BLOODLESS SURGERY. The method originated by Lorenz is employed in orthopaedics and, strictly speaking, is not bloodless, for the bruising that may result is evidence of ruptured blood-vessels ; a better term would be woundless or subcutaneous surgery.
Nerve Stretching.—Of all soft parts the nerves are the most sensitive to stretching. "Pins and needles" is a familiar example of the fact. Should pressure on the nerve last a comparatively short time (say some hours) paralysis may ensue, the nerve re maining anatomically uninjured. Such a paralysis persists for many months.
Reactive Swelling.—Another danger of modelling correction is reactive swelling of the soft parts after the procedure. The plaster cast, maintaining the limb in the corrected position, must therefore be very accurately upholstered and even split appropri ately, to provide room for the swelling, which is always to be expected, or gangrene may develop.
Nature of Deformity.—The aim of modelling procedure is correction of deformity, and the essence of deformity is impair ment of function, with or without obvious alteration in shape of the bones of which a joint is composed. Most of the deformities are represented by fixed joints. The angle, in which a joint is fixed, is of no importance. Ankylosis is beyond the reach of bloodless surgery. If an ankylosed knee is not straight, it cannot be made so by the modelling correction, but solely by the chisel. Contracted joints, however, with even the slightest trace of mobility, represent the most important objects of bloodless treat ment. But even here the field of bloodless surgery is limited by the nature of the underlying disease.
Contractures.—To make evident the necessity of such further limitation, contractures must be classified according to their ori gin. The most important causes of contractures are tuberculous disease of the joints, rickets and similar softenings of the bones and infantile paralysis. Congenital deformities, though less fre quent, are, in many cases, the cause of contractures. In addition there are contractures caused by accident (fractures of bones, luxations of joints), by rheumatic joint diseases, by luetic, cere bral affections, etc.
Tuberculous Contractures.—On the whole the army of crip ples can be divided into two groups, viz., diseased cripples and healthy cripples. Among the first are those whose contractures are due to tuberculosis. The treatment of tuberculous bone and joint diseases exclusively belongs to bloodless surgery. Resections of tuberculous joints in children in the course of time often result in deformities more severe than those occurring naturally. Open air life, plentiful food and sunshine, combined with bloodless mechanical treatment, bring about results which contrast favour ably with those due to the knife. This is particularly noticeable in spinal tuberculosis.
The Plaster Bed.—The apparently difficult problem of im mobilizing the spinal column has been solved by Lorenz's plaster bed, which is a well-upholstered plaster model of the trunk. Though pain has been severe, especially during the night, the patient in his plaster bed is exempt to such a degree that he bears perambulator exercise with equanimity. Thus he is neither con fined to his bed nor to his room, he can enjoy open air, sunshine, undisturbed sleep, his appetite increases, and he gets well without any operation. The developing gibbosity can be lessened, and sometimes even prevented, by adjustable cushions placed under neath the prominent parts. A similar plaster bed has been em ployed with benefit for spinal injuries.
Other Joint Diseases.—In the same way immobilization is essential in the treatment of all other tuberculous diseases of the joints (hip-disease, white swelling of the knee, etc.). Immobiliza tion by plaster casts is superior to extension, though this latter method is also useful as a means of fixation. By far the greater number of cases of tuberculous joint diseases, develop contrac tures, whatsoever method of treatment they may have gone through. Should the contracture not be evident at the time when the treatment has come to an end, it will develop later.
The usual contraction of the knee-joint is flexion, of the hip joint flexion and abduction. Although Lorenz advocates bloodless surgery in the treatment of the acute stage of tuberculous joint diseases, he warns strongly against treatment of the resulting contractures by modelling correction. The healed tuberculous joint is comparable to a bone scar and should not be torn asunder, lest the tuberculous process be stirred up anew. Such contrac tures call for the chisel, and correction is done not in, but near, the joint (pararticular osteotomy).
Rickets.—To the diseased cripples also belong patients suffer ing from rickets. During the acute stages of the disease, correc tion of deformities belongs to bloodless procedures. Patients with lateral deviation of the spine too, belong to this class, because their deformity is due to a pathological softening of the bones of the spine. Besides measures to improve the general health of such patients, gymnastics, massage, corsets, etc., are of great im portance in treatment, in which the plaster bed plays a great part.
Healthy Cripples.—Finally reference must be made to the class of healthy cripples. Leaving on one side deformities due to accident where recourse may be had to bloodless surgery, mention must be restricted to deformities consequent on infantile paralysis, the most terrible scourge of childhood. It can well be asserted that all contractures caused by paralysis can be straightened out by the bloodless method. When the normal shape of the limbs is restored, a very simple brace is sufficient to make walking possi ble. It must be admitted that conditions can be improved by successful transplantation of tendons. But this operation is not absolutely necessary. Many cases do without it—for instance, cases of paralytic flexure-contraction of the knee-joint. Instead of transplanting the active flexors of the knee-joint to the para lysed extensor (quadriceps), Lorenz substitutes the lost power of this latter muscle by the weight of the body. This is done by a slight over-stretching of the contracted knee, by which the line of weight is thrown in front of the axis of the knee-joint.
Arthrodesis, or artificial stiffening of joints by an operation on the cartilage, and on the bone, gives poor results, except in the shoulder joint. Lorenz also strongly objects to extirpating bones in paralytic deformities of the foot. At first the result may seem to be good enough, but very often in the course of years con secutive deformities develop, which are worse than the original ones. To the healthy cripples belong further such congenital de formities as congenital wry-neck, congenital club-foot and (most frequent of all) congenital dislocation of the hip joint.
Advantages of Modelling Correction.—In all these cases modelling correction, assisted by preliminary tenotomy, if neces sary, can overcome the severest deformity. It restores the normal position of the deformed bones to each other and maintains this position by mechanical means. The bandaged foot, being com pelled to support the weight of the body, is subject to the form ative power of physiological function. By acting in their normal function the deformed bones, in the course of time, assume the normal shape. In this way the function, viz., to bear the weight of the body, is forced to serve the purpose of the orthopaedic treatment. Similar benefit may of ten be derived from the treat ment in cases of flat-foot.
Luxation of the Hip-joint.—Congenital luxation of the hip joint can be entirely cured by the method of bloodless surgery. Reposition of the displaced head of the femur into the acetabulum is brought about by manoeuvres which are entirely consistent with those of modelling correction. By repeated stretching of the soft parts the head of the femur is forced into the acetabulum. Far more difficult is the second part of the treatment, i.e., retention of the head of the bone in the socket, the latter being too small and too shallow to retain it within its defective borders. To accomplish this, the thigh has to be fixed in certain extreme posi tions by which the head is prevented from slipping out of the socket. Owing to forced pressure of the head into the socket, the latter develops according to the size and shape of the head of the femur, while without it the socket would get smaller and smaller. Contractures and shortening of certain soft parts caused by the extreme position of the thigh help to retain the head in its normal place. It takes about a year before the socket is developed so far as to guarantee retention of the head. The third part of the treatment consists in gradual reduction of the ex treme abducted position of the thigh into the normal one. The difficulty of simultaneous treatment of bilateral hip luxation can be imagined. Children with unilateral luxation are allowed to move about during the greater part of the treatment's duration and bear fairly well the impediment caused by the fixing bandage.
Described thus shortly the plan of treatment seems to be simple but its actual achievement is by no means so. Experience has proved, that within certain limits of age (up to five or six years) the cure of the children can be a perfect one, while in older cases at least great improvement can be obtained. This is so much the more remarkable, as surgeons of all times regarded the deformity in question as absolutely incurable.
BIBLIOGRAPHY.-A. Lorenz, "Gelenksmobilisierung in der KriegsBibliography.-A. Lorenz, "Gelenksmobilisierung in der Kriegs- chirurgie," Wiener med. Wochenschr. (1915) ; "tYber die Frdhdiagnose einiger wichtiger Def ormitaten," ibid. (1916) ; "Behandlung der Huf t gelenksschdsse," ibid. (1917) ; "Zur Technik der Lehnenverpflanzung," Zentralbl. f. Chirurgie (1917) ; "t)ber die Behandlung der irreponiblen angeborenen Huftluxation, etc.," Wiener Klin. Wochenschr. (1919) ; "A new method of treatment of irreducible acquired or congenital hip dislocations," New York Medical Journal and Medical Record (Feb. 7, the abstraction of a portion of the blood, from three or four ounces up to twenty or even thirty in extreme cases. This may be effected by venesection, or the appli cation of leeches, or more rarely by cupping (q.v.). In the past, blood-letting was used to such excess, as a cure for almost every known disease, that public opinion became opposed to it. Lat terly, this prejudice has disappeared to a great extent. In certain pathological conditions it brings relief and saves life when no other means would act with sufficient promptness to take its place.
Venesection, in which the blood is usually withdrawn from the median-basilic vein of the arm, should be carried out with strict asepsis and then is without danger. If only a small amount of blood is to be abstracted, leeches may be used and the nurse can apply them. From one to twelve leeches are applied at the time, the average leech withdrawing some two drachms of blood. As much again can be abstracted by the immediate application of hot f omentations to the wounds. Leeches should always be applied over some bony prominence, that pressure may be ef fectively used to stop the haemorrhage afterwards. They should never be placed over superficial veins, or where there is much loose subcutaneous tissue. If, as is often the case, there is any difficulty in making them bite, the skin should be pricked at the desired spot with the point of a sterilized needle, and the leech will then attach itself without further trouble. Also they must be left to fall off of their own accord, the nurse never dragging them forcibly off. If cold and pressure fail to stop the subsequent haemorrhage, a little powdered alum or other styptic may be inserted in the wound. The following are the main indications for blood-letting. (I) For stagnation of blood on the right side of the heart with constant dyspnoea, cyanosis, etc. In acute lung disease, the sudden obstruction to the passage of blood through the lungs throws such an increased strain on the right ventricle that it may dilate to the verge of paralysis; but by temporarily lessening the total volume of blood, the heart's work is lightened for a time, and the danger at the moment tided over. This is a condition frequently met with in the early stages of acute pneu monia, and acute bronchitis, when the obstruction is in the lungs, the heart being normal. But the same condition also accompanies failure of compensation with back pressure in certain forms of heart disease (q.v.) . (a) To lower arterial tension. In the early stages of cerebral haemorrhage (before coma has supervened), when the heart is working vigorously and the tension of the pulse is high, removal of a pint of blood may lead to arrest of haem orrhage by lowering the blood pressure temporarily and so giving the blood in the ruptured vessel an opportunity to coagulate. (3) In various convulsive attacks, as in acute uraemia and eclampsia.
Though there is no doubt that blood-letting often benefits the patient remarkably, its mode of action is not fully clear. Changes in the composition and volume of the blood induced by haemor rhage (q.v.) are of short duration unless indeed the amount of blood removed is so great as to be dangerous.
the money-penalty paid in old days by a murderer to the kinsfolk of his victim. The system was com mon among the Scandinavian and Teutonic races previous to the introduction of Christianity, and a scale of payments, graduated according to the heinousness of the crime, was fixed by laws, which settled who could exact the blood-money, and who were entitled to share it ; blood-money could be exacted for all crimes of violence. Some acts, such as killing anyone in a church or while asleep, or within the precincts of the royal palace were excepted ; the criminal was outlawed, and his enemies could kill him wherever they found him. Colloquially the term is used of the reward for betraying a criminal.