubular structure, which may be empty or filled at the time of use by inserting and maintaining in place the central and distal stumps of the severed nerve within the lumen of the tubular structure, centrally and distally. As previously stated, wrapping a nerve after neurolysis or after suture, or after nerve transplantation with a membranous structure is, cor- rectly speaking, not a tubular suture but should be regarded as a procedure for ensheathing an operated nerve. Tubular structures were suggested as a means of union of severed nerves and are to-day used, with a view of maintaining a channel along wliich central neuraxes (monogenetic view) or central and distal neuraxes (polygenetic view) may be enabled to grow, on the theory that such tubular structures along a certain direct path would prevent connective tissue proliferation and organization between the severed and resected nerve ends and at the same time prevent dispersion of the newly formed neuraxes. Among the various methods tried by Gluck90 for the purpose of bridging nerve defects was that of tubular suture, made by inserting the severed nerve ends into a '' Xeuber's bone drain." In no instance did regeneration of the distal stump take place. Vanlair 26 instituted a series of experiments on tubular nerve suture also using "bone drains." In a young dog with the sciatic re- sected 3 cm. and the ends united by means of a bone drain tubular suture, four months after the operation the tissue intervening between the nerve ends was found to contain many nerve fibers. Nerve fibers were also found in the distal stump. Biingner 27 united the resected and separated nerve ends by means of tubular sutures made from sterilized human brachial artery. At the end of about a month and a half nerve fibers were found in the space between the nerve ends. Huber30 reported eight experiments in which decalcified bone tubes made from the ulna of chicken were used for purpose of tubular suture of the resected ulnar nerves of dogs. Three of these experiments were observed for a period varying, respectively, from about four months to about five months, and in these the neuraxes regarded as of central origin were found in the central XEUROSURGERY 1261 end of the distal stump. A relatively early absorption of the bone tube was noted in the experiments of shorter duration. The tubes were found replaced by a relatively loose connective tissue, thus leaving a path of less densely organized connective tissue between the severed nerve ends. These several lines of investigation give experimental foundation for two types of tubular structure perhaps more frequently used in practical surgery than others, namely, bone tubes and arterial tubes. Numerous other tubular structures have been used for this purpose. More than mention of the majority of these is not justified here; nearly all have been or should be discarded, since their use is not justified experimentally. Mention is here made of tubes formed of iodoform gauze, Wolfer; 91 of magnesium tubes, Payr; n hardened gelatin tubes, Lothei- sen; 93 galalith tubes (casein treated with formalin), Auerbach; u rubber tubes and rubber tubes filled with serum, Steinthal;95 rubber bandages, Meuriot and Platon. 81 These and other tubular structures of like nature are more of academic than practical interest and their consideration need not occupy space here. Brief recognition should be given, if only to condemn it, to the method of tubular suture suggested by Edinger,96 who, largely on theoretic grounds and without sufficient experimental warrant, recommended the use of arteries filled with agar, for the purpose of bridging nerve defects. Edinger appears to have reasoned that if neuraxes would grow into agar or blood serum in tissue culture, a tubular suture filled with agar should prove more serviceable than an empty tube. These " Edinger tubes" were prepared commercially and for a period were used extensively in the German service, even in cases in which a direct suture could have been made. A series of contributions appeared so soon as the observations on the results obtained on the use of the Edinger tube could be ascertained; Stracker 97 and a number appearing in 1917 may be listed here, Hohmann and Spiolmoyer, 98 Enderlen and Lobenhoffer, 99 Spitzy, 10° Wollenberg, m Blenke, 102 and Eden ,103 all of whom discredited use of the Edinger tube even in case the prepared artery was filled with autoserum as was later suggested. This method was not tested experimentally in our laboratory but was condemned on a priori considerations. The experimental work reported on briefly by Hohmann and Spielmeyer,98 in which arterial tubes filled with agar were tested, led to the conclusion that agar in the arterial tubes appeared to block the downgrowth of neuraxes rather than facilitate their growth. The use of fascial tubes in the repair of peripheral nerves with loss of substance was tested experimentally by Kirk and Lewis. 86 They conclude that a defect in a nerve may be successfully bridged by means of a fascial tube, regeneration taking place entirely through nerve fibers growing from the central stump. They give directions and precautions for use of a fascial tube in the repair of peripheral nerves. Their experiments were controlled by study of histologic sections stained after differential neuraxes staining methods and had been completed so recently that they could be considered a part of these experimental obser- vations. Tubular nerve suture with the use of vessels is mentioned so frequently in literature on the repair of peripheral nerves and to our knowledge had not been o-iven more than passing consideration experimentally since the few' experiments made by Foramitti88 were recorded, that it seemed to us desirable to make 1262 SURGERY use for this purpose of certain of the ulnar nerves resected to obtain auto-nerve transplants for Series Xo. 16, Xo. 17 and Xo. 18 as previously reported. In all 13 experiments of tubular suture were made. The arteries used were the carotids of dogs. The arteries were obtained from large dogs after bleeding while under anesthesia, were slipped over glass rods of suitable size and fixed in o per cent to 10 per cent solution of formalin, for 48 hours; were then washed in water for 24 hours; boiled in distilled water for 20 minutes and placed in 70 per cent to ) Sicard, J. A.: Traitment des nevrites douloureuses de guerre (causalgies) par 1 alcoohsa- tion nerveuse locale. Presse medicale, Paris, 1916, xxiv, No. 31, 241. ,63i Huber, G. C, and Lewis, D.: Amputation Neuromas, Their Development and 1 re- vention. Archives of Surgery, Chicago, 1920, i, No. 1, 85 (64) Cone, S. M.: Surgical Pathology of the Peripheral Nerves. The British Journal oj Surgery. Bristol, 1917-18, v, No. 20, 524. Mi-", i Corner E M • The Surgerv of Painful Amputation Stumps. Proceedings of the " flo.aZ Noci-rfy o/ .l/«//«-«r, London, 1917-18, xi, 7. The Structure Forms and Conditions of the Ends of Divided Nerves. With a Note on Regeneration Neuro- mata. British Journal of Surgery, Bristol, 1918-19, vi, 273. See also: Marmesco, G.: The Characteristics of Amputation Neuromata. Proceedings of the Royal Society of Medicine, London, 1917-18, xi, 5. 1661 Philipeaux and Yulpian: Note sur des essais de greffe d'un troncon du nerf lingual (m.1 re les deux fonts du nerf hypoglosse, apres excision d'un segment de ce dernier nerf. Arch, de Phys. Paris, 1X70. iii, No. 5, 618. (67) Albert E.: Neurom des Nervus medianus. Berichte des naturwissenschaftligh-medizi- nischen Vereines in Innsbruck, Innsbruck, 1878, ix, 97. H\S) Stookey, B.: The Technic of Nerve Suture. Journal of the American Medical Asso- ciation, Chicago, 1920, lxxiv, 13x0. 69i Elsberg, C. A.: Technic of Nerve Sut lire and Nerve Grafting. Journal of the American Medical Association, Chicago, November 8, 1919, lxxiii, 1422. (70) Forssman, J.: Zur Kenntniss des Neurotropismus. Beitrdge zur pathologischen Anatomie und zur allgemeinen Pathologie, Jena, 1900, xxvii, No. 3, 407. (71) Merzbacher, L.: Zur Biologie der Nervendegeneration. Neurologisches Ccntralblatt, Leipzig, 1905, xxiv, No. 4, 150. (72) Segale, M.: Sulla rigenerazione delle fibre nervose. Riforma medica, Naples, June 23, 1906, xxii, 681. (73) Maccabruni, F.: Der Degenerationsprozess der Nerven bei homoplastischen und heteroplastischen Pfropfungen. Folia Neuro-biologica, Leipzig, 1911, v. No. 6, 59X. (74) Ingebrigtsen, R.: A Contribution to the Biology of Peripheral Nerves in Transplan- tation. The Journal of Experimental Medicine, Lancaster, 1916, xxiii, No. 2, 251. (75.) Ingebrigtsen, R.: Sur la transplantation des nerfs. Lyon chirurgical, Lyon, 1916. xiii, No. 5, X28. (76) Dujarier, C. and Francois: Sur vingt cas de greffe homoplastique dans les sections nerveuses. Bulletins et memoires de la Societe de chirurgie de Paris, Paris, Janu- ary 9, 1918, xliv, 43. (77) Nageotte, J.: Sur une atrophie musculaire reflexe precoce apres suture des nerfs par affrontement et sur les inconvenients de la greffe nerveuse vivante autoplas- tique. Comptes rendus hebdomadaires des seances de la Societe de biologie, Paris, July 20, 1918, lxxxi, 761. (78) Morris, R. T.: A Report on Experiments Made with Cargile Membrane for the Purpose of Determining its Value in Preventing the Formation of Peritoneal Ad- hesions. Medical Record, New York, May 17, 1902, lxi, 773. (79) Craig, A. B., and Ellis, A. G.: An Experimental and Histological Study of Cargile Membrane with Reference to (1) its Efficacy in Preventing Adhesions in the Ab- dominal and Cranial Cavities and Around Nerves and Tendons and (2) its Ulti- mate Fate in the Tissues. Annals of Surgery, Philadelphia, 1905, xli, No. 6,801. .s0) Sherren, J.: Some Points in the Surgery of the Peripheral Nerves. Edinburgh Medical Journal, Edinburgh, 1906, xx, n. s., No. 4, 297. (XI) Meuriot, H.: Cent observations d'isolement des nerfs par manchonnage au caoutchouc. Bulletins et memoires de la Societe de chirurgie de Paris, Paris, May 8, 1918, xliv, 850. 1821 Denk, ,\Y.: Ueber Sclm.-sverletzungen der Nerven. Beitrage zur klinischen Chirurgie. Tubingen, 1914, xci, Nos. 1 and 2, 217. NEUROSURGERY 1283 (83) Doepfner: Zur Methodik der Naht an peripheren Nerven. Munchener medizinische Wochenschrift. Munchen, April 13, 1915, lxii, 526. ;84) Hirschel, G.: Erfahrungen fiber Schussverletzungen der Nerven. (Dcutsch. Zcitschr, f. Chir., cxxxii, 1914-15.) Munchener medizinische Wochenschrift, Munchen, Februarv 2, 1915, lxii, 159. (85) Kredel, L.: Ueber das Verhalten der auf operierte schussverletzte Nerven fiber pflanzten Fascienlappen. Zentralblatt filr Chirurgie, Leipzig March '7 1915 xlii, 201. XO) Kirk, E. G. arid Lewis, D.: Fascial Tubulization in the Repair of Nerve Defects. Journal of the American Medical Association, Chicago, August 7, 1915, lxv, 486. 87) Lewis, D. D., and Davis, C. B.: The Repair of Tendons by Fascial Transplantation. Journal of the American Medical Association, Chicago, February 21, 1914, lxii, 602. (88) Foramitti, C: Zur Technik der Nervennaht. Archiv fur klinische Chirurgie. Berlin, 1904, lxxiii, No. 3, 643. ix9) Eden, R.: Untersuchungen fiber die spontane Wiedervereiningung durch trennter Nervem im stromenden Blut und im leeren Gefiissrohr. Archiv fur klinische Chirurgie, Berlin, 1917, cviii, No. 3, 344. (90) Glfick: Ueber Transplantation, Regeneration and entzfindliche Neubildung. Berliner klinische Wochenschrift, Berlin, 1881, xviii, No. 37, 529. (91) Wolfer: Ueber die Nervennaht und Nervenlosung. Zentrablatt filr Chirurgie, Leipzig, 1893. (92) Payr, E.: Beitrage zur Technik der Blutgefass und Nervennaht nebst Mittheilungen fiber die Verwendung eines resorbirbaren Metalles in der Chirurgie. Archiv fur klinische Chirurgie, Berlin, 1900, lxii, No. 1, 67. 193) Lotheisen, G.: Zur Technik der Nerven und Sehnennaht. Archiv fur klinische Chirurgie, Berlin, 1901, lxiv, No. 2, 310. (94) Auerbach, S.: Galalith zur Tubulisation der Nerven nach Neurolysen und Ner- vennahten. Munchener medizinische Wochenschrift, Munchen, October 26, 1915, lxii, 1457. '95) Steinthal, H.: Die Deckung grosserer Nervendefekte durch Tubularnaht. Zentbl. f. Chir. 1917, xliv, No. 29, 646. Also: Beitrdge zur klinischen Chirurgie, Tubingen, 1916, xcvi, No. 3, 295. (96) Edinger, L.: Ueber die Yereinigung getrennter Nerven; Grundsatzliches und Mitteilung eines Nerven Verfahrens. Munchener medizinische Wochenschrift, Miinchen, Feb- ruary 15, 1916, Ixiii, 225. 97) Stracker, O.: Zu den Ueberbruckungsversuchen von Nervendefekten Zentralblatt fur Chirurgie, Leipzig, December 16, 1916, xliii, 985. (98) Hohmann und Spielmeyer: Zur Kritik des Edingerschen und des Bethcschen Ver- fahrens der Ueberbriickung grosserer Nervenlucken. Miinchcner medizinische Wochenschrift, Munchen, January 6, 1917, lxiv, 97. (99) Enderlen und Lobenhoffer, W.: Zur Uebercbruckung von Nervendefekten. Munchener medizinische Wochenschrift, Munchen, February 13, 1917, lxiv, 225. (100) Spitzv, H.: Bemerkung zur Ueberbriickung von Ncrvendefecten. Munchener medi- zinische Wochenschrift, Munchen, March 13, 1917, lxiv, 372. (101) Wollenberg, R.: Das Edinger-Verfahren der Nervendefektuberbruckung. Deutsche medizinische Wochenschrift, Berlin and Leipzig, May 24, 1917, xliii, 641. 102) Blencke, A.: Ein weiterer Beitrag zu den Ueberbruckungsversuchen von Nervende- fekten mit Edinger-Rohrchen. Zentralblatt fur Chirurgie, Leipzig, March 24, 1917, xliv, 236. (103) Eden, E.: Sind zur Ueberbriickung von Nervendefekten die Verfahren der Tubuliza- tion und der Nerventransplantation zu empfehlen? Zentralblatt fur Chirurgie, Leipzig, February 17, 1917, lxiv, 138. INDEX Abdomen, wounds of_________________________ 443-469 Abdominal operations, anesthesia in_______________~ 178 Abdominal surgery, civil lessons in, gained from the war T - ■■ - - ^ Abdominal wall, nonpenetrating wounds, involving the_________ - - - - - ^ Abdominally wounded, special provisions for the care of____________ 444 Abdominothoracic injuries_____________________ 4^ Abscess: brain— experimental study__________________________________ §50 gunshot wounds of the head____________________________________ 814 treatment of, in forward hospitals, A. E. F_______________________________ 789 Abscess wall: after the introduction of infection, behavior of the brain with regard to the forma- tion of, in gunshot wounds of the head_____________________________________ S15 gunshot wounds of the head— dense fibrous mesoblastic tissue__________________________________________ 815 fairly firm wall containing some fibers proliferated from neighboring meso- blastic tissue_________________________________________________________ 820 of varying thickness, the results of glial proliferation______________________ 823 showing no evidence of a protective reaction_____________________________ 823 types of---------------------------------------------------------------- 815 Absorption, forced, of fluids in wound shock______________________________________ 192 Accessories, splints and, standard, manufacture of_________________________________ 556 Acetone, full strength, injection of, into living uncut nerve_________________________ 1123 Active mobilization in purulent arthritis—Willems' method_____________________ _ 337 Active motion in peripheral nerve lesions______________________________________ 866 Activities of the American First Army Hospital at Deuxnouds___________________ 759-775 Adaptations, respiratory, to pathologic states, with respect to wounds of the chest__ 348 Adhesions, pleural, in wounds of the chest________________________________________ 371 Adj uvant medication in anesthesia____________________________________________ 176 Admissions, battle injuries, statistics of___________________________________________ 57 Advance, area of, conference on problems relating to the__________________________ 130 After-care in wound shock________________________________________.. -____________ 209 Agents: military destructive— anatomical part and; case fatality rates________________________________ 65 battle injuries by__________________________________________------------ 62 physical disabilities by, statistics of_________________________— 85 various causative, general character of wounds from the_____________ 45 Aid station: surgery at the— battalion_______ ___________________________------------------------- 93 company__________ ------------------------------------------ 93 regimental_________________________________________________------ 96 Air circulation, bronchial, with respect to wounds of the chest---------------- - 358 Airplane bombs_________-------------------------------------- -"* Alcohol: absolute— injection of, into a living nerve without cutting the nerve----------- 1117 injection of, into the central end of a divided nerve to obviate the formation of amputation neuroma_________________________ --- ------------- W25 fifty per cent— 199_ hetero-nerve transplants stored in---------------- j*£' homo-nerve transplants stored in-------------------- ------------ liy5 American Expeditionary Forces: . . management of gunshot wounds of the head and spine in----------- <<« neurological service, organization and activities---------------- ' j■> orthopedic surgery in embarkation hospitals------------------ ()43 1285 12S(i INDEX American First Army Hospital at Deuxnouds: _a_g° activities_________________________________------------- .T clinical data_________________________________________ ----- L™ cranial cases evacuated--------------------------- iy' deaths_______________________________ ! .(J ])atients evacuated___________---------- -------------- '■"- Amnesia, in gunshot wounds of the head---- ----------------- ------ 797 Amputated, care of tlie, in the United States: administration______________----------------------------- £|3 amputation center_______ ------ £j4 educational program--------------------- ------------------------------- £13 hospital service___________________________________________________________ - ' l,r> Amputation: . and reamputation, site of, with reference to prosthetic requirements, lower extremity_______________________________________________________________- '31 at the ideal site of the leg_________________________________________________ - 733 Chopart's________________ ________________________________ ------------- "32 Lisfranc 's__________________________________________________ --------------- 731 localized terminal osteomyelitis following---------------------------- 699 or reamputation, site of, with reference to prosthetic requirements----- 731 Pirogoff's osteoplastic______________________________________________ "33 protruding bone following____________________---------------------- ------ 699 secondary, knee-joint___________ _____________----------------- ---- 331 Syme____ ________________________________________________________------- 733 treatment immediately following, in base hospitals, A. E. F-----------------. _ 693 Amputation cases returned to the United States______________________________ _ 718 Amputation center, in care of the amputated in the United States__________________ 714 Amputation neuromas________________________________ _ ______________________ 981 formation in aseptic wounds________________________________ ______________ 1125 injection into divided nerve to prevent_______________________________________ 1125 injection of absolute alcohol into the central end of a divided nerve to obviate the formation of___________________________________________ ______________ 1125 protocols______ ________________________________________ _______________ 1125 treatment________________________________________________ ______________ 981 Amputation service, A. E. F__________________________________ ____________ 687-712 functions________________________ _ __________________ _____________ 688 organization and development_________________________________________ 687 technique of amputations__________ _____ ___________ ____ _ 689 Amputation stumps: attention to adjacent joints____ _ ________________. _ _______ 727 cinematization of_________________ ____________ ___ _____ _____ 737 operative treatment of unhealed cases_________________ _ __________ 728 post operative treatment______________________________ ______ 738 preoperative and nonoperative treatment______________ ___ 726 treatment of, in the United States____________________________ 7^ when secondary stump surgery should be done_______________ 728 wound antisepsis in___________________________________ 727 Amputations: fractures, and their sequeke, ratings of____________ ____ 495 hemorrhage in_______________________________________ gg8 in lower third of leg_________________________________ --y^ intractable joint deformities following_________________ 7qi joint deformity in___________________________________------ ^^ of lower extremity, use of provisional appliances in_____ 73$ painful neuromata following__________________________ 7qq painful osteophytes following_______________________ 7qq phalangeo-metatarsal and transmetatarsal______ 701 provisional prosthesis, following_________________ " " 702 responses to questionnaire on________________ T icq rules concerning, at evacuation hospital. _ V)'s sepsis in________________________________ ;."'_ soft-part retraction in_______________'______ " "_' j?™ stumps unsuitable for prosthesis following."" 7^9 technique of— U-J amputation service, A. E. F______________ RSQ in base hospitals, A. E. F____ . " ------ 5q, in the zone of the Advance, A. E. F £00 terminal conditions following______ ^ terminal ulcers following___________ ™* transt arsal___________________ 7UU upper extremity, use of provisional appliances in -?? use ©f provisional appliances in________________ ~~ 'Vl 738 INDEX 1287 Page Analgesia________________________________________________________ 175 Analysis: of foot defects found in recruits________________________________________ 595 statistical, of gunshot wounds of the head______________________________ Ml Anastomosis, nerve, in facial paralysis______________________________________ 1068 Anatomic or branch identifications, in nerve surgery___________________________ 960 Anatomical localization in localization and extraction of foreign bodies under N-rav control_________________________________________________________"_ 220 part and military destructive agents; case fatality rates____________________ 65 Anatomy, general: median nerve_______________________________________________________ 1013 musculocutaneous nerve______________________________________________ 993 musculospiral nerve__________________________________________________ 995 of the brachial plexus____________________________________ ____ __._ 982 of the circumflex nerve___________________________________ 991 sciatic trunk and its terminal divisions__________________________________ 1048 ulnar nerve_________________________________________________________ 1028 Anesthesia___________________________________________________________ 166-184 adjuvant medication in_______________________________________________ 176 criteria for the choice of method_______________________________________ 170 ether— and chloroform__________________________________________ ______ 170 limitations of________________________________________ __________ 183 in abdominal operations__________________________________ _____ ____ 178 in exhaustion and shock______________________________________________ 177 in gassed cases________________________________________ 181 in nerve surgery______________________________________— — ------- 952 in operations— in the presence of acute infections__________________ 1X2 in wound shock_______________________________ — ----------- 206 on the chest_____________________________ - - - ------- 178 on the extremities________________________ --------- 180 in wounds of the chest_____________________________----------------- 380 inhalation________________________________------------ 170 limitations of different types of---------- ----------------- 182 local___________________________________________________ |,i£ methods in special groups of cases------------------------ ----- 1" nitrous oxide________________________________________________ |i~ nitrous oxide-oxygen________________________________________________ *' 1 spinal-------------------------------------------------------- - - - J7^ limitations of_______________________________________________ — fit Anesthetics, responses to questionnaire on------------------------------- luf Anesthetist, the_____________________________________________________ 'M \nkle- and foot, gunshot wounds of, treatment of, in embarkation hospitals, A. E. 1Z_ 650 wounds of_______________________________________________________ '('r Ankylosed joints with nerve defects------------------------------------- Ankylosis: -9 in battle injuries----------------------------------------------- 0^9 in wounds of joints-------------------------------------- q.,o Anterior crural nerve, lesions of, motor disturbances in---------- ^ Antisepsis, wound, in amputation stumps------------------------------ --- ' -' Antlactionof, upon the central nervous system, in infections of, experimental study_. S51 responses to questionnaire on--------------------------- 3Q Antitank rifle------------------ - - - - - - - - - - - cm Aphasia, residual, in gunshot wounds of the ^ead --------------------- -- ■ -- Apparatus required for localization and extraction of foreign bodu s under A ia> ^ control_______________________________ Appliances: 73S provisional, use of, in amputations----------------------- splints and, manual of— -55 first edition-------- ---- -,sq second edition----------------. --.--. ~ . z 305 Application of biologic principles to thoracic injuries. .. Approximation technique: ,Hi3 nerve surgery---------------- 968 A,,TS™TeV,^^ 12SS INDEX Arm: Page exposure of the ulnar nerve in___________ --------- 1930 surgery of the median nerve in___________ --------- ----------- 1915 upper— gunshot wounds of, with fracture of humerus, treatment of, in embarkation hospitals______________________________________________________ 64(i site of amputation or reamputation with reference to prosthetic requirements. 737 Armor: body, helmets and—the medical viewpoint------------------------------- 1-8 problem, frequency in the location of wounds and its bearing on the---------- 4 the frequency of injury from missiles of low velocity, with respect to the wearing of______________________________ --------------------- 3 Arms, small, ratio of wounds from missile from___________________---------- 51 Army shoe, the____________________________ _________________ -------- 599 Arterial circulation, bronchial, with respect to wounds of the chest----------- . 358 Arterial sheaths, formalized, auto-nerve transplants wrapped in----------- 1253 Artery, formalized, use of, with tubular nerve suture_________________ 1260 Arthritis:. purulent, active mobilization in—Willems' method________________ 337 suppurative, wounds of joints_________________________________ -------- 333 Artificial limb laboratory, in the United States______________________ . _ . _ _ — 716 Artificial limbs, supply of, in the United States_______________________________ 716 Artillery___________________ __________________ __________________ 11 projectiles__________________________________________________________ 14 Atelectasis, in relation to wounds of the chest_______________________________ 359 Atrophy: in peripheral nerve lesions_____________________________________________ 877 muscle, in lesions of musculospiral nerve_________________________________ 888 Autogenous bone grafts for nonunion in atrophic long bones, and in chronic suppura- tive osteitis (osteomyelitis), following war wounds_________________________ 652-686 Autogenous-fat flap, auto-nerve transplants wrapped in________________________ 1258 Auto-, homo-, and hetero-nerve transplants, degenerated_______________________ 1184 Autoloading automatic rifle_______________________________________________ 30 Automatic rifle, autoloading_______________________________________________ 30 Auto-nerve transplants: including cable-auto-nerve transplants______________ _ ______ __________ 1146 protocols____________________________________ _______ _______ 1147 wrapped in auto-fascial sheaths of fascia lata________________ __ 1243 protocols______________________________ __ 1244 wrapped in autogenous-fat flap______________________ 1258 protocols------------------------------------________ T ! _ ~ _ _ 1258 wrapped in cargile membrane______________________________________ 1232 protocols____________________________________ 1233 wrapped in formalized arterial sheaths__________________ T 1253 protocols__________________________________ 1254 wrapped in protective material_________________________ 1232 protocols_____________________________ 1233 Axillary exposure, circumflex nerve__________________ 992 Back, general principles of training for the, special training" battalion" "ortliopedic department, A. E. F__________________ 586 Base: collective surgical experiences at the front and at the_.__ 130 152 surgery at the, responses to questionnaire on __ ___ ' 153 treatment at the, wounds of the kidnev 47-. Base hospitals, A. E. F.: " " °fr1enLhua^l hV.ufie? and inJuries of the spine and peripheral nerves, in 758 oi 1,UU0 beds, list of splints, splint accessories, and dressings for 624 representative in, neurological service__________ ___ 759 staffs, consensus of opinion among, concerning anesthesia 182 technique of amputations in. _ _ _ fiql treatment of fractures in_________ «24 of lower extremity .. __ _ ;T Battalion aid station: ""------------------------ D,iZ operative technique at___ _. Qfi surgery at the______ ;!° Battalion: ----------- yo special training, orthopedic department, A E F rccs the training, and the foot camp. ?qq Battle dead, site and character of injury in the 40 Battle field, surgery on the ' ™ Battle fractures, statistics of °° INDKX Battle injuries: Page admissions______________ T all causes__________________ g^ by gunshot missiles______________ g4 by military destructive agents____ 62 day of death___________________ gl days lost________________________ 5g deaths______________ _______ -s statistics_________________________ '^'s discharges for disability _ . ______'_'_'_'_ "~~~ 59 duration of treatment______________T___ " go invalided home____________________ gl statistics of____________________________ 57 Behavior of the brain with regard to the formation of the abcess wall after the intro- duction of infection, gunshot wounds of the head_______________ S15 Biologic principles, application of, to thoracic injuries____________ 365 Bladder, wounds of___________________________________ 4^5 476 Blocking the phrenic nerve in wounds of the chest_________________ / ~ '_ 387 Blood pressure, low, in wound shock________________________________ 192 Blood transfusion: in wound shock____________________________________________ _________ 197 method employed in the A. E. F_________________________ 198 in wounds of the chest_____________________________ ____ ______________ 389 responses to questionnaire on____________________________ ______________ 163 Boat-tail bullets_____________________________________________ _____ __ 44 Body armor, helmets and—the medical viewpoint_____________ _____________ 1-8 Body heat, loss of, in wound shock___________________________ _________________ 188 Bombs, airplane____________________________________________________________ 24 Bone: protruding, following amputation___________________________________________ 699 stump pathology referable to_______________________________________________ 721 Bone grafts, autogenous for nonunion in atrophic long bones and in chronic suppurative osteitis (osteomyelitis), following war wounds__________________________________ 652 case reports____________________________________________ _________________ 659 types of________________________________________________ ________________ 653 Bone shortening for defects in nerve continuity___________________ ________ 958 Bones: long, fractures of, end results______________________________ ______________ 491 tarsal, treatment of fractures of, in base hospitals____________________________ 642 Bonnet method, localization and extraction of foreign bodies under N-ray control--- 261 Brachial plexus: general anatomy of________________________________________ __________ 982 lesions of, motor disturbances in____________________________ __________ 905 technique of exposure_____________________________________ ---------- 987 Brain: abscess of—• experimental study______________________--------------------------- 850 gunshot wounds of the head__________________________----------------- 814 treatment of, in forward hospitals, A. E. F-------------------------.---- 789 behavior of the, with regard to the formation of the abscess wall after the intro- duction of infection, gunshot wounds of the head--------------------------- 815 injuries to, without destruction of tissue, gunshot wounds of the head---------- 798 Brain volume, alterations of, in infections of the central nervous system, experimental study_______________________________________________________________________ 849 Breathing unit, treatment with respect to, in wounds of the chest------------------ 362 British, training with the, orthopedic surgery------------------- 552 Bronchial air circulation, with respect to wounds of the chest---------- 358 Bronchial arterial circulation, with respect to wounds of the chest----- 358 Bullet wounds, perforating, rules regarding, at evacuation hospital.. 128 Bullets: boat-tail______________________________ .q irregular movements of, in tissues-------- ™ pistol. __----- 4] special rifle------------------------------------------------- qfio Bundle identification, nerve surgery------------- - - ------- ™jj Cable grafts, autogenous, for defects in nerve continuity _------- »™ Cable-auto-nerve transplants, auto-nerve transplants, including. _ 114b Capacity, vital. (See, Vital capacity.) Camp, foot, and the training battalion---------- J^ Carbine pistols, machine------------ 1290 INDEX Care: P„a8e of head injuries and injuries of the spine and peripheral nerves in base hospitals, 75s A. E. F__________________ ____________________________________- _. of the amputated in the United States----------------------- ------- ' 13-< 4S postoperative, wounds of joints------------------------------- 32.". Cargile membrane, auto-nerve transplants wrapped in----------- ----- 1232 Carpal extension, tendon transplantations for restoration of------ ------------------- 1011 Case fatality rates, anatomical part and military destructive agents------------------ 05 Case reports: autogenous bone grafts for nonunion in atrophic long bones, and in chronic suppurative osteitis (osteomyelitis), following war wounds--------------------- 65!) extraperitoneal wounds________________________________________ ---------------- 180 wounds of the bulbous urethra________________________________----------------- 4S3 wounds of the kidnev_______________ . .-- - — ------------------ 174 Cases: amputation, returned to the United States________________________________ ---- 718 cranial, evacuated, American First Army Hospital at Deuxnouds--------- 767 disposition of, gunshot wounds of the head________________________________ 846 mild, gas gangrene___________ ___________________________________________ - 277 preoperative, responses to questionnaire on______________________________ _ . 157 severe or malignant, gas gangrene______________________________________ _ 277 spinal, care of, in forward hospitals, A. E. F_______________________. _. . - .. _ 757 Causes: all, battle injuries___________________________ ______________________ ___ _ 64 of death, gunshot wounds of the head, a statistical analysis___ ______ _ _ _ _ 847 Cavity, pleural, cleaning the, in wounds of the chest____________ ________ _ __ 386 Center, amputation, in the care of the amputated in the United States_________ . . 714 Centers, neurological, A. E. F___________________________________ ____________ _ 750, 75S Central nervous system: action of antiseptics upon, in infections of, experimental study___________________ 851 experimental study of problems of infection of, and the treatment therefor______ 848 Cerebral symptoms, residual general, factors causing, gunshot wounds of the head___ 798 Cerebral tissue, loss of, gunshot wounds of the head__________________________________ 798 Cerebrospinal fluid: in meningitis, experimental study______________________ ________________________ 856 pressure, effect of intravenous injections of various concentrations upon, in in- fections of the central nervous system, experimental study_______________________ 819 Character: general, of wounds from various causative agents________________________________ _ 45 site and, of injury in the battle dead________________________ 49 Chest: operations on, anesthesia in_________________________________ 17S wounds of the_____ ________________________ 349 Chest injuries {see also Wounds of the chest): types of_________________________________________ 37 j Chest surgery, responses to questionnaire on_____ _ _"__"_. 158 Chest wall, closure of the, in wounds of the chest 393 Chloroform and ether anesthesia___________________________ ~ 170 Choked disc, slow pulse, headache, vertigo and, in gunshot" wounds of "the" head 797 uhopart s amputatron___________________________ -■>., Cicatrices, gunshot wounds of the head. _ _ _ T _ 79s Cinematization of amputation stumps ____ __ T7 Circulation: bronchial air, with respect to wounds of the chest 35s bronchial arterial, with respect to wounds of the chest 3^8 pulmonary, with respect to wounds of the chest "" 35.; CircuIaTor^^ 343 Urculaton unit, treatment with respect to, in wounds of the chest 361 Circumflex nerve: --------------- dorsal or lateral exposure_____ _ _ QQ9 general anatomy of_____________ ''£: lesions of— " 991 motor disturbances in______ _ QfU supplementary motility in " ------- ooj surgery of_______ ____T ^7, Cistern puncW Civrl abdominal surgery, lessons in gained, from the war } '' Classification: --.----- 468 of head injuries____________ of wounds, gunshot wounds of the"h"e^d,~a^ati_T^"anaiTis_T;;T.""_'_'_\ J™ 992 849 INDEX 1291 Page Cleaning the pleural cavity in wounds of the chest________ __________ 386 Clinical: data, American First Army Hospital at Deuxnouds_________ _ . _ 700 manifestations in gas gangrene_____________________ ____ 271 pathology, gas gangrene_____________________ __ __.._. 278 picture, wounds of the kidney___________________ 471 Closure: delayed primary, responses to questionnaire on_______________________________ 156 of the chest wall in wounds of the chest_______________________ ___________ 393 Collapse of the lung with respect to wounds of the chest_________ _______________ 352 Collective surgical experiences at the front and at the base________________ ____ 130-165 Colon, wounds of______________________________________________________________ 460 Combined lesions of median and ulnar nerves, surgery of____________ ____________ 1039 Company aid station, surgery at the____________________________________________ 93 Complications: gunshot wounds of the head, a statistical analysis_______________ 845 late, of wounds caused by projectiles__________________________ ____________ 333 of wounds of the chest___________________________________________ _____ _ 399 postoperative, wounds of the abdomen___________________________ _ 455 Compound fractures, rules concerning, at evacuation hospital_____________________ 128 Compression: and strangulation lesions, nerve surgery____________________________ ___ 971 epidural of the spinal cord, experimental study______________________________ 852 external, on lungs, with respect to wounds of the chest_______________________ 355 internal, on lungs, with respect to wounds of the chest_______________________ 356 Condyle, internal humeral, surgery of the ulnar nerve in the region of______________ 1031 (Conference on problems relating to the area of advance____________________ ____ 130 Consciousness, disturbances of, gunshot wounds of the head_______________ 795 Constitutional symptoms, gas gangrene_________________________________________ 276 Continuity defects: median nerve_____________________________________________________________ 1023 musculospiral nerve_______________________________________________________ 1006 operation for______________________________________________________________ 953 sciatic trunk, surgery of___________________________________________________ 1060 ulnar nerve, surgery of____________________________________________________ 1037 Convulsions, in gunshot wounds of the head_____________________________________ 801 Course of treatment dependent upon the type of injury, wounds of the abdomen---- 407 Cranial cases evacuated, American First Army Hospital at Deuxnoud------------- 707 Cranial defects, gunshot wounds of the head---------------------------------- - 798 treatment of______ _________________________________________ s,)1 Cranial nerves: lesions of, motor dist urbances in----- _---------- -------------------- 913 simultaneous injuries of, motor disturbances in— ----- -------------------- 916 Craniocerebral surgery prior to our entrance into the World War----------- 776 Cranioplasty, experimental------------------------------------------ *°- Craniotomy, head wounds-------------------------------------------- '*'* Criteria for the choice of method of anesthesia-----.------------ 170 Crural nerve, anterior, lesions of, motor disturbances in-------------- 913 Dav of death, battle injuries, statistics of-------------------- V, Days lost_________________________________________________ ^ battle injuries, statistics of-------------------------------- - ^ Dead, battle, site and character of injury in the----------------- 4J Death: . . . „._ causes of, gunshot wounds of the head, a statistical analysis------ *4/ day of, battle injuries, statistics---------- Deaths: 7fin American First Army Hospital at Deuxnouds__ 'ou battle injuries, statistics of. operated, American First Army nospnai a. j^eu.Miouuo ■ unoperated, American First Army Hospital at Deuxnouds. _„ operated, American First Army Hospital at Deuxnouds..- 762 unoperat Debridement , • 981 nerve mj ury during---------------------------------------- 155 responses to questionnaire on------------------------------------------- 12_ rules regarding, at evacuation hospital-------------------------------------- technique----- ------------------------------------ 299 wounds of t he soft parts------------------------------------------ Defect: . . , , , ■ XT'. in motion, factors producing, in peripheral nerve lesions--------------V'lV median nerve, .sacrifice of the ulnar nerve, as a viable neuroplastic transplant for the repair of a, technique------------------------------------------------ 1292 1XDEX Page Defects: , _.u ,. --- -- 1023 continuity of the median nerve. -------------- 10Q6 of the musculos])iral nerve,--------- 1060 of the sciatic trunk, surgery of---------- -.()s cranial, gunshot wounds of the head-------------- .j^'. foot, found in recruits, analysis of---------- ------------------ in nerve continuity— g^ bone shortening in---------------- 95'^ flexion-relaxation for-------------- ---------------- g^ operation for—------------------- -------------- gt^ primary stretching for---------------- --------"I" "N 7"" " or;i. stretching, with secondary suture (two-stage operatron), for _ jjM viable neuroplastic transplants for... irreiandbdrfective regeneration in the sciatic trunk and its terminal divisions, supplementary procedures for----------------------------------------- l™o musculocutaneous nerve----------------------------------------------- in.. of the median and ulnar nerves, surgery of------- ---- x"*| musculocutaneous nerve----- nerve— . qro ankylosed joints with operation for------------------------- ---------- ™° i tt'pd*! riiolf1 —__— — — —__—______________ _ — — — — ____ — — — — — — — — - - — — - — — — — tibial, viable neuroplastic transplant for the correction of ...----------------- 1064 Defense reactions, natural, with respect to wounds of the chest--------------------- **oy Deformity: fi0c joint, in amputations-----------------------------~e~-'~'I-------------------- iac\ partially ankylosed joints with or without, wounds of jomts------------------- o*u Deformities', intractable joint, following amputations------------------------------ 701 Degenerated auto-, homo-, and hetero-nerve transplants--------------------------- ||°* protocols___________________________________________________________________ j |~. Degenerated nerve transplants--------------------------------------------------- ||°| protocols_________________________________________________________________ l Degeneration: and regeneration of peripheral nerves----------------------------------------- iy»° in the peripheral and central zone of traumatism, perrpheral nerves------------ 1102 of myelinated nerve fibers--------------------------------------------------- 10*^ of nerve endings------------------------------------------------------------ 1J01 of nonmyelinated nerve fibers------------------------------------------------ 1101 Delayed primary closure, responses to questionnaire on---------------------------- 156 Delayed primary suture: wounds of soft parts-------------------------------------------------------- 310 technique______________________________________________________________ 311 Derangements other, of the knee-joint, treatment of, in embarkation hospitals, A. E. F. 650 Destructive agents, military: anatomical part and; case fatality rates-------------------------------------- 65 battle injuries by___________________________________________________________ 62 Deuxnouds, American First Army Hospital at, activities of the--------------------- 759 Development of peripheral nerve fibers------------------------------------------- 1096 Diagnosis: extraperitoneal wounds------------------------------------------------------ 480 intraperitoneal wounds______________________________________________________ 478 of peripheral nerve inj uries, electrical examinations in_________________________ 942 preoperative physical, of chest injuries________________________________________ 375 wounds of the kidney------------------------------------------------------- 472 Diameters, multiple, method of, in localization and extraction of foreign bodies under X-ray control_________________________________________________________________ 229 Diaphragm, operations upon the, in wounds of the chest___________________________ 393 Digits, tendon transplantation for restoration of the_______________________________ 1011 Disabilities: physical-— by military agents, statistics of__________________________________________ 85 from wounds, statistics of_________________________________________ _____ 71 wounds of the chest__________________________________________________ _____ 437 discharges for--------------------------------------________________________ 59 Disturbances of consciousness, gunshot wounds of the head_________________________ 795 Division of military orthopedic surgery___________________________________________ 549 Donors, selection of, for blood transfusion, in wound shock_________________________ 200 Dorsal or lateral exposure, circumflex nerve_______________________________________ 992 Double-shift fixed-angle method, localization and extraction of foreign bodies under X-ray control________________________________________________________________ 234 INDEX 1293 Drainage: Page in wounds of the chest_____________________________________________________ 396 rules concerning, at evacuation hospital_____________________________________ 128 Dressing station, surgery at the_________________________________________________ 96 Drill for front-line application of Thomas splint, fractures of lower extremity________ 613 Drugs, vasoconstrictor, in wound shock________________________________'_________ 191 Duration of treatment, battle injuries, statistics__________________________________ 60 Edema, in gas gangrene________________________________________________________ 274 Effect of intravenous injections of solutions of various concentrations upon cerebro- spinal fluid pressure_________________________________________________________ 849 Effects of gunshot wounds of the head, neurological aspects of the_________________ 795 Effusions, restriction of pleuritic, in wounds of the chest__________________________ 370 Elbow: gunshot wounds, treatment of, in embarkation hospitals, A. E. F_____________ 047 wounds of________________________________________________________________ 332 Electrical examinations: in the diagnosis of peripheral nerve injuries______________________________ 942 948 of nerves at operation_____________________________________________________ 973 Electro-anatomic method, nerve surgery_____________________________ __________ 961 Embarkation hospitals, A. E. F.: gunshot wounds of shoulder with fractures, treatment of_____________________ 646 orthopedic surgery in______________________________________________________ 643 treatment in— of gunshot and other fractures of the femur____________________________ 649 of head injuries with paralysis_________________________________________ (545 of other derangements of the knee-joint_________________________________ 650 of soft-part wounds of upper and lower extremities, with damage to muscles and tendons of____________________________________________________ 651 of the forearm, wrist, and hand____________ __________________________ 647 of the hip___________________________________________________________ 048 of the knee-joint______________________________________________________ 649 of the leg and ankle___________________________________________________ 650 of the leg, with fractures______________________________________________ 650 of the median, musculospiral, and ulnar nerves------------------- ---- 647 of the neck with nerve injury, ulnar paralysis---------------- ....... 645 of the spine____________________________________________ ------------ 648 of the thigh and leg, with nerve injury------------------ ------------ 650 of the upper arm, with fracture of the humerus-------------- 646 Emphysema, with respect to wounds of the chest------------------ ------------ 359 Encephalitis, lethargic, experimental st udy---------------------- -------------- 852 Endings, nerve, degeneration of--------------------------------- ------------- HOI End results: _ . fractures of long bones------------------------------------------------ 9 TT wounds of knee-joint-------------------------------- --------- ^} Epidural compression of the spinal cord, experimental study ---------- 8o2 Epilepsy, in gunshot wounds of the head---------------------- ---------------- °39 Ether: 17„ and chloroform anesthesia------------------------------------------------- j'" anesthesia, limitations of------------------------------------------ ------ J s'' Etiology: 265 gas gangrene------------------------------------------------------ 290 trench foot--------------------—■---1" v/""l " ,.,„ Evacuation and mobile hospitals, fixation treatment of fractures in _ _. ---------- 021 Evacuation hospital, A. E. F.: ^ functions-------------------- ------------------------- , r>fi general plan of operating schedule----------------------------------------------- j^« or$00SbeS splint aceVssories, and dressings for.. 622 preoperative preparation at--------;-;" — ;-; 7R1 routine preliminary treatment of head injuries at an----------------------- 781 rules of guidance for operating teams--------------------------------------- J* < sterilization and surgical supplies at---------------------------------------- ^ surgeons, qualifications of--------------------- ^ surgery in---- ---------------------------- Examination: , f =qo and care of the soldier's foot, personnel for. _ oM£ eleCtrnCth7diagnosis of peripheral nerve injuries. - 942 of nerves at operation- ---------------------- _94 roentgenologic, wounds of joint.---- 1294 INDEX Page Excision of parietal wounds of chest--- >_z Exhaustion and shock, anesthesia in---------------------- ^ Experimental cranioplasty----------------------------------- ' '*- Experimental meningitis-------------------------------------- ' '*'! pathology of--------------------------------.------------ inoi. i'>v-' Experimental observations on peripheral nerve repair------------- ----- n'"i- 1 _.v, degenerated nerve transplants---------------------- ---- injection into— ..... divided nerve to prevent amputation neuroma------- 11^ living uncut nerve----------------------------------- --------- \ •>}•!) nerve suture___________________________------------- 1 ~ ' nerve transplants__________ . '2 stored hetero-nerve transplants--------------- — - I--' stored homo-nerve transplants----------------- - il-',) Experimental study: encephalitis lethargica------------------------------ —y ,v - - 0- of problems of infection of the central nervous system and the treatment there- for_______________________________________ --- ----- ------- S4S 86.) Explosive missiles, wounds from--------------- 4,) Exposure: , , , . ,„,,„ and repair of the facial nerve through its course in the temporal bone, technique _ 1069 circumflex nerve— axillary____________________________ •'•'- dorsal or lateral______________________ --------------------- )()- median nerve— at the wrist_____________________ -- 1023 in the palm___________________ - '025 musculocutaneous nerve_______________ 094 of brachial plexus, technique of_______------------ - 987 of nerve, in nerve surgery__________ ----------- ----- 952 of sciatic trunk— in gluteal region______________ --------------------------------- 1052 in the thigh____________________________________________________________ 1053 of sensory portion, musculocutaneous nerve--------------------------- _ 994 of the peroneal nerve (external popliteal) in the popliteal space---------- 1058 of the tibial nerve (internal popliteal) in the popliteal space------------- . _. _ 1056 of the ulnar nerve— in middle and lower thirds of forearm------------------------------------ 1035 in region of internal humeral condyle____________________________________ 1031 in the arm_____________________________________________________________ 1030 in the palm____________________________________________________________ 1036 Extension of the terminal phalanges (lumbricales and interossei function), metacarpophalangeal flexion and tendon transplantation for restoring, technique._. 1044 External compression on lungs, with respect to wounds of the chest_________________ 355 External popliteal nerve, lesions of: motor disturbances in. _____________________________________________________ 910 partial______________________________________ __ ________________________ 911 recovering___________________________________ _____________ . _____ 911 supplementary movement in________________________________________ _ _____ 911 Extraction, localization and, of foreign bodies under X-ray control__________ __ 214, 285 Extraperitoneal wounds____________________________ _ ________________ ____ 479 case reports_________________________________ __ _______________ . ... 480 diagnosis------------------------------------ _________________ 480 mortality_____________ _____________________ ___________________ 480 symptoms_____ _________________ __ __________________________________ 479 treatment_____ __________________________________________________________ 480 Extremities: operations on, anesthesia in__________________________________________________ 180 upper and lower, soft-part wounds, with damage to, treatment of, in embarka- tion hospitals, A. E. F_______________________________________________ 651 Extremity: lower— fractures of____________________________________________ g09 site of amputation or reamputation with reference to prosthetic requirements. 731 treatment of fractures of, in base hospitals_________.________________ 632 use of provisional appliances in amputations of_________________________ 73s position of, in nerve surgery operation______________'______________________ 951 preparation of, for operation, nerve surgery_______________________ 951 INDEX Extremity—Continued. upper— fractures of____________________________________________________________ site of amputation or reamputation with reference to prosthetic requirements. treatment of in base hospitals___________________________________________ use of provisional appliances in amputations of___________________________ Eye localization, localization and extraction of foreign bodies under X-ray control_____ Eyes or eyesight, loss of, battle injuries__________________________________________ Face, wounds of________________________________________________________________ Facial nerve: lesions of, motor disturbances in_____________________________________________ surgery of_________________________________________________________________ technique of exposure and repair of, through its course in the temporal bone_____ Facial paralysis________________________________________________________________ nerve anastomosis in_______________________________________________________ Factors: initiating, in wound shock_______________________________________________ .. producing defect in motion, in peripheral nerve lesions______________________.. sustaining, in wound shock_________________________________________________ Fascia lata, auto-fascial sheaths, auto-nerve transplants wrapped in________________ Fatalities, wounds of the chest__________________________________________________ Feet, general principles of training for the, special training battalion, orthopedic department, A. E. F_________________________________________________________ Femur: fractures, end results_______________________________________________________ gunshot and other fractures of, treatment of, in embarkation hospitals, A. E. F---- Fibers, nerve: myelinated, degeneration of_________________________________________________ nonmyelinated, degeneration of--------------------------------------------- peripheral, development of_________________________________________________ regenerating, myelin sheath and neurolemma sheath of----------------------- structure of________________________________________________________________ Fibula: and tibia, fractures of— end results_____________________________________________ ----- treatment of in base hospitals---------------------------------- fractures, end results of--------------------------------------- Field, battle, surgery on the--------------- -------------------------- Field hospital, surgery at the-----------------------—,------------------------- Firearms and projectiles; their bearing on wound production---------- First-aid splinting, fractures of lower extremity------------ --------- First Armv Hospital, American, at Deuxnouds, activities of the... Fistula: of urethra________________________________________________________ penile______________________________________________________ operation to close----------------------------------------------------- urethrorectal---------------------------------------------- treatment___________________________•""•"? — t------------- Fitting provisional appliances in amputatrons, principles ot... ... Fixation treatment of fractures in mobile and evacuation hospitals. _______ Fixed-angle, double-shift method, localization and extraction of foreign bodies under X-rav control----------------------- ----------y. Flap, autogenous-fat, auto-nerve transplants wrapped in-------------------------- Kiofm^ and"nt?rossei function), tendon transplantation for restoring, technique. _ ^l" FSpafa^ U1 forced absorption of, in wound shock---------------------------------------- FluoroSo^mX^^ bodies under X-ray control.-------------------------------- Focal symptoms, gunshot wounds of the head---------------------- F°°t: a i io o-nnshot wounds of, treatment of, in embarkation hospitals, A. E. F--- *So ofampgutetton or manipulation with reference to prosthetic requirements... solder's personnel for examination and care of the-------------------------- 40997—27----S4 1296 IXDEX Foot—Continued. •■uii-.u.i the, and its relation to military service------------------ •'•'1 °" the soldier's------------------------------------------ '!'. instruction in requirements with respect to----------------- ;»■'' wounds of----------------------------- ------------------- '. Foot camp and training battalion------------ ------------------ '.'; • Foot defects found in recruits, analysis of-------------------------- ;)'';) Foot efficiency: _ potential, estimation of--------------------------------------------- '.'''^ summary of the estimation of---------------------------------------- ^ Foot examination------------------------------------------------------------------------ ^ routine method of rapid------------------------------------------------------------ ^t Forceps, identification, in nerve surgery---------------------------------------- ------- -)M> Forearm: and humerus, fractures of------------------------------------------------ - - ""' exposure of— the median nerve in the------------------------------------------------- 1U^U ulnar nerve in middle and lower thirds of the----------------------------- 1035 physiologic approximation in the upper two-thirds of, of the median nerve------ 1021 site of amputation or reamputation with reference to prosthetic requirements---- 736 surgery of the median nerve in the antecubital fossa and upper two-thirds of----- 1016 wrist and hand-—• gunshot wounds of, with fracture, treatment of, in embarkation hospitals, A. E. F_____________________________________________________ <>■*" treatment of fractures of, in base hospitals-------------------------------- 629 Foreign bodies: location and extraction of, under X-ray control------------- ------------ 214 removal of, spinal injuries________________________________ ------------ 791 retained gunshot wounds of the head_________________________________________ 835 Forward hospitals, A. E. F.: care of head injuries and injuries to the spine and peripheral nerves in--------- 755 management of gunshot wounds of the head and spine in______________________ 776 Fractures: amputations, and their sequela?, ratings of___________________________________ 495 caused by projectiles________________________________________.____________ 602-642 primary management________________________________ _________________ 602 compound, rules concerning at evacuation hospitals___________ _______________ 128 femur, end results__________________________________________________________ 507 fibula, end results of________________________________________________________ 508 fixation treatment of, in mobile and evacuation hospitals______________________ 621 gunshot and other, of the femur_______________________________________;______ 649 of the hip______________________________________________________________ 048 gunshot wounds— of the forearm, wrist and hand, with______________________ ____________ 647 of the leg, with____________________________________________.__________ 650 of the shoulder, with___________________________________________________ 646 of the upper arm with, of the humerus_______________________ _________ 646 of the forearm, wrist and hand, treatment of, in base hospitals___ _______ 629 of the humerus— and forearm_______________________________________________ 607 end results of________________________________________ 508 of the long bones, end results______________________________ 491 of the lower extremity____________________________________ 609 drill for front-line application of Thomas splint______________ 613 first-aid splinting___________________________________ 609 treatment of in base hospitals_________________________ 632 of the radius— and ulna, end results_______________________ 509 end results________________ ggg of the shoulder__________________________________ gQg of the tarsal bones, treatment of, in base hospitals. _ _ 642 of the tibia and fibula— end results___________________________________ gg- treatment of, in base hospitals_________________ g39 of the tibia, end results of_______________________ 50g of the ulna, end results of_______________________ ~ egg of the upper extremity________________________ gg-. treatment of, in base hospitals______________ gog of the wrist and hand__________________________ '__ ggq operative treatment of, in hospitals at the front _ goi treatment of in base hospitals_______________ g24" INDEX 1297 Page Frequency in the location of wounds and its bearing on the armor problem_________ 4 Frequency of injury from missiles of low velocity with respect to the wearing of armor, 3 Front: collective surgical experiences at the, and at the base________________________ 130 operative treatment of fractures in hospitals at the______________________ 621 surgery at the------------------------------------------------""__"]""_ 86-129 treatment at the, wounds of the kidney__________________________ 472 Front packets____________________________________________ ^ Function, proper, work for restoration of, special training battalion, orthopedic depart- ment, A. E. F______________________________________________ 586 Functional results after resection, wounds of joints_____________________ 337 Functions: amputation service, A. E. F__________________________________________ 688 of the evacuation hospital_______________________________________ HI Fungus cerebri, in gunshot wounds of the head___________________________ . _ 833 Gangrene, gas. (See Gas gangrene.) Gas formation, gas gangrene______________________________________.. _____ 274 Gas gangrene________________________________________________ _ _______ 265-283 character of wound______________________________________ _____ 272 clinical manifestations in_______________________________ _____ 271 clinical pathology______________________________________ . _ 278 edema____________________________________________ _____________________ 274 etiology--------------------------------------- . _ ______________ 265 gas formation in__________________________________________________________ 274 grouped symptoms___________________________ _____________________ 276 increasing swelling_______________________ . _ _. __________________ 275 invasion______________________________________ . 272 lesions in distant organs________________________ _____ 271 leucocytosis in__________________________________ _.__ 278 local signs and symptoms________________________ 272 mild cases______________________________ ______ 277 pathology______________________________________ - 268 period of incubation___________________________._ --- 272 prognosis________________________________________ -------------- 283 prophylaxis___________________________________- . - ------------ 278 responses to questionnaire on__________._-------..--- ------ 154 serum therapy_____________________________________ ------ 279 surgical treatment______________________------------------- 280 toxicogenic changes in_____________________________ --- .-_-_-___— 269 treatment____________________________________-----— - 278 Gassed cases, anesthesia in______________________________— - ------ 181 General character of wounds from various causative agents. _._.._. 45 General plan of operating schedule, evacuation hospital------- ------------ 126 General surgery___________________________________--- ------------ 1-547 General surgical rules for evacuation hospital--------------------------- 123 General symptoms: early, gunshot wounds of the head------------------ ^95 late, gunshot wounds of the head---------------------------- 797 General treatment of wounds at the front-------------------------- 87 Genitalia, external, wounds of------------------------------------- ----- _ 48b Genitourinary tract, wounds of the------------------------------------_-_-_- 4/0-490 Glossopharyngeal nerve, lesions of, motor disturbances in----------..._... ---- 914 Gluteal region, exposure of sciatic trunk in-------------------------------_.--.. 1052 Grafts: oc.R antogenous cable, for defects in nerve continuity----- - --------------------- Joo bone. (See Bone grafts.) nerve, for defects in nerve continuity--------_______-.-----__-__-------_-_- yoo types of, in autogenous bone grafts for nonunion in atrophic long bones and in chronic suppurative osteitis (osteomyelitis), following war wounds.. _ _ 653 Grenades: 9^ hand____________________------------------------ r^ Gum^uaa'and'gTucose" hypertonic, in wound shock------- 196 Gum-salt solution in wound shock------------------------ ^ Guns, machine-------------------------------------- Gunshot and other fractures: ., . . „ „ „._ of the femur, treatment of, in embarkation hosprals, A. E. F.. 649 of the hip, treatment of, in embarkation hospitals, A. E. t--------- 648 Gunshot missiles, bone injuries from-------------------------------------------- 129S INDEX Pag. Gunshot wounds: •+ 1. \ _? iv »_iv and other injuries of the spine, treatment of, in embarkation hospitals, .\. n,. r - h-.s of the brain, abscess of the brain in------------ ... - ---------- ----- 81 j of the elbow, treatment of, in embarkation hospitals, A. Iv t. ... --------- classification, a statistical analysis---------------.---------------------- 841 complications, a statistical analysis------------- ---- *4o cranial defects_____________— ------------------------------- ■- '„'. early general symptoms------------------- ------------_.-... - / .)o epilepsy in_________-----------_..___-------------------------------- 839 focal symptoms of____----._...._ --------------------------------— '99 fungus cerebri in_______________-------------------------------------- - - i_^_ late general svmptoms of____------------------- ------- -------------- '•*' late treatment of_____________________-----------------------------------804-840 motor symptoms_______________________________________------------------- 799 neurological aspects of the effects of------------------- ------------------- 795 pathology______________________________-------------- ------------------- 802 persisting symptoms, a statistical analysis------------ ------------------- 846 primary operations, a statistical analysis------------- ----------- - 844 retained foreign bodies_________________________ ---- ------------------- 835 secondary operations, a statistical analysis______________________________ .- 844 symptomatology__________________________--------------------------------- 795 symptoms, a statistical analysis____________________________________________ 842 treatment of________________________________________________________________ 803 of the knee-joint, treatment of, in embarkation hospitals, A. E. F.______________ 649 of the leg, with fracture, treatment of, in embarkation hospitals, A. E. F-------- 650 of the median, musculospiral, and ulnar nerves, treatment of, in embarkation hospitals, A. E. F_____________________________________________________________ 647 of the neck with nerve injury, ulnar paralysis, treatment of, in embarkation hos- pitals, A. E. F___________".____________'_______________________________________ 645 of shoulder, with fracture, treatment of, at embarkation hospitals, A. E. F______ 646 of the thigh and leg, with nerve injury, treatment of, in embarkation hospitals, A. E. F________________________'_____________________________________ 650 of the upper arm, with fracture of humerus, treatment of, in embarkation hospi- tals, A. E. F__________________________________________________________ 646 Hamstring muscles, nerve to, general anatomy of________________________________ 1049 Hand: and wrist, fractures of____________________________________________________ 609 site of amputation or reamputation with reference to prosthetic requirements __ 735 surgery of the median nerve in the________________________________________ 1025 wrist, and forearm-— gunshot wounds of, treatment of, in embarkation hospitals, A. E. F_________ 647 treatment of fractures of, in base hospitals______________________________ 629 wounds of___________________________________________ 314 Hand grenades_______________________________________ 24 Hand-muscle paralysis, intrinsic, tendon transplantation for restoring opponens action to the thumb in, technique______________________________ 1041 Harpoon method, localization and extraction of foreign bodies under X-rav control. 236 Head: and spine, gunshot wounds of the, management of, in forward hospitals \ E F 776 gunshot wounds of the— a statistical analysis of________________________ §41 late treatment of_________________________ g04 neurological aspects of the effects of______... _ I 795 Head injuries: and injuries of the spine and peripheral nerves, care of__ in base hospitals, A. E. F____________________ -,-.s in the forward hospitals, A. E. F_____ _ -'='= classification of_________________________ " " L'-q responses to questionnaire on_____________~_____'_' ig4 routine preliminary treatment of, at an evacuation "hospital" \" E F" 781 with paralysis, treatment of, in embarkation hospitals, A E F »u. Head wounds________________________ ' '*. arrangements for the care of, neurological service \ E F " ~\?\ treatment of different grades of, in forward hospitals, A. E F """ -<■> Headache, vertigo, choked disc, and slow pulse, gunshot wounds of the head 7qz INDEX 1299 Page Healing, parietal, in wounds of the chest___________________________________ 370 Heart and mediastinum, operations upon, in wounds of the chest_______ .______ 393 Heat, body, loss of, in wound shock______________________________ 188 Helmets: and body armor, the medical viewpoint_________________________________ 1-8 of various nations________________________________ ___ 2 Hematogenous meningitis, experimental study____________ 858 Hemorrhage: in amputations, in base hospitals, A. E. F___________ ____________ 698 in wound shock__________________________________ ______________ 187 secondary, responses to questionnaire on_________________________________ 159 Hetero-, homo-, and auto-nerve transplants________ _________________________ 1184 Hetero-nerve transplants_____________________.___________________________ 1165 protocols__________________________________________________________ 1166 stored_____________________________________________________________ ] 227 in 50 per cent alcohol_____________________________________ ______ 1227 in liquid petrolatum_____________________________________________ 1227 High-explosive shell_____________________________________________________ 17 Hip, gunshot and other fractures of, treatment of, in embarkation hospitals, A. E. F_ 648 Hirtz compass: method, localization and extraction of foreign bodies under X-ray control______ 237 setting the, localization and extraction of foreign bodies under X-ray control___ 243 use of the, with plates, localization of foreign bodies under X-ray control______ 246 Homo-, hetero-, and auto-nerve transplants__________________ _______________ 1184 Homo-nerve transplants_________________________________ ____________ 1163 protocols__________________________________________ ______________ 1163 stored__________________________________________ ____________ 1195 in 50 per cent alcohol___________________________ ____________ 1195 in sterile vaseline________________________________________________ 1195 Hospital: American First Army, at Deuxnouds, activities of the_________ 759 base. (See Base hospital.) evacuation. (See Evacuation hospital.) field, surgery at the__________________________ ------ ------- ----- 99 nontransportable, for abdominally wounded----------------------- 445 Hospital problems, responses to questionnaire on----------------------------- 164 Hospital service, the, in the care of the amputated in the United States._ -------- 715 Hospitals: at the front, operative treatment of fractures in----------- -------------- 621 base. (See Base hospitals.) embarkation. (Sec Embarkation hospitals.) evacuation. (See Evacuation hospitals.) forward, A. E. F.— care of head injuries and injuries to the spine and peripheral nerves in the.. 755 management of gunshot wounds of the head and spine in--------------- 776 in the zone of the advance, teams for, neurological service, A. E. F__ 750 mobile. (See Mobile hospitals.) Humerus: and forearm, fractures of--------------------------------------------- 607 fr&c*turps cud results of _ ___________________------------------------ ouo gunshot wounds of the upper arm, with fractures of the, treatment of, in embarka- tion hospitals, A. E. F____________________------------------------ 6f6 Hydrocephalus, experimental study of, in infectrons of the central nervous system... 848 Hypertonic gum acacia and glucose, in wound shock-------------------- ----- 196 Hypoglossal nerve, lesions of, motor disturbances in-------- ---------- 915 Identification: anatomic or branch, in nerve surgery---------------- ----- 9oO bundle, nerve surgery---------------------------- ----- ™j* Identification forceps, in nerve surgery------------------ ---------- 9bU Identification sutures in nerve surgery----------------- ------ ----------- 9oU Immunity, passive, duration of, in tetanus-------------- ------- ^»t> Incidence: . insi of peripheral nerve injuries--------------------- ------------- llJ°* of wounds of the abdomen---------- 44t> Incision: 7SP flap, head wounds. ---- IT scalp, head wounds----------------- _Z'. three-legged, or Isle-of-Man. Incomplete lesions, in lesions of median nerve----- ----- 893 1300 INDEX Page EI^Ttorf .OTo.g-flexor TTth. "thumb. Umchm tram, ....utaHou 7o. ™ paralysis of----------------------------------- Indications for operation: .,-.- based on preoperative findings in wounds of the chest---------------- --- .'1 based upon operative findings, in wounds of the chest---- in wounds— 451 of the abdomen------------------------------------ 3'76 of the chest------------------------------------------ giS of the joints---------------------------------------- 9yo Infected wounds and nerve surgery--------------------------------------- Infection: , 070 in cicatrized wounds, recrudescence of, nerve surgery ..-------------- - ------- - »'» of the central nervous system and the treatment therefor, experimental studj of ^ problems of-------------------------------------------- ggi action of antiseptics upon------------------------------------------- alterations of brain volume-------------------------------------------- 85Q brain abscess---_--------------------------------------------- 049 cistern puncture in------------------------------.----------- --- effect of intravenous injections of solutions of various concentrations upon cerebrospinal fluid pressure-------------------------------------------- ZZ subarachnoid irrigations------------------------------------------------- ^ hydrocephalus---------------------------------------------------------- 097 post operative, wounds of joints---------------------------------------------- Infections: . . 189 acute operations in the presence of, anesthesia in---------------- ------------- Jg* Inflation, pulmonary, in wounds of the chest---------------------- ------------- ^'1 Inhalation anesthesia------------------------------------------------------------ _ Initiating factors in wound shock------------------------------------------------ 180 Injection: . 110c into divided nerve to prevent amputation neuroma---------------------------- 11^0 into living uncut nerve_____________________________________________________ 1117 of absolute alcohol— into a living nerve without cutting the nerve--------------------------ill/, 1118 into the central end of a divided nerve to obviate the formation of amputation neuroma_____________________________________________________________ Too of full strength acetone into living uncut nerve-------------------------------- 1123 of salt solutions in wound shock---------------------------------------------- 193 intravenous, effect of, of solutions of various concentrations upon cerebrospinal fluid pressure_____________________________________________________________ °49 Injuries: abdominothoracic___________________________________________________________ 466 battle— admissions______________________________________________________________ 59 all causes_______________________________________________________________ 64 by gunshot missiles_____________________________________________________ 64 by military destructive agents____________________________________________ 62 day of death____________________________________________________________ 61 days lost_____________________________________•-------------------------- 59 deaths_________________________________________________________________ 58 deaths, statistics of______________________________________________________ 58 discharges for disability_________________________________________________ 59 duration of treatment___________________________________________________ 60 invalided home__________________________________________________________ 61 statistics of_____________________________________________________________ 57 chest, types of______________________________________________________________ 371 head— classifications of________________________________________________________ 779 responses to questionnaire on____________________________________________ 164 routine preliminary treatment of, at an evacuation hospital, A. E. F_____ 781 spine, and peripheral nerves, care of, in base hospitals, A. E. F_____________ 758 involving thoracic viscera alone_______________________________________________ 374 of the thoracic parietes alone_________________________________________________ 371 other gunshot wounds and, of the spine, treatment of, in embarkation hospitals, A. E. F___________________________________________________________ 648 peripheral nerve— incidence of_____________________________________________________ 1081 organization for the care and study of____________________________________ 1081 spinal, treatment of, in forward hospitals, A. E. F_____________________________ 789 INDEX Injuries—Continued. thoracic— Page application of biologic principles to_______________________________ _____ 365 basic principles in the treatment of_____________________________________ 370 involving both parietes and viscera_____________________________________ 372 visceral, wounds of the abdomen, treatment of_______________________________ 457 Injury: character of, wounds of the bladder_________________________________________ 476 from missiles of low velocity, the frequency of, with respect to the wearing of armor________________________________________________________________ 3 site and character of, in the battle dead_____________________________________ 49 visceral, symptoms of, in penetrating and perforating wounds of the abdomen___ 450 Inoculation, subarachnoid, meningitis produced by_______________________________ 854 Instruction: in requirements with respect to the soldier's foot_____________________________ 591 of divisional medical personnel in orthopedic department, A. E. F_____________ 584 Instructions for neurological surgeons, neurological service, A. E. F________________ 750 Instruments, special surgical, for the care of head wounds, neurological service, A. E. F_ _ 750 Interdependence, physiologic, of respiration and circulation, with respect to wounds of the chest____________________________________________________________________ 3 43 Internal compression on lungs, with respect to wounds of the chest________________ 356 Internal popliteal nerve, lesions of, motor disturbances in_________________________ 911 Interosseous nerves, surgery of_________________________________________________ 1004 Intestine, small, wounds of_____________________________________________________ 458 Intracranial procedure, head wound_____________________________________________ 787 Intrameningeal virulence of microorganisms, in infections of the central nervous sys- tem, experimental study_____________________________________________________ 857 Intraperitoneal wounds______________________________________________________ . 478 diagnosis_______________________________________________________________ _ 478 prognosis_________________________________________________________________ 479 symptoms_______________________________________ _______________________ 478 treatment________________________________________________________________ 478 Intrathoracic therapy, significance of vital capacity in, with respect to wounds of the chest__________T__________________________________________________________ 343 Intravenous injections: effect of, of solutions of various concentrations upon cerebrospinal fluid pressure, in infections of the central nervous system, experimental study-------------- 849 precautions to be observed in, in wound shock------------------------------ 205 Invalided home, battle injuries, statistics of------------------------------------- 61 Invasion, gas gangrene--------------------------------------------------------- 272 Irregular movements of bullets in tissues---------------------------------------- 49 Irrigations, subarachnoid, experimental study------------------------------------ 851 Ischemic paralysis in peripheral nerve lesions-------------------------- ------- 875 Isle-of-Man, or the three-legged, incision, head wounds--------------------------- 786 Joint changes in peripheral nerve lesions----------------------------- ---------- 873 Joint deformity: in amputations___________________________________________________ ----- ^™ intractable, following amputations------------------------------------------ '01 Joints: _0_ adjacent, attention to, of amputation stumps-------------------------------- 7^7 ankylosed, with nerve defects---------------------2"'t~'~'Z--------------- o^n partially ankylosed, with or without deformity, wounds of joints-------- 340 rules concerning, at evacuation hospital------------------------------------ 128 wounds of---------------------------------------------------------------- ^lq ankylosis------------------------------------------------------------- Z^Z earlv active mobilization-------------- ----- *£> functional results after resection--- -------- «M / indications for operation--------------- ------------------------------- ^ mobility versus stability after resection.. _ --------------------- 66b partially ankylosed joints, with or without deformity-------------------- 340 postoperative care----------------------------------------------------- frf* postoperative infection------------------------------------------ **< ^ ..„___j...... +w_<_ + rr.or>+. nf thfi wound______________________________________ 0Z0 postoperative treatment of the wound preoperative management---------------------------------------------- * 1 / preparation of patient------------------------------------------------- **» resection-----------~.~~7.-------- " qis roentgenological examination------------------------------------------- ^i» suppurative arthritis--------------------------------------------------- ^6 technique of operation _------------------------------------------------ 1302 INDEX Page Kidney, wounds of_________________________________________ ------------ 464.470 case reports______________________________________________ ---------- 474 clinical picture_____________________________________________ - 471 diagnosis______________________________________________________ 472 mortality________________________________________________________ — ---- 474 pathology_________________________________________________________________ 470 symptoms_________________________________________________________ 471 treatment__________________________________________________________ 472 at the base____________________________________________________________ 473 at the front___________________________________________________________ 472 Knee-joint: gunshot wounds of, treatment of, in embarkation hospitals, A. E. F_________ i>49 other derangements of, treatment of, in embarkation hospitals, A. E. F_________ 650 primary operation__________________________________________________________ 331 responses to questionnaire on_______________________________________________ 160 secondary amputation______________________________________________________ 331 wounds of_________________________________________________________________ 328 end results____________________________________________________________ 331 Landmarks, anatomical, depth of, beneath the skin, localization and extraction of foreign bodies under X-ray control_____________________________________________ 250 Late treatment of gunshot wounds of the head__________________________________ 804-840 Lateral or dorsal exposure, circumflex nerve______________________________________ 992 Leg: and thigh, gunshot wounds of, with nerve injury, treatment of, in embarkation hospitals, A. E. F_________________________"______________________________ 650 gunshot wounds of, with fracture, treatment of, in embarkation hospitals . A. E. F----------------------------------------------------------_P___: 650 site of amputation or reamputation with reference to prosthetic requirements.. 733 Lessons in civil abdominal surgery gained from the war____________________________ 468 Lethargic encephalitis, experimental study____________________________________ 852 Leucocytosis, in gas gangrene_______________________________________ 278 Limitations of different types of anesthesia_________________________________ 182 Lisfranc's amputation_________________________________________ 731 List of splints, splint accessories, and dressings for: a base hospital of 1,000 beds_____________________________________ 624 an evacuation hospital of 1,000 beds______________________________ 622 Liver, wounds of_______________________________________ 4go Local anesthesia_______________________________________ -tjz Local signs and symptoms, gas gangrene__________________________ 272 Localization and extraction of foreign bodies under X-ray control________T _ 214-264 anatomical localization___________________________________ • 220 apparatus required_____________________________________ 21" bonnet method_______________________________ 2fii centering the tube in___________________________________~~ 218 depth of anatomical landmarks beneath the skin___ _ o'.O double-shift fixed-angle method_________________ 234 early history and literature_________________________~~ 214 eye localization_______________________________ r,tt fluoroscopic method, with auxiliary compass 040 harpoon method________________'_________ tit Hirtz compass method________________ ___T 907 marking the skin___________ __ ____ _ jf*' method of right-angled planes. _ iVi methods__________________ ---------- j^t multiple-diameters method". __T_ ---- 7rA nearest-point method____________________ ----- jfi3 open screen in darkened room__ " ' ^ orthodiagraphic method_________ --------- j£r parallax method________________ ^* rotation of the part_______________~~ 225 setting the Hirtz compass_____ ~~ 224 single-shift triangulation method _ "" itj. technique________________ 230 use of Hirtz compass with plates 222 Location of wounds, frequency in the, and its bearing on the armoVproblem: I 4 of body heat in wound shock________ of eyes or eyesight in battle injuries 158 Low blood pressure in wound shock 72 191 INDEX 1303 Page Low velocity, the frequency of injury from missiles of, with respect to the wearing of armor_______________________'________________________________________ 3 Lower extremity: fractures of_________________________________________________________ 609 site of amputation or reamputation with reference to prosthetic requirements___ 731 treatment of fractures of, in base hospitals_______________________________ 632 use of provisional appliances in amputation of____________________________ 738 Lumbar puncture as a factor in the causation of meningitis, experimental study____ 863 Lumbosacral plexus, lesions of, motor disturbances in__________________________ 913 Lung, operations upon, in wounds of the chest_______________________________ 389 M achine carbine pistols__________________________________________________ 36 Machine guns__________________________________________________________ 30 Macrophages, formation of, by the cells lining the subarachnoid cavity, in infections of the central nervous system, experimental study___________________________ 856 Magnesium salts in anesthesia_____________________________________________ 176 Management: of gunshot wounds of the head and spine in forward hospitals, A. E. F______ 776-794 preoperative, wounds of joints_________________________________________ 317 primary, of fractures caused by projectiles_______________________________ 602 Manual of splints and appliances: first edition________________________________________________________ 555 second edition______________________________________________________ 580 Manufacture of standard splints and accessories______________________________ 556 Marking the skin, in localization and extraction of foreign bodies under X-ray control- 219 Material, sensory disturbances in peripheral nerve lesions______________________ 919 Median and ulnar nerves: irreparable defects of, surgery of_______________________________________ 1044 combined, lesions of— motor disturbances in_______________________________ — ------- 901 partial lesions___________________________________________________ 903 supplementary motility in---------------------------------------- 902 surgery of______________________________________________________ 1039 total paralysis in________________________________________________ 901 Median, musculospiral, and ulnar nerves, gunshot wounds of, treatment of, in embar- kation hospitals, A. E. F____________________________________ --------- 647 Median nerve: branches_________________________________________________________.- 1014 defect, sacrifice of the ulnar nerve as a viable neuroplastic transplant for repair of the, technique__________________________________________________ 1046 exposure— at the wrist________________------------------------------------ J[j^ in the forearm__________________________________________________ J^zO general anatomy____________________________________________________ or!n irreparable lesions of------------------------------------------------- ^oIU lesions of— ... in0o at the wrist, and combined tendon injuries---- -------------- WZ6 incomplete lesions------------------------------------ --------- °£J> motor disturbances---------------------------------------------- ~°j painful, motor disturbances in---- - - - ^ recovery in-------------------------------------- Uq^ supplementary movements in----- -------- °*^ total paralysis in------------------ — .v.~~.—_"!_."* i no. physiologic approximation of, in the upper two-thirds of the forearm.. 1021 SUr^7tte"antVc^ forearm__ 1016 in the arms-------------------------------- 1025 in the hand-------------,~~~~~~t---------- 1027 tendon transplantation for paralysis ot _ _ - ---------z y-~ v ; y - 393 Mediastinum and heart, operations upon the, in wounds of the chest.. 6M Medication, adjuvant, in anestliesa _ 853 Meningitis, experimental. 856 cerebrospinal fluid in--- ^5$ hematogenous-------------- ----- S62 .umb^.uXcas-afadoriu.h.causa.m^ofV.: 863 pathology of---------------- ----- S54 nroduced bv subarachnoid inoculation ------------------- McnFal symptoms, gunshot wounds of the head.... 801 1304 INDEX Page Metacarpophalangeal flexion and extension of the terminal phalanges (lumbricales and interossei function) tendon transplantation for restoring, technique-------- ----- 1044 Method: (. . electro-anatomic, nerve surgery--------------------------- ------------ --- Jbl of blood transfusion, in wound shock, employed in the A. IZ F--------- 1 .)8 Willems', active mobilization in purulent arthritis------- ------------ ------ 337 anesthetic, in special groups of cases-------------------------------------- - 177 of investigation, sensory disturbances in peripheral nerve lesions------ --------- 920 of localization and extraction of foreign bodies under X-ray control-------- _ _ 215 bonnet____________________________________________________________________ 261 double-shift, fixed-angle___________________________ - '-"34 fluoroscopic, with auxiliary compass______________ --------------- - 242 harpoon________________________________________ --■ ----.--------------- 236 Hirtz compass___________________________________ -------------------- 237 multiple diameters_____________________________ ----------- ------- 229 nearest-point______________________________________________________________ 224 of right-angled planes_____________________________________________________ 228 orthodiagraphic___________________________________________________________ 228 parallax___________________________________________________________________ 225 single-shift triangulation___________________________________________________ 230 surgical, in wounds of the chest______________________________________________ 367, 379 Microorganisms, intrameningeal virulence of, in infections of the central nervous systems, experimental study_____________________________________________________ 857 Military destructive agents: anatomical part and; case fatality rates________________________________________ 65 battle injuries by_____________________________ _______________________________ 62 physical disabilities by, statistics of____________________________________________ 85 Military importance of wounds of the abdomen_____________________________________ 446 Military orthopedic surgery, division of_____________________________________________ 549 Military service, the foot and its relation to_________________________________________ 591 Missiles: explosive, wounds from________________________________________________________ 46 from small arms, ratio of wounds from_________________________________________ 51 gunshot, battle injuries from___________________________________________________ 64 of low velocity, the frequency of injury from, with respect to the wearing of armor_______________________________________________________________________ 3 rifle___________________________________________________________________________ 39 small-arms____________________________________________________________________ 39 weapons and______________________________________________________________ 29 wound production by______________________________________________________ 46 Mobile and evacuation hosipitals, fixation treatment of fractures in____ ____________ 621 Mobile unit for abdominally wounded____________________________________________ 445 Mobility versus stability after resection, wounds of joints__________________________ 336 Mobilization: active, in purulent arthritis—Willems' method________________________________ 337 early active, wounds of joints____________________________________ __________ 323 Morphine in anesthesia______________________________________________ 176 Mortality: extraperitoneal wounds__________________________________ 480 wounds of the kidney______________________________________ 474 Motility, supplementary: in lesions— of the median and ulnar nerves combined________________________ 902 of the musculospiral nerve_____________________________ 886 of the sciatic nerve___________________________________ 909 of the ulnar nerve. ------------------------------------------------- 898 voluntary, recovery of, in peripheral nerve lesions _ 872 Motion: active, in peripheral nerve lesions________________________ ^67 factors producing defect in, in peripheral nerve lesions _ . _ _ 873 Motor disturbances: in lesions— of the anterior crural nerve________________________ 913 of the brachial plexus_________________________ qnc of the circumflex nerve__________________________ qq4 of the cranial nerves________________ __._____ 913 of the external popliteal nerve_____ ~~__ __~ 910 INDEX 1305 Motor disturbances—Continued. in lesions—Continued. Page of the facial nerve__________________________________ _______________ 913 of the glossopharyngeal nerve__________________________________________ 914 of the hypoglossal nerve_________________________ ____________________ 915 of the internal popliteal nerve__________________ _ __________________ 911 of the lumbosacral plexus______________________________________________ 913 of the median nerve___________________________________________________ 889 of the musculospiral nerve_____________________________________________ 886 of the peripheral nerves______________________________________________ 866-917 of the pneumogastric nerve____________________________________________ 914 of the posterior tibial nerve____________________________________________ 911 of the sciatic nerve____________________________________________________ 908 of the spinal accessory nerve___________________________________________ 915 of the trigeminal nerve________________________________________________ 913 of the ulnar nerve_____________________________________________________ 895 simultaneous injuries of cranial nerves______________________________________ 916 Motor function, examination of, in motor disturbances in peripheral nerve lesions___ 866 Motor symptoms, gunshot wounds of the head___________________________________ 799 Movement: range of, in peripheral nerve lesions_________________________________________ 866 supplementary— in lesions of external popliteal nerve____________________________________ 911 in lesions of median nerve_____________________________________________ 892 in peripheral nerve lesions_____________________________________________ 872 Movements, irregular, of bullets in tissues_______________________________________ 49 Multiple diameters method, localization, and extraction of foreign bodies under X-rav control____________________________________________________________________1 229 Muscle atrophy in lesions of musculospiral nerve________________________________ 888 Muscle movement, supplementary, in peripheral nerve lesions_____________________ 872 Muscle regeneration, secondary operations for defective, nerve surgery_____________ 974 Muscle shortening resulting from spasm, in peripheral nerve lesions________________ 875 Muscles and tendons of upper and lower extremities, soft-part wounds, with damage to, treatment of, in embarkation hospitals, A. E. F____________________________ 651 Musculocutaneous nerve: defects_______________________________ __________________________________ 994 exposure______________________________ --------------------------------- 994 of sensory portion____________________________________________________ 994 general anatomy__________________________________________________________ 993 lesions of, motor disturbances in------------------------------------------- 903 surgery__________________________________________________________________ 993 Musculospiral, median, and ulnar nerves, gunshot wounds of, treatment of, in embar- kation hospitals, A. E. F____________________________________________________ 647 Musculospiral nerve: and its terminal divisions, physiologic approximation of---------------------- 1007 branches_________________________________________________________________ 995 continuity defects_________________________________________________________ one general anatomy---------------------------------------------------------- 995 indications for reoperation------------------------------------------------- 10U9 irreparable defects________________________________________________________ 995 lesions of— „ motor disturbances in--------------------------------- -------------- |°^ muscle atrophy in---------------------------------------------------- °°8 recovery in----------------------------------------------------------- ^ supplementary motility in--------------------------------------------- ™ secondary suture of------------------------------------------------------- LTZ2. surgery-------------------------------------------------------- qqq dorsal portron-------------------------------------------------------- qqg median portion------------------------------------------------------- „m ventrolateral portion------------------------------------------------- |^y^ Musculospiral paralysis, tendon transplantation for------------------------------ |oiu Musculospiral transposition, technique of--------------------------------------- J""° Myelin sheath and neurolemma sheath of regenerating nerve fibers------ - - - - 1112 Myelinated nerve fibers, degeneration of------;r"y+V"" _._.%"------------------ rw Natural-defense reactions, with respect to wounds of the chest. -----_ ____ soy Nearest-point method, localization and extraction of foreign bodies under X-ray ^ NecT^unshot wound of^ with nVrvVfnjury; ulnw paralysis; treatment of, embarkation ^ hospitals, A. E. F----------------------------------- 1306 INDEX Nerve (.sec also, name of individual nerve): . divided— Page electrical identification of physiologic components of a .__________________ 974 exposure of, in nerve surgery_______________________________•_________________ 952 injection into, to prevent amputation neuroma________________________________ 1125 injection of absolute alcohol into the central end of, to obviate the formation of amputation neuroma______________________________________________________ 112., living uncut, injection into___________________________________________________ 1117 of absolute alcohol______________________________________________________ 1117 of full strength acetone__________________________________________________ 1123 peripheral— cases, care of, in forward hospitals, A. E. F_______________________________ 757 lesions, motor disturbances in____________________________________________ 866 repair, experimental observations on_____________________________________ 1091 surgery, results of_______________________________________________________ 1081 phrenic, blocking the, in wounds of the chest__________________________________ 387 structure of a_______________________________________________________________ 1093 to hamstring muscles, general anatomy_______________________________________ 1049 Nerve anastomosis in facial paralysis_____________________________________________ 1068 Nerve bed, preparation of, approximation technique_________________ ____________ 968 Nerve continuity, defects in operation for__________________________ _ 953 Nerve defects: ankylosed joints into, operation for___________________________ ___ ____ 958 irreparable_______________________________________________________________ 959 Nerve endings, degeneration of______________________________________________ 1 iqi Nerve fibers: degeneration of myelinated______________________________________________ 1099 nonmyelinated, degeneration of_____________________________________ H01 regenerating, myelin sheath and neurolemma sheath of______________T _ 1112 structure of____________________________________________________ 1095 Nerve grafts for defects in nerve continuity_________________________. \ _ 955 autogenous cable___________________1___________________ 056 Nerve injury: during debridement____________________________________ qc 1 gunshot wounds of thigh and leg with___________________'______ qcq Nerve injuries, peripheral, electrical examinations in the diagnosis of 049 Nerve lesions: y*z partial— operation for____________________________ ____ „„Q technique of repair of________ peripheral, sensory disturbances in_ 969 Nerve overlap, sensory disturbances in peripheral "lierve lesions "" qoe Nerve supply, exclusive, sensory disturbances in peripheral nerve lesions 09? Nerve surgery: l " y^1 amputation neuromas_______________________ anatomic or branch identification__________'_'_ 9^1 anatomic requirements_____________________ ~"" ---- ^ u and infected wounds____________________ ---- 951 anesthesia in_________________________ 979 ankylosed joints with nerve defects____~ _ _ _ „^2 approximation technique___«.____________ 958 bundle identification__________________'_[ 963 compression and strangulation lesions'.'.'.'.'_'. 963 defects in continuity_____________ 971 electrical examination of nerves at operation."" n^o electroanatomic method___________ 973 exposure of nerve in___________ 961 forceps identification____________ - - - - 952 general technique_______________ 960 identification of sutures_________ ---- 951 irreparable nerve defects______ 960 nerve injury during debridement ------ 959 neurolysis___________________----- 981 partial nerve lesions__________T - ---- 972 preparation of an extremity for operation - 969 primary operations_________________ 951 recrudescence of infection in cicatrized wounds 980 secondary operations for defective regeneration"" - - 979 technique__________________ ----------____ 974 torsion of the nerve trunk during suture---------- 949-1080 ---- 959 INDEX 1307 Page Nerve suture_____________________________________________________________________ 1260 tubular, with use of formalized artery, protocols_______________________________ 1262 Nerve transplants (see also Auto-nerve, cable-auto-nerve, homo-nerve, and hetero- nerve transplants)______________________________________________________________ 1145 degenerated__________________________________________________________________ 1184 Nerve transposition for defects in nerve continuity_________________________________ 954 Nerve trunk, torsion of, during suture_____________________________________________ 959 Nerves: cranial, lesions of, motor disturbances in____________ ........ _________________ 913 electrical examination of, at operation______________....... _______________ 973 median and ulnar combined lesions of, surgery of______________________________ 1039 irreparable defects of the, surgery of______________________________________ 1044 median, musculospiral and ulnar, gunshot wounds of, treatment of in embarka- tion hospitals, A. E. F_____________________________________________________ 647 peripheral— degeneration and regeneration of_________________________________________ 1098 regeneration of__________________________________________________________ 1102 spine and, injuries to, and head injuries, care of, in base hospitals, A. E. F._ 758 spine and, injuries to, and head injuries, care of, in the forward hospitals, A. E. F___________________________________________________________ 755 resected, sutured under extreme tension, with or without secondary wrapping in alcoholized Cargile membrane or formalized arterial sheaths________________ 1268 rules concerning, at evacuation hospital____________________________________ 128 section of, sensory disturbances in__________________________________________ 929 Nervous system, central, experimental study of problems of infection of, and the treat- ment therefor______________________________________________________________ 848 Neuraxon regeneration, secondary operations for defective________________________ 975 Neurolemma sheath_______________________________________________________ . 1102 and myehn sheath of regenerating nerve fibers_______________________ 1112 Neurological aspects of the effects of gunshot wounds of the head_______ 795-803 Neurological centers, neurological service, A. E. F_____________________ 750, 758 Neurological service, A. E. F.: arrangements for the care of head wounds----------------------- -------_ 750 organization and activities of_______---------------------------- 749-758 plan of organization___________________________________________ 750 problems of organization--------------------------------------- - 749 Neurological surgeons, instructions for, neurological service, A. E. F------------- 750 Neurolysis: in peripheral nerve surgery-------------------------- -------------------- 1086 technique of---------------------------------------- ------------------- 972 Neuromas, amputation-------------------------------------------------------- 981 formation in aseptic wounds----------------------------------------------- ||25 injection into divided nerve to prevent------------------------------------- H25 injection of absolute alcohol into the central end of a drvided nerve to obvrate the formation of____________________________________________________________ \\o\ protocols____________________________________________________________________ qsi treatment--------------------------------------------------------------- - ~nn Neuromata, painful, following amputations--------------- - ---------------- - - '^u Neuroplastic transplants, viable, for defects in nerve continuity-- -49-1283 Neurosurgery------------------------------ •----------------------- - ' -.. Neurosurgical teams in forward hospitals, A. E.J.-- ---- ' 2*? Nitrous oxide-oxygen anesthesia,--------- 189 limitations of-------------------.----------------------------- 11fl7 Nonmyelinated nerve fibers, degeneration of--------------------- L™* Nonoperative, preoperative and, treatment of amputation stumps.. _ _ ito Nonpenetrating wounds of the abdomen-------- --------------------------------- > following war wounds, autogenous bone grafts for _ ------- Normal respiration, with respect to wounds of the chest: ^_ activities gradually varied-------- 348 activities varied abruptly------------------- 346 Operating teams, rills of guidance for, evacuation hospital... 12, Operation: _____ _ 785 head wounds----------------- - T T ~____________________ 206 in wound shock------------fV •" M)0 precautions to be observed during.. -. 1308 INDEX Operation—Continued. indications for— "j?1' in wounds of the abdomen________________________----------- -- 451 in wounds of the chest______________________________________ ■ - 376 wounds of joints____------------------------------------------------ 31s nerve surgery, preparation of an extremity for------------------ 951 primary knee-joint_______________________________----------- ------ 331 spinal injuries____________________-------------------------- 791 time of, in wound shock-------------------------------- - 207 to close fistula_______________________-------------------- 487 Operations: abdominal, in anesthesia_______________------------------------- - 178 in the presence of acute infections, anest hesia in----. _--------------------- 182 on the chest, anesthesia in.:____________________ --_------------------ 178 on the extremities, anesthesia in_____________________ —------------------ 180 primary— gunshot wounds of the head, a statistical analysis________---------------- 844 nerve surgery__________________________________________________________ 980 secondary, gunshot wounds of the head, a statistical analysis___________------- 844 upon the diaphragm, in wounds of the chest________________________ - _------- 393 upon the heart and mediastinum in wounds of the chest______________________ _ 393 upon the lung, in wounds of the chest_______________________________________ _ 389 Operative findings, indications for operations based upon, in wounds of the chest____ 377 Operative technique: at battalion aid station_____________________________________________________ 96 in wounds of the abdomen__________________________________________________ 453 Operative treatment: of fractures in hospitals at the front_________________________________________ 621 of unhealed cases, amputation stumps_______________________________________ 728 wounds of the soft parts____________________________________________________ 997 Opponens action, tendon transplantation for restoring, to the thumb in intrinsic hand- muscle paralysis, technique___________________________________________________ 1041 Organization: and activities of the neunjilogical service, A. E. F__________._______________ 749 758 and development, amputation service, A. E. F________________________________ 687 for the care and study of peripheral nerve injuries_____________________________ 1081 medical; special training battalion, orthopedic department, A. E. F_____________ 587 orthopedic surgery_______________________________________________________549-590 Orthodiagraphic method, localization and extraction of foreign bodies under X-ray control______________________________________________________________ _"_ 228 Orthopedic department, A. E. F____________________________________ 580 instruction of divisional medical personnel...____________........____.... 584 special training battalion___________________________________ 5^5 training battalion, medical organization__________________.____ 5^7 Orthopedic surgery-------------------------_______ _______..... 549-748 in embarkation hospitals, A. E. F_____________.____.......... ^ „. _ 643-651 military, division of__________________._________-........._. 549 organization---_----------__________________S.^JS~ ~" " 549-590 standardization of splints________________________________ - r, training with the British___________________________'_ '?'-<> Osteitis, chronic suppurative (osteomyelitis), autogenous bone "grafts"for " and" for nonunion in atrophic long bones, following war wounds case reports________________________________ __ .'i. °Sam Stations(S6e ^ Chr°niC suPPura*iv? osteitis)," localized "terminal^" following Osteophytes, painful, following amputations _" """" "" Snn Osteoplastic amputation, Pirogoff's_ _____ ___--------------- <\j\j Overlap; existing, effects of resection and suture" on" ---- oof nerve, sensory disturbances in ________------------_. yai Packets, front,_________________ y^s Pain, and restlessness in wound shock , ftn Painful lesions of sciatic nerve_ iyu Palm: .-- 910 exposure of median nerve in the_____ _*__ surgery of the ulnar nerve in the. _ 1025 Pancreas, wounds of__________ _ ------------------------- 1036 _.__o INDEX 1309 Paralysis: Page. complete flexor, tendon transplantation for, technique___________ 1047 1067 1068 facial. nerve anastomosis in. intrinsic hand-muscle, tendon transplantation for restoring opponens action to the thumb, in technique_____________________________________ 1041 ischemic, in peripheral nerve lesions______________________ 875 musculospiral, tendon transplantation for___________________ 1010 of the long flexor of the thumb and the flexors of "the index finger, tendon trans- plantation for_______________________________________ 1028 of the median nerve, tendon transplantation for________________ 1027 total— of median and ulnar nerves combined___________________________ 901 of median nerve_________________________________________ §§9 treatment of, in head injury with_________________________________ 545 ulnar— in gunshot wounds of the neck, with nerve injury________________________ 645 progressive peripheral_______________________'__________________ 1031 Parietal healing in wounds of the chest__________________________________________ 370 Parietal wounds of the chest, excision of_________________________________________ 382 Parietes: and viscera, thoracic injuries involving both__________________ 372 thoracic, alone, injuries of__________________________________ 371 Partial injury: in lesions— of the sciatic nerve____________________________________________________ 909 of the median and ulnar nerves combined_______________________ ___ 903 of the musculospiral nerve_____________________________________________ 888 of the ulnar nerve_____________________________________________________ 897 of external popliteal nerve, motor disturbances in_____________________ ____ 911 Partial nerve lesions: operation for_________________________________________________________ 969 problems relating to the care of, at the front and at the base____________ 144 technique of repair of____________________________________________________ 969 Pathologic states, respiratory adaptations to, with respect to wounds of the cliest. 348 Pathology, gas gangrene_____________________________________________"** _;:______ 268 clinical____________________________•.. ________________________-______ 278 gunshot wounds of the head_________________________________________ 802 of experimental meningitis__________________________________________ ---- 855 of hematogenous meningitis, experimental study____....._______________ .. 862 of stump_____________________________________________ ------------ 721 of trench foot__________________________________________ --------------- 290 of wounds of the kidney_________________________________ — 470 Patient, preparation of, wounds of joints-------------------------- ---------- 319 Patients: evacuated, American First Army Hospital at Deuxnouds --------- 762 Penetrating and perforating wounds of the abdomen------------------ 449 Penis, anterior urethra, scrotum, testicles and, wounds of----------------- 488 Perforating and penetrating wounds of the abdomen---------------------- 449 Perforating bullet wounds, rules regarding, at evacuation hospital------------- 128 Peripheral nerve: ___ cases, care of in forward hospitals, A. E. F--------------_------------ '57 degeneration in the peripheral and central zone of traumatism----------------- 1102 fibers, development________________________________________________________ 1996 injuries— . 0 electrical examinations in the diagnosis of------------------------------- 94^ incidence of---------------------------------------------------------- 19°1 organization for the care and study of----------------------------------- 1U81 Peripheral nerve lesions: atrophy in--------------------------------------------------------------- gio joint changes in----------------------------------------------------------sfifi-Ql 7 motor disturbances in---------------------------------------------------SDO *_.' muscle shortening resulting from spasm in----------------------------------qi8-941 sensory disturbances in-------------------------------------------------- 873 Peripheral nerve repair" experimental observations on--------- ---------- 1091-1283 Peripheral nerve surgery: 1086 neurolysis---------------------------------- ' 10*1-1090 results ol---------------------------------- 1082 technique------------------------------------- '_"_"_ i089 transplants--------------------------------- 1310 INDEX t. • , i Page Peripheral nerves: .,)()(, degeneration and regeneration of---------------- ... ^. head and spine, care of injuries of, in base hospitals, A. E. 1*---------------- - < •>> regeneration of------------------------------ - r - - - - ------- - - - - - - - - ; - vr ,/ __ Z spine and, injuries to, and head injurres, care of, m the forward hospitals, A. E. 1 . too Peroneal nerve (external popliteal), exposure of, in the popliteal space----- ... 1058 Personnel: „ „ _„. divisional medical, instruction of, orthopedic department, A. E. *----- ------- 584 for examination and care of the soldier's foot...------------------------------- 592 Petrolatum, liquid, hetero-nerve transplants stored in------------------------------ 1227 Phalangeo-metatarsal and transmetatarsal amputations-------------------------- - - 731 Phalanges, terminal, extension (lumbricales and interossei function), metacarpophal- angeal flexion and, tendon transplantation for restoring, technique---------- 1044 Phrenic nerve, blocking the, in wounds of the chest--------------------------------- 387 Physical disabilities: by military agents-------------------------------------------- -------------- °5 from wounds, statistics of------------------------------------ ----------- - 71 Pirogoff's osteoplastic amputation------------------------------------------------- 733 Pistol bullets______________________--------------------------------------------- 43 Pistols _,____________________________________________________________------------ 39 machine carbine__________________________________________________------------ 36 Plan, general, of operating schedule, evacuation hospital---------------------------- 126 Planes, right-angled, method of, in localization and extraction of foreign bodies under X-ray control__________________________________________________________________ 228 Pleural adhesions in wounds of the chest------------------------------------------- 371 Pleural cavity, cleaning the, in wounds of the chest________________________________ 386 Pleural effusions, restrictions of, in wounds of the chest----------------------------- , 370 Plexus: brachial— general anatomy of____'__________________________________________________ 984 lesions of, motor disturbances in__________________________________________ 905 lumbosacral, lesions of, motor disturbances in__________________________________ 913 Pneumogastric nerve, lesions of, motor disturbances in____'_________________________ 914 Pneumonias, with respect to wounds of the chest___________________________________ 358 Popliteal nerve: external, motor disturbances in lesions of________________________ ______ 910 internal, lesions of, motor disturbances in________________________ _________ 911 Popliteal space: exposure of the peroneal nerve (external popliteal) in___________________________ 1058 exposure of the tibial nerve (internal popliteal) in the_____________ __________ 1056 Posterior tibial nerve, lesions of, motor disturbances in_________________ __________ 911 Postoperative care, wounds of joints_______________________________________________ 323 Postoperative complications, wounds of the abdomen________________ ___ 455 Postoperative infection, wounds of the joints_______________________________________ 327 Postoperative treatment: in wounds of the chest_______________________________________ ___ 398 of amputation stump__________________________________________ _______ 738 wounds of the abdomen_______________________________________ 454 Posture: in motor disturbances in peripheral nerve lesions____________________ _ 866 in wound shock________________________________ 191 Precautions to be observed: during operation in wound shock____________________________ 209 in intravenous injections, in wound shock____________ ____ 205 Preoperative— and nonoperative treatment of amputation stumps____________ 726 cases, responses to questionnaire on___________________ 157 findings, indications for operation based on, in wounds of the "chest 377 management, wounds of joints_______________ 017 physical diagnosis of chest injuries_____"]" "~ o7- preparation— at evacuation hospital_________________ 19o of patients, in wounds of joints ""-------- ofn treatment, in wounds of the chest__________ 070 Pressure, cerebrospinal fluid, effect upon, of intravenous injections of" "solutions"ofvari"- PrevenCtioneoifte£££."! _S °f ^ ^^ nerV0U8 SyStem' exPeri™ntal stud? 849 Primary and secondary suture, wound's" of" soft" parts - ~ «_t Primary closure, delayed, responses to questionnaire on___________... ... fr-g INDEX Primary operations: page gunshot wounds of the head, a statistical analysis____________ 844 knee-joint________________________________________ ogi nerve surgery_________________________________________ ggn Primary suture: wounds of soft parts__________________________ 305 delayed ---------- ----------------" I"---". 111111111111111 _310, 311 technique—-------------------------------------------------------- 308 Problems: hospital, responses to questionnaire on___________________ 1^4 relating to the— area of advance, conference on_______________________ 130 care of patients, at the front and at the base________________" ~ 144 Prognosis: gas gangrene----------------------------------------------- 283 intraperitoneal wound________________________________ 479 Projectiles: artillery____________________________________________________ 14 firearms and; their bearing on wound production________________ 9 fractures caused by_______________________________________ __ ^02 wounds caused by, late complications of________________ _ 333 Prophylaxis: gas gangrene---------------------------------------- ______ 278 serum, of tetanus____________________________________ ___ 285 trench foot__________________________________________ ________ 291 Prostate, posterior urethra and, wounds of__________________ . ..___ 482 Prosthesis: provisional, following amputation__________________________________ 702 stumps unsuitable for, following amputations___________________________ __ 702 Prosthetic requirements, site of amputation or reamputation, with reference to______ 731 Protective material, auto-nerve transplants wrapped in____________________ __ 1232 Protocols: amputation neuroma--------------------------------- ..._________ _____ 1125 auto-nerve transplants— including cable-auto-nerve transplants_______________ _________________ 1147 wrapped in auto-fascial sheaths, fascia lata_______ _ . _________________ 1244 wrapped in autogenous-fat flap________________________________________ 1258 wrapped in Cargile membrane_________________________ ___________ 1233 wrapped in formalized arterial sheaths__________________________________ 1254 degenerated auto-, homo-, and hetero-nerve transplants______________________ 1184 hetero-nerve transplants-------------------------------------------------- 1166 homo-nerve transplants___________________________________________________ 1163 injection of alcohol into a living uncut nerve________________________________ 1118 injection of full strength acetone into living uncut nerve______________.....____ 1123 stored hetero-nerve transplants____________________________________________ 1227 stored nerve transplants__________________________________'---------------- 1197 tension sutures; resected nerves sutured under extreme tension, with or without secondary wrapping in alcoholized Cargile membrane on formalized arterial hearts_________________________________________________________________ 1269 tubular nerve suture, with use of formalized artery___________________________ 1262 Provisional appliances in amputations: principles of fitting_______________________________________________________ 739 use of_________________________f----------------------------------------- 738 Psychoneurosis, gunshot wounds of the head------------------------------------ 798 Pulmonary circulation, with respect to wounds of the chest----------------------- 356 Pulmonary infection in wounds of the chest------------------------------------- 371 Pulse, slow, headache, vertigo, choked disc, and gunshot wounds of the head-------- 797 Purulent arthritis, active mobilization in Willems' method------------------------ 337 Qualifications of evacuation hospital surgeons----------------------------------- 125 Questionnaire on surgery at the base, responses to------------------------------- 153 Radial nerve, surgery_________________________________________________________ 100° Radius and ulna fracures, end results of----------------------- -•---------------- 509 Radius fractures, end results-------------------------------------------------- 509 Range of movement in peripheral nerve lesions---------------------------------- 866 Ratings of amputations, fractures, and their sequela;----------------------------- 495 Ratio of wounds from missiles from small arms---------------------------------- 51 Reactions, natural defense, with respect to wounds of the chest------------------- 359 Reamputation, amputation or, site of, with reference to prosthetic requirements.. 731 46997—27----85 1312 INDEX Records: raK" of the wounded, wounds of the chest_______________________ --------401-402 Group I. Excision of parietal wound____________________ ---------- 40.'. Group II. Limited thoracotomy_______________ ______ -------- 408 Group III. Thoracotomy of necessity ------- 416 Group IV. Thoracotomy of election_______.. ___ -------- 430 rules concerning, at evacuation hospital.. ____ ______________ ...... -------- 128 Recovery in lesions: of the external popliteal nerve_________________________________ ---------- 911 of the median nerve_____________________________________________.....------- 893 of the sciatic nerve______ ---- .-------------_---------------- ------ 909 of the ulnar nerve____________________________________________________________ 901 signs of_______________________________________________________ -------- 901 of the musculospiral nerve___________________________________________________ 889 signs of__________________________________________________________ . 889 Recrudescence of infection in cicatrized wounds, nerve surgery_____________________ 979 Recruits, foot defects found in, analysis of_________________________________________ 595 Rectum, wounds of_______________________________________________________________ 461 Regeneration: defective— and irreparable defects, in the sciatic trunk and its terminal divisions, sup- plementary procedures for_____________________________________________ 1063 secondary operations for, nerve surgery___________________________________ 974 degeneration and, of peripheral nerves________________________________________ 1098 muscle, secondary operations for defectives, nerve surgery_____________________ 974 of peripheral nerves__________________________________________________________ 1102 ulnar nerve, determination of_______________ ______________________________ 1038 Regimental aid station, surgery at the_____________________________________________ 96 Reoperation, indications for,.musculospiral nerve__________________________________ 1009 Repair: of tendons in combined nerve and tendon lesions, median nerve________________ 1024 peripheral nerve, experimental observations on________________________________. 1091 Resection: and suture, effects of, on existing overlap___________________________________ 931 functional results of, wounds of joints____________________________________ 337 mobility versus stability after, wounds of joints_________________________ 336 wounds of joints___________________________________________ 334 Residual: aphasia, gunshot wounds of the head_____________________________ 801 focal symptoms, gunshot wounds of the head__________________________ 799 sensibility, sensory disturbances in peripheral nerve lesions__________ ."..'_ 933 sensory symptoms, gunshot wounds of the head____________________ 800 visual symptoms, gunshot wounds of the head__________'_____I" T" 801 Respiration: and circulation, physiologic interdependence, with respect to wounds of the chest 343 normal— activities gradually varied—with respect to wounds of the chest 347 activities varied abruptly—with respect to wounds of the chest. _"" 348 during rest, with respect to wounds of the chest____________ '346 Responses to questionnaire on surgery at the base_______________ 153 Responsibility of the surgeon, rules regarding, at the evacuation"hospital""" 128 Rest, normal respiration during, with respect to wounds of the chest 34fi Restlessness and pain in wound shock____________________ 1 qq Restoration of proper function, work for, speciar."rai"n_ng~battah^ ment, A. Jb_. r-------------________ ^ ^ ro„ Results: 58b end— fractures of long bones_______________ _ .Q1 wounds of knee-joint__________________ 001 functional, after resection, wounds of joints I 007 of perrpheral nerve surgery_______ :^ T?' of serum therapy in gas gangrene x x^q Resume of the records of the wounded", wound's of "the" chest" ~ In 1 Retained foreign bodies, gunshot wounds of the head -------- « Retraction, soft-part, in amputation.. °!*° Rifle bullets, special________________ 693 Rifle grenades__________________ 41 Rifle missiles _______ 24 Rifles____________________-"_______ -■'-------- 39 antitank__________________ --------------- 29 autoloading automatic --------- 30 -------------- 30 INDEX 1313 Page Right-angled planes, method of, in localization and extraction of foreign bodies under X-ray control_______________________ _____________________________ 228 Roentgenologic examination, wounds of joints".../.'.'.____________________________ 318 Rotation of the part in localization and extraction of foreign bodies under X-rav con- trol___________________________________________________________________;_____ 224 Rules: general surgical, for evacuation hospital_____________:______________________ 123 of guidance for operating teams, evacuation hospital__________________________ 127 Rupture: and traumatic stricture of the urethra_____________________________________. _ 489 operative treatment_________________________________________ . _______ 489 prophylactic treatment_________________________________________________ 489 subcutaneous, of viscera, in wounds of the abdomen__________________ . 447 Salt solutions, injection of, in wound shock______________________________________ 193 Scalp, wounds of the, treatment of, in forward hospitals, A. E. F__________________ 782 Scalp incision, head wounds____________________________________________ __ . 785 Schedule, operating, general plan of, evacuation hospital__________________________ 126 Sciatic nerve: lesions of— motor disturbances________ __________________________________________ 908 painful_____________________________________________________________ 910 partial injury________________________________________________ -------- 909 recovery in____________________________________________________ ______ 909 supplementary motility in______________________________________________ 909 Sciatic trunk: and its terminal divisions— general anatomy_______________________________________________________ 1048 irreparable defects and defective regeneration in, supplementary pro- cedures for_________________________________________________________ 1063 continuity defects, surgery of_______________________________________________ 1060 exposure of— in gluteal region_______________________________________________________ 1052 in the thigh___________________________________________________________ 1053 secondary suture of________________________________________________________ 1061 surgery of the______________________________________________-------_-------- 1051 Screen, open, in darkened room, localization and extraction of foreign bodies under X-ray control_______________________________________________________________ 259 Scrotum, testicles, penis, and anterior urethra, wounds of------------------------- 488 Secondary amputation, knee-joint----------------------------------------------- 331 Secondary hemorrhage, responses to questionnaire on-------------------------- 159 Secondary operations, gunshot wounds of the head, a statistical analysis--- 844 Secondary suture: wounds of soft parts_________________________________________------------- ^jl technique_____________________________________________________________ bi- section of nerves: „„.. effect of, of overlapping nerve---------------------------------------------- ^j* * of adjacent nerves--------------------------------------------------------- ^Jq sensory disturbances in------------------------------------------------ ^_^ Selection of donors for blood transfusion in wound shock---- ----------- ------ ^u Sensibility, residual, sensory disturbances in peripheral nerve lesions-------- __ yjd Sensory disturbances in peripheral nerve lesions-------------------------------yi8 »*j exclusive nerve supply---------------------------------------------- ^g in section of nerves------------------------------------------- o^o material____________------------------------------------ 92Q methods of investigation------------------------------------ g28 nerve overlap---------------------------------------- 933 residual sensibility---------------------- - - - - - - - - - onn Sensory symptoms, residual, gunshot wounds of the head.. _ o™ Sepsis in amputations, A. E. F---------------;--. 40^ Sequelae, ratings of amputations, fractures, and their---- Serum: 285 prophylaxis of tetanus-------------------------- 279 therapy, gas gangrene--------------------------- Sheaiutofascial fascia lata, auto-nerve transplants wrapped in 1243 formal zed arterial, auto-nerve transplants wrapped ________ 253 myelin and neurolemma, of regenerating nerve fibers. _ ---------- 1112 neurolemma------------------------ " " _ __________ 17 Shell, high-explosive---------------------- 1314 INDEX Shock: and exhaustion, anesthesia in------------------- ------- in peripheral nerve lesions--------------------------- primary, treatment of in wound shock------------------------- Shock, wound. (See Wound shock.) Shock teams, their training and duties----------------------------------- Shoe, the Army_________________________ ------------------------------------- Shoulder: fractures of_________________________---------------------------.----------- gunshot wounds of, with fracture, treatment of in embarkation hospitals------- wounds of_________________________ --------------------------------------- Shrapnel_______________________________________________________________________ Significance of vital capacity in inthrathoracic therapy, with respect to wounds of the chest________________________________________________________________________ Signs and symptoms, local, gas gangrene----------------------------------------- Single shift* triangulation method, localization and extraction of foreign bodies under X-ray control________________________________________________________________ Sinus (.venous)___________________________________----------------------------- Site: and character of injury in the battle dead____________________________________ of amputation or reamputation with reference to prosthetic requirements------ Skin, marking the, in localization and extraction of foreign bodies under X-ray control. Small arms, ratio of wounds from missiles from___________________________________ Small-arms: missiles____________________________________________________________________ wound-production by___________________________________________________ weapons and missiles____________________________________________________ - Small intestine, wounds of___________________________________________________ Soft parts: stump pathology referable to________________________________________________ wounds of the. (See Wounds of the soft parts.) Soft-part retraction, in amputations______________________________________________ Soft-part wounds, with damage to muscles and tendons of upper and lower extremities treatment of, in embarkation hospitals, A. E. F_________________________________ Soldier's foot, the______________________________________________________________ instructions in requirements with respect to the_______________________________ personnel for examination and care of the____________________________________ Solution: gum-salt, in wound shock___________________________________________________ hypertonic gum acacia and glucose, in wound shock___________________________ Solutions: of various concentrations, effect of intravenous injections of, upon crebrospinal fluid pressure, in infections of the central nervous system, experimental study. salt, injections of, in wound shock_________________________________________*_ _ Spasm, muscle shortening resulting from, in peripheral nerve lesions________________ Special provisions for the care of the adominally wounded________________________ Special rifle bullets_________________________________________________________ Special training battalion, orthopedic department, A. E. F____________________ Spinal accessory nerve, lesions of, motor disturbances in___________________________ Spinal anesthesia________________________________________________ limitations of_______________________________________________ Spinal cases, care of, in forward hospitals, A. E. F______________________ Spinal cord, epidural compression of the, experimental study___________" Spinal injuries, treatment of, in forward hospitals, A. E. F._________________'___ Spine: and head, gunshot wounds of, management of, in forward hospitals, A. E. F__ and peripheral nerves, injuries to, and head injuries, care of, in the'forward hos- pitals, A. E. F___________________________________ gunshot wounds and other injuries of, treatment of, in "embarkation hospitals, A. E. F______________________ head, and peripheral nerves, care of" injuries of, in base hospitals" A EF Spleen, wounds of the____________________________ Splint, Thomas, drill for front-line application of, "fracturesof lower "extremit v Splinting, first-aid, fractures of lower extremity_____ Splints: and accessories, standard, manufactures of___________ and appliances, manual of— first edition____________________________ second edition__. INDEX 1315 Splints—Continued. splint accessories, and dressings— Page for a base hospital of 1,000 beds, list of_______________________ ... 624 for an evacuation hospital of 1,000 beds, list of________________ 622 standardization of_______________________________________________ .___ 554 Stability, mobility versus, after resection, wounds of joints________________________ 336 Standardization of splints______________________________________________________ 554 Station: battalion aid, surgery at the________________________________________________ 93 company aid, surgery at the________________________________________________ 93 dressing, surgery at the____________________________________________________ 96 regimental aid, surgery at the______________________________________________ 96 Statistical analysis of gunshot wounds of the head______________________________ 841-847 Statistics_________________________________________________________________ ___ 57-85 battle injuries____________________________________________________________ 57 admissions________________________________________________________ _ _ _ 57 ankylosis________________________________________________________ _ _ 72 day of death_________________________________________________________ 61 days lost________________________________________________________ _____ 59 death_______________-------____________________________________ ___ 58 discharges for disability___...._______________________________ ._____ 59 duration of treatment_______.____________________________________ .... 60 fractures____________________...___________________________ _ 70 loss of eyes or eyesight___________________..._____________ 72 of physical disabilities— by military agents__________________________.______________ 85 from wounds_________________________________________________________ 71 Sterilization and surgical supplies at evacuation hospital_____________________.____ 124 Stomach, wounds of_________________________________________________ _________ 457 Stored hetero-nerve transplants________________________________________________ 1227 protocols_________________________________________________________________ 1227 Stored homo-nerve transplants_________________________________________________ 1195 protocols_________________________________________________________________ 1197 Strangulation and compression lesions, nerve surgery_____________________________ 971 Stretching: primary, for defects in nerve continuity_____________________________________ 954 with secondary suture (two-stage operation), for defects in nerve continuity---- 955 Stricture, traumatic, rupture and: i >f urethra________________________------------------------------------- -^•■' operative treatment_________________------------------------------ 489 prophylactic treatment______— ------------------------------- 489 Structure: of a nerve_____----_ _----------- ------------------------ --- --- 1093 of nerve fibers__________--------- ---- -----------—--------- l_!p^ Stump pathology_____----------------- ---- ^2| referable to bone___--------------------- '_jy referable to soft parts---------------------- - - - 724 Stump surgery, secondary, when should be done _ _--------- - - 728 Stumps: amputation— _ attention to adjacent joints---------------------------- _T cinematization of--------------------------------------- '*' operative treatment of unhealed cases----------------------- -_-- --- <^» postoperative treatment------------------------------------- .-__-_ /o» preoperative and nonoperative treatment------------------_____.__-.-_- tib treatment of, in the United States.------------------------- '1° when secondary stump surgery should be done. . _----------............. / zb wound antisepsis in--------------------------------------- - - - '"' condition of, on arrival in the United States-------------_------------ ----- ' iy unsuitable for prosthesis, following amputations-----------------............ nu Subarachnoid inoculation, meningitis produced by------------------ - - - *o* Subarachnoid irrigations, experimental ^udy----------- - ------- ■ •> Subcutaneous rupture of viscera in wounds of abdomen-----_. _ 4-t / Supplementary motility: in lesions— 994 of circumflex nerve------_-----:-------- Qn9 of median and ulnar nerves combined--------- - - - - »v* of sciatic nerve------ - ^()s of ulnar nerve------- ---------------------- s'()., of median nerve---_. - 1316 INDEX .... Page Supplementary movement in lesions. ^^ of external popliteal nerve--------------__._----- - ----- ■ Supplies, surgical, sterilization and, at evacuation hospital---------- ' -** Suppurative arthritis, wounds of joints-----_------■-----1----.--., , \tt Surgeon, responsibility of the, rules concerning, at evacuation hospital i_.H Surgeons: ->.}- evacuation hospital, qualifications of------ ^ - - - - -- lt'\ neurological, instructions for, neurological service, A. E. 1- <•>» Surgery: ,„ at the base, responses to questionnaires on_ _ _ 10? at the battalion aid station------------------ ™ at the company aid station------------------ at the dressing station. 9(5 at the field hospital----------------------- 99 atthefront______________________________ or at the regimental aid station------------------- "£ chest, responses to questionnaire on----------- li]* civil abdominal, lessons in, gained from the war------_ jt>8 craniocerebral, prior to our entrance into the World \\ar_ nb general----------------------------------- — -------- ill in the evacuation hospital------------------ -------- ^ military orthopedic, division of------------- - - - j^9 musculocutaneous nerve------------------------ ---- 993 musculaspiral nerve----------------------------- ------ 996 nerve, technique________________________________----------- inon of combined lesions of median and ulnar nerves----- ---------- 1039 of interosseous nerves___________________________ -------- 1004 of irreparable defects of the median and ulnar nerves---- ------- 1044 of the brachial plexus_______________________ ------ 984 of the circumflex nerve________________________ ------- 992 of the facial nerve__________________________ ------ 1067 of the median nerve in the hand_____________ -------- 1025 of the posterior tibial nerve_________________ ------- 1057 of the sciatic trunk_________________________ -------- 1051 of the ulnar nerve in the palm___________________ 1036 on the battle field_________________________________ . _ _ __ ^88 orthopedic (see also Orthopedic surgery)----------------- _ - 549-748 peripheral nerve— results of______________________________________________ ------------- 1082 technique___________________________________________ ___________ 1082 radial nerve____________________________________________________ ________ 1006 ulnar nerve__________________________________________________ ______________ 1030 in the region of the internal humeral condyle_________________ __________ 1031 Surgical experiences, collective, at the front and at the base______________ ________ 130 Surgical methods: in wounds of the chest______________________________________ __________ 379 with respect to wounds of the chest__________________________ _________ 367 procedures in tetanus_________________________________________ ______ 287 rules, general, for evacuation hospital_________________________________________ 123 supplies, sterilization and, at evacuation hospital_________________ __________ 124 treatment, gas gangrene_______________________________________ _ _________ 280 Sustaining factors in wound shock_________________________________ 186 Suture: delayed primary— wounds of soft parts__________________________________ ___________ 310 nerve--------------------------------------------------- .. ..______________ 1260 primary— and secondary, wounds of soft parts__________________ ______________ 304 wounds of soft parts_________________________________ ______ 305 secondary— of musculospiral nerve_____________________________ ________ 1008 of the sciatic trunk_________________________________ _______ 1061 of ulnar nerve____________________________________________ 1037 wounds of soft parts____________________________________ 311 torsion of nerve trunk during________________________________ 959 tubular, nerve, with use of formalized artery_______________ ~_ 126O Sutures: identification sutures, in nerve surgery_____________________ i of fractures, in hospitals at the front------------------------------------------- ^ of unhealed cases, amputation stumps------------------------------------ '*; rupture and traumatic strict ure of urethra----- yy wounds of the soft parts.. _ --------------------------------- postoperative— • ^ng in wounds of the chest------------------------ ------------- _., of amputation stumps--------------------------- ''' of the wound, wounds of joints------------------------- y® wounds of the abdomen--------- °4 preoperative— 7oft and nonoperative, of amputation stumps---------------- ---------- /£» in wounds of the chest--------------------------------- - - ' '' prophylactic, rupture and traumatic stricture of urethra--- ---- *om routine preliminary, of head injuries at an evacuatron hosprtal, A. h.. v---- /»i surgical, gas gangrene--------------------------------------- ---------- t)y trench foot________________________________________________ Tqr urethrorectal fistula_____________________________________________ y,® wounds of the kidney _ _ ------- - ' - at the base___ --- - yA at the front______ ---------- ----------- %'* Trench foot... _______ _______________________ ---------------------- 290 etiology----- ------- ---------------- *™ |)athology___ _ _ ________________________________________________— fyy prophylaxis--- ----------------------- *jjj symptoms__ _____ _____________________________________________________ f'y t reat ment____________________________________________________________- - - 293 Triangulation, single shift, method, localization and extraction of foreign bodies under X-ray control______________________________-------------------------------- 230 Trigeminal nerve, lesions of, motor disturbances in------------------------- — 913 Tube, centering the, in localization and extraction of foreign bodies under X-ray control______________________________________________________________ 218 Types: of abscess wall, gunshot wounds of the head--------------------------- __ 815 of anesthesia, limitations of_________________________________________ — 182 of chest injuries__________________________________________________________ 371 Fleers, terminal, following amputation_________________________________ ---- 700 Ulna and radius fractures, end results_____________________________________----- 509 Ulna fractures, end results____________________________________________________ 509 Ulnar and median nerves, irreparable defects of, surgery of----------------------- 1044 Ulnar and median nerves combined: lesions of— motor disturbances in_____ _ _______________________________________ 901 surgery of_______________ ___________________________________________ 1039 Ulnar, median, and musculospiral nerves, gunshot wound of, treatment of, in embar- kation hospitals, A. E. F____________________________________________________ 647 Ulnar nerve: branches________________________________________________________________ 1029 defects in continuity, surgery of____________________________________________ 1037 exposure of— in the arm___________________________________________________________ 1030 in the middle and lower thirds of the forearm____________________________ 1035 in the palm__________________________________________________________ 1036 in the region of internal humeral condyle________________________________ 1031 general anatomy_________________________________________________ ______ 1028 lesions of— motor disturbances in_________________________________________________ 895 partial lesion_________________________________________________________ 897 recovery in__________________________________________________________ 901 supplementary motility in_____________________________________________ 898 sacrifice of the, as a viable neuroplastic transplant for the repair of a median defect, technique_______________________________________________________ 1046 secondary suture_________________________________________________________ 1037 INDEX 1321 Ulnar nerve—Continued. Page surgery of_______________________________________________ ________ 1030 in the palm____________________________________________ ____________ 1036 in the region of the internal humeral condyle________________ ___________ 1031 transposition of______________________________________________ ____ _______ 1032 Ulnar paralysis, progressive peripheral, surgery of___________________ ____ _______ 1031 Unhealed cases, amputation stumps, operative treatment of__________________ _ 728 Unit, mobile, for abdominally wounded_____________________________________ 445 United States: amputation cases returned to_______________________________________________ 718 care of the amputated in___________________________________________________ 713 Upper arm, site of amputation or reamputation with reference to prosthetic require- ments______________________________________________________________________ 737 Upper extremity: fractures of____________________________________ _________ _____________ 607 treatment of in base hospitals__________________________________________ 626 site of amputation or reamputation with reference to prosthetic requirements- 735 use of provisional appliances in amputations of____________________________ 745 Ureter, wounds of the___________________________________________ _________ 465, 475 Urethra: anterior, scrotum, testicles, penis, and, wounds of_____________ ________ _ 488 bulbous, wounds of_ _.. _ _______________________________ _____________ 483 case reports______ _________________________________ _. ___________ 483 fistula of__________________________________________________ ____________ 485 penile, fistula of___________________________________ _ _ 485 posterior, and prostate, wounds of___________________ __ . ____________ 482 rupture and traumatic stricture of______________ _________ 489 operative treatment_______________________ ___________ _____ 489 prophylactic treatment- _________________ ___________ __._______ 489 Urethrorectal fistula___ __________________________________ . — . - 486 treatment_____________________________________ ________________________ 486 Vaseline, sterile, homo-nerve transplants stored in____ __________________________ 1195 Vasoconstrictor drugs in wound shock___________________________________________ 191 Velocity, low, the frequency of injury from missiles of, with respect to the wearing of armor______________________________________________________________________ 3 Vertigo, choked disc, slow pulse, headache and, in gunshot wounds of the head----- 797 Viable neuroplastic transplants, for defects in nerve continuity------- ------- 957, 1046 Virulence, intrameningeal, of microorgans, in infections of the central nervous system, experimental study__________________________________ ------ s5" Viscera: parietes and, thoracic, injuries involving--------------------- 372 subcutaneous rupture of, in wounds of the abdomen----------------- --- 44. thoracic, alone, injuries involving____________________ ---------------- 374 Visceral injury: symptoms of, in penetrating and perforating wounds of the abdomen------ 45U treatment of, in wounds of the abdomen------------------------- 45' Visual symptoms, residual, gunshot wounds of the head-----------------Vili' Vital capacity in intrathoracic therapy, significance of, with respect to wounds ot the chest____:____ ___________________________________ T Voluntary motility, recovery of, in peripheral nerve lesions __ *<- Weapons, small-arms, and missiles------------------7--------- "i Willems' method, active mobilization in purulent arthritis---- •>•">< Wound: ,,-.; character of, gas gangrene---------------- - - - - - r v o9c postoperative treatment of the, in wounds of the joints. - *f*> Wound antisepsis in amputation stumps-------- — 7,-y~ [Zu Wound dressing, rules concerning, at evacuation hospital __ Wound production: ±^ bv small-arms missiles-----------_--------------- q firearms and projectiles; their bearing on---- ^_ ^' Wound shock_______________________________ 209 after-care in-------------------------- 206 anest hesia in operation in... _ - - 186 earlv treatment------- ---------- 192 forced absorption of fluids in. _.-- ~ ~ _\V_'/_Y_\ 194 gum-salt solution in------------ ~___~___\____ 1S2 hemorrhage in------------------________ 195 hypertonic gum acacia and glucose---- ___________________ l s. initiating factors------------ _ ly;. injection of salt solutions in------ 1322 INDEX Wound shock—Continued. ge loss of body heat in___ ----------------- l^s low blood pressure in_______________________ ------- 192 method of blood transfusion employed in the A. E. F------------ 198 pain and restlessness in____________________ 190 posture in__________________________________________________ 191 precautions to be observed during operation-------_--------- 209 precautions to be observed in intravenous injections in------------ 20;. selection of donors for blood transfusion in----------------------- 200 transfusion of blood in--------------------- --------------- 197 treatment of primary shock in-------------------------- 209 vasoconstrictor drugs in_____________________________________ 191 Wound suturing, rules regarding, at evacuation hospital-------------- 12S Wounded: abdominally—■ mobile unit for__________________---------------- 445 nontransportable hospital for____________________________ - 445 special provisions for the care of_____________________________ ----- _ 444 transportation and the time factor in the care of------------------------_. 444 resume of the records of, wounds of the chest____________________ -------- 401 Wounds: aseptic, amputation neuroma formation in_______________________ ----------- 1125 caused by projectiles, late complications of___________________________________ 333 cicatrized, recrudescence of infection in, nerve surgery------------------------ 979 extraperitoneal____________________________________________________________ 479 case reports___________________________________________________________ 480 diagnosis_____________________________________________________________ 480 mortality_____________________________________________________________ 480 symptoms____________________________________________________________ 479 treatment____________________________________________________________ 480 frequency in the location of, and its bearing on the armor problem_____________ 4 from explosive missiles_____________________________________________________ 46 from missiles from small arms, ratio of______________________________________ 51 general character of, from various causative agents___________________________ 54 general treatment of, at the front___________________________________________ 7S gunshot (see also Gunshot wounds)— of neck, with nerve injury, ulnar paralysis, treatment of, in embarkation hospitals, A. E. F___________________________________________________ 645 of the head and spine, management of, in forward hospitals, A. E. F_______ 776 of the head, classification, a statistical study_____________________________ 841 of the head, neurological aspects of the effects of_________________________ 795 of the knee joint, treatment of, in embarkation hospitals, A. E. F__________ 649 of upper arm, with fracture of humerus, treatment of, in embarkation hos- pitals, A. E. F______________________________________________________ head— arrangements for the care of, neurological service, A. E. F________________ 750 treatment of different grades of, in forward hospitals, A. E. F_____________ 782 infected, and nerve surgery______________.__________________________________ 979 in joints, roentgenological examinations______________________________________ 318 intraperitoneal____________________________________________________ 478 diagnosis_____________________________________________________ 478 prognosis___________________________________________________ 479 treatment________________________________________________ 478 of the abdomen_____________________________________________ 443-469 course of treatment dependent upon type of injury________ . . 467 incidence_____________________________________*______ 44^ indications for operation in__________________________ 45I military importance of______________________________ 446 nonpenetrating___________________________________ 44g nonpenetrating, involving the abdominal wall.__________"""_ 446 operative technique in____________________________ 453 penetrating and perforating________________________ 449 postoperative complications_______________________ 455 postoperative treatment___________________________ 454 special provisions for the care of wounded____......... 444 subcutaneous rupture of viscera in_____________________ 447 symptoms of visceral injury in_______________________ 459 treatment of visceral injuries____________________ 4^7 of the ankle______________________________________ 000 INDEX 1323 Wounds—Continued. Page of the bladder__________________________________________________________ 405 470 character of injury________________________________________________ _ ' 470 of the bulbous urethra______________________________________________ 4gg case reports___________________________________________________ 4^ of the chest (see also Thoracic injuries)________________________________ - 342-442 activities gradually varied1—with respect to__________________________ 347 activities varied abruptly—with respect to_________________________ 34§ adaptations to pathologic states—with respect to______________ 34^ anesthesia in treatment of____________________________________ 309 atelectasis in relation to______________________________________ org blocking the phrenic nerve in______________________________ 3gg blood transfusion in___________________________________ oog bronchial air circulation with respect to___________________________ 353 bronchial arterial circulation with respect to_______________________ 353 cleaning the pleural cavity in_____________________________ 3gg closure of the chest wall in______________________________ 390 collapse with respect to_________________________ 352 complications of_____________________________________ ggg disabilities_____________________ <57 drainage in___________________________________________ ^gg emphysema in relation to______________________________ 3 eg external compression with respect to____________________________T 355 external impression with respect to______________________________ 350 fatalities______________________________________________ ^gg Group I. Excision of parietal wound____________________ 493 Group II. Limited thoracotomy_______________________________ 40g Group III. Thoracotomy of necessity_____________________________ 41g Group IV. Thoracotomy of election_______________________________ 43O indications for operation based upon operative findings_______________T_ 377 indications for operation based upon pre operative findings_______________ 377 indications for operation in_______________________________________ 37g natural defense reactions with respect to._____________________________ 35g normal respiration during rest, with respect to______________________. _ _! 346 operations upon the diaphragm in_______________________________________ 3g3 operations upon the heart and mediastinum ir___________________________ 393 operations upon the lung in_____________________________________________ 389 parietal, excision of__________________________________________________ 382 parietal healing in______________________________________________________ 370 physiologic interdependence of respiration and circulation, with respect to.. 343 pneumonia in relation to_______.________________________________________ 358 postoperative treatment in______________________________________________ 398 preoperative physical diagnosis of_______________________________________ 375 preoperative treatment in_________________________________________ 379 pulmonary circulation with respect to__________________ _________ 356 resume of the records of the wounded________________________________ 401 significance of vital capacity in intrathoracic therapy, with respect to___ _ 343 surgical methods in_____________________________.__________________ _ 379 surgical methods with respect to________________________________ ____ 367 thoracotomy in___________________________________ ___________ ____ 382 treatment with respect to breathing unit in______________________ _______ 362 treatment with respect to circulatory unit in_________ ________________ 361 of the colon_____________________________________________ _________________ 460 of the elbow________________________________________________________________ 332 of the external genitalia_____________________________________________________ 488 of the face_________________________________________________________________ 314 of the foot______________________________________________________.__________ 314 of the genitourinary tract_________________________________________________ 470-490 of the hand________________________________________________________________ 314 of the joints____________________________________________-----------------317 341 ankylosis______________________________________________________________ 339 early active mobilization----------------------------------------------- 323 functional results of resection------------------------------------------- 337 indications for operation------------------------------------------------ 318 mobility versus stability after resection---------------------------------- 336 partially ankylosed joints, with or without deformity--------------------- 340 postoperative care------------------------------------------------------ 323 postoperative infection------------------------------------------------- 327 postoperative treatment of the wound----------------------------------- 326 preoperative management---------------------------------------------- 317 1324 INDEX Wounds—Continued. of the joints—Continued. page preparation of patient__________________________ --------- 319 resection_______________________________________ ___________ 334 suppurative arthritis__________________________ _____ _________ 333 technique of operation______________________________ 320 of the knee-joint_________________________________ _____ 328 of the kidney____________________________________________ 464,470 case reports_____________________________ ____________ ._ 474 clinical picture__________________________ _____________ 471 diagnosis_______________________________ ________________ _ ________ 472 mortality_______________________________ ________________ __________ 474 pathology______________________________ _________________ ________ 470 symptoms______________________________ ____________________________ 471 treatment______________________________ __________________ 472 treatment, at the base___________________ ____________________________ 473 treatment, at the front__________________ _____________________________ 472 of the liver________________________________________________________________ 462 of the pancreas____________________________________________________________ 463 of the posterior urethra and prostate________________________________________ 482 of the rectum_____________________________________________________________ 461 of the scalp, treatment of, in forward hospitals, A. E. F_______________________ 782 of the scrotum, testicles, penis, and anterior urethra__________________________ 488 of the shoulder____________________________________________________________ 332 with fracture, treatment of, at embarkation hospitals_____Z______________ 646 of the small intestine_____________________________'______________________ 458 of the soft parts_____________________________________________________ 294-316 debridement__________________ _________________________ 299 delayed primary suture________ ____________________________________ 310 delayed primary suture, technk\ir:____________________________________~~ 311 operative treatment______________________________________ 297 primary and secondary suture_______________________________ 304 primary suture_______________________________________ 305 secondary suture_____________r_____________________ 311 secondary suture, technique__________________ _ 312 of the spleen_______________________________________ 4gg of the stomach_________________________________ 457 of the ureter--------------------.__________Y_~_Y_~_~_Y_~_~_ 465 475 perforating bullet, rules regarding, at evacuation hospital _ ' 128 physical disabilities from, statistics of____________________ 71 produced by sharp instruments__________________________~____" 333 soft part, with damage to muscles and "tendons of upper and "lower"extremitie"s" treatment of, in embarkation hospitals, A. E. F________... _ ' 651 war autogenous bone grafts for nonunion in atrophic long "bones" and" in "chronic osteitis (osteomyelitis), following fir9 Wrist: DOZ and hand, fractures of_____________ _ _ finq exposure of median nerve of__________ ,^, hand, and forearm— " " luZd 647 ^A^F °UndS °f' Wlth fractures' ^atment of, in embarkation hospitals, treatment of fractures of", in base "hospitals" goo median nerve lesions at the, and combined tend"on in j uries " 1 rv^. Zone of the advance, A. E. F.: UZcS teams for hospitals in, neurological service_____ 7cn technique of amputations in the _ ~™ b90 ADDITIONAL COPIES OF THIS PUBLICATION MAY BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE WASNINGTON, D. C. AT $4.00 PER COPY V Bridgeport National Bindery, Inc. JAN. 1983 | '^0|1 National 'Bound to last NLM 0005^21 5 NLM000599212