JOURNAL OF SURGERY.

Infective Hemorrhages from War Wounds. HAROLD NEUHOF and FORDYCE B. ST. JOHN, New York. Surgery, Gynecology and Obstetrics, August, 1919. Neuhof and St. John present 45 cases of so-called secondary hemorrhage from war wounds. They prefer the term infective hemorrhage rather than secondary hemorrhage, because in practically all cases of war wounds showing late hemorrhage, the infectious process is present, and can often be pathologically shown invading the arterial wall. In all specimens of arteries resected for infective hemorrhage, the rupture was an oval defect or elliptical defect, lying in the long axis of the vessel. The margin of the defect was often smooth and rounded off, shaggy in other cases. Thrombi in the lumen were occasionally observed. The authors present a detailed study of the pathological condition of the arteries involved, showing the invasion of the infective agents. Many types of bacteria were found, but they could rarely be demonstrated in the muscularis except at the site of rupture. There is often associated a fatal vein infection, or suppurative thrombosis of the adjacent veins. The treatment is mainly prophylactic. Conservative measures, such as packing are dangerous even in the slighter cases. Amputation is indicated for most cases of hemorrhage from the popliteal or posterior tibial artery. The main artery should be tied off in a non-infective area. Where amputation is not indicated, it is better to resect the artery through an incision above the source of hemorrhage, preferably in a noninfected area. The authors call this the "surgical approach." The veins, unless they are important trunks, should be resected at the same time.

The Treatment of Metastatic Carcinoma of the Spine by Deep Roentgenotherapy. GEORGE E. PFAHLER. Surgery, Gynecology and Obstetrics, September, 1919. The author presents four cases of metastatic carcinoma of the spine treated by roentgenotherapy. From his observations in these cases, he feels warranted in presenting the following conclusions:

1. The roentgen-rays when applied properly and in sufficient quantity upon deep-seated cancer tissue, may be ex

pected to destroy the cancer cell, and this cancer cell is replaced by healthy scar tissue or fibrous tissue.

2. As a result of this healing process, the patient's life is prolonged and he is made more comfortable.

3. One cannot expect the patient to make a complete, permanent recovery, for ultimately the disease is apt to show metastases particularly in the areas not treated.

4. It is entirely likely that these metastatic carcinomata of the spine, without other evidence of metastatic involvement, have an unusual amount of natural resistance, and that this increased resistance on the part of the patient helps us greatly in the healing process. It seems likely that many of the patients, or most of them, die of visceral involvement, before there is time enough for symptomatic disease to develop in the spine, and so it is only in more resistant cases that there is time for spinal metastasis.

5. With the clinical and microscopic proof of the destructive action on malignant tissue followed by a healing process, and with the experimental proof of a decrease in malignancy of cancer tissue, which has been exposed to the x-ray, and a decrease in its capacity for inoculation, we can recommend most strongly the use of deep roentgenotherapy both as pre-operative treatment to be followed immediately by operation, and as post-operative treatment, given after the proper interval, which should be four weeks after the pre-operative treatment.

Chronic Septic Inflammation in Bone Following Gunshot Wound. W. E. GALLIE, Major, C.A.M.C. The Journal of Orthopedic Surgery, August, 1919. Gallie reviews the older and modern methods of treatment of bone sepsis and chronic osteomyelitis. From previous knowledge and from experiments in bone repair and bone infection in animals, the author presents the following conclusions as regards the mechanism of bone repair and the treatment of bone infections:

1. The periosteum is the medium by which the bloodvessels are distributed to the shafts of the bones. Reflection of the membrane produces superficial necrosis and should never be done when sepsis is present or feared. 2. The periosteum as reflected in an ordinary surgical operation is merely a fibrous tissue membrane and is not osteogenetic. It should therefore never be relied upon to restore the shaft after resection.

3. Mild chronic septic infection is a strong stimulant of inflammatory osteogenesis. It causes widespread osteoporosis, increased vascularity, and abundant callusformation. This is the state in which cavities are most apt to heal, and fractures to unite, unless prevented by some definite condition such as the presence of sequestra or the existence of too large a gap.

4. When the irritation subsides or disappears, this rarefying oste 'tis gives place to an intense sclerosis which is very inimical to the healing of cavities or fractures.

5. Treatment should therefore take advantage of the pathological condition which is present at the time the sequestra have separated, and aim at a complete cure before osteosclerosis has supervened. It should consist of the complete excision of the scar and sinus, and the wide removal of the walls of the cavity for the purpose of thorough evacuation of sequestra and unhealthy granulation tissue. All irregularities and pockets must be obliterated, and when possible the depth of the cavity should be reduced by allowing the soft structures to fall into it. Pedunculated muscle- or fascia-flaps are of great assistance in promoting rapid healing. Finally, wide-open drainage must be provided so that the cavity can hea1om the bottom without depending on the danes alternative of a narrow sinus.

6. Taylor's apparatus is useful in cleansing these wounds before operation and is of great value in the treatment of post-operative sepsis.

7. Non-union in compound fractures, uncomplicated by great loss of bone, is rare. When present, the fact that the wound is septic is no contra-indication to active treatment of the fracture, as well as of the osteomyelitis. Gratifying results may be anticipated from thorough freshening of the ends and adjusting of the fragments, providing efficient dra'nage is secured.

8. The best time to correct mal-union in septic cases is at the time of the operation for the disease in the bone.

VOL. XXXIII.

SURGERY IN DIABETICS.

MARCEL LABBÉ.

Professeur Agrégé a la Faculté de Paris, Medecin de la Charité.

There are few situations more delicate than that of the physician who has to assume responsibility for surgical intervention in a case of diabetes. Should the patient be operated upon? Is there less danger in temporizing than in operating? What anesthesia should be used? What pre- and postoperative treatment should be followed. These are serious questions, difficult to decide, because many points are not yet settled in spite of important contributions, by Becker, Naunyn, Ruff, Karewski, Berger, Poucel. I propose simply to state the problem and to present certain indications, based upon rather numerous observations.*

The main conditions rendering operations in diabetics dangerous are: 1, Hyperglycemia; 2, Acidosis. I do not mention the dangers due to vascular lesions, because while these occur frequently in diabetes, they are not essentially diabetic lesions; they are due to associated conditions (syphilis, arteriosclerosis, Bright's disease); gangrene due to endarteritis in the extremities does not occur in young subjects with severe diabetes, but in the moderate diabetes of stout subjects, suffering from venal sclerosis.

I. Hyperglycemia. Hyperglycemia favors suppuration. Some years ago, this was the main dread of the surgeons; Roser, Israel, König, had insisted upon the necessity of reducing the hyperglycemia before operation, by a suitable diet. Today suppuration is less feared; in aseptic operations it is rarely a fatal complication, numerous cases of healing by primary intention could be cited; in order to cause suppuration, there must be not only a predisposition, but bacteria, and the surgeon does not usually introduce them.

Complications resulting from hyperglycemia, while they often delay the cure, are practically never fatal. They can be prevented by reduction of the hyperglycemia and glycosuria, by appropriate diet; carbohydrate restriction. This preventive treatment is especially useful, when surgery is per

Labbé, La chirurgie chez les diabetiques. Academie de Médecine, 19 Mai, 1914.

No. 11

formed in areas like the perineum, subject to soiling by the urine.

When the surgeon is faced by suppuration (phlegmon, carbuncle, moist gangrene), requiring immediate surgical intervention, the hyperglycemia must be reduced as quickly as possible. It is here, that the absolute fast, with or without purgation is of great assistance; the aggravating action of fasting upon acidosis, should not be feared. This has been considerably exaggerated. I have observed cases of diabetic acidosis, in which fasting diminished the ammonuria and acetonuria.

II. Acidosis. This is a much more serious menace. It causes post-operative coma, and speeds the death of many diabetics. Hoffa has cited striking cases of post-operative coma, in cases which were sugar-free after diet. Death surpervened in one day, sometimes more slowly or occasionally at the end of several hours, the subject never awakening from the anesthesia and falling thus into coma.

Numerous conditions affect the course of postoperative acidosis; these are the severity of the diabetes, the nature of the operation performed, the anesthetic employed, and the treatment followed.

1. The severity of the diabetes. In diabetics, suffering from emaciation and acidosis, the slightest operations are dangerous; chloroform is almost fatal; a simple incision, even without anesthesia, may lead to coma.

In diabetics without emaciation, but in an attack of acidosis, the danger is also very great, but the resistance is better. Many such subjects survive after operations under general anesthesia.

In diabetics without emaciation or acidosis, coma, as a rule need not be feared; but it should not be forgotten, because operation under an anesthetic may cause the appearance of acidosis in a subject who did not present this symptom before operation. I saw such a complication, in a diabetic woman, who had been under chloroform one hour, for a perineorrhaphy. Before the operation, her urine contained no diacetic acid; at the end of the opera

tion, a catheterized specimen of urine gave a strong Gerhardt reaction; for three days the patient was in danger, but thanks to energetic alkaline treatment, she recovered and several days later the acidosis diminished and then disappeared.

JOURNAL OF SURGERY.

Thus the pre-operative condition of the patient assists in determining the prognosis. Three degrees of severity can be distinguished: 1, diabetes with emacination and acidosis; 2, diabetes without emaciation but with an attack of acidosis; 3, diabetes without emaciation or acidosis.

2. The Nature of the Operation. The nature and the gravity of the operation are conditions which influence the danger of acidosis. Extensive operative traumata and operations requiring a long time, are most to be feared. Pre-operative anxiety caused by fear of the knife may also play a part; I have seen one case in which such anxiety was the cause of a severe attack of acidosis in a diabetic without emaciation. Acetone rose from 0.32 to 0.51, and diacetic acid which was not present before, appeared in the urine. But, in fact, the anesthetic is more dangerous than the knife in operations upon diabetic subjects.

III. The Anesthetic. The most dangerous anesthetic is chloroform. It may even produce mild acidosis in non-diabetic subjects. Rolland has reported frequent acetonuria and occasionally diacetic acid in the urine, following chloroform anesthesia; Baldwin has seen acetonuria as a result of chloroform and other anesthetics. As a matter of fact, in subjects who have neither diabetes nor liver disease, acidosis is simply a matter of record; I have often looked for Gerhardt's reaction, without ever finding it.

From another angle, Nicloux, who has studied the decomposition of chloroform in the tissues, has reported that it is accompanied by extraction of alkali from the tissues in considerable proportion, with a consequent tendency to acidification. If the organism is healthy, it counteracts the acidosis and repairs the loss, but this does not occur when the organism is sick.

Even in diabetics without loss of nutrition, chloroform may produce acidosis. In cases presenting no emaciation and slight acidosis, chloroform aggravates the intoxication and may precipitate coma, but in any event recovery may take place; I have seen such a case recently, a woman who underwent amputation of the forearm, necessitated by a very severe phlegmon, now has a perfectly healed wound; she still has glycosuria, but no acetonuria.

In diabetics with malnutrition and acidosis, chloroform is fatal. Chloroform should also be feared in subjects with liver lesions. The toxic. action of chloroform on the liver has been ably demonstrated by the researches of Doyon, N. Fiessinger, Chevrier, R. Bénard and Sorrel, Rolland and the observations of Quénu. Severe icterus has

been seen to follow chloroform anesthesia, and I have seen several cases of hepatic insufficiency with or without icterus, which caused rapid post-operative death; hepatic necrosis has been produced experimentally in animals, and finally the following substances have been found in the urine of patients operated upon under chloroform; urobilin, albumin, biliary pigments, acetone, glucose (or the possibility of provoking alimentary glycosuria by ingestion of sugar); these are indications of serious functional disturbances of the liver. The tendency of chloroform to injure the liver, is one of the chief reasons for the gravity of operations upon this organ.

Ether is supposed to have to have a less toxic action than chloroform. But one cannot depend on this, for I have seen ether cause the death of a patient, a diabetic, without emaciation, but in an attack of acidosis, for whom the most careful preand post-operative precautions had been taken.

Prolonged ethyl chloride anesthesia seems to be the best tolerated by diabetics. I have seen a diabetic without emaciation, withstand remarkably well an anesthesia lasting 55 minutes, under ethyl chloride, for mastoidectomy; he had previously shown traces of diacetic acid in the urine; not only was he free of post-operative complications. but the day after the operation the diaceturia was no longer present.

Boureau, who has had wide experience in prolonged ethyl chloride anesthesias, told me that he had anesthetized 17 diabetics by this method. Six of these had acetonuria. The operations were of a serious nature lasting twenty to sixty minutes, and requiring the use of 35-100 cc. of ethyl chloride. A number of these patients were of advanced age. In spite of all this he had not a single death.

Spinal anesthesia by lumbar injection of cocaine or novocain is preferable to ether or chloroform in diabetics.

It was well withstood by a patient who underwent disarticulation at the knee for gangrene. No reaction of acidosis appeared in the urine.

Local anesthesia, by means of the subcutaneous injection of cocaine or stovaine, or novocain is the method of choice to be employed in cases of diabetes. I have seen it well tolerated by many patients. It does not provoke acidosis. Professeur Réclus has told me that he obtained excellent results with it, in amputations upon diabetics.

IV. Pre-operative and Post-operative Treatment. Vegetable diet (dry legumens, oatmeal) or milk diet, either of which counteract acidosis; the administration of a large dose of bicarbonate of soda before the operation may diminish the danger of

acidosis. The following case observed at the Dubois hospital furnishes a good example. This diabetic with acidosis had to undergo at a few days interval, two successive amputations, for gangrene of two toes. The two operations were identical. The first time I gave him 30 grams of bicarbonate of soda before the operation. The result was excellent; the second time this precaution was negnected and the patient went into coma and died.

It has been suggested that preventive injections of glucose be given to combat acidosis; this may be of use in healthy subjects who can utilize the glucose, but in diabetics who do not burn the sugar, I see no advantage; on the contrary it seems quite disadvantageous.

Surgeons seem to be agreed on this point,-not to subject patients about to be operated upon to an unnecessary fast. Certain of them even give preoperative doses of sugar, in non-diabetic subjects.

Even if the main lines of prognosis are known, it does not follow that cases always take the cause indicated in the examples given. There are always unforeseen accidents and successes, in as much as we are still in ignorance of many of the conditions affecting acidosis. However, one cannot be too careful or too cautious, or too conservative about surgical intervention and especially of general anesthesia in diabetic patients.

Conclusions. The following rules seem to me to be the best guide in cases of diabetes where surgical intervention is necessary.

1. Only those operations should be performed which are absolutely necessary. Particular caution should be used in cases with acidosis. However, it is better to operate, than to allow an infection to become generalized which may kill the patient by septicemia or the acidosis which it provokes.

2. The operation if not urgent, should be preceded by treatment directed against the hyperglycemia and the acidosis. The treatment has the following basis: 1, mixed diet with little meat and reduced carbohydrate (if there is no acidosis) so as to reduce the hyperglycemia; 2, diet of dry vegetables or oatmeal, or milk if there is acidosis; 3, the administration of bicarbonate of soda in sufficient dosage to render the urine alkaline.

3. Immediately before the operation the fast should be lifted. The patient may also be given 40 grams of bicarbonate of soda.

4. The choice of anesthetic is of great imporThe following are preferred: Local anesthesia with cocaine or its substitutes; if this is impossible, spinal anesthesia; if general anesthesia is necessary use ethyl chloride; in cases of diabetes

JOURNAL OF SURGERY.

with acidosis neither chloroform nor ether should ever be used.

5. After the operation, bicarbonate of soda should be given by mouth, or if this is impossible by intravenous injection in sufficient quantity to render the urine alkaline. If there is severe acidosis 100 grams may have to be given. As soon as the patient can eat, he should be given vegetable broths, oatmeal soup, purées of dry vegetables, or milk. The alkaline treatment should be continued until all reactions of acidosis have disappeared.

THE TREATMENT OF MAXILLO-FACIAL
INJURIES IN THE ZONE OF THE
ADVANCE.

ARTHUR M. SHIPLEY, M.D., F.A.C.S.,
BALTIMORE, MD.
and

JOHN F. DILLON, D.M.D.,
BOSTON, MASS.

During the time the junior author served in the British Expeditionary Force in 1915-1916, a certain period was spent in a Base Hospital devoted almost exclusively to the treatment of jaw injuries.

When these cases were received, it was often days after injury, due to lack of cooperation in the transportation of this class of cases. The startling fact was that when admitted to this hospital the fractured jaw cases had been given no previous treatment. Cases of fracture of other parts of the body arrived in this same base area with splints applied.

The reasons for this were obvious:

1. No men properly trained in the treatment of fractured jaws were assigned to Casualty Clearing Stations.

2. While the principle of the treatment of fractured jaws differs in no way from that of other parts, viz. early reduction and fixation of the bony parts, the application is not so simple. There is no standard splint that can be applied.

With this experience as a basis, as well as what we learned from the Paris base hospitals later, especially the American Ambulance at Neuilly, we determined to bend our efforts to earlier treatment of fractured jaws than had hitherto been attempted. During the months of June and July, 1918, Evacuation Hospital No. 8, was stationed at Juilly, not far from Paris, and we had occasion to visit the hospitals in Paris to which many of the wounded of the Belleau Woods affair and the Second Battle of the Marne had been evacuated. We were especially interested in learning what we could of

jaw and face surgery. We were much impressed by the big, gaping and infected face wounds, associated with fracture of the upper or lower jaw. The junior author had spent nine months with Major Kazanjian in General Hospital No. 20-a British hospital-and we were very much interested in the entire subject.

It was noticed that these wounds behaved badly, they were heavily infected, there was much sloughing with consequent loss of tissue that could ill be spared, and that great retraction of the wound. edges took place. All this required in many cases repeated plastic operations before a good result could be obtained. This made for a long convalescence, with oftimes considerable deformity and consequent disfigurement.

We therefore decided to undertake, if possible, an immediate surgical treatment of these cases in our own service, which was an Evacuation Hospital near the front.

In August we were sent to a new station near Verdun, and were behind the American Armies during the entire offensive that began with the reduction of the San Mihiel salient September 12th and continued until the armistice on November 11th. During this time Evacuation Hospital No. 8, was receiving seriously wounded men, and admitted 6,200 wounded, among whom there were 43 with fractured jaws. In practically all of these the fracture was associated with injury of the adjacent soft part, sometimes a small wound, but often a large and extensive one. One of the first One of the first things to impress us was that no matter how extensive the wound in the soft parts or how wide the separation, there was rarely any considerable loss of substance, but the defect was caused chiefly by retraction of the wound edges. Most of these men reached us within 18 hours of the receipt of injury and many of them much earlier. In all cases of suspected fracture of the upper or lower jaw the junior author was called at once in consultation. If the jaw was fractured and there was accompanying injury of the adjacent soft parts, some form of splinting was applied and the soft parts were immediately repaired. These two proceedings will be taken up separately, to which will be added a report of the cases and some conclusions therefrom.

We regret very much the lack of photographs, but the machinery of an evacuation hospital during an offensive will not tolerate delay. Its efficiency depends upon many things, of which speed is not the least important.

Between October 1st and November 11, 1918, forty-three cases of fractured jaws were admitted to Evacuation Hospital 8, A. E. F. Of these, thirty-seven were of the mandible, one of the maxilla, and five involving both the mandible and maxilla.

FIXATION. When time permitted permanent splints were made, and twelve cases were evacuated to base hospitals with apparatus of a permanent character in place.

As soon as patients had been admitted, they were immediately radiographed. At first only flat plates were available, but Capt. Alleman later was able to secure a stereoscope, which gave more definite information. In the operating room the wounds were thoroughly examined and the method of treatment was decided upon. In all cases dependent drainage was provided if not already established, and foreign bodies were removed.

The method of fixation used depended upon circumstances existing in the hospital, and the problems presented by the cases themselves. It is impossible to lay down rules for the reduction and fixation of fractured jaws. Each case must be considered individually. As stated, in twelve cases permanent splints were adjusted. These were metal band and wire splints, and vulcanite splints.

In eleven cases the injuries were at the angle of the mandible, and the lower jaw was wired to the upper jaw with the teeth in occlusion.

In several cases, especially where the tongue was swollen, temporary open bite splints were applied. In fractures of the maxilla, Kingsley splints with extensions, extra-buccally, connected with head-gear, were used.

In cases of extensive wounds of soft parts, immediate reduction and temporary fixation of bony parts were secured. Heavy arch wire of german silver and brass orthodontia wire were used. Often when these were partly in place, the final adjustment was left until the post-operative period of nausea had passed, when they were tightened up. After fixation the plastic operation of soft parts was performed. As soon as the sutures could be removed, the temporary apparatus was replaced by one of a more permanent character, or the patient was evacuated to a base hospital where it could be done.

The splints used were those which could be easily and quickly made, and in fact all the work was made as simple as possible.

It is not feasible to keep cases of fractured jaws in an evacuation hospital for more than a few days,