PART III.

H A L F - Y E A R L Y R E P O R T S .

R E P O R T ON SURGERY.

By WILLIAM THOMSON, M.A., F.R.C.S.I. ; Surgeon to the Rich- mond Hospital; Member of the Surgical Court of Examiners, Royal College of Surgeons, Ireland.

EXCISION OF CALLUS FROM THE CLAVICLE. A MAN, aged forty-two, fractured his left clavicle and also two ribs on the same side, so that no apparatus could be applied. There was great displacement of the fragments of the clavicle. A large mass of callus was developed, which pressed upon the subclavian artery and the brachial plexus, causing weakening of the radial pulse and formication in the arm. Eight centimetres of the bone and callus were removed by Dr. Delens subperiosteally. The radial pulse returned in normal fulness and force. After three months the strength of the left arm nearly equalled that of the r i g h t . - Archives Ggndrales, August, 1881; Lancet, ~qov. 19, 1881.

T R E A T M E N T OF E P I L E P S Y BY L I G A T U R E OF T H E V E R T E B R A L ARTERIES.

Dr. W. Alexander, of Liverpool again calls attention to this method of treating bad cases of epilepsy (Med. Times and Gazette, March 11, 1882), and publishes details of five more cases in which he has performed the operation. He says that in three others he has ligatured both the vertebrals simultaneously without any bad effects, and in none of these have any fits recurred. In all, without exception, the amelioration has been decided, whether we have regard to the reduction of the fits or the improvement of the mental power. :No lesions referable to the diminished supply of blood to the spinal cord have been observed, and no deaths have occurred from the operation in any of his cases.

REMOVAL OF GO~TRES.

W~lfler in the Wien. reed. Woch, Nov. 1, 1882 (Med. Timee and Gazette)mentions that owing to the security given by anti-

132 Report on ,Surgery.

septic surgery Billroth has felt himself justified in resuming the operation for the removal of goltres. In five years he has operated 58 times on 55 patients. Forty-eight were cured and 7 died ; of these one died of periton{tis, and the other of the bursting of an aneurism. Among the remaining 53 there were five cases of malignant disease of the thyroid. From 1860 to 1876, in the pre-antiseptic period, the mortality was 36"1 per cent.; from 1877 to 1881 the mortality was 8"3 per cent. In five cases tracheotomy was per- formed, and of these three died, giving a mortality of only 2"3 per cent. for non-tracheotomised patients. Age seemed to exercise no unfavourable influence; one patient was aged sixty-five and recovered.

EXCISION OF A STRICTURE OF TH E DESCENDING COLON IN T H E

LUMBAR REGION.

At the March meeting of the Royal Medical and Chirurgical Society, Mr. Thomas Bryant read the record of a case of stricture of the descending colon, in which he excised the diseased segment of bowel through the wound made for a left lumbar colotomy, the patient recovering. The operation was performed on a lady aged fifty, who had suffered from complete obstruction for eight weeks, and was very feeble. The stricture could not be felt from below. The bowel was removed through the oblique incision made for left lumbar colotomy, by simply pulling the segment strictured through the wound, and stitching each portion of the bowel, with its two orifices as divided, to the lips of the wound. The stricture was of the annular kind, and involved about one inch of the bowel ; it was so narrow as to admit the passage of a :No. 8 catheter. The pre- paration was exhibited, with microscopical appearances of the growth in section, as made by Dr. Goodhart. Mr. Bryant said he believed the operation he had performed was a new one, and that it was applicable to not a few of the cases of stricture of the descending colon. I t had suggested itself to his mind from seeing cases of localised or annular stricture of the bowel which were free and movable, both in operations of colotomy as well as in the post mortem room ; but the case read was the first in which he had put the suggestion into practice. He suggested that the question of excision of the diseased growth should be entertained as soon as the diagnosis of the case was made, and that, in every case of colotomy for chronic obstruction of the descending colon, the possibility of being able to remove the diseased bowel by operation

Report on Surgery. 133

should be considered before the bowel was opened for a eolotomy operation.--Brit. Med. Jour., April 1, 1882.

T H E D E V E L O P M E N T OF OSSEOUS CALLUS.

Marcy, in the Annals of Anatomy and Surgery (London Medical Record, Feb. 1882), arrives at the conclusion that the doctrine of the:formation of the callus--either as taught by Ollier, i.e., as being derived from the osteogenetic layer of the periosteum, or by Billroth, i.e., as being formed by the medulla of the Haversian canals of the extremities of the fractured bone--is untenable.

Professor Ercolani, of Bologna, had already maintained that neither the periosteum nor the extremities of the fractured bone are concerned in the formation of the osseous callus, but that, on the contrary, the periosteum becomes destroyed in the place where the callus is formed. Dr. Marcy finds that the material forming the soft callus in the first days after a fracture is furnished from the blood of the lacerated vessels both of the connective tissue and of other tissues injured, including those of the medulla and Haversian canals. That, however, the part the medulla takes in the formation of the callus is, in some cases, in the long bones, not indispensable, is proved by the fact that, in the bones of birds, which have no medulla, a' well-formed callus may be met with. In man and animals, where the fragments of the broken bone are kept apart, the medulla takes no part in the formation of the' osseous callus, this being entirely of external origin, and the surfaces of the separated fragments remain inert.

Dr. Marcy, having examined several specimens of healed frac- tures in animals, and also a large number in man, found definite evidence of atrophy of the extremities of the fractured bone. In fissures, or partial fractures in bones, especially of the cranial vault, there is no new formation taking place from the borders of the fracture, but distinct evidence of absorption and atrophy. These changes may be referred to the destruction of the periosteum at the place of injury.

From a series of carefully conducted experiments on rabbits, Dr. Marcy obtained specimens of fractures of the bones of the leg from the third to the twenty-fourth day. These were injected with blue gelatine solution from the aorta, and, after decalcification, sections were cut therefrom and examined with the microscope. The deductions made from this examination are these--the old periosteum at the point of injury becomes destroyod ; the exudation

134 l~eport on Surgery.

from the parts surrounding the fracture is well developed, as early as the sixth or eighth day, and covered with a new periosteum. In common with Ercolani, the author finds " t h a t the new periosteum impresses its osteogenetic action on the exuded cellular elements, and that it is by this that they are transformed into bone."

Dr. Klein observes on this : - - " From the description of the appearances in the microscopical specimens as given in the paper, it appears that the formation of the osseous callus takes place in essentially the same manner as that described by Bi l l ro th-- that is to say, the new blood-vessels and the cells of the soft callus, as well as the new periosteum--or, rather, its osteogenetic layer, it seems, are derived from the medullary tissue of the Haversian canals at the extremities of the fractured bone."

B O R O G L Y C E R I D E I N O P E R A T I V E S U R G E R Y .

Mr. Richard Barwell, in The Lancet of May 13th, 1882, calls attention to the value of this new antiseptic in wound dressing. He has used it in a few cases with satisfactory results. He uses a watery solution of 1 in 20, and with this he saturates a few folds of lint, then covers it with Mackintosh, and applies a bandage. He thinks we have in boroglyceride an aseptic for woundsr less irritating locally than carbolic acid, free also from the danger of constitutional poisoning. I t may be that he has not hit on the best strength of the solution; and certainly some other diluent besides water will be desirable. Nothing, however, can be better than the action of this compound. The intricate and not very safe complications of carbolic t rea tment- - the spray, and all the inconveniences belonging to i t - -may now be laid aside.

D I G I T A L E X P L O R A T I O N O F T H E B L A D D E R .

Sir Henry Thompson, in reporting four additional cases in which he has with good results explored the bladder with the finger through incision from the perinmum, observes, in The Lancet of May 6th, 1882 : - -

" I t is only during the last few years that I have gradually realised the fact that it is possible, in not a few cases, to explore through a small perineal incision the whole~ or nearly the whole, of the internal surface of the bladder with the index finger. A necessary condition, of course, is that the bladder should be empty; and in that condition it is--as is sometimes perhaps not sufficiently recognisedwno longer a cavity, as represented in diagrams~ but a mere cul-de-sac at the end of the urethra.

Report on Surge~'y. 135

Taking it for granted that the incisions to be made--which involve only the urethra with the tissues between it and the surface~ and not at all the bladder and prostate--enable the operator to place the last joint of his left index finger within the neck and thus to draw it somewhat towards him, the exploration may be accomplished in the following manner :--Maintaining his finger at the spot described~ the operator should stand up at the foot of table~ a little to the left of the patient (who is in the lithotomy position)~ so as to make firm pressure with the right hand above the pubes~ the resistance of the abdominal muscles being overcome by the influence of ether. He may now easily feel, unless the patient be very stout~ the opposite side of the bladder coming into contact with the tip of his finger ; and by concerted movements of supra-pubic pressure by the right hand~ with slight movements of the left index in the bladder, almost every portion .of the internal coat of the latter may be brought under examination. If the patient be thin~ the proceeding is easy; it becomes less so in proportion to the depth of perineum and thickness of the supra-pubic coverings~ both of which are increased by fat. In the latter case aid may be rendered by an assistant, who makes firm pressure with both his hands~ but the operator should also employ~ if he can~ the concerted movements described.

"Now~ I think~ it will be admitted that~ however effective is the ordinary examination of the bladder by the sound and by rectal examina- tion~ and it amply suffices for the great majority of cases~ there are still a few obscure examples of disease~ respecting which~ even in the most experienced hands~ examination does not reveal facts which it is of the utmost importance to ascertain. This being s% the question arises--Can digital exploration of the bladder be performed without much risk to the patient? I unhesitatingly answer in the affirmative. The results of external urethrotomy~ on a grooved staff previously introduced~ an operation largely performed by Professor Syme about thirty years a g o - - results which were jealously watched and closely scrutinised--go far to warrant this reply. But although the external incisions in his pro- ceeding were almost identical in situation with those I shall advise for digital exploration~ the internal incision in Syme's operation was made not only in tissues very often largely diseased~ but was far more exten- sive than that required for the purpose now in view. To this evidence I may add that I have myself opened the urethra from the perineum many times for various purposes besides that of extracting calculus; and I do not recollect a single fatal result. Fifteen cases of external division of stricture on a staff are included among them. Next, the method of operating in order to reach the bladder from the perineum demands a few words. I think there is little ground for doubting that a vertical median incision--that is, in the line of the raphe--introduces the finger by the shortest and most direct route. The prominence formed

136 Report on Surgery.

by the operator's bended knuckles, while using his index-finger as an explorer, lies equidistant between the nates~ and is firmly pressed on the perineum in a straight line from the external surface towards the centre of the bladder. Any line right or left of the median must of necessity lead obliquely to the centre, and be a longer libra, because it commences at a point on the external surface more distant from the neck of the bladder than the raphe of the perineum. Accordingly I always adopt the central incision, using a median grooved staff, and a long~ straight, narrow-bladed knife~ with the back blunt to the point. Having placed the left index-finger in the rectum the knife may be introduced, edge upwards, about three-quarters of an inch above the anus, with or without a small preliminary incision of the skin (I prefer the former), until the point reaches the staff about the apex of the prostate gland, where it divides the urethra for half an inch or so, and is then drawn out, cutting upward a little in the act, but so as to avoid any material division of the bulb. The left index-finger i.s now removed from the rectum, and fol- lowing by the groove of the staff, slowly passes through the neck of the bladder as the staff is withdrawn~ when exploration is made, as described above. A moderate division of the bulb when made in the middle line is not to be feared as a cause of hmmorrhage, while an incision involving the side of the bulb, and nearer to the entry of its artery, is more prone to bleed freely. Hence some have preferred another mode of incision in order to avoid it--namely~ one crescentic form, with the convexity up- wards, just above the anus ; the dissection to be carried transversely to the apex of the prostate, and opening the urethra there, as before mentioned."

THE COAT-SLEEVE METHOD OF CIRCUL&R AMPUTATION.

Mr. Richard Davy, of the Westmins ter Hospital, London, describes, in the British Medical Journal of J u n e 17th, 1882, a modification of the circular method of amputation. A long integu- menta ry sleeve of four or six inches in length is made. Hav ing dissected this carefully down to the deep fascia, the muscles are divided down to the periosteum, which is carefully peeled upwards to the point at which the saw is to be applied. The vessels being secured, a piece of tape is passed round the sleeve near its extremity, and drawn sui~iciently t ight, the two ends being passed through a small cylinder, which serves to keep the tape in position. The ends of the ligatures are brought out through the crucial slit on the face of the stump. " Trea t your wound either with or without d ress ings- - I prefer none - - and carefully watch tha t no undue strangulation of t h e ' off end ' of the sleeve occurs. Should the s tump become oedematous, or any necessity of drainage arise,

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insert a drainage tube into the centre of the face of the stump of a sufficient firmness to prevent a t~)o-ready collapse of its walls (e.g., a piece of gum-elastic catheter) , and allow the excretion to flow into a pledger of marine tow, or some absorbent material. The wound cicatrises up to one-half or one-fourth of an inch, and a central button of depressed scar-tissue results, surrounded by soft, f a t t y skin-cushions, plaited in a radiating manner from the centre to the circumference of the s tump."

T H E TREATMENT OF GUN-SHOT WOUNDS OF T H E ABDOMEN.

Dr. Marion Sims, in a series of papers on this subject in the British Medical Journal for Feb. and March, 1882, deals with the unsatisfactory treatmei~t of wounds of the abdominal contents, in view of the successes now achieved in other branches of peritoneal surgery. He believes tha t what kills in these cases is septicmmia, not peritonitis, and tha t the danger consists not in opening the peritoneal cavity but in keeping it closed, with its retained fluids, to poison the blood and take the life of the poor sufferer. H e s a y s : - -

" Look at the history of military surgery from its earliest day to the present moment ; and what has it ever done for lesions of the abdominal viscera ? Absolutely nothing, if we except a few cases of punctured and incised knuckles of intestine, whicl b having protruded through the outer wound, were sutured and returned to the cavity of the abdomen. But if we profit by the teachings of ovariotomy and avariotomists~ we shall soon wipe out this reproach. Heretofore, when a man was shot or stabbed in the abdomen, w e laid him down, gave opium to arrest pain and peristalsis, and applied "simple dressings," waiting and hoping for it to result in a f~ecal fistula. And how rarely did nature gratify our wishes, except when the lower ends of the colon and rectum were wounded I But all this must be changed. In the treatment of perforating shot and other wounds of the abdomen, we should strictly observe the following rules : - -

" 1. The external wound or wounds should be enlarged as soon as possible, and sufficiently to ascertain the whole extent of the injuries inflicted.

"2 . These should be remedied by suturing wounded intestines and ligaturing bleeding vessels.

" 3. Diligent search should be made for extravasated matter, and the peritoneal cavity should be thoroughly cleared of all foreign substances, whether f~ecal or bloody, before closing the external opening.

"4. The surgeon must judge whether the case requires drainage or not. Generally it will not, if these rules be strictly carried out. We

138 Report on Surgery.

must not forget that fmcal effusion has taken place after intestinal wounds have been sutured~ simply because the surgeon failed to find and suture all the lesions. And we must not forget that fatal results have followed enterorrhaphy when thoroughly done, simply because f~ecal effusion had taken place before the intestine was sutured, and had been left in the peritoneal cavity, producing death as speedily and as certainly as if the lesion had not been found and closed. Therefore~ it is essential not only to find all lesions and remedy them, but to be sure that we leave the whole cavity of the peritoneum perfectly clean.

"These principles are the foundation of success in all other operations involving the peritoneum, and they must be equally successful when applied to shot and other wounds of the intestinal canal."

NERVE-STRETCHING.

Dr . W . J . Mor ton , of N e w Y o r k (Journal of Nervous and Mental Disease, Vol. I X . , J a n u a r y , 1882), repor t s some cases in which he has s t r e t ched nerves in spast ic spinal para lys is and o the r ne rvous

affections. I n discussing the subject , he observes : - -

~' The nerves are very inextensible~ therefore it is necessary to stretch long, say three to five minutes; they are very strong, and therefore con- siderable force must be employed. A n analysis of successful eases shows that the nerves had been thoroughly and vigorously pulled upon. But, obviously, in drawing conclusions as to the amount of force used we must also know the instrument with which the nerve was stretched. Strong stretching with the finger would probably produce less rupture of the axis-cylinders than moderate stretching over the edge of a director.

~According to the experiments of Trombetta on the cadaver~ the brachial plexus withstood a tension of from 48 to 8l lbs. before breaking or tearing off at the posterior roots ; the crural withstood about 83 lbs. ; while the sciatic on an average sustained~ before breaking, a traction of 184 lbs. Experiments on the cadaver also show that the main strain after the resistance of the natural adhesions to surrounding parts is over- come, is expended upon the posterior roots. In this may lie an explana- tion of the observation made~ that sensation is interfered with to a greater extent than motion.

~ I s the spinal cord stretched? Harless and Huber~ Valentine and Conrad are cited by Chauvel a as saying it is not. But functional dis- turbances created on the other side of the body, in certain reported experiments~ would seem to indicate that the spinal cord is in real i ty pulled downward. According to Gilette the medulla oblongata in a cadaver was felt to move when the sciatic was pulled down. This obser- vation~ if correct~ certainly renders the conclusion definite, that we may

a Archives Gdngrales de Mddgcine. Juin, 1881.

Report on Surgery. 139

hope to influence the cord by the operation, and i t is on this supposition that I have operated in a number of cases. In case the cord is stretched, we have still another reason why it is difficult to prescribe the remedial limits of the operation, since its effects are not confined to the terri tory innervated by the stretched nerve, but extend widely to other nerve terri- tories. I t is beyond the province of this contribution to the subject of nerve-stretching to enter into a discussion of the anatomical, physiological, or pathological lesions produced by the operations, or to speculate upon the modus operandi of the benefits derived, the cures effected~ or the failures reported.

" F r o m my own experience I can simply draw these conclusions : " Firs t . That moderate stretching of the nerves produces merely a tem-

porary motor paralysis, easily recovered from, and a very considerable paralysis of sensation, likewise easily recovered from.

" Second. That severe stretching produces a marked motor paralysis of long continuance (months), and a tolerably complete paralysis of sensation, much more quickly recovered from than is the motor paralysis. Cases of spasm should therefore be stretched vigorously.

" Third. That profound cutaneous anaesthesia may be removed for several months and perhaps permanently; Case 4.

" Fourth. I have been unable to observe, as has been claimed, that sen- sibility is relatively lost to a greater extent and more persistently than motion, either by moderate or severe stretching. In my cases motor paralysis has been more persistent than sensory."

PARAPLEGIA FROM PHIMOSIS; RECOVERY AFTER CIRCUMCISION.

J. H. BLANKS reports a case of a child two years old, unusually healthy, and of healthy parentage, who in September, 1880, became fretful, ner- vous, and restless, sleeping only a few minutes at a time. These symptoms increased, and in two weeks his gait became unsteady, and finally complete paraplegia developed with some degree of torticollis. Examination determined the presence of phimosis, not, however, to such a degree as to interfere with the free flow of the urine, nor was there any irritation or evidence of inflammation. The introduction of a probe revealed a slight adhesion on one side. On the next day strabismus, sometimes convergent, sometimes divergent, lasting a few minutes at a time, at intervals of two or three hours, was noticed. Circumcision was performed, and in twenty-four hours all the nervous symptoms had sub- sided. In ten days the child was walking, and in all respects well.-- ~t. Louis Courier of Medicine.

S . W .