Talk:The Johns Hopkins Medical Journal 11 (1900)
VOLUME XI
BALTIMORE
THE JOHNS HOPKINS PRESS
1900
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BULLETI
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. XL-No. 106.1
BALTIMORE, JANUARY, 1900.
[Price, 15 Cents.
COK-TEUTSI.
Contributions to the Surgery of the Bile Passages, especially
of the Common Bile-Duct. By W. S. Halsted, M. D., - - 1 Early Exploratory Operations in Tuberculosis of the Hip. By
Joseph C. Bloodgood, M. D., - jj
Gunshot Injuries by the Weapons of Reduced Calibre. By
L. A. LaGardb, U. 8. A., - - - - - . oq
A Reconstruction of a Glomerulus of the Human Kidney.
William B. Johnston, - - - -Medical Commission to the Philippines.
Barker, M. D.,
By
Ry Lewellys F.
An Apparatus to Aid the Introduction of a Catheter or Bougie. By George Walker, M. D.,
Summaries or Titles of Papers by Members of the Hospital and Medical School Staff appearing Elsewhere than in the Bulletin, ------ Proceedings of Societies :
Hospital Medical Society, - - Exhibition of Surgical Cases [Dr. Mitchell] ;— An Improved Stethoscope [Dr. Cabot] ;— The Pulmonic Second Sound [Dr. Cabot].
Books Received,
30
34
CONTRIBUTIONS TO THE SURGERY OF THE BILE PASSAGES, ESPECIALLY OF THE
COMMON BILE-DUCT.*
By W. S. H.lstkd, M. D., Baltimore, Surgeon-in-Chief to the Johns Hopkins Hospital, Professor of Surgery in the Johns
Hopkins University.
Just now I am very much impressed with the splendid results of operations for gall-stones in the common duct, for we have had of late a series of cases very desperately ill, and so transformed by their emaciation and discoloration, and so feeble in body and mind, that I could hardly picture to myself the various stages of metamorphosis toward convalescence. Every one has seen a patient whose life has been despaired of convalesce from acute disease ; they watched his rapid decline and expected an almost equally rapid recovery; but when the decline has covered a period of five or ten or perhaps twenty years the changes wrought are so great and apparently of such permanent character that the complete restoration to health is the more astonishing. The large cirrhotic liver, the dry slateyellow skin, the enfeebled intellect, the body emaciated to the last degree, seem at times almost to preclude all hopes of recovery to the practitioner who has not witnessed the changes so quickly brought about by nature as soon as the mechanical obstacles to recovery have been removed by the surgeon. What nature accomplishes without the surgeon's aid in her attempts to rid herself of the obstruction in the gall-passages and to
•Read at a Meeting of the Surgical Section of the Suffolk District Medical Society, May 3, 1899.
repair self-inflicted damage is marvelous ; but her methods are very crude and attended with much suffering and great danger, immediate and remote. I have, however, in mind at this moment two particularly creditable examples of nature's surgery.
In the first one the gall-passages were shortened to just the length of the two large stones which completely filled them. One occupied the gall-bladder, the other the pancreatic portion of the common duct; the duodenum was not only adherent to the gall-bladder, but served in place of its anterior wall, which had been destroyed; the stone in the gall-bladder, therefore, rested on the wall of the duodenum, which was pasted, so to speak, over the great hole in the front wall of the bladder. There was nothing that could be called cystic duct ; the choleductus was almost completely covered by the duodenum; the hepatic duct was much distended, admitting easily one finger. All signs of inflammation, except its results, had disappeared. The simplest conditions had been produced, and those most favorable to the expulsion of the stones in some subsequent attack ; gall-bladder and common duct were reduced to a short, wide, nearly straight tube, which bore a striking resemblance to an atheromatous aorta. The stone in the common duct was behind the duodenum and buried in its wall.
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 106.
The second patient had his first colic twenty-one years before admission to the hospital. He was never jaundiced. In the third attack, which began one month prior to operation, his temperature reached 106°. A physician aspirated pus from the distended gallbladder about twenty-four days after the onset of the third attack, or three or four days before we operated. The gall-bladder was opened in two acts. The fluid in the gall-bladder was almost clear and not bile-stained. Diagnosis : Stone in the cystic duct. Cover-slips showed few bacilli. Cultures yielded bacillus coli communis, pure. Patient applied for re-admission in eighteen months, because he had noticed a hard body just beneath the skin in the mouth of the sinus. By simply dilating the sinus I removed four large, very darkgreen, almost perfectly cylindrical stones, which were piled up upon each other in this sinus, forming a column 10 centimeters high. Nature would herself have extruded these stones which she had brought to the surface without causing the patient any discomfort.
Equally marvelous are the processes by which nature destroys all traces of her surgical handiwork. I have operated upon two cases in which perforation of the gall-passages and intestinal walls, and the expulsion of the stone, had undoubtedly occurred, but was unable in one of them to find any evidence of the perforation other than a few light and easily separable adhesions. Again, in a case of appendicitis, followed by gangrene of the greater part of the cecum and a wide preternatural anus, there were, within a year, only a few very light adhesions about a pinhole opening in the colon to tell the story. These facts are enough to make the ordinary operations for suspension of the spleen, liver, uterus, etc., seem ridiculous. Adhesions about an artificial opening fortunately never disappear. If innocent fistula? could be established, with the organs to be suspended, the problem might in a way be solved.
I wish to ask your attention to-night to a few of the unusual facts observed by us in our operations upon the bile-passages j particularly the common bile-duct. Almost every one of our common duct cases has presented us with a new fact or two which can hardly fail to interest the general practitioner, as well as those who concern themselves with the surgery of the bile-passages. To be as brief as possible, for the time is short, I will summarize at the outset some of the more noteworthy incidents observed by us in this department of surgery.
I. Dilatation of the first part of the duodenum caused by constricting adhesions ; as the result, perhaps, of tlie dilatation, an ulcer (" distention ulcer" — Kocher) on the confines of the pylorus ; the ulcer gave rise to a dissecting submucous abscess (chronic), rich in organisms because not reached by the most painstaking sterilization of the stomach. This abscess was punctured during the operation and a fatal peritonitis resulted (terminal infection), although, literally, only a drop or two escaped, and these were carefully wiped away.
II. Primary carcinoma of the duodenal papilla and diverticulum Vateri.
First operation. — Excision of portions of the duodenum (nearly its entire circumference), pancreas, common bile-duct and pancreatic duct in order to give the little growth, no larger than a pea, a wide berth ; circular suture of the duodenum and
transplantation of the stumps of the common duct and the pancreatic duct (Wirsung's) into the line of this suture.
Second operation. — Cholecystcysticoenterostomy by the writer's method* for intestinal lateral anastomosis.
III. Dynamic dilatation of the first portion of the duodenum and of the pyloric portion of the stomach, corresponding accurately to the limits of a sharply-circumscribed peritonitis; gall-stones in the gall-bladder; hydrops vesicas. Case full of interest for diagnostician. Beautiful instance of circumscribed dynamic dilatation caused by local inflammation ; no adhesions.
IV. Conditions suggesting hepaticocholecystostenterostomy (hepaticocholecystostcholecystenterostomy) as a possible operation ; common and cystic ducts reduced to fibrous cords ; dilated hepatic duct and gall-bladder. Remarkable toxic (?) renal colic resembling closely intestinal colic, associated with anuria ; colic and anuria entirely relieved by salt infusion.
V. Choledochotomy performed twice. The gall-bladder, which was shriveled at the first operation when two stones were probably in the common duct, was large and distended at the second operation when only one stone occupied the common duct (the ampulla). Hematemesis after the second operation.
VI. The densest adhesions that I have ever encountered in these operations, and probably the most difficult of my operations upon the bile passages. A small abscess in the midst of the adhesions; muscular coat of the duodenum converted into fibrous tissue; the exposed submucosa resembled gall-bladder so closely that the duodenum was aspirated and opened.
VII. Case illustrating the rapidity with which adhesions after perforation and extrusion of stone can be absorbed. Renal pains resembling intestinal colic (third observation of the kind within eighteen months). Tachycardia, believed to be due to toxemia of some kind (possibly benign embolism), suddenly disappeared during counting of pulse and while preparations were being made for subcutaneous infusion.
VIII. Discharge of pus and blood by mouth and rectum during severe gall-stone attack. Two years later, adhesions so extensive and so dense that the common duct was reached by a retroperitoneal route, over the right kidney. A stone in the ampulla had just ulcerated through the wall of the common duct and through its duodenal coverings.
Case I. — Duodenal stenosis from gall-stones ; dilatation of the stomach and of the pyloric end of the duodenum ; duodenal ulcer giving rise to a dissecting abscess. — J. S., age thirty-six, admitted February 5, 1899. Never had typhoid fever. Had malarial fever ten years ago with shaking chills. Never suffered from stomach trouble until present illness. Ever since he was eight years old has had sick headaches, lasting three to four hours, once a month ; these would be relieved by emptying his stomach. Has never been jaundiced nor had clay-colored stools. Present illness began very gradually. Three years ago, he noticed that his stomach would swell after eating and hardly regain its normal size before the next meal. Had more or less pain in the epigastrium, which was most marked about one hour after eating. No nausea or vomiting at first ; bowels regular. About the first of last October the pain became worse, and his sick headaches were more numerous and more severe. His vomiting now began. The vomiting was accompanied by colic, so severe as to double him up. Patient was obliged to stop
"Bulletin of the Johns Hopkins Hospital, No. 10, 1891.
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
work for two weeks. He then resumed work until Christmas, since which time he has been unable to work. Patient now vomits much more frequently. The vomiting is preceded by heartburn for about three hours and much pain in the epigastrium. Patient feels greatly relieved after the vomiting. For two weeks after Christmas he had eructations of gas ; none since then. Bowels usually constipated ; sometimes did not move for three weeks. He still suffers much from headache. His appetite is good, but he is afraid to eat. In October, 189S, patient weighed one hundred and forty-five pounds ; he now weighs one hundred and twentythree pounds, and is very weak. Neither stools nor vomitus have ever been blood-stained. Urine normal. Stools clay-colored. Patient not jaundiced.
On palpation of the abdomen no distinct tumor can be felt, but one detects an increased resistance just to the right of the umbilicus. The stomach's longest diameter is 31 cm.; its shortest diameter, 21 cm. The lowest limit of the stomach (tympanitic) is 3^ cm. below the umbilicus. Spleen not palpable. Heart and lungs normal. Glands nowhere enlarged. Pulse slow, feeble, 60 beats to the minute.
January 24th. Test breakfast (Ewald). Two hundred and sixty cc. removed one hour later ; green color ; acid. Total acidity, 5.9 cc. ; 0.1 normal NaOH. Free hydrochloric acid ; no lactic acid. No sarcinse nor Opper-Boas bacilli.
February 4th. Test breakfast. Sixty cc. removed. Total acidity, 20. No hydrochloric acid ; no lactic acid. A few Opper-Boas bacilli (?).
February 5th. Stomach tympanitic. Clapatage readily obtained. Stomach peristalsis quite marked at times. Gurgling felt over small intestines. Stomach washing with sterile salt solution, as preparation for operation, begun. Stomach holds about two liters. Cover-slip preparations show streptococci and staphylococci and numerous bacilli.
February 7th. Stomach washing continued. Cultures taken from the residual material. Cover-slips show only a few streptococci in short chains ; number much decreased since February 5th.
February 8th. Only a trace of free hydrochloric acid ; no lactic acid. Total acidity, 6.2 cc, 0.1 NaOH solution. Stomach peristalsis readily seen at times. Patient has been kept on sterile diet ever since his transfer to the surgical side. Has carbolic-acid gargle three times daily. Teeth cleansed three times daily with listerine and brush. Ingesta are boiled water, boiled milk, softboiled eggs, albumin. Micro-organisms seem to have entirely disappeared from the stomach, for the Petri plates are now sterile. Patient has shown great irregularity in amount of hydrochloric acid — at one time five per cent., at another zero.
February 9th. Operation.— Vertical incision through left rectus. This incision was made with the expectation of a possible gastroenterostomy. Stomach much dilated. In the region of the gallbladder is a mass of tissue tangled by dense adhesions. In this mass are gall-bladder and pylorus. The mass feels not unlike a new growth. Search for metastases negative, but a small, hard, dark tumor, the size of a pea, is discovered in the right lobe of the liver, near its edge, evidently an angiosarcoma. Pylorus separated from gall-bladder with the greatest difficulty. The separation had to be effected with the knife. It was impossible at first to determine accurately the relations of the gall-bladder, pylorus and duodenum to each other. In the course of the dissection a pinhole opening was made in what proved to be the duodenum. The surrounding parts had been well protected against such an accident. A drop of fluid escaped, and from these cultures were taken. The little hole was immediately sutured. The gall-bladder was next opened, and not until then could it be determined positively that the pinhole opening was not in the gall-bladder, the contents of duodenum and gall-bladder so closely resembled each other ; it was a thick, ropy, mucoid, colorless material. The gall-bladder was finally completely isolated. It was small and misshapen and
contained two or three hard mulberry-like gall-stones. The cystic duct contained no stones ami seemed to be very short and very fine. It was surrounded by numerous small vessels, two of which were tied. There was no bile in the freely opened gall-bladder, which was drained in the usual way with a rubber tube, a catgut purse-string suture sealing the bladder hermetically about the tube. Bismuth gauze was packed about the outside of the gallbladder. The peritoneum was closed with silk ; the muscles, fascia and skin with silver. Patient bore the operation very well. At G p. m , temperature 101°; respirations quiet and regular. Some distention of upper abdomen.
February 10th. Patient has been vomiting. Complains of pains in stomach and tightness across abdomen. Pulse 108 and feeble ; respirations 24 ; temperature 101°. Leucocytes at 12.30 p. m., 26,800 ; at 1.30 p. m., 34,000 ; 5.30 p. it., 36,000 ; 7 p. m., 37,800. At 6 p. m. patient drowsy, quiet ; respirations, 34 ; hands cold ; pulse barely perceptible. Cover-slips show no micro-organisms in the blood. Five hundred cc. salt solution infused under each breast. At 10 p. m. 1000 cc. salt solution infused under breasts. Pulse improved, 140 to minute ; low tension but regular rhythm. Respirations 36 ; expirations accompanied by short groans. Occasional hiccough ; no vomiting; no nausea ; no pain.
February 11th, 2.15 a. m. Patient died quietly.
Autopsy. — General peritonitis. Organisms, streptococcus pure. In the walls of the first portion of the duodenum, very near the pylorus, was an accumulation of thin mucopurulent fluid. This was held in bounds by a soft wall of granulations ; it was evidently an old abscess between mucosa and submucosa, which communicated with the lumen of the duodenum by a fine opening. A minute ulcer had perhaps been the starting point.
The first portion of the duodenum was distended, and the stomach was dilated ; the distention was due to the constriction produced by the adhesions, for which the gall-stones were responsible ; as a consequence, perhaps, of the distention and the resulting venous stasis, a minute duodenal ulcer ; and from the ulcer, the abscess, which was probably responsible for the fatal streptococcus peritonitis.
Of special interest in this case is: (1) the fact that carcinoma had been suspected — the duodenal stenosis, the dilatation of the stomach, the presence of Opper-Boas bacilli (?) justified the suspicion ; (2) the success which attended Dr. Cushing's efforts to sterilize the stomach ; the micro-organisms had apparently entirely disappeared from the stomach on the day preceding the operation, for the Petri plates, which from day to day showed fewer colonies, for that day were sterile; (3) the dissecting intramural abscess, starting probably from an ulcer which may have been due to thrombosis of a small artery, or to distention of the first part of the duodenum, or to vascular disturbances of some kind, infectious or mechanical. Although thrombosis of a small intestinal artery does not lead to infarction it may cause hemorrhages into the lumen of the intestine and slight intramural extravasations.*
Kocherf has demonstrated that in consequence of distention of the gut by retention of its contents and the resulting venous stasis, very considerable changes take place in the wall of the intestine. He writes as follows: "Arnd has proved that in strangulated hernias, when the circulation is greatly interfered with, micro-organisms make their way into the mucous mem
- Archiv fur pathol. Anat. u. Physiol., 1875.
t Kocher : Mittheilungen aus den Grenzgebieten der Medizin und Chirurgie, Bd. iv, Heft 2, 1898.
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 106.
brane and can pass through the intestinal wall (diapedesis of the micro-organisms). On the other hand, Cassin* and Charrin f have shown how very important the normal epithelium of the intestine is as a protection to the intestinal wall against micro-organisms as well as ferments. The absence of this protection against ferments and bacteria leads to intoxication and infection. Finally, Beichel J has demonstrated that the considerable accumulation of fluid above the site of the obstruction is due in part to a hypersecretion of the mucous glands. Under the influence of the intestinal contents which, increased in amount and stagnating, are the more rapidly decomposing (the ofttimes considerable phenoluria and indicanuria is proof of the increased decomposition), the epithelium in the first place becomes destroyed because its nutrition is interfered with under the influence of the venous stasis. There result circumscribed necroses and hence ulcerations of mucous membrane, particularly in places where the venous stasis led to ecchymosis, and, finally, perforation of the serosa and peritonitis may occur. For the origin of these ulcers which, many times observed, have not been properly estimated in their relations to ileus, various explanations have been given. The most substantial explanation is the one which attributes them to the pressure of hard scybala, and it is not to be doubted that hardened fecal matter, just as foreign bodies — gall-stones, for example — can have pressure ulcers as a consequence. But the ulcers which we have pictured are certainly not dependent upon hard intestinal contents and the decubitus which they may mechanically bring about. They occur in jejunum and ileum as well as in colon by the filling up of these intestines with fluid or gas. The only factor which constantly accompanies these ulcers is overdistention of the intestine. Inasmuch as one can experimentally bring about a significant impairment of the circulation of the intestinal wall and its consequences, by overstretching of the gut, we hold to the proposition that the ulcers are best called distention-ulcers (Dehnungageschwure). Long ago I called attention to the fact that ulcers of just this kind could also in cases of strangulated hernia lead to a fatal peritonitis after constriction had been relieved, or a gangrenous loop of intestine had been resected and an entirely trustworthy suture had been made."
Case II. — Primary carcinoma of the duodenal papilla and diverticulum of the Vater, successfully removed by operation ; cyslico-enterostomy three months after the first operation. — Mrs. M. L., age sixty. Until August, 1897, patient was well. Her first symptom was itching of the skin, which came on suddenly and soon became severe. Patient says jaundice did not appear for nearly a month after the onset of the itching. Before the appearance of jaundice diarrhea set in, and there were six or seven stools a day which were watery and clay-colored. Patient has had no chills, no fever and no sweating. With the onset of the jaundice she noticed shortness of breath and an occasional swelling of the feet and legs. About the firstof January, 1898, she had persistent bleeding of the gums for three days, following the extraction of a tooth. At times the hemorrhage was profuse.
- Mittheilungen aus Kliniken der Schweiz, Basel, 1898.
fFonctions protectrices de la muquese intestinale, Soc. de biologie, December, 1895. }Zur Pathologie der Ileus, Deutsche Zeitschrift fur Chirurgie.
Two months ago a tumor was noticed in the region of the gallbladder. This tumor does not seem to the patient to have increased in size and has never been tender. In March, 1897, she had several attacks of severe pain in the epigastrium. These attacks were not accompanied by vomiting or fever or sweating. A few weeks later she had a second but milder attack. The stools were light in color for two or three days at the beginning of these attacks, but patient recalls no change in the color of the urine or the skin at that time. The daughter of the patient states that these attacks of pain were very severe, and that her mother seemed very ill.
Examination February 14, 1898. — Patient somewhat emaciated, but fairly well-nourished. Mucous membranes pale. Heart and lungs normal. There is a distinct prominence on the right side, the highest point of which is midway between the umbilicus and anterior superior spine. The prominence descends markedly with inspiration. On palpation the prominent area proves to be pearshaped and distinctly fluctuating. The border of the liver, which reaches almost to the crest of the ileum, can be distinctly felt.
February 14, 1898. Operation. — Vertical incision through rectus muscle. A greatly dilated but not especially dense gall-bladder presented no adhesions. Liver projects five cm. below costal margin. Four silk sutures* placed in fundus of gall-bladder with French needles. Small aspirator introduced in center, between sutures; syringeful of clear fluid withdrawn. Gall-bladder opened ; contents evacuated. In the latter part of the fluid were many fine, sand-like, hard, greenish, round particles, suggesting miniature gall-stones. Common and cystic ducts were dilated to the size of one's thumb. A longitudinal opening two cm. long was made in the common duct. The same colorless fluid escaped from this incision. Duct explored with probe and finger. What seems to be a small, very hard stone is felt at site of ampulla. To determine the nature of this body, an incision was made through the wall of the duodenum. Noglandular metastases discoverable. Thestonelike body proved to be, as was feared, a carcinoma of the papilla.
Excision of the cancerous growth. — To give the growth a wide margin, a large piece of duodenum was excised, a wedge-shaped piece with the apex at the mesenteric border of the intestine. About three-quarters of an inch of the common duct and a shorter piece of the pancreatic duct were excised. The wound in the duodenum was closed in the usual way with mattress sutures. This was practically an end-to-end anastomosis of the duodenum. The common duct and pancreatic duct were transplanted into the duodenum along the line of suture. A linear incision into the common duet, which had been made for diagnostic purposes, was closed over a hammer. The gall-bladder was sutured to the peritoneum.
Abdominal wound closed in the usual way ; the peritoneum with a running silk suture, the muscles and fascia with buried silver sutures, and the skin with a continuous subcuticular silver suture. Bismuth gauze inserted to protect the suture of the intestine and common duct. Drainage tube surrounded by bismuth gauze, and gutta-percha tissue inserted into gall-bladder and held in place by a purse-string suture of catgut. Wound dressed with silver foil. Gutta-percha tissue placed between the raw edges of the skin and the gauze packing. Operation lasted three hours and ten minutes. Patient experienced apparently no shock from the operation.
February 16, 1898, first dressing. Profuse discharge of bile in dressing. Icterus less intense. Considerable abdominal distention, but no signs of peritonitis.
- We find this a very useful procedure. The gall-bladder is manipulated by
these sutures and handling is thus avoided. These sutures are of additional service when it seems advisable to distend, subsequently, the gall-bladder with (iuid, and when it is desirable to close it temporarily during the operation.
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
February IS, 1898. Distention has almost completely disappeared. Tongue clean. Patient comfortable.
February 22nd. Discharge of bile into dressings still profuse. Stools becoming distinctly bile-stained. Icterus rapidly disappearing. Urine dark and gives bile reaction. Patient hungry.
February 27th. Skin sutures, tube from gall-bladder and the last of the bismuth gauze removed. Evacuations not bile-stained.
March 4th. Discharge of bile diminishing. Opening in gallbladder has been plugged for several days with bismuth gauze in order to determine, if possible, whether or not the transplanted common duct is patulous. Yesterday patient vomited 125 cc. of brownish fluid.
March 5th. Patient has had a large stool, quite dark in color. There is very little leakage from the opening into the gall-bladder, which is almost closed.
March 13th. Icterus continues undiminished. Stools are still slightly bile-stained. Abdomen somewhat distended. Active peristalsis is occasionally visible through the abdominal walls. Liver still readily palpable, the right lobe extending almost to the iliac crest. Appetite good ; tongue clean ; no indigestion.
March 27th. Attempts to plug the opening of the gall-bladder, with the hope of forcing bile into the intestine, not satisfactory, although there is some bile in the stools. Patient's general health good. Icterus has disappeared. Patient able to walk about, and is gaining strength rapidly.
April 5th. The conjunctivae are clear, but there remains still some evidence of bile pigment in the skin. No bile whatever in the stools, although the opening into the gall-bladder is almost closed ; it is barely large enough to admit a probe. Patient is beginning to have indigestion. The appetite as a rule, however, is good. The liver is diminished in size.
April 8th. Patient complains of colic and abdominal pain. Considerable abdominal distention. Dressings bile-stained. No nausea ; tongue is clear.
April 12th. Some nausea and vomiting. No distention of abdomen. Dressings very slightly bile-stained.
April loth. Abdomen soft and relaxed, but borborygmi heard by attendant and appreciated by patient. Little or no bile in dressings.
May 5th. Second operation: cholycyslduodenostomy, or eysticoduodenostomy. — Snture of fundus of gall-bladder. Complete closure of abdominal wound except for drainage. Incision alongside of old cicatrix, circumscribing fistula. Gall-bladder quite small, no larger than one's thumb. Liver about normal in size. Many fine adhesions about gall-bladder, which were easily separated. Gallbladder and ducts thoroughly exposed. The line of suture of common duct at previous operation was readily distinguishable by black-silk stitches, but it was almost impossible to find any trace of the duodenal suture. Common duct incised at site of old suture. Probe cannot be passed into the duodenum, but there is no positive evidence of the recurrence of the cancer. Unsuccessful attempts had been made before the operation to pass a probe from the gall-bladder through the common duct into the duodenum. Opening into the common duct closed in the usual way with mattress sutures over hammer. An anastomosis between duodenum and the gall-bladder or cystic duct was effected without much difficulty, although the parts to be sutured were very deeply situated and inaccessible. The duodenum was probably a little less freely movable than at the previous operation, and the gallbladder was so much reduced in size that we were compelled to pass some of the stitches into what seemed to be the cystic duct; in any event, the neck of the gall-bladder had to be used for the anastomosis. A bougie a boule, passed into the gall-bladder, was used as a darning ball to assist in the placing of the sutures. All the sutures were passed (none of them tied) before the openings into the neck of the gall-bladder and duodenum were made, the method employed being that which I described many years
ago for intestinal anastomosis. The opening in the fundus of the gall-bladder was closed with mattress sutures which inverted the wall. The abdominal wound was completely closed except for protective wicks which were passed through this line of suture into the gall-bladder. What seemed to be an enlarged gland was palpated during the operation but not removed ; it was forgotten. Patient suffered little or no shock from the operation.
May 6th, 4.30 p. m. Patient very restless, tossing about and occasionally vomiting. Ten p. m., has had occasional quiet naps and is more comfortable.
May 7th. Complains of pain in back and abdomen.
May 8th. Is very comfortable. Yellow stool, containing small particles of brown fecal matter.
May 9th. Large greenish-yellow stool.
May 11th. Patient has had daily, since last note, one or two greenish-yellow soft stools. She still complains of slight pain in abdomen.
May 12th. A large, quite well-formed greenish-brown stool. Considerable flatus expelled ; complains of gas in stomach. Slight nausea. Four p. it., vomited thick, mucus-like, chocolate-colored fluid containing milky curd.
May 29th. Patient complains of itching in the hands where the pruritus has always been the greatest when icterus was pronounced. No jaundice, however, is apparent.
June 8th. Slight chill, followed by rise of temperature to 39°. Trace of bile in the urine. Nausea, but no vomiting. No pain and scarcely any tenderness of the abdomen. Wound almost completely closed.
June 9th. Temperature normal ; patient feels well.
In the early autumn of 1898 this patient returned to the hospital too ill for operative interference, and in a few weeks died. During the summer I had corresponded with her, urging her to return to the hospital, for it was clear from her letters that the fistulous communication between the gall-bladder and the duodenum was not working well. At the autopsy it was found that the carcinoma had recurred in the head of the pancreas and duodenum closing the common duct and interfering with the perfect action of the cholecystenterostomy, or cystico-enterostomy. The anastomosis, as we had supposed, had been made between the dilated cystic duct and the duodenum ; the fistula was still perfectly pervious and should have acted nicely except for the interference, a little twisting or bending, created by the new growth.
The result in this case is not encouraging, for it was my opinion at the time of the operation that the case could not have been more favorable. But I did in this case what I never do if it can be avoided, namely, cut well down to or perhaps a little way into the new growth for the sake of diagnosis. It is furthermore a rule in myelinic that pieces shall not be excised from new growths in vivo for diagnostic purposes ; we must learn to make the diagnosis in other ways. In the case of a very small breast tumor it is occasionally impossible to make the diagnosis before operation. I have sometimes approached the tumor with the knife very cautiously, and could tell before I reached the growth, from the findings in the outlying tissues, whether we had a malignant tumor to deal with or not. I shall have more to say about this at another time, but I feel that one cannot condemn too strongly the universal practice of exploring tumors with the knife or with the harpoon or even with the needle. After investigating the subject superficially, I have the impression that amputations for the truly malignant
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[No. 106.
sarcomata have comparatively seldom been successful when preliminary exploration has been done. If I find it necessary to make an incision into a sarcoma of an extremity, I first apply an Esmarch bandage, and if the tumor is a malignant growth, the bandage is not removed until the growth has been removed. So, too, in cysts of the breast; we should not aspirate them, because (1) they may be malignant and the aspiration harmful, and (2) if maliguant, the aspiration does not tell us so. This is the first and I believe the only instance in which an operation for primary carcinoma of the duodenal papilla has been done ; moreover, I know of no other case of excision of a portion of the common duct. Heidenhain* (Worms) demonstrated last year at the twenty-seventh Congress of German Surgeons, a shriveled gall-bladder which he had removed for a small cancer of its wall ; after extracting six calculi from the bladder, a little button-like prominence on its wall caught his eye. The microscopical examination showed little or no thickening of the mucous membrane, but unmistakable alveoli in the muscular wall of the gall-bladder; furthermore, some of the lymph-vessels were plugged with cancer cells. In three months the patient succumbed to livercancer which had attained great dimensions, although at the time of the operation the liver was apparently perfectly normal. At the same session Hollander! (Berlin) reported an extirpation of the gall-bladder and cystic duct and resection of a portion of the liver for cancer, which per continuitatem involved the liver. The result he could not give, for he had performed the operation only three weeks before. There can be little doubt as to the ultimate result of Hollander's operation, although, having operated only three weeks previous to his report, he could not give it.
Case III. — Dynamic or paralytic dilatation of first portion of duodenum and of the pyloric end of the stomach correspondiyig accurately to the limits of a sharply circumscribed peritonitis. Oall-stones in gallbladder and cystic duct. Obstruction of cystic duct and hydrops vesical. — Mrs. S. G. M., age forty six. Admitted January 31, 1899. Never had typhoid fever. Headaches at intervals all her life, sometimes very severe and lasting several days; especially severe during menstruation. Digestion has been bad for sixteen years. After meals a heavy feeling in epigastrium followed by fullness and a feeling of suffocation. Belching of gas common; occasionally would regurgitate a mouthful or two of food. Rarely vomited ; never any blood in vomitus. Bowels generally constipated. Micturition frequent, occasionally twenty times a day ; generally several times at night. Menses regular. Average weight, one hundred and fifteen pounds. Has lost in weight of late. Present illness, patient states, began December 31, 1898, although she was much run down before that time. This attack came on gradually. Some distention of stomach, and in the afternoon some pain which became severe at night. The pain was in the epigastrium — a colicky pain — which, as she expressed it "went through the abdomen." Morphia exhibited. Next morning patient felt easier. Morphia continued for next two days. Pain relieved but not entirely subdued. Stools after this were very black, like tar. Physician found something in the stools which he thought might possibly be a gall-stone. Since this attack patient has never been well ; constantly in bed. Great deal of soreness through abdomen, and at times attacks of colic. These
- Heidenhain : Verhandl. d. deutsch. Ges. f.Chirurgie, 1898, p. 126.
t Hollander, I. c. p. 131.
attacks usually came on in the evening without known cause. Much belching of gas. Bowels regular. Stools not clay-colored. No jaundice. Patient's daughter states that for many years her mother has had attacks of abdominal pain, for which the doctor gave morphia hypodermically. There were intervals of several months between the attacks.
Examination. — On palpation no tenderness except beneath the right costal margin. Here there is to be felt a rounded mass resembling a distended gall-bladder. Right rectus muscle very hard. The mass which is to be felt at the outer edge of this muscle seems lobulated.
January 29th. Attack of what patient calls "colic." She ia nervous and distressed, and complains of abdominal pain. Swallows air and belches it up again.
January 31st. Transferred to surgical side. On inspection a distended piece of gut between umbilicus and tumor, extending obliquely from the left and above to the right and below, probably six or eight inches in length. Peristalsis is to be observed at intervals ; it is not very active, but at times is quite constant. A tumor suggesting gall-bladder projects from the lower border of the liver. It seems to be nodular, or rather has a nodule on it at its upper part. This tumor descends with respiration, and is somewhat tender. The edge of the liver can be felt on each side of the tumor.
February 3d. Operation. — Vertical incision through right rectus muscle. No fluid in abdomen. Gall-bladder distended to size shown in diagram on blackboard. Its walls were thickened and white. The first portion of the duodenum and the pyloric end of the stomach were distinctly distended. Corresponding accurately to the distended portion of the bowel was a slight peritonitis, scarcely more than an injection of the serosa, and an exudate, only enough to cause very fresh adhesions between the duodenum and the gall-bladder. We should hardly call them adhesions ; the duodenum seemed rather to be lightly glued to the gall-bladder just as it might be an hour or two after an operation.
I was extremely interested to find that the vascular injection seemed to correspond accurately to the limits of the dilatation (almost ileus at times). The adhesions, if we choose to call them such, were so fresh that they were separated by very slight pressure of the finger. The general abdomen being walled off by gauze packing, the gall-bladder was opened. Its contents were colorless and in consistency like the white of an egg. Cover-slips were negative. First, one large gall-stone was found with a facet at each end. Then a second stone was detected with a probe in the cystic duct, but it could not be dislodged. Cysticotomy was performed and the stone removed in fragments. The previous attempts to dislodge it had evidently broken up the stone. Incision in cystic duct closed by mattress sutures. Gall-bladder treated in the usual way, namely, hermetically sealed about a rubber tube and protected by bismuth gauze, from the general peritoneal cavity. Abdominal wound closed in the usual way.
At first no bile escaped by the tube, but on the 10th of February, bile was abundant in the dressings.
March 2d. Wound has completely healed. Patient discharged eured.
Various diagnoses had been made in this case : (a) distended gall-bladder with adhesions ; (b) cancer of bile-ducts and liver, involving secondarily the colon; (c) carcinoma of the colon, involving secondarily the gall-bladder and gall-ducts. The distended intestine I watched with much interest several times. It seemed to me too small for colon : and no mass could be felt in the distal side of the distended gut to explain the distention. Peritonitis is undoubtedly the most common cause of paralytic ileus, and I have repeatedly observed in appendicitis that dilatation of the cecum and of the ileum may
Jaxuart, 1900.]
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be caused by a very slight, perhaps merely a toxic peritonitis, but I have never before noticed such a sharp line of demarcation between the inflamed and noninflamed portion of the intestine. The dilatation corresponded accurately to the vascular injection. This was the more striking because two portions of intestine so very different were involved. That the comparatively thin wall of the duodenum should be more or less affected by inflammation of its serosa is to be expected, but that such a thick-walled gut as the pylorus and the pyloric end of the stomach should be paralyzed by such a very slight inflammation of the serosa was surprising.
Case IV. — Conditions suggesting hepaticocholecystostcholecysienterostomy as a possible operation. Common and cystic ducts reduced to fibrous cords, dilated hepatic duct and gall-bladder. Renal colic
stimulating intestinal colic; relieved by salt infusion. — Mr. ,
age sixty, had been suffering from gall-stones for several years, but not until be became persistently icteric and very ill was the first operation performed. The operator, a distinguished surgeon, found most difficult conditions confronting him. The entire common duct was impervious and reduced to a librous cord ; the cystic duct, greatly narrowed, was probably impervious ; the gall-bladder and hepatic ducts were dilated. The surgeon, very skillfully, I am told, attempted to construct a new common duct over a tube or catheter from the tissue which he had at his disposal. Just what these available tissues were I do not quite understand. For about five weeks, and until this tube was removed and the surgeon went away on his vacation, the patient was fairly comfortable and seemed to be gaining a little. Then he developed high daily fever and occasional chills, and became jaundiced again. I saw the patient in consultation with Dr. Gardner, of Providence, about one week, I believe, after the fever and the symptoms of obstruction had manifested themselves. The gall-bladder could not be felt. There was perhaps a little more muscle resistance on the right side over the region of the bile-ducts than on the left side, also perhaps the suggestion, rather indefinite, of a little induration such as might be caused by fresh adhesions. It occurred to me that in case the gall-bladder and hepatic ducts were still both dilated one might establish a fistulous communication between them, making an hepaticocholecystostomy and then, immediately, a cholecystenterostomy ; in all an hepaticocholecystostenterostomy. In any event, we thought that an operation for the relief of the symptoms was imperative. Accordingly a vertical incision through the inner margin of the right rectus muscle was made, avoiding the fistulous tract which remained after the withdrawal of the tube over which the new common duct had been constructed. I worked for two hours trying to identify and to separate the parts concerned in this operation. The gall-bladder, the ducts and the duodenum were glued tightly together and to the under surface of the liver. The gall-bladder which was finally extricated from the tangle was very small, contracted and empty ; the cystic duct was a fibrous cord. When bile was at last reached the patient was in such bad condition that the operation had to be discontinued. The parts in the neighborhood of the common and hepatic ducts were so firmly matted together that neither the latter nor the remains of the former had been demonstrated when it was necessary to bring the operation to a flose.
The patient rallied satisfactorily from the immediate effects of the operation ; but twelve or fourteen hours thereafter complained of very severe abdominal pain, which, as he indicated the location of it, ?eemed to be in the region of the colon and passing from right to left. The pain, though perhaps constant, became excessive during the paroxysms. It was never referred by the patient to his back or sides, nor did it radiate to the testicles or groin or crest or ilium. The abdomen was perfectly flat, and peristalsis could
not be observed. Nevertheless, large high enemata of hot water were given, but without appreciable relief- The urine was scanty and very dark and contained albumin and casts and a few bloodcells. Dr. Gardner promptly attributed the pains to the kidney, and related a somewhat similar case. Believing his interpretation of the pains to be correct and recognizing the fact that something must be done quickly for the relief of the kidneys, I transfused about 750 cc. under the breasts. The pulse, which was alarmingly rapid before the transfusion, dropped 40 beats within thirty minutes, and 20 beats within five minutes, and the colicky abdominal pains disappeared. Within twenty-four hours the infusion was repeated with similar results. The kidneys responded promptly to both infusions.
I report this case because (1) it suggested a new operation, hepaticocholecystostcholecystenterostomy, or hepaticocholecystosteuterostomy ; (2) it was the first of three cases of colic which I have seen associated with scanty high-colored urine ; and (3) it was, so far as I know, the first instance of subcutaneous infusion of salt solution for the relief of toxic renal colic. Soon after this Dr. Young, by salt infusions, undoubtedly saved the life of one of my patients whom I had operated upon for appendicitis, and who was suffering from perhaps the most furiously rapid toxemia that I have ever known of. This case has been reported by Dr. Young in the Maryland Medical Journal. The resemblance to intestinal colic is so great that it would undoubtedly be mistaken for it even by experienced practitioners of medicine. This was a valuable lesson for me, for since then I have twice recognized as renal colic this pain, which had been regarded as intestinal colic and treated with high injections. Our list of desperate cases of toxemia treated advantageously with infusions of salt solution is assuming large proportions.
Case V .—Choledochotomy performed twice within four and onehalf months. The gall-bladder, small and contracted at the first operation, when two stones were in the common duct, was large and distended when only one stone occupied the common duct (the ampulla). — Mrs. M. P. E., age fifty-eight, admitted May 3, 1897. October, 1892, patient began to have moderately severe attacks of pain in the region of the gall-bladder. The attacks would come ou suddenly and last several hours unless relieved by anodynes. The pain, milder at first, would gradually increase until it became very severe ; it commenced in the epigastrium and extended into the right hypochrondrium. During the winter of 1892-1893 the attacks occurred every two or three days. Occasionally there would be an interval of two or three weeks. During the remainder of 1893 and all of 1894, the attacks persisted at longer or shorter intervals, the pain always beginning in the epigastrium and radiating to the back. Sometimes during a severe attack there would be slight vomiting. Morphia generally gave relief. Patient says that the attacks were not accompanied by tenderness nor tumefaction. In the attacks observed by me there was always tenderness and, after the first operation, distention of the gall-bladder. In the spring of 1895, she went to Hot Springs, Va., where she remained several months. After this she had no pain for fifteen months, but did not seem to gain or improve in health. In September, 1896, in Italy, the pain returned. The attacks recurred with great regularity for seven or eight weeks. Most of them were attended by nausea and some by vomiting. She became jaundiced for the first time in December, 1896, and has remained more or less icteric until admission. Just after the paroxysms the icteric is deeper. For the past five months she had remained in bed most of the time. She vomits frequently, is seldom free from nausea. The bowels
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have not been markedly constipated ; appetite is poor ; headaches occasional but not severe. Prior to this illness, however, she suffered very much from headaches. At no time has she had chills or sweating.
Examination. — Patient is quite deeply jaundiced ; her color is a dark slate-yellow ; tongue heavily coated ; body much emaciated ; expression rather dull, eyes lusterless. Heart not enlarged ; no adventitious sounds. Lungs negative. Urine dark, almost coffeecolored, trace of albumin, much bile-stained sediment. A few bilestained casts and epithelial cells. Red blood-corpuscles, 4,220,000 ; white, 6,000.
May 4, 1897. First operation. — Longitudinal incision through right rectus muscle ; resection of cartilages of eighth, ninth and tenth ribs, because the common bile-duct was very inaccessible. Choledochotomy ; removal of one small mulberry calculus. Exploration of duct fails to detect a second stone. Suture of duct wound. Gall-bladder atrophied and not opened. Bismuth gauze packing to suture in duct. Peritoneum sutured with fine silk, muscles and fascia with silver wire, and skin with a buried suture of catgut. Little or no shock from the operation.
On opening the abdomen the tissues were bile-stained. There was no fluid in the peritoneal cavity. The outer surface of the contracted gall-bladder was covered with new connective tissue in which were little masses of fat. The omentum was loosely adherent to the gall-bladder. The cystic and common ducts were easily isolated after division of three of the costal cartilages. No stones could be felt in the bladder or cystic duct. The stone found in the common duct could be moved quite freely up and down in this duct, but could be forced into the cystic duct, the common duct, about 1J cm. in diameter, being uniformly dilated. Bile flowed from it when opened. It was carefully explored with the fingers but not with an instrument. The gall-bladder was not opened. Two mattress sutures closed the opening in the duct, one preliminary suture being taken before the duct was opened. The sutures were passed without difficulty, the wall of the duct being about 3 mm. in thickness. No leakage occurred after the stitches were tied. The calculus, without facets, was spherical, about 1.6 cm. in diameter, and had a granular surface like a mulberry calculus.
May loth. Patient has recovered uneventfully from the operation. She is easily nauseated, however, and has very little desire for food. The stools have about the color of dark coffee and the skin has become lightened perceptibly. She complains, however, of an aching pain in the back, not relieved by posture.
May 24th. Patient has no inclination to eat; takes almost nothing by mouth. Nutritive enemata, which have been administered uninterruptedly since the operation, are still well borne. About every two days there is quite a definite attack of pain in the umbilical region and back, ushered in by nausea. Vomiting usually follows in a few hours and the distress is relieved.
May 29th. Condition little changed. Patient is fairly comfortable except for the attacks. Takes a little more food. Stools semi-solid and still quite dark. Urine has trace of bile.
June 13th. No bile in urine. Vomitus contains considerable hydrochloric acid.
June 26th. Appetite and digestion have steadily improved. Nausea less constant, often absent. Patient constipated, requires enemata; stools normal as to color.
July 4th. Much more comfortable. Nausea has disappeared ; color greatly improved, but the attacks of pain continue, although they are less frequent.
July 13th. Slight chill at 5.30 p. m., accompanied by pain in the back and head. Temperature reached 103° at 7.30 p. m.; fell to 99.2° at 5 a. m. Examination of blood for malaria, negative.
July 25th. Patient has lost one and one-half pounds in weight in the past week. The right lobe of the liver is enlarging. The spleen is palpable. Patient is having short attacks of fever accompanied by slight chills ; headache and yawning usually associated
with them. The attacks of pain continue ; they are still controlled by very small doses of morphia, one-sixtieth to one-fortieth of a grain. She sits up out of bed most of the time.
July 27th. The pain in the back has of late been accompanied by a slight rise of temperature, 99.2° to 105.5°. The urine contains no bile. The stools consist of light and dark portions sharply separated. Patient is gaining quite rapidy in weight.
August 5tb. Stools clay-colored. Temperature reached 102° last night during an attack of pain. Skin is becoming icteric ; urine contains bile ; slight pruritus. Patient's weight has increased five pounds in ten days. From August 8th to 12th no bile in urine.
Sept. 12th. The attacks of pain and the pyrexia continue. Patient is decidedly icteric after some of the more severe attacks. What we have feared ever since the operation we are now quite certain of, namely, that there is still a stone in the common duct, probably in Vater's diverticulum. The liver is considerably enlarged, but the gall-bladder has not been definitely made out.
September 13th. Second Operation. — Vertical incision near linea alba. Adhesions from previous operation separated without much difficulty. Liver much enlarged ; gall-bladder and common duct distended with bile. The wall of the common duct was much thicker; the wall of the gall-bladder, on the other hand, was probably thinner than at the previous operation. A small stone was palpated deep down behind the duodenum, presumably in the ampulla. The line of the old suture in the ductus choledochus could not be very definitely made out, but a short yellowish-white streak, evidently cicatricial tissue, corresponded, I thought, to the site of the original slit in the duct. A fine suture was placed in the common duct to serve as a handle for the subsequent manipulations. The duct was opened, and about 60 cc. of clear greenish bile escaped. A gauze plug was inserted into the proximal end of the slit to prevent the stone from slipping into the hepatic duct. Interrupted sutures were taken over a hammer of the proper size. The dislodgment of the stone was somewhat difficult. It was a little smaller than the first stone, but otherwise repeated the original exactly. The gall-bladder was opened, sewed to the peritoneum, and drained in the usual way ; a rubber tube surrounded first by gauze and then by protective being held in place by a purse-string suture of catgut. Wicks of bismuth gauze protected the line of suture in the common duct. The operation was attended with very little shock and the patient reacted very well.
Sept. 20th. There has been more or less nausea ever since the operation. Patient objects decidedly to stomach washing. Bile is draining actively from the tube. There has been little or no nausea to-day, but patient is weak and much depressed. The removal of a piece of gauze from the gall-bladder gives patient the first sensation of "heartburn," which she has had since the operation ; it lasted several hours.
Sept. 22d. Patient is thin and emaciated and alarmingly weak ; speaking is a great exertion to her. Temperature subnormal. There are no wound complications, nor any signs of peritoneal irritation or obstruction. Alimentation is almost exclusively rectal ; 6 p. m. vomited 1000 cc of fluid thick with "coffee grounds." Patient very restless. Examination of vomitus: No bile; bloodcorpuscles abundant; altered blood pigment; free hydrochloric acid ; no lactic acid.
Sept. 23d. Patient has vomited several times during the day ; in all about 2000 cm. of the same dark coffee ground vomitus. The pulse is very feeble.
Sept. 24th, 8 a. if. Pulse barely susceptible early this morning ; rallied a little after exhibition of salt solution per rectum. Still vomiting large amounts of same fluid, though nothing is being administered by mouth. 12 m. Patient is very low but still conscious. Infusions of salt solution were given under breast and in buttocks. 5.15 p. m. One drachm of one per cent, solution cocaine given by mouth. 5.30 p. m. Patient vomited 360 cc. of same dark fluid. Cocaine given again. No vomiting since second dose.
January, 1900.]
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Sept. 25th, 1 a. m. Patient responds a little to the saline infusions. She is moaning and restless. Her nose and extremities are cold. She sleeps in short naps, with her eyes open and eyeballs rolled up. Complains greatly of thirst. Champagne and albumin retained and apparently relished.
Sept. 28th. Infusion again soon after midnight. Involuntary stools and small amount of dark vomitus. Is somewhat flighty at times. Pulse is thready, irregular, and cannot be accurately counted. She is sighing and seems almost moribund. Too weak to recognize surroundings or members of the family. About noon to-day I saw the patient for the first time since the third day after the operation, having returned to town as rapidly as possible in response to a telegram sent forty-eight hours ago. Dr. Cushing, house surgeon, who had attended her constantly, day and night, met me at the door of the hospital with the words, " no hope, she is dying. We went to her room ; she was cold and almost unconscious ; her eyes were open, the eyeballs rolled up ; the lower jaw had dopped. She had had more involuntary movements and could retain no nourishment. Her pulse was littre better than a flutter and could not be counted. In less than forty-five minutes I returned to the patient and found her pulse 120, and fairly regular in force and rhythm. I doubted my senses when I counted it. She was moreover not so cold, her eyes were not staring, and her lower jaw was raised. A miracle ! From that moment her convalescence was uninterrupted. She slept an hour, and on waking looked better than she had in two or three days. For twenty-four hours she was so weak that she could barely move her arms. She remembers nothing that transpired on the 23d, 24th and 25th of September.
In eight weeks, on November 22d, this patient left the hospital, not only able to walk but to take a long journey on the railroad. In one period of seven days she gained nine pounds. Her liver was rapidly diminishing in size.
In April, 1898, I had the pleasure of seeing this patient again. Her color was natural, her digestion excellent, her weight above normal and her strength steadily increasing. Her liver did not extend below the costal margin.
I have seen many cases regarded as hopeless recover, but never a being so near death as this have I known to escape it. I have speculated much as to the possible explanation of the very sudden change in her favor, but it would lead us beyond the limits of this paper to discuss the matter. In toxemias I have noted almost instantaneous drops in the pulse rate. Twice within a month I have observed a fall of 30 beats to the minute follow in less than thirty seconds the opening of an abscess. The abscesses were large and very acute ; one was a suppurating laparotomy wound and the other was a circumscribed abscess in the peritoneal cavity. The very instant that the abscesses were opened the change in the pulse was noted. A few months ago we were preparing to infuse with salt solution a patient upon whom I had operated for gall-stones and whose condition gave me not a little anxiety. His respirations were about 40 per minute and his pulse between 130 and 140. The physical signs indicated not very clearly some consolidation of the lower lobe of the right lung. While the instruments were being sterilized for the infusion, and while Dr. Cushing, the house surgeon, was counting the pulse, it fell to less than 100.
Was the hemorrhage from the stomach in the case of Mrs. R. (Case V) due simply to the prolonged vomiting; or to interference with the circulation of the portal vein (liver cirrhosis, pressure of packing) ; or to thrombosisof a small arterial branch:
or to a retrograde embolism (Recklinghausen,* von Eiselsbergt) or malposition of the pylorus or duodenum? It could hardly have been due to sepsis for there were no signs of infection. As long ago as 186?, Billroth J remarked that in septic cases we might have duodenal ulcers and fatal hemorrhages therefrom. He showed in his experiments upon animals that sepsis might cause intestinal hemorrhage, although, in his experience, it seldom did so in man; if, however, there existed an obstruction to the circulation, such as liver cirrhosis causes, little hemorrhages in the stomach plus the action of the gastric juices might lead to the formation of ulcers. The nausea began almost immediately after the operation. Whatever was the cause of this almost continuous nausea and frequent vomiting was also, probably, at least the remote cause of the hemorrhage. Von Eiselsberg has just reported seven cases of stomach and duodenal hemorrhage following operations upon the abdomen. Hematemesis occurred in six of his cases, and never later than the second, usually on the first day. The hemorrhages were demonstrated in three cases post mortem.
In my case the vomiting of" coffee grounds " was not observed until the tenth day. This patient was so carefully watched that I am quite sure that if hematemesis had occurred earlier it would not have been overlooked. In seeking for a common cause for the stomach and duodenal hemorrhages, Von Eiselsberg excludes vomiting because in two cases there was no vomiting, and in two, hematemesis occurred only a single time; he also excludes sepsis because in four of the cases there was no infection, and reaches the conclusion that " If the behavior of the wound is to be regarded as the cause of the hematemesis, then it must be assumed that in the cases which healed by first intention a retrograde embolism from a non-infected thrombus had taken place."
I wish that there was time to discuss this feature of the case more fully, but I must pass on to the consideration of another fact which this remarkable case developed. There were at the first operation almost certainly two stones in the common duct, one in the ampulla, the other more or less freely movable in the duct, although it fitted it quite snugly; but the gallbladder was small and contracted and not opened, and the liver was little if at all enlarged; the color of the skin was a light slate-yellow or ash-yellow — not the darker bronze-yellow of complete obstruction. At the second operation, however, when there was only one stone in the common duct, the gall-bladder was distended with bile and quite large, and the liver was greatly enlarged, its right lobe almost reaching the crest of the ilium. The patient's color and symptoms indicated that the stone in the ampulla did not at all times obstruct the duct completely. It sounds almost paradoxical to say that the removal of a stone should increase the obstruction, or that the one stone plugged the duct more completely than the two. I believe that a stone in the diverticulum, particularly a small
- Die Storungen des Blutkreislaufes.
t Die Verhandlungen der duutschen Gesellschaft fur Chirurgie, 1899.
t Ueber Duodenalgeschwurebei Septicaemia. Wiener med. Wochenschr., 1867.
10
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one, is more likely to block the duct effectually and to lead to distention of the gall-bladder than a stone, however large it may be, elsewhere in the common duct. A stone in the middle of the duct may at first occlude it completely, but the duct wall soon becomes infiltrated and thickened, it loses its elasticity, and, when distended with bile, stretches. The stone no longer plugs the duct tightly and bile trickles by into the intestine even when a second stone occupies the diverticulum, but when the proximal stone is removed, the bile instead of trickling up to the distal stone is probably jetted against it with sufficient force to hold it as a ball-valve. Furthermore, dilatation should not occur so readily in the portion of the common duct protected by the duodenal wall as in the free portion. In 1885 I operated upon a patient whose common duct contained a stone larger than the largest pecan-nut; at times one half of this stone projected into the duodenum, the other half occupied the duct; a flange had been cut on the calculus by the cicatricial ring, which engaged it and prevented it from slipping into the intestine; and yet this patient was so very slightly jaundiced that a stone in the common duct had not been suspected.
Cask VI. Miss M. H., age thirty. Transferred to surgical from medical side, January 27, 1896. Indigestion for eight years. For past four years the " gastric distress " has been very great. Patient describes a "gnawing sensation" in the epigastrium. Colicky pains radiated throughout thorax, but were at times very severe " in the back." Two years ago she had typhoid fever. For the past six months she has had frequent definite sharp gall-stone attacks with nausea, and four times with vomiting. Never blood in the vomitus. No chills, fever nor jaundice. Patient is a confirmed invalid. She suffers from headache and occasionally from vertigo.
Examination. — Abdomen flat. On deep inspiration spheroidal tumor is to be seen just below the costal margin on the right side. This tumor can also be felt. It moves with the enlarged liver, ascending and descending with the respirations. Last September patient first began to have attacks of pain in right hypogastrium, and accompanied by nausea and sometimes by vomiting. Spleen not palpable. The severe pain suffered by patient could be relieved by drawing up the knees. This pain radiated to the right shoulder-blade.
January 28, 1896. Operation. — Cholecystostomy. Vertical incision through the right rectus muscle. Elongated right lobe of liver. Very dense fibrous adhesions between the gall-bladder and duodenum. These adhesions were divided with great difficulty, and finally what appeared to be gall-bladder presented. It was aspirated, and a thick greenish fluid withdrawn. It was consequently opened with some confidence, but proved to be duodenum. It was sutured again at once, the suturing being very difficult because the muscular coat had been separated from the submucous coat during the dissection of the adhesions. The muscular coat, owing to the chronic inflammation which had existed for so many years, had become sufficiently fibrous to resemble cicatricial tissue, and consequently was unintentionally stripped from the submucosa. When the submucosa presented, it did so in the form of a little knob-like bladder, this coat resembling almost precisely the wall of the gall-bladder. The gall-bladder was finally found, deeply imbedded in adhesions, almost four cm. to the right of its usual position and far under the enlarged liver. It was opened, and one large oval stone, two cm. by one cm., removed. In the course of the operation a small abscess was discovered in the midst of the adhesions. Patient's recovery was considerably retarded by digestion disturbances, which finally disappeared completely
April, 1899. Patient says that she is in robust health and wishes
to become a masseuse.
Cask VII. The history of this case cannot be published at present.
Case VIII. Discharge of pus and blood by mouth and rectum during severe gall-stone attack. Tteo years later adhesions so extensive and so dense that the common duct was reached by a retroperitoneal route, over the right kidney. — Mrs. M., age thirty-five. Admitted March, 1895. No typhoid fever. First attack of gall-stones, six years ago, began with sharp attack of pain in the right side of the abdomen. Two years ago miscarriage at seventh month ; was ill in bed thereafter four months. While in bed patient had great pain in region of gall-bladder, with high fever, for ten weeks; was continually blistered over liver. Eight weeks after the abortion she felt suddenly something "give way" ; this giving way was followed by great relief, and by horribly offensive discharge of pus and blood from the rectum and mouth. These discharges were irritating, gave her a very sore throat and mouth. She spat blood and matter for two or three weeks, and the stools during this time were very offensive. She has had pain and tenderness constantly, with occasionally severe attacks since that time ; has been jaundiced more or less ever since, but more markedly so since last July. On admission, body jaundiced and greatly emaciated; tenderness over the entire abdomen, especially in the region of the gall-bladder. Liver, in deep inspirations, extends two fingers' breadth below costal margin, and has a fairly sharp edge. Spleen palpable; stools acholic.
March 19, 1895. — Operation. Liver small, barely reaches costal margin ; its high position complicated the operation. Colon adherent to liver by rather loose bands ; gall-bladder exposed when these were divided. It was high up under the liver and no larger than the tip of the little finger; it was not opened. Adhesions were so dense over the common duct that the peritoneum was opened over the right kidney, and the common duct approached from behind under the peritoneum. A stone being felt, the common duct was the more readily exposed ; the stone was extracted through a hole made by ulceration. This hole proved to be at the junction of the duct and the duodenum, and was shut off from the peritoneal cavity by very delicate adhesions. The intestinal part of the opening was closed completely, the duct part as well as possible. The sutures were passed with great difficulty. The opening in the duct could not be completely closed, the tissues being necrotic, and bile escaped through it even after the sutures were drawn tight. Probing of the duct was carefully done. No other stones were found.
October, 1895. Six months after operation, patient is very well, She weighs one hundred pounds.
April, 1S99. Examined in my private office : patient still enjoys perfect health ; she now weighs one hundred and ninety pounds. Patient states that she has recently given birth to a healthy child.
I report the case of this woman because (1) she was so very ill when operated upon; (2) it is one of the two cases in which intestinal perforation had undoubtedly occurred prior to operation ; (3) the common duct was approached in a new way, namely, from behind the peritoneum ; (4) the stone, in the ampulla, had ulcerated through the walls of the ductus choledochus and the duodenum, and would perhaps soon have been extruded ; (5) the increase in the weight of the patient seemed phenomenal ; it was almost doubled within the year following the operation.
What the result to the patient would have been if this stone had ulcerated its way out of the common duct is quite certain, and yet I have several times found stones imbedded in adhe
January, 1900.]
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sious outside of the bile passages; they were usually close to the gall-bladder. Once I discovered a stone in the wall of a thick-walled gall-bladder; it was completely buried and was causing no disturbance, and was detected in the process of sewing in the drainage tube. This is, I believe, the only case in which I have not divided all of the adhesions encountered. If no contraindication exists, such as necessity for abbreviating
the operation, we should separate the adhesions if possible. The chance of meeting fistulous openings between bile passages and the intestine I regard as an indication for thorough exploration rather than a contraindication to it. Not infrequently adhesions alone are responsible for the symptoms which persist after the calculi have been removed by the surgeon or have escaped in other ways.
EARLY EXPLORATORY OPERATIONS IN TUBERCULOSIS OF THE HIP.
A PRELIMINARY REPORT.
(From the Clinic of Prof. Halsted, The Johns Hopkins Hospital).
By Joseph 0. Bloodgood, M. D., Associate in Surgery.
I wish to report a case of early operation in tuberculosis of the hip, and am sorry the patient is not here to demonstrate the very happy result.
Case I. — Tuberculosis of left hip, of seven weeks' duration. Operation: Capsule distended; tubercular synovitis; small tubercular focus in the neck of the femur. Result, January, 1899 (13 months), perfect. No restriction of motion.
M.K. Surg. No. 8380. Male, set. 42 years, butcher by trade, was first admitted to the hospital October 6, 1893, 5 years ago, suffering from tubercular arthritis of the left shoulder joint. The disease of the soft parts and bone was extensive ; for this reason excision was performed at once. Although 3 cm. of the shaft of the humerus were removed, the functional use of the arm is an excellent one.
It is of interest to note the possible etiology of the arthritis of the shoulder. This man had always been in excellent health. He could remember no cases of tuberculosis in his family. Eight months ago, he cut his left wrist with a dirty butcher-knife. The wound healed in about one week. One month later he noticed pain in the left shoulder, which was followed by a slight stiffness. The condition was treated for rheumatism. Five weeks ago he noticed a swelling of the upper third of the arm to the inner (medial) side of the biceps muscle.
The patient was readmitted November 30, 1898 (5 years later), complaining of pain and stiffness of the left hip joint. The following are the important facts in the history:
About seven weeks before admission, without any recollection of a traumatism, he experienced, when getting out of bed one morning, pain in the left hip. This pain has been increasing, and is now and then referred to the knee. During the last two weeks the joint has become almost immovable. He baa been able to walk some, although it gives him a good deal of pain. He limped into the hospital.
Examination. — When the patient lies flat on his back with both legs extended, the anterior superior iliac spines appear to be on a level. There is very slight apparent shortening of the
- Read before the Johns Hopkins Hospital Medical Society. May
8th, 1899.
left leg. This, however, is due to real shortening between the trochanter and external malleolus. There is no shortening between the iliac spine and great trochanter. The hip is fixed at about 25°. There is no apparent abduction or adduction. Any attempt at motion at the hip joint gives pain, and with each motion the pelvis moves with the limb. There is no swelling about the hip joint except on the anterior surface of the thigh. This swelling is situated below the outer twothirds of Poupart's ligament, to the outer side of the vessels and extends downwards a distance of about 4 cm. It is most prominent 2 cm. within the line of the tensor vaginas femoris and 2 cm. below the iliac spine. The swelling is not very painful and on palpation seems to fluctuate. When the patient is quiet in bed and does not attempt to move the limb he suffers no pain. The leg is only painful when he attempts to walk or when some one attemps to bend it at the hip joint. The examination of the lungs was negative. The general health of the patient appears to be excellent. The patient remained under observation from November 30th to December 8th. On December 2nd, following an injection of 2 milligrams of tuberculin, the temperature rose to 100.5°. On December 4th, following 4 milligrams of tuberculin, the temperature rose to 100°. With these two exceptions, a two-hour chart shows a registration of rectal temperature between 98.5° and 99.5°. Following the injections of tuberculin the patient complained of no discomfort whatever. The only fact to be noted was that shown in the slight fever. The leucocyte count before operation was 4,000.
The arthritis was considered to be, without much doubt, tubercular, and the swelling on the anterior surface of the thigh to be due to distention of the capsule of the hip joint which had not yet ruptured.
Operation. — December 8, 1898. Anaesthetic, ether. When the patient was fully narcotized, it was demonstrated that with the exception of flexion there was but little restriction of motion in the hip joint. An incision was made in the anterior surface of the thigh, beginning at the anterior iliac spine, and the capsule of the hip joint was exposed by separating the tensor vaginaa femoris on the outer side from the rectus muscle on the medial side. As soon as the muscles were sepanih sd a tense swelling was found, which upon its surface was smooth
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and white in color. Upon its outer surface there was no exudate, nor was it adherent by connective tissue to any of the surrounding structures. When incised, it was found to be from 3 to 4 mm. in thickness, of firm white tissue, and proved to be the distended capsule of the joint. The cavity contained a large amount of viscid serous fluid containing numerous flakes of lymph and some necrotic material. The inner surface of the capsule of the joint presented the ordinary picture of tubercular synovitis. Here and there one saw cedematous hemorrhagic granulation tissue, in which were areas of yellow necrotic tissue, which could be easily scraped from its fibrous base. Between these areas of granulation tissue were smooth areas paler in color. On retracting the muscles more widely and enlarging the opening in the capsule, the head and neck of the femur were easily exposed. The examining finger at once found a small cavity on the inferior and slightly anterior surface of the neck, near its junction with the head of the bone, which about admitted the index finger (Fig. 1 «). One could also see the cavity, and in its
Case I. Fig. 1.
bone removed.
Focus of tubercular osteomyelitis, b. Area of
center was a small area of yellow necrotic tissue. The bone lining the cavity was slightly hemorrhagic, but when cut with the ehisel was found not to be very soft. About 3 to 4 mm. of bone about the cavity were removed with the chisel (Fig. 1 b.) Beyond this, the cancellous bone appeared to be normal. The head of the femur was easily seen. The cartilage was not eroded. The cartilage lining the cotyloid cavity could be seen only at the rim about the head. It also appeared to be normal. The trochanter and shaft of the femur were exposed. The periosteum was not thickened. The entire surface of the capsule of
the joint was curetted. The bone cavity in the neck, and the surface of the synovial membrane after curetting were swabbed with pure carbolic. The wound was then thoroughly irrigated with 1 to 1000 bichloride, followed with salt solution. After mixing iodoform powder with the blood clot, the wound was closed, leaving a small drain extending into the capsule but not into the cavity in the bone. The entire limb and pelvis were fixed in a fully extended and slightly abducted position in plaster.
Notes after Operation. — The patient was perfectly comfortable and at no time during the convalescence experienced pain in the wound. The night after operation the temperature rose to 103.2°, falling to normal in the morning. On the second evening it rose to 104°; on the third to 103°; and on the fourth to 102°, falling to normal each morning. With this rise of temperature there was very little change in the pulse. The leucocyte count varied from 2700 to 4000. Nothing was found to explain the fever. Culture and coverslips from the serum in the wound were sterile. From December 12th to January 28th the temperature chart records no fever. The drain was removed on the sixteenth day. For four weeks the sinus communicating with the joint was irrigated daily with 1 to 1000 bichloride and injected with an emulsion of iodoformized oil. The wound at no time showed any evidence of infection and was completely closed at the end of five weeks. The patient was kept in bed in extension for six weeks, and then allowed to get up in plaster.
Note, August 14, 1899. The patient returns to the hospital walking without crutches or cane. It is eight months since the operation and six months since the plaster cast was removed. For five months the patient has been able to return to his work as a butcher. He has had no further pain. The wound is healed solidly. Careful measurements show no difference in the length of the bone or between the anterior iliac spine and trochanter, except the one noted before operation of 1 cm. shortening between the trochanter and external malleolus. Motions in the left hip joint are possible in every direction, and are but very little restricted in each (see Figs. 2, 3, 4). Forced motions are painless. Previous to operation the left leg was flexed to 25 degrees ; it now can be fully extended without change in the pelvis.
Examination. — January 10, 1900. The patient's condition is the same as that noted in August. The result so far appears to be a perfect one, not only with every evidence of an eradication of the disease, but with complete function of the joint. (See Case IX for operation in the right hip.)
Case II. — Tuberculosis of right hip, of seven years' duration. Operation: Firm fibrous ankylosis; no evidence of bone or joint tuberculosis; incapsulated extra-articular tubercular abscess. Result, Jan. 1900, 9 months, excellent.
Surg. No. 3540. There is at present (May, 1899) in the wards, a young girl who was admitted to the hospital November, 1, 1894. At that time she was suffering with tuberculosis of the right hip, the onset of which had been two years previous, when she was eleven years of age; that is, seven years ago.
Examination. — November 5, 1894, under ether. No apparent shortening. The right (affected) limb is flexed to 45 degrees,
JOHNS HOPKINS HOSPITAL BULLETIN. JANUARY, 1900.
Fig. 2. — Result lu Case I, eight months after operation.
Fig. 3. — Limit of abduction, Case I
Fig. 4.— Limit of flexion, Cum- I
January, 1900.]
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slightly abducted and slightly rotated out. Apparently do real shortening between anterior iliac spine and trochanter or trochanter and external malleolus. The measured shortening between anterior iliac spine and internal malleolus 1 cm. (due to abduction).
Examination. — April 25, 1895, after seven months. The flexion is less 20 degrees. Apparent shortening 1 cm., due to tilting up of the pelvis. Measured shortening between iliac spine and external malleolus 2.5 cm. Keal shortening between iliac spine and trochanter perhaps 1 cm. Patient is very fat, and these measurements are difficult to make. The leg is still slightly abducted. Kotation out less.
Examination. — December 8, 1896, after two years. Apparent shortening 3 cm. Keal shortening between anterior iliac spine and trochanter 1 to 1.5 cm.; between trochanter and external malleolus 2.5 cm. (about equally distributed between thigh and leg). These measurements demonstrate that within the last two years, under the best orthopedic treatment, a centimeter of real shortening has taken place, and there has been a lack of growth in the shaft of the femur of 2.5 cm.
Examination. — April, 1898. Very little if any change.
From November, 1894, up to the present time, a period of almost five years, she has been under treatment. After her first admission to the hospital she remained in the wards for two years. The treatment consisted of iodoform injections, and later of fixation in plaster. During this time her general health has remained about the same. There has been little or no loss of flesh, no fever, and no evidence of tuberculosis elsewhere. On December 6, 1896, she was given tuberculin, which was followed by no evidence of reaction. Four weeks later an abscess formed below the great trochanter. It was opened, and healed rapidly. In October, 1897, there was slight reaction to tuberculin. About four weeks ago she returned to the hospital for inspection. She was still using crutches, and suffered a good deal of pain in the hip, not only during the day when she was sitting in a chair or walking on her crutches, but also at night. This pain was generally relieved by extension.
Operation. — April 20, 1899. Ether. Under the anaesthetic it was found that the hip joint was almost completely fixed in a flexed and very slightly abducted position, with no rotation. An incision similar to that employed in the first case was made. On dividing the fascia lata about 5 cm. below the anterior iliac spine, a small cavity (2 cm. in diameter) was opened. In the center of the cavity was a mass of yellow necrotic material and a little clear serous fluid. The wall of the cavity was of smooth white fibrous tissue. No granulation tissue could be found. This cavity corresponded in position to the abscess which formed and healed a year and a half ago. It was completely excised and no communication between it and the bone or joint could be demonstrated. (A very small healed sinus, however, might have been overlooked). On exposing the joint, the head and neck and trochanter of the femur were covered with dense connective tissue. This was excised, exposing the periosteum over the trochanter and upper part of the shaft. The periosteum was slightly thickened, and on stripping it back the bone was a little rough. The outer layers of the bone of the shaft and trochanter were very thin, also that of the neck. The anterior surface of the neck, troch
anter and shaft was removed with a chisel (Fig. 5 a). The
cancellous bone was very softand hemorrhagic; the marrow was
also fatty and very hemorrhagic. The head of the bone and t he
acetabular cavity were covered with scar tissue, in which no
granulation tissue could be found. Over a small portion of
the head of the bone which was exposed there was normal
cartilage. No disease of the pelvic bones about the acetabular
cavity could be demonstrated. About the acetabular cavity
there was a narrow ridge of new bone (Fig. 5 c). The wound
was thoroughly irrigated, and the small bone cavity made
during the exploration was allowed to fill with blood
clot mixed with iodoform, and the wound closed without
drainage.
Case II. Fig. 5. — a. Area of outer table removed to expose neck,
epiphysial line and head. 6. Gouge groove to explore acetabulum
through head. c. New bone about rim of acetabulum.
At the operation, although the junction of the neck and the shaft was exposed, it was difficult to tell whether the angle between the neck and the shaft were more or less than normal. The neck, however appeared to be shorter than normal. Following the operation, the patient had no discomfort and the wound healed perfectly. She was discharged September 15, 1899, wearing a splint and using crutches. This supporting apparatus was used because I feared that following the removal of the bone, the neck of the femur might possibly have been weakened, and that to allow the patient to walk without some support might be followed by bending of the neck with its resultant deformity. While in the hospital, especially after the patient was up and about on crutches, the pain complained of before operation was not present.
Examination. — January 19, 1900. The patient has no pain. She walks much better but still uses the crutches and wears
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[No. 106.
the splint. No change in measurement. Advised to discontinue crutches and later the splint.
I have reported these cases to the Society to illustrate the happy result, in the first case, after an early operation. Here, seven weeks after the beginning of the disease, we found a greatly distended capsule filled with necrotic material and lined by tubercular granulation tissue and a tubercular focus in the neck of the femur. Following the partial removal of the disease of the soft parts and the apparent complete removal of the disease of the bone, we have every evidence of the complete cure of the disease, and three months after operation the patient is able to resume his occupation as a butcher, and the functional use of the joint is almost perfect.
In the second case, after seven years of conscientious orthopedic treatment, the patient is practically in the same condition. The exploratory operation, however, demonstrated that the disease was to all appearances cured. In this latter case an earlier exploratory operation, if it had demonstrated the same condition, would have relieved the patient of a number of years of enforced rest, or, if the disease had been present, would have allowed its earlier eradication.
ADDITIONAL CASES.
Note, January, 1900. — Since the above report was made, twelve cases of tuberculosis of the hip have been subjected to operation. Nine are here reported — three cases of very recent date not being included in this report. In all, the immediate results have been very encouraging.
Case III. — Tuberculosis of left hip, of 15 months' duration. No relief of symptoms after two and a half months' treatment with extension in bed. Operation: Distention of capside ; erosion of head and neck ; no bone foci found ; immediate relief of symptoms. Residt January 1 , 1899, six months, excellent G. L. H. Surgical No. 8874. Male, at. 10. Was admitted April 19, 1899, complaining of pain in the left leg. His father died of tuberculosis of lungs, and one brother had been operated upon in this hospital for genu varum. About fifteen months ago this patient complained of pain in the left hip. The pain was intermittent, but had not prevented him from going to school or playing about ; now and then he would limp ; for different periods he would be free from pain and limping ; no history of trauma. About six weeks ago, after a well interval, he complained of sudden pain in the left hip and began to limp. The pain in a day increased so rapidly that he went to bed, being unable to walk, and that night, for the first time, cried out from pain. Being more comfortable the next day he was taken to a hospital where he remained a few days, and left with a brace. Yesterday, twenty-four hours before admission, he fell on the brace and had passed a very uncomfortable night.
Examination. — The left hip was so tender that any attempt at motion produced much pain, and an examination was made with difficulty. There was flexion (40°), abduction (45°), but no aversion. From April 20th to May 12th (22 days) the patient was placed in extension, and was more comfortable. Measurements made on the last day showed apparent shortening of .5 cm., due to slight adduction, but no real shortening. The hip was still very tender and fixed. April 29, reaction to tuberculin. From May 28th to July 2nd, although the patient was in extension, night cries increased and he was uncomfortable. From July 2nd it was noticed that there was a fullness in Scarpa's triangle. The hip was still very painful and fixed in a position of flexion and adduction. For this reason an operation was decided upon.
July 3, 1899. Operation (Dr. Cushing): Ether ; anterior incision. The joint capsule was distended and thickened ; no evidence of rupture. On incising the capsule, about an ounce of seropurulent fluid escaped. A part of the cartilage over the head was roughened and slightly elevated from the bone. The joint cavity was full of tubercular granulation tissue. In places one could see that the cartilage of the acetabulum was eroded and lifted from its base. A portion of the anterior surface of the head and neck was chiseled away, showing the epiphysial line. No focus of disease in the bone was found. The area of most marked erosion of the cartilage, and the erosion of the bone at the edge of the epiphysis, as shown in (Fig. 6, a. a. a.) were chiseled away. After disinfection
Case III. Fig. 6. — a. a. a. Areas of superficial erosion, b. Areas
removed.
of the joint and bone cavity, dry iodoform was dusted in the wound, which was closed without drainage. The operation lasted one hour and five minutes.
For a few days previous to operation the pulse ranged between 90 and 100, and for three days after operation it ranged between 120 and 150 ; the temperature rose to 102°. By the seventh day pulse and temperature had reached normal. The patient was comfortable.
On August 2nd (thirty days after), a small sinus opened in the wound, discharging a clear, serous fluid, which completely healed on August 29th. Measurements made on August 30th showed a lengthening of 1 cm. and no real shortening. The flexion had disappeared, and there was a slight tendency to outward rotation. Motion in the joint was much less restricted. On August 31st, two months after the operation, the patient was fitted with a brace. On September 6th he left the hospital wearing a brace.
In this case the usual orthopedic treatment of extension and rest in bed had been given a fair trial, but did not relieve the symptoms. At the operation, tension was relieved by incision and drainage of the distended capsule, after which the patient was much more comfortable. The incision of the capsule also allowed
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
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correction of the flexion, and a short time after the operation all movements of the hip joint were freer and without pain.
Case IV. — Tuberculosis of left hip, of <>ne year's duration. Operation : Distended eapsuie, with purulent material ; synovial membrane convt rted into granulation tissue; sliglit erosion of head and neck and acetabulum ; wound closed ; healing per primam. Result, January, 1899, six months, excellent.
Surgical No. 9234. W. C, colored boy, aet. 2 years. Admitted July 26, 1899. One year ago the child complained of pain and tenderness in the left hip, and in a few days began to limp. The parents noticed that the leg became shorter ; the pain was worse at night, and there were night cries. The child continued to walk a little.
Examination. — The general condition was good; no evidence of rickets. The left leg was flexed to 70 degrees at the hip and 45 degrees at the knee, and adducted. Motions at the hip are restricted in all directions, but not at the knee. It was difficult to make accurate measurements, but there appeared to be no real shortening.
August 2nd (six days after admission). Operation (Dr. Mitchell): Ether: anterior incision. The capsule of the joint was thickened and ccdematous. On incising the capsule, an ounce of thin, brownish, purulent and necrotic material escaped. The synovial tissue seemed to be converted into granulation tissue. There was noticed a slight erosion on the anterior and superior surfaces of the neck at its junction with the head ; round ligaments, intact ; the rim of the acetabular cavity was covered with grayish granulation tissue ; both of these areas, as well as the capsule of the joint, were curetted. The wound was irrigated with salt solution, dusted with dry iodoform powder, and closed without drainage. The full time of the operation was fifty-five minutes.
Pulse previous to the operation was 120; during the operation, 140. The chart registers an average pulse of 120 previous to operation and one rise of temperature to 103°, which, however, followed tuberculin given on the 27th of July. Following the operation the highest temperature was 101.5°, the evening of the first day, and the pulse rose to 180, but fell that evening to' 130; up to November 27th. when patient was discharged, the average pulse was from 110 to 120. With the exception of a slight rise of temperature to 102° on October 2nd, there was no fever after August 4th, 48 hours after operation. The patient left the hospital on November 27th in plaster. The wound healed per primam.
Case V. — Tuberndosis of left hip. Subgluteal extraarticular abscess. Operation : Incision of abscess and arthrotomy ; tubercular synovitis ; erosion of head and neck ; posterior perforation of capsule. Result, January 1, 1899, two months, improved.
J. W. G.. colored boy, set. 2 years. Admitted November 9, 1899. The parents not being with the child it was impossible to get a history.
Examination. — The child is placed flat on his back. The left anterior iliac spine (the affected side) is a little lower than the right. There is a marked lumbar lordosis unless the left hip is flexed to a position of 90 degrees ; motion at the hip joint in this position is possible in all directions, but only to a few degrees. The knee is flexed to an angle of 90 degrees. Extension is only possible to a few degrees ; no rotation of thigh. If the right leg is placed in a similar flexed position at the knee and hip, there is an apparent shortening of about 1 cm., but no real shortening of the left leg. Between the anterior iliac spine and trochanter on the outer surface of the left thigh and beneath the gluteal muscles there is a fluctuating swelling.
Operation.— November 11, 1899. Ether. Under complete narcosis the leg can be veiy slightly flexed and extended. This restriction almost completely disappeared after the abscess was incised. The abscess was situated beneath the gluteal muscles and fascia
lata and contained thick, gelatinous, purulent material, with shreds of necrotic tissue, and was found to communicate with the hip joint through a small opening in the posterior wall of the capsule. The joint capsule, which was not distended, was opened through the usual anterior incision. The synovial membrane was covered with tubercular granulation tissue. On account of the youth of the child, a large incision was not made, so that the head, neck and acetabular cavity were not seen, but with the index finger erosions were felt on the anterior surface of the head and neck, which were curetted Theabscessaud thecapsuleof the joint were also curetted, swabbed with pure carbolic, irrigated with salt solution and filled with emulsion of iodoform and oil. The operation took fifty-five minutes. Very little ether was given. The condition of the patient at the end of operation was excellent.
January 15, 1900. The child is still in extension, which has reduced the flexion of both knee and hip from 90 to 35 degrees. There are no night cries. The patient appears to be perfectly comfortable. The wound is now a superficial granulating area.
Case VI. Tubercidosis of left hip, of seven months' 1 duration. No relief of symptoms after one month's treatment with extension. Operation: Tense distended capsule ; no bone focus of disease; slight erosion of the head, with loosening q) articular cartilage ; round ligaments separated ; wound closed ; healing per primam. In six weeks the wound reopened. Second operation. Result. January, 1899. after two months, excellent. Wound closed.
Surgical No. 9117. G. B.. aet. 4A years; admitted June 26, 1899. One and one-half years ago the boy fell on the ice and bruised his left hip. An area of ecchymosis over the hip remained some days. Following the injury, however, there was no special pain complained of and no limp. Eleven months later (that is, 7 months ago), the parents noticed that the child began to limp, and complain of pain, first in the calf of the leg, later in the ankle, then in the knee. About two months later the parents noticed that the affected leg was shorter and the boy walked on his toes. In about a month he began to have night cries. For the past two weeks the boy has been unable to walk on account of pain.
Examination —The left leg is flexed at the knee and thigh, with marked adduction ; no rotation ; very little motion at the hip joint. The patient was placed in extension from June 26th to July 24th. He cried a good deal at night, when asleep or awake. All attempts to overcome the flexion by extension were unsuccessful. Manipulation of the hip joint continued to be painful ; for this reason operation was decided upon.
Operation.— July 24,1899 (Dr. Cushing) : Ether: anterior incision. After separating the muscles a very tense distended capsule was exposed ; it was incised, and about an ounce of flocculent, yellow, serous fluid was evacuated. The joint, head and neck of the bone were thoroughly exposed. The round ligament seemed to be destroyed. When the thigh was flexed, one got a good view of the acetabular cavity. The lining cartilage seemed smooth. The cartilage over the head of the bone appeared to be loose. The head epiphysial line was exposed by chiseling. No focus of disease was seen. The wound was irrigated with salt solution, dusted with dry iodoform powder, and closed without drainage.
Dr. Cushing noticed that under an anaesthetic the leg could not be fully extended. As soon as the capsule was incised and the tension was relieved, full extension was possible. Time of operation about fifty-five minutes ; pulse before operation, 120 ; during operation about 140. As in the previous cases in children there was a slight tachycardia after the operation for five days, and some fever for three days. The wound healed per primam.
It was noticed on August 5th, 11 days after operation, that the leg was but slightly flexed, very little adducted, but there was slight outward rotation. On the 14th of August there was no flexion. At this time he was sent into the country in a brace.
On September 6, 1899, about a month later, he was readmitted
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to the hospital, not in as good condition as when he left. He had night cries and some pain. Twenty days after admission a sinus formed in the wound which discharged tubercular pus.
From September 28th to November 4th he was placed in extension. November 3d, measurements: Apparent shortening of 1 cm., and real shortening from trochanter to anterior iliac spine of about 1 cm. No abduction or adduction or flexion, but marked outward rotation. The hip is pretty firmly fixed in this position except that it can be slightly rotated in.
Operation, November 4, 1899 (Bloodgood) : Ether. It was found that the sinus of the previous operation passed through the rectus muscle into the joint. At this second operation the joint was exposed by an incision which separated the tensor vaginas femoris and gluteus medius on the outer side and the sartorius and rectus on the medial side. The sinus and cavity corresponding to the capsule of the joint were lined with tubercular granulation tissue. It was found that the head and neck of the bone were intact. A few pieces of partly separated cartilage were removed from the head of the femur. The outer surface of the neck was rough, soft and hemorrhagic. On extending the femur and pushing it upwards, the head of the bone moved a little in each direction. Under ether there was very little restriction of motion at the hip joint. The soft parts and bone surface were curetted, the exposed surfaces were swabbed with pure carbolic, the wound irrigated with salt solution, dusted with dry iodoform powder, and closed with a piece of protective drain into the joint cavity- No loss of blood ; no shock. Time of operation was about sixty minutes. Average pulse about 140.
Following the operation there was a slight tachycardia for a few days, but no rise of temperature. The operation in this case was a secondary one and of less extent than others. The patient was put up in plaster and later in extension, and was much more comfort able than previous to operation. The wound was irrigated, and at frequent intervals swabbed with pure carbolic and filled with emulsion of oil.
Note. — December 9, 1899, 35 days after operation. Measurements between iliac spine and trochanter and iliac spine and malleoli are about equal. Position of leg after removal of extension is as follows : The left (affected) anterior iliac spine is elevated 1 cm., the left leg is rotated out perhaps a little more than the right (this outward rotation is much less than previous to operation). The apparent shortening (1 cm.) corresponds to the elevation of the iliac spine. There is no flexion. The motions of the hip joint are about 10 degrees in flexion and extension ; adduction to a few degrees ; no restriction of outward rotation ; a marked restriction of inward rotation and abduction. Although the hip is pretty well fixed, the position could not be a better one- Attempts at motion are not painful. The wound has healed.
December 15, 1899. The patient is in the hospital, and is walking about on crutches, in a brace.
Case VII. Tuberculosis of left hip, of one year's duration. Subgluteal, extra-articular abscess and abscess beneath the adductor muscles. These abscesses developed during orthopedic treatment. Operation: Incision of subgluteal abscess; anterior arthrotomy of joint; anterior and posterior perforation of joint ; abscess beneath adductors drained through joint ; tubercular focus in neck. Result, January, 1899. two months, improved.
Surgical No. 8201. Boy, set. 8 years. Admitted October 6, 1898, one year ago. The arthritis of the left hip had been present one year, following traumatism. The limb was in a position of flexion (28 degrees) and adduction (21 degrees), with slight internal rotation. Apparent shortening, 4 cm. ; real shortening (anterior iliac spine to trochanter), 1 cm. Muscle spasm was marked. There was no evidence of abscess. The patient was placed in bed in an extension apparatus, which at once relieved the pain. He was discharged February 28, 1899 (five months), wearing a splint, and
appeared to be in excellent health. This patient was readmitted October 1, 1899, not because he was suffering any pain or discomfort, but in answer to a letter inquiring as to his present condition. He was still wearing the splint and walking with crutches. When the splint was removed and the patient placed in bed, and the anterior iliac spines fixed to the same horizontal plane, the left affected leg was so adducted that it crossed its fellow on a level with the patella. There was a large abscess behind the great trochanter in the gluteal region, and a slight fullness beneath the adductor muscles. The patient was observed in the hospital from October 1st to October 28th. There was no fever. He suffered no pain except when the apparatus was removed or when forced motions were attempted at the hip.
Operation.— October 29, 1899. Ether. The gluteal abscess was incised. It was situated between the gluteus minimus and medius and extended down to the middle third of the leg beneath the fascia lata. Passing the index finger, one could feel the capsule of the joint on its posterior surface. In this position a probe found communication with the joint cavity.
The usual exploratory incision on the anterior surface of the thigh was then made. The capsule of the joint when exposed was slightly distended, but on i:s outer surface there was no exudate and no adhesions. When incised, it was slightly thickened, and the joint cavity contained a moderate amount of seropurulent material filled with cheesy necrotic masses. The head and neck of the bone were easily felt and seen, and on the anterior and slightly inferior surface of the neck, near its junction with the head, a small tubercular bone focus was found. (Similar to Case I, Fig. 1.) This was removed with a chisel. The head of the bone seemed firmly in place in the joint cavity, and there was very little restriction of motion. The rim of cartilage which could be seen was not eroded. By pressure over the thigh in the adductor region, a great amount of tubercular pus was expressed into the joint cavity, and the finger and probe demonstrated a second opening in the capsule of the joint leading to a large abscess cavity on the lateral surface of the thigh, beneath the adductor muscles. This opening was enlarged and the cavity curetted out. The patient had a comfortable convalescence. January, 1900. Extension has corrected to some extent the adduction and flexion. The patient walks well in his brace. The wounds are almost healed. The marked adduction will need further operative treatment.
Case VIII. — Tuberculosis of right hip; orthopedic treatment for 12 months, during which time an iliac abscess, from perforation of the acetabulum, developed. Operation : Incision of abscess and arthrotomy of joint ; tubercular synovitis ; slight erosions of head and neck, with partial separation of the articular cartilage of head and acetabulum. Residt, January 1899, two months, excellent.
Surgical No. 8086. R. H., ast. 4. First admitted September 7th, 1898, with the following history : About five months ago it was noticed that the child limped; at the same time the parents noticed that the right ankle was swollen. Six weeks later the child wakened at night, crj-ing from pain in the hip ; next day was unable to walk ; this pain and inability to walk disappeared in a few days, the night cries and pain at night continuing. About eight weeks ago a slight trauma was received by the right knee; The knee became swollen and was put up in plaster by a physician. Night cries continued. The hip became more stiff.
Examination. The child walked into the hospital. The limb is flexed; slightly adducted; no rotation of foot; apparent shortening of about 1 cm; no real shortening between anterior iliac spine and trochanter; no fullness in Scarpa's triangle; adduction is impossible, and there is about 10 degrees of abduction. Patient was placed in extension September 2oth. 18 days later, he was discharged from the hospital, wearing a brace and using crutches, with a high shoe on the left foot. March 29, 1899, 7i months, patient was readmitted.
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Examination. Perfectly comfortable. Night cries have ceased. Examination reveals no muscle spasm. There is no flexion, abduction or adduction. Apparent shortening is \i cm. There is very little motion at the hip. No real shortening between trochanter and anterior iliac spine. May 6th, 37 days, discharged, wearing a splint and using high crutches and high shoe. On October 27, 1899, tive months latter, he was readmitted, not because of any pain or discomfort, but on account of swelling which had been noted for two weeks over the outer third of Poupart's ligament. Measurements : No apparent shortening; no real shortening. Leg is in a straight position, slightly rotated out. Flexion is possible to 30 degrees; abduction to 10 degrees, but adduction is impossible. There is only slight muscle spasm, associated with attempts at motion. On account of the abscess an operation was decided upon.
Operation.— November 4, 1899. Ether. Usual anterior incision, which also opened into the abscess. The abscess cavity was between the skin and fascia of the muscle. From it a sinus led below Poupart's ligament, passing between the sartorius and tensor vaginse femoris. then into the iliac fossa, anterior to the sheath of the iliac muscle. After curetting this abscess cavity the joint capsule was exposed by separating the rectus from the tensor vaginse femoris. No infiltration of the tissues outside the capsule. By pressure over the capsule a purulent material was expressed from the sinus, but on opening the capsule of the joint a direct communication could not be found. The cartilage of the head of the femur was soft and separated easily : it was removed by catching it with a clamp. The base consisted of soft hemorrhagic bone, the gross picture of tuberculosis. The anterior surface of the head and neck was chiseled. There was no evidence of disease in the neck, which seemed to be confined to the head of the bone, especially beneath the cartilage. The round ligaments had been torn and that portion of the acetabular cavity which was exposed showed evidence of disease. The cartilage was soft, and some could be pulled away, leaving a base of soft hemorrhagic bone. No attempt was made to find out the direct communication between the joint and the iliac abscess, as it would have required too much destruction of bone. The abscess cavity was traced into the pelvis between the iliac and the psoas muscle. The wounds were swabbed out with pure carbolic, irrigated with salt solution and dusted with dry iodoform. A protective drain was left into the abscess cavity and into the joint. Time of operation was about one hour and thirty-five minutes. Patient was in excellent condition.
Following the operation there was the usual tachycardia pulse of 130 to 160 for about ten hours ; no rise in temperature ; no pain or discomfort.
Examination. — December 1, 1899, twenty-seven days since operation. There is no apparent shortening. The anterior iliac spines are about even. Both legs are straight ; no outward rotation ; no real shortening ; position of the leg is perfect. Flexion, extension, abduction and adduction and outward rotation are possible only to a few degrees. Inward rotation from a position of outward rotation is possible to a greater extent than outward rotation. Attempts at motion give no pain.
Wound healed except a small granulating area and a sinus communicating with the abscess cavity. Patient is ordered brace, high shoe and crutches.
January, 1900. No change.
Case IX. Tuberculosis of right hip. Slight symptoms four months; very acute symptoms three days. Operation at once. Capsule distended, very tense; synovial membrane hyperemic; on chiseling outer table of neck, a definite bone focus found in the neck near epiphysial line. January 1, i900, six weeks, excellent result.
Surgical No. 9699. N. K.. set. 40. Admitted November 32, 1899. In July (four months ago) patient began to have pain in the right hip, and he stopped work and rested for about two weeks. Was comfortable when he kept quiet. Returning to work, he was free
from pain for a couple of weeks, but since that time he has found that he has to rest quite frequently during the day when these attacks of pain come on. He is a butcher by trade and has to stand a good deal. Three days before admission, while at work, he was seized suddenly with severe pain, so intense that he went home to bed, and sent for a physician who gave him morphia, but this did not relieve the pain. He was brought to the hospital on a stretcher in the ambulance.
The right leg was fixed in a position of flexion of about 45 degrees. Any attempt at motion was intensely painful. Extension was at once applied in this flexed position, which in a few hours relieved the patient of the pain. Next morning he was more comfortable. On examination there was a distinct fullness in Scarpa's triangle. The history and the present condition were similar to the attack in the left hip joint (Case I). There is no apparent or real shortening. The result in the left hip is a perfect one. The patient was in extension with complete relief of symptoms from November 22nd to November 27th, but any attempt at motion gave him pain. Chart records a temperature between 99° and 101° ; pulse of 70 to 80.
Case IX. Fig. 7. — a. Tubercular osteomyelitic focus, b. Area of
outer table chiseled to expose aud remove a and 6. c. Area of softened
cancellous bone.
Operation.— November 27, 1899. Cocaine and chloroform. The usual anterior incision was made without difficulty under cocaine, but it was found that the retraction of the muscles necessary to expose the hip joint was so painful that chloroform was given. As soon as the patient was under the anaesthetic it was still found that complete extension was impossible. The capsule of the joint was distended. On incision a fluid spurted out. demonstrating the great tension. It was a seropurulent fluid filled with coagulated lymph. On examining the capsule carefully, it was found that the synovial membrane was intensely injected and hyperemic. There was no evidence of granulation tissue. The head of the bone was easily seen in the acetabular cavity, and the cartilage, both on the head and acetabular rim, seemed normal and was not sepa
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rated. No disease could be seen at the head or neck or trochanter of the femur. The bone of the anterior surface of the neck, between head and trochanter, was chiseled ( Fig. 76) , and in the epiphysial line, between the head and neck, on the anterior and inferior surface, a small focus (about 5 mm. in diameter) of definitely tuberculous bone was found (Fig. 7 a). Surrounding this and extending into the head and neck, the bone was soft and hemorrhagic (Fig. 7c.) The tuberculous area and this softer cancellous bone were removed with the curette. The appearance of the bone lining the cavity was normal except perhaps slightly hemorrhagic but firm. The bone cavity and joint capsule were swabbed out with pure carbolic, irrigated with salt solution, and the bone cavity allowed to fill with blood mixed with iodoform. The wound was closed with a small drain extending into the capsule but not into the bone cavity. Operation required two hours and ten minutes. There was no shock, and the condition of the patient at the end of the operation was excellent.
Examination.— December 16, 1899. Wound is healed with the exception of a small sinus which was filled with iodoform and organized blood clot. Patient has had absolutely no discomfort since operation, and for about seven days has moved his right hip in every direction, and we find on examination to day that one is able to flex, abductaud adduct, rotate in and rotate the hip outwards to quite a marked degree, but not completely. These motions are without pain. January 12, 1900. The patient is up on crutches ; the wound is healed except a small superficial area. Passive and active motions with hip are but slightly restricted and give no pain.
For some years before this report, which I made to the Society in May, 1899, I had given a good deal of consideration to the subject of tuberculosis of the joints, and especially of the hip, and had been forced to the conclusion that there was much room for improvement upon the usual orthopedic treatment. I had in mind early exploratory operations in which the surgeon might be fortunate to find the focus of the disease in the bone at a period when its complete excision ; or, if the tubercular osteomyelitis were more extensive, a partial excision might be done without interfering with the continuity of the bone or function of the joint. From early experiences, especially in the knee, arthrotomy with irrigations with antiseptics and injections of large quantities of iodoform seems to have been the best procedure for treatment of the tuberculosis of the synovial membrane.
The majority of surgeons now follow the more conservative and orthopedic treatment. In the past many, and at present, without doubt, some, surgeons resort to operation, even early in the disease, but as a rule such operations have been accompanied with excision of at least the head of the femur and frequently more, of the neck and trochanter.
My first object in the early operation for tuberculosis of the hip was to avoid a complete removal of the head or of an amount of bone sufficient to interfere with the continuity of the upper end of the femur, or function of the joint, to excise the diseased bone only in small areas by a gouge and curette, trusting to antiseptic irrigation, and especially to the healing process, to check the further extension of the tubercular processes, and to encourage healing of the tissues already diseased, both of bone and soft parts. Every surgeon must have observed, especially in excisions of the knee, that tuberculous bone has frequently been left behind, but that the disease has been cured. Change of circulation, due to the operative interference, and the scar tissue of the healing process, both seem to exert a curative influence on the tubercular tissues.
The more frequently one operates, and the earlier in the disease, the more frequently he may be fortunate in finding single focus, of tubercular osteomyelitis which can be completely excised without injury to the continuity of the bone or function of the joint as in Cases I and IX. As our experience grows, I trust we will find that early operations check the disease with more certainty and in a greater number of cases than the usual orthopedic treatment. I trust also we will find that it shortens the period of treatment.
In five of these cases the joint capsule was greatly distended. It would seem beyond question that arthrotomy and irrigation in such cases are the only reasonable treatment. The symptoms due to tension are relieved, and both the infiltrated and uninfiltrated tissues, relieved of this pressure, are better able to take care of the tubercular process. In addition, the arthrotomy allows a thorough local disinfection of the surfaces of the capsule and bone, and with the aid of a small gouge one is able to explore the trochanter and neck and head of the femur without endangering the continuity of the bone. In this early exploration, any focus of bone can be completely or partly excised according to its extent. Loose articular cartilage, both on the head of the femur and on the acetabulum, can be removed and the diseased bone beneath subjected to local disinfection.
From these observations it would seem that in many cases of tuberculosis of the hip, synovitis with effusion is present early in the disease ; in a number of cases the capsule ruptures and extra-articular abscesses form. An anterior arthrotomy, if performed before rupture takes place, would effectually prevent this complication.
In three of our Cases, Nos. V, VII and VIII, extra-articular abscesses were preseut at the operation. The joint capsule in these three cases was not distended but perforation and communication with the abscess cavity were found in each case. In addition to the incision of the abscess, the joint was opened by the usual anterior incision and drained. In Case VII there were two abscesses; the one beneath the adductor muscles, on the inner lateral surface of the thigh was drained through the joint capsule. Microscopic examination of the wall of abscesses from tuberculous bone, demonstrates, especially early in the disease, that the wall of such " cold " abscesses is composed of ordinary granulation tissue. We seldom find evidence of tuberculosis. Clinical observations demonstrate that extensive excisions of the abscess wall are not necessary. The most important point in the treatment is the removal of the source of infection in the bone. For this reason in operations for tuberculosis of the hip in which extra-articular abscesses are present, I believe it is better in every case to simply incise the abscess, curetting and thoroughly disinfecting in addition, if you wish, but most important of all in every case to explore the joint and search for the focus of tubercular osteomyelitis. We however, will have to wait before forming definite conclusions, and compare the immediate and ultimate results in these cases with those in which the extra-articular abscesses have simply been incised. Kecent observations, however, have impressed me with the value of early exploratory arthrotomies in tuberculosis of the hip, not only for a confirmation of the diagnosis early iu the disease, but for treatment.
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In all the joints, especially the hip and knee, the synovial sac can be thoroughly disinfected and filled with iodoform, and with a small chisel the more common positions for the tubercular focus can be explored. To open and irrigate a normal joint, even with 1 : 1000 bichloride of mercury solution, is not followed by any restriction of motion, and Case I demonstrates that the hip joint can be drained for six weeks and yet almost complete restoration of the function result. Anterior arthrotomy of the hip is a simple operation and its dangers should be confined almost entirely to the danger of the anaesthetic. However, it must always be borne in mind that a virulent pyogenic infection of the wound at the operation or later would be a serious complication, and if we found that this occurred with any degree of frequency, it would most certainly detract from the results, even in comparison with the orthopedic treatment. More extended experience will be necessary before we can judge of the risk of infection. (There has been no iufection in our series of 12 cases.)
The anterior incision in cases of tuberculosis of the hip is not a new procedure. Mr. Barker (Manual of Surgical Operations, 1887) describes it as R. W. Parker's operation. More recently, in Treves' System of Surgery, Mr. Barker again gives this incision first place, and in addition states that Professor Hueter, of Greifswald, described asimilar method independently but at about the same date of Mr. Parker's. (Transactions of Clinical Society of London, 1880, page 105.) Bradford and Lovett (Orthopedic Surgery, second edition, 1899) describe the anterior incision for the excision of the joint, but prefer the posterior incision. As far as I am able to find in the more recent authorities, the suggestions made and the methods followed in these cases are sufficiently original to justify their publication.
To repeat, the chief object in the early operation for tuberculosis of the hip is to take the disease in its early stage, to relieve the tension of the distended capsule, to check and cure the tubercular synovitis by disinfection and drainage, to explore the bone with the hope of finding the tubercular osteomyelitis, in which case it can be partially or completely excised ; trusting also to disinfection, drainage and the healing process to check and later cure the disease of the bone without injury to its continuity. The acetabular cavity can be explored, as shown in (Fig. 55) by chiseling through the head ; more extensive operations on the acetabulum, however, could not be performed without removal or temporary dislocation of the head. It is too early to judge of the results, except in Case I, in which the patient has now a perfectly functional joint one year after operation.
In operations for tuberculosis of the joints, one must always bear in mind the possibility of disseminating the tubercle bacilli. In operations on joints where the Esmarch can be used, this danger may not be as great as in operations on the hip and shoulder. It will require, however, a number of years and careful observation to get at data for this study. The method of operation is clearly described in the details of the history of the nine cases reported. The most important anatomical point is to bear in mind the deep external circumflex vessels. Sometimes it is not necessary to divide these, but if it is found that more room is required, these vessels should
be carefully ligated. The joint can be exposed easily without dividing the muscle by separating the tensor vagina' femoris and the glutei muscles on the outer side and the sartorius and rectus to the inner (medial) side. I believe it is a better plan to lengthen the incision rather than to make a cross cut of the muscles. The separation of the muscle leaves a cleaner and a less ragged wound, and perhaps detracts much from the danger, not only of pyogenic infection but of tubercular dissemination. Through this wound, by separating the muscles, one can clearly see the capsule of the joint and the trochanter and upper portion of the shaft of the femur. On dividing the capsule, one can explore with great ease the neck and head of the femur. In these operations the head has not been dislocated from the acetabular cavity, but if one found the round ligaments destroyed, with extensive disease of the head and acetabular cavity, the head of the bone could easily be temporarily displaced to allow a better treatment of the head itself and the acetabular cavity, after which it could be replaced. This course was followed in a recent case by Professor Halsted.
Discussion.
Dk. Halsted. — To indicate what we may hope for as a final result in certain cases of hip-joint disease, even when a considerable portion of the head of the femur has been removed, and in support of what Dr. Bloodgood has said, I will refer very briefly to a case which I intend very soon to report in full with other interesting hip-joint cases. The patient, a boy, thirteen years old on admission, had an acute osteomyelitis in 1895, at the age of eleven, which involved the entire diaphysis of the right femur. Eleven months he spent in bed, and for seven months could not lie on the affected side. After walking about with a cane and without much pain for more than a month he had to take to his bed again for about a week during a second acute attack of pain in the same bone. Two or three months later two abscesses appeared, one behind the knee and one internal to the trochanter. The boy was thenceforth for nearly a year quite comfortable and considered himself sufficiently well, until the 1st of November, 1897, when he was hit in the right groin by a wagon-pole. He suffered greatly from this blow, and the following morning could not flex his . thigh. Two weeks later, November 19, 1897, he was brought to us by his physician, who stated that for several days he had been having very high fever with daily intermissions. The boy was emaciated; his expression anxious and indicative of suffering. He lay on his back; the right thigh was abducted, rotated outwards and slightly flexed ; the groove in the right groin was obliterated and there was an appreciable fullness over the head and neck of the femur. Pressure over the joint and all attempts to move the head of the femur caused pain. About the level of the top of the trochanter of the right femur, but internal and anterior to it, was a sinus from which pus escaped. Behind the inner hamstring tendons was the orifice of a second sinus discharging more pus than the other. The femur was much enlarged, and the soft parts of the thigh were swollen. An involucrum had evidently replaced the entire diaphysis. A probe in the popliteal sinus touched rough bone. The measurements, which developed a fact or two of interest, I will give at another time.
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1st Operation. Nov. 2J,, 1S97.— Excision of One-Half (Anterior) of the Head, Neck and Upper Portion of Trochanter of the Eight Femuk by Frontal Section. There was a small abscess containing only a few drachms of pus just below and in front of the capsule of the hip joint, which communicated with this joint. The wall of the abscess was carefully excised. Having made the frontal section of the trochanter, neck and head of femur, the extent of the disease in these parts could be accurately determined. The upper end of the soft sequestrum was cut off. The disease had involved the neck and head and had finally, perhaps just after the blow from the pole, infected the hip joint. By some oversight no drawing was made of the lesions in the head, neck and trochanter. Nowhere were there signs of active bone disease; there was a little sequestrum near the top of the trochanter, and a little, very slender bit of sequestrated bone in the neck; the shape of the head and of the neck was not altered by the disease; the head of the bone had lost some of its cartilage, and granulations were growing from the denuded parts. The infection of the joint was probably recent, and it could be demonstrated how this might have taken place. It was not contemplated at the outset to do more at the first operation than to relieve the trouble about the hip joint, for the patient's condition contraindicated an extensive operation. The patient recovered promptly from this and from two subsequent operations upon the middle and lower thigh. As you may see in the photographs, the boy can extend his thigh perfectly, and can flex it to nearly a right angle. He walks without a cane and says that he finds the right thigh as useful as the left. The operated thigh is from 1 to 1.5 cm. longer than the other; and there are 2 cm. of apparent
lengthening on the right or operated side. This apparent lengthening is due in part to abduction and will undoubtedly disappear.
This case sheds a new light upon the surgery of the hipjoint, proving as it does that not only a useful but functionally an almost perfect joint may be obtained even when onehalf of the head and neck of the femur have been removed by, approximately, a frontal section. We may, therefore, attack tuberculous cases in the early stages in some such conservative way, taking a fine and very thin slice from the anterior surface of the neck or head, or trochanter, or from all, and having located the disease, excise only as much as may be necessary. The acetabulum can be explored in a similar manner. If the disease is operated upon early it would probably rarely if ever be necessary to remove the whole head of the femur ; and we may find that having removed a part of the disease the remainder, as in tuberculous peritonitis, may take care of itself the better for having been interfered with aud assisted.
The hip joint, a simple ball and socket joint, promises more for these conservative operations than any other joint ; large surfaces covered with cartilage do not lend themselves so readily to the formation of strong adhesions and ankylosis as the less simple joints; of all the joints the knee is perhaps the least suitable for conservative surgery. With its ligaments and reduplication of synovial membrane, with its fibro-cartilages and numerous recesses and pockets it furnishes conditions well suited to the propagation of the tubercle bacillus ; and when the crucial and lateral ligaments have been much weakened by the disease, an ankylosed joint is usually more serviceable and more comfortable than one in which motion has been secured.
GUNSHOT INJURIES BY THE WEAPONS OF REDUCED CALIBRE.*
By L. A. LaGarde, Surgeon, U. S. A.
My first acquaintance with the military weapons of reduced calibre dates from a time wheu I was pursuing studies with firearms in this institution. I am, therefore, very happy to return here to-night to talk of guns and missiles with you. .
In considering the effects of the modern arm, experimenters have generally studied it by comparison with the older weapon. I hold in my hand the Springfield rifle, calibre 45, which was used by our foot troops from 1874 to 1892. It is a single loader and in expert hands it is capable of delivering 20 shots per minute.
Its projectile has a velocity of translation of 1301 f. s., a Telocity of rotation on its long axis of 800 turns per second, and a maximum effective range of almost 2000 yards. It is made of lead hardened with antimony, cylindro-conoidal in shape, weighing 500 grains, and is propelled by 70 grains of black powder.
I will now exhibit our present service rifle — the KragJorgensen — adopted in 1892 for use by the foot troops. It is
♦Read before the Johns Hopkins Hospital Medical Society, Nov. 10, 1899.
a typical example of the reduced-calibre weapons at present in use by all the powers. It is provided with a magazine which holds five cartridges. In expert hands it is capable of delivering as many as 40 shots per minute. Its projectile weighs 220 grains, 30 calibre, composed of a nucleus of lead, enclosed iu a hard steel mantle. Its velocity of translation is 2000 f. s., the velocity of rotation 2400 turns per minute; whilst it possesses a maximum effective ran^e of 4000 yards, propelled by 37 grains of smokeless powder.
In some experiments which I conducted iu 1892 at Frankford Arseual, under the orders of the Secretary of War, my efforts were especially directed to the difference in destructive effects between the missile of the 45 calibre weapon, and that of a missile so similar to the Krag-Jorgensen bullet, that for all practical purposes they may be regarded alike.
We fired the two bullets altogether one hundred and ten times, into ten cadavers. Our aim was to traverse similar parts of the body or parts offering about the same resistance, with first one and then the other bullet at all the ranges — from 100 to 2000 yards. The ranges were not actual ; they were simulated by reducing the charge of powder so that the projectile was
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given the remaining velocity which was common to it for any given range.
Impart. — The first thing to attract our attention at the outset of our experiment was the difference in the amount of shock imparted to a member when hit first with one and then with the other bullet. The shock was estimated by the oscillation of a limb when suspended. As might have been expected, the greater sectional area and greater weight, of the 15-calibre projectile, caused greater shock than that noted by the smaller and lighter bullet on impact with a resistant bone. Indeed, the difference was so marked that it often happened that the presence of a fracture from the latter was only noticeable upon close inspection, whereas it was invariably predicated by the motion imparted to the member when traversed by the larger bullet. The shock from either bullet as judged by the motion to the limb, was nil when soft parts alone were hit.
The minimum amount of shock from the smaller calibre bullet has been the cause of much concern among military men. The English in the Soudan, and in the Ashanti campaign were so doubtful of the efficacy of this small calibre missile to arrest the impetus of savage tribes that they resorted to the practice of making their missile explosive by filing the nose through the steel casing enough to expose the lead core. This is the famous Dum-Dum bullet which takes its name from the place of its manufacture in India. When the lead is exposed, as stated, the projectile disintegrates on impact with a resistant structure. The fragments of the steel mantle and lead core, acting as individual missiles add greatly to the destructive effects in the foyer of fracture.
Explosive Effects. — Our observations with the old and new rifles were next directed to explosive effects. We noticed these so called explosive effects with the new weapon up to 350 yards, whilst they were seldom exhibited with the old arm beyond 200 yards. Explosive effects in gunshot wounds are peculiar to rifle projectiles impressed with high velocities. Within the zone of explosive effects they are common in the experience of the military surgeon, whereas they are seldom witnessed by the civil surgeon whose experience is almost entirely confined to wounds by pistols, whose projectiles are possessed of comparatively low velocities.
In speaking of explosive effects, one should not confound the term explosive effects with explosive action. The latter term should be restricted to those wounds caused by an explosive bullet — that is, a projectile that explodes on impact. Such a projectile is hollow, charged with explosive materials which ignite when the bullet strikes against a hard substance, like bone. The bullet is thus torn asunder, causing usually an extensive lacerated wound. On the other hand the projectiles possessed of superior velocities do not explode on impact. They are solid, and at most, seldom become altered in shape. Indeed, those of the small calibre, enclosed in a mantle of the hardest steel, do not even deform when they collide with the most resistant parts of the human body; and yet they are proverbial for their explosive effects in the proximal ranges.
Explosive effects are well exhibited by firing the projectile of the old and new arm into tin cans at close range. For the
purpose of comparison, if the experiment is done by firing into tins when empty, and into another set of tins of similar capacity filled with water, the empty cans will exhibit no alteration in shape. The orifice of entrance and exit of the bullet will correspond in size to the sectional area of the projectile; on the other hand the tins that were filled with water will show great alteration in shape. The sides of the vessels will exhibit a bulging as if some interior force had exerted an outward pressure in all directions. The orifice of entrance will usually correspond to the calibre of the projectile, whilst the orifice of exit will be marked by a large irregular opening with everted edges.
If the exjieriments are continued upon a cadaver at close range, impact with a resistant bone will present certain characteristic features: The wound of entrance in the skin will correspond in size to the diameter of the bullet; the wound of exit will be marked by a bursting forth of the skin. "The track leading to the bone is conical in shape, the base of the core corresponds to the wound of exit in the skin, and the apex of the core corresponds to the seat of fracture. The bone is finely comminuted. A close inspection shows that the bony particles have been driven into the tissues at right angles to the bullet track ; it is not uncommon to find bony sand in the wound of entrance."
Five theories have been advanced to explain these explosive effects.
1. Hydraulic Pressure.
2. Compressed air, or the projectile air.
3. Rotation of the bullet.
4. Deformation of the bullet.
5. Heating of the bullet.
1. Hydraulic Pressure. — The term " hydraulic theory " has been employed by many writers to explain the highly destructive effects often found in gunshot wounds at the proximal ranges. It is based on the principle of Pascal. This principle is only applicable to a closed vessel tilled with liquid. In accordance with this principle if a certain pressure is made upon a given area of the imprisoned liquid a similar pressure will be exerted within on like areas of the vessel walls.
The experiments of Coler, Stephenson and others have effectually disproved this so-called hydraulic theory. They have shown that the highly destructive effects noted by firing into sealed vessels filled with liquid were to be noted in the same way when the vessels were unsealed. Ordinary tin buckets filled with water whether the tops were in place or not sustained the same amount of destruction.
2. Compressed air, or projectile air. — This is called the projectile air of Melsens, because it is he who recently revived this theory of projectile air in explanation of the destruction in wounds that so often suggest explosive action. Boys lias succeeded in making exact photographs of bullets in transit. He caused the bullet to cross an electric circuit. At the moment of contact with the circuit the bullet and the immediate vicinity of its trajectory are illumined by a spark which serves to throw the image upon a photographic plate. A study of the views thus obtained distinctly shows a pad of compressed air in front of the projectile. Melsens believed
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JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 106.
that this cushion of air entered the tissues at the moment the skin was penetrated or before, and that the destruction of tissues was to be accounted for by the explosion which occurred when the compressed air again regained its normal volume. The tissues fail to show any evidence of air having been forced into them, such as one might infer from the presence of emphysema, and altogether it may be said that the theory of projectile air has but little to recommend it to consideration.
3. Rotation of the bullet. — The rotation of a rifle bullet is imparted to it by the twist in the barrel. The longer the bullet the sharper must the twist be. The old Springfield 45-calibre bullet, which was but two calibres in length, and which revolved 800 turns per minute at the muzzle described one complete turn in 22 inches, because the twist in the barrel corresponded to one complete turn in 22 inches. In the present rifle the twist is sharper, viz., 1 turn in about 10 inches, and the rate of revolution is estimated at 2400 turus per minute. It is generally admitted by ballisticians that the velocity of rotation is well maintained, — that it does not diminish with the velocity of translation. Taking for granted that the projectile makes a complete turn in ten inches, we must admit that the rotation of the bullet can have but a minimum amount of effect to disjday in traversing a thigh bone which may be but one inch in diameter, because in traversing it the ball is making only T \ of a turn.
4. Defortri'ition. — The fact that the old leaden bullet became deformed when colliding with a resistant bone, especially at short range, added greatly to the amount of destructive effects. Deformation can find no plea as a cause of destructive effect in all cases since the steel-clad bullet that does not deform is proverbial for the creation of explosive effects.
5. Heating. Heating of the bullet by the act of ignition to explain explosive effects found adherents long ago, and it was not until recent years that this erroneous notion was set aside. It is not necessary to explain to an audience like this in the very institution where the significance of heat imparted to missiles was forever determined. We ware able to show in 1892 that the heat on a bullet caused by the ignition of the powder is not sufficient to destroy the ordinary septic germs. The experiments were conducted with missiles from lowvelocity rifles and the weapons of reduced calibre with the same result. To speak briefly we can truthfully say that the heat of a missile cuts no figure in gunshot wounds.*
The true cause of explosive effects is the superior energy possessed by the bullet at the moment of impact. The bone, and even the soft parts, receive a large amount of this energy and move "outwards in lines radiating from the long axis of the bullet-track with such a degree of force that they act as secondary missiles on the neighboring tissues and cause still further smashing and pulping of the tissues. Even fluid particles participate in this secondary action but it is all the more marked when fragments of bone are driven apart in this manner." (Stephenson.)
Soft Parts. — Our next experiment at Frankford with the
♦Proceedings Pan American Congress for 1893, Vol. 1. N. Y., Med. Record, Vol. 47, No. 25.
small-diameter bullet demonstrated that the wound of entrance was usually round, the size corresponding to the diameter of the bullet; the edges of the wound were at times clear cut, but more often they were rolled in and often blackened like the wound of entrance of the old leaden bullets. This, as you know, once gave rise to the idea that the edges of the wound were discolored by burning ; but thanks to the assistance of Professors Welch and Councilman, as already stated, this idea was refuted for all time in the laboratory of this institution.
The wound of exit of the small-calibre bullet was generally larger than the wound of entrance, and beyond the zone of explosive effects especially it was generally round, marked at times by a mere slit; again it was star-shaped, T-shaped, semicircular, &c; the edges were generally turned out.
Diaphyses of long bones. — Our next observations at Frankford Arsenal referred to the effects of the small-calibre bullet upon the compact substance of long bones. Here I may state that the destructive effects of the old and new bullet up to 350 yards were alike, and severe. Beyond 350 yards the lesion in the bony tissue changed perceptibly with the smaller bullet, the comminution was less, the fissures were larger, and the spiculae of bone were not so often detached. The general tendency with the little bullet between 500 and 1500 yards was to inflict a wound approaching a perforation, although a clear-cut perforation in the diaphysis itself was seldom seen. At 2000 yards the small bullet showed a tendency to again shatter the bone.
Effects upon the epiphysial ends of long bones. — Clear-cut perforations were generally observed when the small bullet traversed the spongy ends of bones. This was especially true after the zone of explosive effects and even within this zone — 350 yards — complete perforations with little or no Assuring were often seen.
Actual Conditions. — Of the wounds noticed in Cuba during the Santiago campaign I may add that they partook the general characters of the wounds that I have described as exrjerimental wounds. The wounds of the soft parts healed immediately, without an exception to my knowledge, under antiseptic dressings. The wounds of joints, including the knee, elbow, shoulder and hip were immobilized, dressed antiseptically, and they all did well. The wounds of the skull, including brain substance almost invariably suppurated, owing no doubt to the amount of dirt introduced from the scalp with the bullet.
Wounds of the lungs. — Those that survived 24 hours generally did well. In the majority of instances it was difficult to restrain the men after two or three days.
The wounds of the abdomen were generally fatal. Four or five men recovered with gunshot wounds that appeared outwardly to have perforated the intestines, but no actual proof of such perforation was obtainable. I was told that three laparotomies for gunshot injury of the abdomen were done at one of the field hospitals. The patients all died in a few hours after operation. For mauy reasons laparotomy for gunshot wound in the abdomen on the field was not considered safe or practicable. Upon the whole, the gunshot injuries by the Mauser, the reduced-calibre rifle of the Spaniards, were in keeping with those humane effects so confidently predicted by
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
23
experimenters generally. The wounds of soft parts healed without suppuration. The lesions of bone that formerly caused such a high mortality in the statistics of wars were most successfully treated by antiseptic dressings and the proper use of immobilizing materials. Comminution, and Assuring were noticed in the diaphyses. It was, however, seldom necessary to cut down for the purpose of removing spiculse of boue, as the displacement of fragments did not require this amount of interference. The clean-cut perforations of the epiphyses, without fracture, rendered joint injuries the most favorable of all bone lesions for rapid healing, with little or no loss of function. This was especially true of gunshots of the knee.
The difference between the gunshot wounds of civil and military hospitals will be more marked in the future. The civil surgeon will continue to treat pistol-shots in which the balls often lodge. Some lesions from this source often show complete separation of fragments, which necessitates cutting down. The joint lesions are often severe, necessitating the opening of the joint, under antiseptic precautions, turning out blood clots, removing fragments, etc. Such precautions are necessary to insure against sepsis. On the other hand, it may be said that the action of the steel-clad bullets from the present military weapons and the use of antiseptics have so modified the results in the gunshot wounds of warfare that the burden of the military surgeon and the sufferings of the patient, immediate and remote, will be very much lessened.
Discussion.
Exhibition of Radiographs showing Results of SmallCalibre injuries. — Dr. W. C. Borden, U. S. A. — During the late war I was stationed at Key West with an X-ray machine, and from a study of the wounded soldiers I have arrived at some general conclusions relative to the effects of the small-calibre bullets on the human body, more particularly upon the bones. Dr. LaGarde has gone over the consideration of the theoretical effects of the bullets and these pictures will show the clinical effects as demonstrated by the Roentgen ray.
It seems to me that there are four main elements that influence the effect upon bone tissue — (1) the velocity of the bullet — (2) the part of the bone struck — (3) the angle of incidence and (4) the form of the bullet. Clinically, there is one thing above all others that affects the course of the case, and that is the presence or absence of sepsis in the wound.
When the bullet is traveling at extremely high velocity the explosive effects are produced whether the bullet strikes the bone, I mean now the shaft of the bone, at any angle or in any part. For instance, if it strikes the bone perpendicularly, it will produce a bad fracture, and it will do this equally if it merely grazes the bone. When the bullet strikes the bone laterally, merely grazing the periosteum at a high velocity, it produces a fracture that may be termed a fracture by contact. Here is an illustration (showing radiograph) ; the bullet passed across the front of the forearm, just grazing the radius, and yet, as you see, it shattered the bone completely; and here is an example showing a similar effect upon the hand at short
range. In this case the whole distal end of one of the metacarpal bones has been blown completely out, and yet the wound of exit was very little larger than the wound of entrance; the range was five hundred yards.
So much for the effect upon the human body when the velocity of the bullet is at its greatest. Now, the angle of incidence seems to me to have a marked influence. When the bullet strikes the bone in the median line with perpendicular impact, it shatters the bone as badly as if it were within the explosive range. Here is an illustration of a fractured thigh, in which the bullet went straight through, striking the femur with a median impact, and you see how badly the femur is shattered. In a little over a year after the injury I radiographed this same case; the wound had healed readily without any suppuration, and though there is a tremendous callous formed about the fracture, the position and function of the limb are almost perfect. Now as to tangential impact, when the bullet strikes the bone at an angle the fracture and Assuring are not so great, no matter what the range may be, provided it is outside the explosive zone. In this case (showing radiograph) the bullet struck the outer side of the radius, tore off a piece of bone and made a straight fracture.
Now as to the form of the bullet. Dr. LaGarde has spoken only of the bullet as it strikes after passing through the air; but in war it may ricochet, strike some object, become deformed and then strike the body. In these cases the effect of the bullet is decidedly different from that of the plain undeformed bullet. In this case (showing radiograph), for instance, the bullet struck some object before it hit the man, and the whole end of it became flattened so that it was practically like a Dum-Dum bullet. The velocity was low, for the bullet lodged in the tissues and yet because of its extreme deformity when it struck the bone it shattered it immensely. Here is an injury of the same class showing two bullets in the same limb. Both bullets were deformed and the shattering was very great. Here is a photograph of several Mauser bullets removed after X-ray examinations of the patient. All but one of them are deformed.
Here is a rather interesting radiograph showing the passing of a Mauser bullet through a phalanx. The bullet is so small and travels with such velocity that it may pass through a finger and not tear it off as would a larger bullet. Relative to this case I would say that gunshot injuries of the hand always cause some permanent loss of function. This is due to injury to the soft parts; and in regard to injury to the soft parts by the small-calibre bullet I would say that we have had a great many cases where, though the bones were markedly shattered, if the soft parts were not much torn there was not much loss of function ; but if the soft parts were greatly disturbed, the resulting cicatrizing tissues caused considerable disturbance of function.
The injury produced by these bullets to the ends of long bones is quite different from that of the shafts. In the shaft the Assuring and comminution are always greater than in the extremities. Whatever the theory of explosive effect may be it is certainly true that the dense tissue of the shaft transmits the shock more than the softer tissues and causes greater solution of continuity.
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JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 106.
Concerning the humane effect of these bullets I should say that where they do not kill outright they are certainly much more humane than the old bullets were. I saw some cases, — one I remember in particular — where the bullet passed through
the abdomen, directly through the liver, and yet the patient was up and ran away from the hospital eleven days after receiving the injury.
A RECONSTRUCTION OF A GLOMERULUS OF THE HUMAN KIDNEY.
By William B. Johnston.
(From the Anatomical Laboratory of the Johns Hopkins University, Baltimore.) WITH SIX FIGURES.
Since the appearance of Carl Ludwig's article upon the Kidney in 1872,* in which he devotes but a few words to the structure of the glomerulus, and in which are reproduced a few drawings of the glomeruli of mammalian kidneys, other investigators have been inclined to pass over this part of the vascular mechanism of the kidney, mentioning only its afferent and efferent vessels. The difficulty of seeing anything but the exterior of a glomerulus has, of course, always obscured its intimate structure. For these reasons it has appeared advisable to make a more careful study of the arrangement of the blood-vessels of the glomerulus by means of the method of reconstruction.
The requirements for such a reconstruction are a perfect set of serial sections through a well injected glomerulus, the sections being thin enough to pass at least twice through any of its vessels which may be struck parallel to the plane of cutting, as well as a conception of the outward form of the glomerulus previous to cutting.
Preliminary injections of the dog's kidney with a variety of substances brought out the advantages of a supersaturated aqueous solution of Berlin blue over other injection masses, and the advisability of selecting and cutting a single glomerulus. Adult human kidneys from the autopsy table were usually abnormal and always failed to be well injected. In order, therefore, to obtain a good injection of a normal glomerulus, the kidney of a child three months old, dead but a few hours, was injected in situ through the abdominal aorta until the Berlin blue appeared in the renal vein. The difficulty of obtaining a faultless series of very thin sections was greater than that of selecting and cutting out a well-iujected glomerulus from clear bits of this kidney, though very many seemingly perfect glomeruli proved to be but partially injected. A chosen glomerulus from the child's kidney was imbedded in paraffin in the usual way and cut into serial sections 3 /x thick. The 3-1 sections through this glomerulus were then stained in Upson's carmine and mounted in balsam. Drawings of each of these sections enlarged 1333 diameters, the greatest convenient enlargement, were made with a camera lucida (Figs. 4, 5, 6) and the corrected drawings transferred with carbon paper to wax plates 4 mm. thick, i. e. 1333 times as thick as the original sections.
•Handbuch der Lehre von den Geweben des Menschen und tier Thiere. S. Strieker, Vol. 1.
Before beginning the reconstruction, that part of each plate representing the glomerulus proper was cut out, the line of iucision following the outer borders of the external vessels, leaving Bowman's capsule in the outer shell. The remaining wax shells thus obtained were carefully piled in order, and a plaster-of-Paris cast made of the cavity. The solid cast roughly indicated the external form of the enlarged glomerulus. As a further guide to the reconstruction, the sections of the blood-vessels appearing in each plate were cut out with the exception of wax bridges connecting them. The internal relation of these sections in wax representing the blood-vessels was thus preserved, which aided materially in piling and blending the individual sections.
XV
Fig. 1. — Was model of the glomerulus, enlarged 444 diameters, seen
in profile from the left side. A F afferent vessel ; E Fefferent vessel.
From the model thus made it appears that the afferent vessel of the glomerulus, after entering the capsule of Bowman, immediately divides into five diverging branches, which with their subdivisions and with the efferent vessel form an almost spherical tuft of blood-vessels. For the sake of description we may assume that the glomerulus is suspended from its afferent vessel. The efferent vessel originates, roughly speaking, from a loop of capillaries which projects in the equatorial plane from the side of the glomerulus opposite the efferent vessel, but to the right of the median line (Fig. 2 E. V.). From this point the course of the efferent vessel is upward, inward, and to the left, grooving the superior surface of the glomerulus and dividing it into two unequal parts. This vessel leaves the glomerulus a little superior and
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
25
anterior to the point where the afferent vessel divides and in a direction opposite to that of the efferent vessel. (Fig. 1.)
Fig. 2. — Wax model of the glomerulus, same enlargement and same
view as in Fig. 1. The left lateral group of capillaries is separated
from the median group and turned back, exposing the interior of the
glomerulus, a. A short section of a capillary of the median group is
removed to show the course of the deeper-lying capillaries.
Externally the upper half of the glomerulus is seen to be composed of freely anastomosing capillaries, somewhat more pronounced on the left than on the right side. The capillaries of the lower half, except on the posterior surface, are loDger and more direct. The projecting loop of capillaries mentioned above, the course taken by the efferent vessel within the glomerulus, and the tendency of many of the external capillaries to turn towards the right side, give the glomerulus the appearance of being twisted to the right. Except on the superior surface where the left half is a little above the right, the spherical form is well preserved. Lobulation where it appears at all is superficial. (Fig. 1.)
Fig. 3 — Diagram of the wax model seen from the left side. Enlarged
444 times. The right lateral group of capillaries is turned back from
the main group. The group E F is a connecting loop turned over to
expose deeper capillaries. The lines marked Figs. 4, 5 and 6 indicate
that Figs. 4, 5 and •', are taken from those planes, representing sections
7, 17 and 30 respectively of the original series.
The capillaries of the glomerulus can be roughly divided into a right, a left and a median group, corresponding to a right branch (Fig. 3 A), a left branch (Fig. 2 B) and a median branch (Figs. 2-3 C) of the afferent vessel. Two additional branches, a right lateral branch (Fig. 3 D) and a
left lateral brauch (Fig. 2 E ), take part in the fornmtiou of the lateral group of the corresponding side and of the median group. All rive branches arise from the afferent vessel at the same time though at different angles. The distances between their points of origin are not the same. According to Ludwig, the glomerulus is composed of from 4 to 8 groups of bloodvessels.
Each main brauch from the efferent vessel subdivides almost immediately. Each of the two lateral branches (D and E) has three subdivisions which are soon lost in the three main groups. They have in general the same arrangement.
Fig 4.
In the upper half of the left group (Figs. 1-2) there is a complex network of anastomosing capillaries. In the right group (Fig. 3), which is smaller than the left group and lies at a lower level, the course of the capillaries is more direct.
Fig. 5.
FlOS. 4, r> and fl. — Camera tracings of sections 7, 17, and 30, showing the capillaries, reticulum nuclei and Bowman's capsule. Enlarged 444 diameters.
The capillaries of the median group nearest to and farthest from the origin of the median branch (C) are in general longer and freer than those of the other group. The intermediate capillaries are short and the anastomoses frequent
