ARTICLE IV.

REPORT OF COMMITTEE ON SURGERY.

BY PROF. H. PALMER, M. D., OF JANESVILLE, CHAIRMAN OF COMMITTEE.

Discoveries and new things may not be improvements, and they may not take position in the ranks of progress. The crucial tests of time and repeated experiment will give them their proper place and order, and in offering for your consideration a report of the progress made in surgery I think I will best accomplish the task if I confine myself chiefly to gathering together from the medical literature of the year the most practical, the most useful suggestions that may be made for the benefit of the surgeon.

The most of us, both in medicine and surgery, look to diagnosis and therapeutics, how to recognize and how to remedy, while the more abstruse or refined departments of our science receive from us less attention. If I can briefly and concisely give you facts that have been developed or improved upon by repeated trial in the department of surgery they will probably be of more service to you than abstruse theories, and in carrying out this programme I must ask leniency for what may seem abruptness, for the field is so large that I must abruptly pass from one subject to another.

The theory that the cranium is a hermetically sealed cavity that must not be invaded by the surgeon as a primary procedure and in which when injured, operative measures must be restricted to their narrowest limits, no longer finds a place in surgical literature. Recent cranial surgery has rapidly advanced beyond such limits and offers us the following propositions:

(First). That the conversion of a simple fracture of the skull into a compound one by incising the scalp is attended with but little increased risk to life when done in accordance with recent improved methods of treating wounds.

(Second). That the removal of portions of the skull by the

surgical engine, bone chisel or trephine, when properly performed, is no more dangerous to life than the amputation of a finger.

(Third). That the results of the study of cerebral localization has rendered perforation of the cranium as an exploratory measure more necessary and frequent than is required for therapeutic purposes.

(Fourth). That in many regions the cranial contents may be incised and excised with comparative safety.

(Fifth). That in operations or accidental injuries, the cranium or contents should be treated the same as similar structures in other localities.

(Sixth). Opening the cranium for blood clot, suppuration, epilepsy and cerebral tumors appears to be the field of operations for the brain surgery of the present and future.

(Seventh). That more patients die with fractured skull from complications that might have been prevented by timely operation than from any operative measures that may have been resorted to for relief.

Of the 115 cases of trephining and kindred operations collected by Dr. Amidon, which were performed for various causes, the mortality was about three per cent., after excluding such cases as had symptoms endangering life previous to the operation.

A CURIOUS FRACTURE OF THE SKULL.

Before a recent meeting of the New York State Medical Society, Dr. Govan read the report of this rather peculiar case. The patient was struck by a railroad train, and when seen was found to be perfectly unconscious, to have a fracture of the skull, with depression behind and above the left ear, which was caused by his head striking the ground. The patient remained unconscious for four days, and an operation for raising the depressed bone was just about to be undertaken, when it was ascertained that the bone had risen spontaneously to nearly its normal position. On the following day the depression had still further disappeared, and the patient was found to be conscious and able to speak. From this time he gradually recovered.

In the Lancet, May 1885, p. 881, Dr. W. MacEwen records the case of a man aged 36, who in August 1883, fell down stairs and was rendered unconscious for twelve hours. In November,

1883, the patient was admitted into the Glasgow Royal Infirmary, with impairment of power in the left arm, accompanied by muscular twitchings and pricking sensations in some parts. A lesion was diagnosed in the motor cortex of the upper half of the right ascending frontal convolution, probably due to irritation set up around an extravasation of blood, due to the previous injury. In December the author trephined, and found a membrane-like patch over the surface of the brain, involving the arachnoid and pia mater along with the external surface of the gray matter; there was also blood effused into the substance of the brain in the ascending frontal convolution. All this was removed, the bone was replaced after having been broken up into several small pieces, and the wound was dressed with eucalyptus gauze. The patient made a perfect recovery without a bad symptom, and two months afterwards was able to do his ordinary work.

A case of extensive wound of the skull and brain is reported in the Russian Herald of Forensic Medicine. The patient was a man who was struck by a piece of an anvil of about seven pounds weight. The wound extended from half an inch above the concha of the left ear to the right parietal eminence. The fracture of the skull corresponded in length and position with the external wound. In many places it was splintered, the posterior edge of the fracture being raised above the level of the anterior edge. The whole wound was filled with crushed brain substance, partly gray and partly white. There was both motor and sensory paralysis of the

The power of sensation in the right leg was diminished; the pulse was 80 and the respirations 20; the temperature was also normal. The patient was fully conscious and in a peculiarly placid state of mind, being pleased with everything. He forgot however, a number of abstract nouns and all proper names; his memory for numbers was also affected, and he had forgotten how to read. The wound was dressed with antiseptic bandages, and completely healed in fourteen weeks. During this time ten splinters were removed. The symptoms of amnesic aphasia gradually passed off. The memory for abstract nouns returned in about a fortnight. The placid humor passed away, and the man became decidedly irritable, and suffered from insomnia and headache. The paralysis of the leg passed off during the first few weeks. Sensation returned in the arm, and movement also, and after three months contraction occurred.

After the lapse of eight months the man was still unable to read, and complained of constant headache and great feebleness of memory.

Before the Baltimore Academy of Medicine, Dr. J. J. Chisholm related a case of evisceration of the eye-ball after a plan recently recommended. The operation consists in completely excising the cornea by means of a circular incision around its margin. The contents of the ball are then to be entirely removed, leaving the sclerotic intact. The advantage claimed for the operation is that the socket tissues are not disturbed, neither is the muscular apparatus of the eye interfered with; besides, the stump left after cicatrization leaves an admirable seat upon which to locate the artificial eye. The operation itself is a very simple one, and can be performed much more expeditiously than can complete enucleation, but convalescence is so very tedious, and at times gives rise to such painful and alarming symptoms, as occurred in his case, that in future he will confine himself to the old plan of complete enucleation. Dr. Chisholm said that it was his usual custom to allow a patient to go about his affairs very soon after the operation, at the outside, twenty-four hours; but in the evisceration operation, even up to the fourth day and later, there was such œdema and pain that he could not think of allowing the patient to be from under his observation. He had never had such an experience with the old method.

Dr. S. C. Chew wished to know if sufficient anæsthesia could be produced by the use of cocaine to enable one to perform this operation without painful sensations on the part of the patient. Dr. Chisholm thought not.

The advance in nerve suture in man makes it a recognized surgical operation both as a primary and secondary procedure.

Surmay reports a case of a man receiving a cut above the wrist resulting in the abolition of the function of the median nerve.. Six months after, three-fourths of an inch of the nerve was resected and the ends united with fine cat-gut threads, resulting in reestablishing nerve function in twenty-four hours.

Depre in a case where there was extensive destruction of the median nerve preventing the approximating of the ends, engrafted its distal end with the trunk of the ulnar, resulting in partially restoring the functions of the parts supplied by the median nerve in fifty-four days.

Dr. Gunn engrafted the distal end of a resected ulnar nerve to the trunk of the median by removing the sheath of the median, chamfering the end of the ulnar, bringing them together and securing contact with fine cat-gut sutures, resulting in partial restoration of function to the parts deprived of their normal nerve tissue in four months.

The evidence furnished by these cases, and others similar, is that the functions of a given nerve depend not so much on its intrinsic quality as upon the organic machinery at its ends.

The intubation of the larynx or introduction of a tube through the natural passages to the lungs has excited no little interest in the profession of late as a substitute for tracheotomy. As a result of Dr. O'Dwyer's investigations and experiments we have a set of instruments and appliances which will enable the surgeon to perform this novel procedure with ease and safety. The history of the cases operated upon by Dr. O'Dwyer, of New York, Waxham, of Chicago, and others, indicates that this method must receive an important place among the agencies for relieving suffering and prolonging life in young children suffering from diphtheritic, or croupous stenosis and kindred affections of the larynx.

Traumatic Nephrosis is a subject of interest, hence I note that before the Medical Society of London, Dr. John Lowe read the notes of a case in which the patient, a healthy, robust young man, was run over by an empty wagon, the wheel passing over the abdomen. Some weeks later a tumor formed in the right hypochondrium, which yielded distinct signs of fluctuation and fluid vibration. There was no albumen in his urine, no history of hæmaturia, nor any distinct jaundice. The tumor was slightly tender on pressure. The opinion was in favor of its being a renal cyst, resulting from injury to the ureter. Dr. Lowe introduced a moderate-sized trocar, and withdrew nine pints of fluid which deposited a copious precipitate on the application of heat, the precipitate not being soluble in nitric acid. Subsequently, even larger quantities were evacuated, and tincture of iodine was injected into the sac. The area of dulness and the circumference of the abdomen gradually diminished, and he was finally made an out-patient, ultimately resuming his laborious occupation on the railway, without inconvenience. The diagnosis rested mainly on the following points: 1. The rapid formation of the tumor soon after the injury. 2. The highly albuminous charac