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sults, function being completely restored in one case after resection of one inch and a half of the sciatic and a bridge of six strands of fine silk in twelve days. The longest time required where there was complete restoration of function was forty-eight days. In one cat there is now failure of function after thirty-one days. This method of bridging the defect in nerves is, in my opinion, one of the best yet devised and a method that will give excellent results in practice.
THE USE OF DECALCIFIED BONE.
In ten experiments upon dogs, Van Lair resected a portion of the sciatic and stitched the nerve ends to the ends of decalcified bone. Van Lair thought that the defect in the nerve might be bridged over by the young nerve fibers growing from the proximal end and that the medullary and haversian canals in the bone would afford an excellent passage and conduct the young nerve tubes to the distal portion of the nerve. I resorted to a slight modification of Van Lair's method in two experiments. After resecting an inch and a half of the sciatic, I ran four strands of fine silk from one end of the nerve to the other, bringing the nerve ends inside of the medullary canal of the decalcified bone. In one dog function was restored in fifty-one days. In the other there was complete failure after fifty-four days. The technique in this operation is more complicated than by the use simply of strands of silk or catgut, and I believe it has no advantages. The specimens. in both of my experiments showed that the decalcified bone had been absorbed and in one, macroscopically, it was to be seen that a very considerable number of the new nerve fibers had not been conducted to the distal extremity of the nerve, but ran off into the adjacent muscle, probably led there by growing through some of the haversian canals.
ADJACENT MUSCLE USED FOR BRIDGING THE DEFECT IN RESECTED NERVES.
While making these experiments and seeking for some suitable material with which to bridge the defect in a resected nerve, it occurred to me that a portion of the adjacent muscle might afford a suitable material, as it had longitudinal fibers, was sufficiently porous, possessed a sufficient degree of firmness and was always at hand. Resections of an
inch and a half to two inches of the sciatic nerve were made in two dogs, four cats and seven rabbits, and the interval bridged with muscle. In the two dogs complete restoration of function occurred, in one in twelve days and in the other in fifteen days. Unfortunately, two of the cats and three of the rabbits died, either on the table or within a few days and before restoration of function was possible. Of the four rabbits that lived, function was restored in two in twenty days, in one in thirty days, and in the remaining one in thirtysix days. In the two cats that lived function was restored in one in twenty-eight days and in the other in thirty-one days. There was not a failure in a single instance. The macroscopical appearances when the specimens were removed were most interesting. In a few cases the muscle had undergone degeneration in whole or in part, presumably from too large a piece of muscle being used. In those cases where the quickest and best results were attained, the muscle had retained its vitality and the fibers appeared as fresh and healthy as those adjacent to it, and what was most surprising was the strong and firm bond of union which the muscle had maintained between the nerve ends. This was quite in contrast to the union which has occurred where silk or catgut had been used. In these cases there was but a slight amount of connective tissue bridging the interval between the nerve ends. In this exceedingly frail tissue the nerve fibers ran. In the most successful experiments with muscle, a strong band of new nerve fibers could be seen running through the muscle and connecting the nerve ends. All of the animals in which the muscle had degenerated were rabbits, in which animal the muscle fibers are very small, closely set, and have a low state of vitality, as does the animal.
For the success of this operation it is necessary that the piece of muscle taken should correspond in direction with the fibers and should be small, not larger than a small lead pencil. The fascia of the muscle must be preserved, as this gives it greater firmness. The ends are cut squarely across and united evenly by two sutures to the nerve, one perpendicular. the other transverse. The deep part of the wound should be closed with catgut sutures, bringing the muscles together about the piece inserted. The skin is united with silkworm
gut. In my experience, the bridge of muscle has given the quickest, the most satisfactory and the best results. The method is easy of execution, the material always at hand, the union strong and firm, and the results surprisingly good. I offer this method to you with confidence, and believe it will prove to be the best of all methods yet devised for the restoration of continuity in nerves.
DISCUSSION OF DR. LEVING'S PAPER.
President Murphy: I congratulate the association and myself on having Dr. Levings accept an invitation to come to this meeting to read a paper. This is certainly an epochmaking paper in the repair of nerves. starts a new field and puts us again in advance of our competitors and justifies what I claimed in my opening address, that this association would produce as many advanced ideas as any medical society in America or in the world. (Applause.) I will ask Dr. Outten to open the discussion.
Dr. W. B. Outten: After having listened attentively to the valuable paper of Dr. Levings, I find there is very little for me to say, except to congratulate the association upon having heard this important contribution to our knowledge of the restoration of nerves after injury. The doctor, by experiment and research, has demonstrated the utility of his procedure and claims to have accomplished results never before realized, and these results he has laid before us. He has led us along a new path. This is the kind of work that makes America; it is the kind of work that makes the West, and forces me to say that a man need not make a pilgrimage to the East in order to get knowledge; neither has he to go to Europe, to France, or to Germany for this purpose. I think the time is not far distant when the Germans and the French will have to plant their feet on American soil and come to the wild and woolly West in order to obtain their advanced knowledge. This is certainly a magnificent paper, and I am glad to have heard it. It shows us the talent we have in our native land, and makes us appreciate the fact, that when opportunity comes, we have never yet failed to find the proper
On motion of Dr. Thorn, a rising vote of thanks was extended to Dr. Levings for his valuable contribution.
WHEN TO AMPUTATE-BRIEF RULES FORMULATED.*
BY S. BIRDSALL, M. D., SUSQUEHANNA, PA.
So much has been written in the past few years regarding this important subject, and by experienced surgeons, too, that it may seem superfluous, and I might say presumptuous, for me to offer anything on this topic at this time, but I write with a view to assisting the younger and more inexperienced surgeons to decide this often difficult and perplexing problem, and not to instruct those whose long experience enables them to decide promptly and correctly without any apparent process of reasoning. I will endeavor to do this by presenting the subject catechetically.
If two brief questions can be answered affirmatively the surgeon need never be in doubt. I might also say, need never wait.
First: Is an amputation necessary? While this is the first question to be decided, and of paramount importance, it is wholly unnecessary for me to discuss the conditions rendering amputations necessary, except to say, that in the practice of railway surgery, a part or the whole of an extremity is often so completely crushed as to leave no doubt whatever as to the necessity of amputation. It is only in exceptional cases that any great difficulty would be encountered in deciding this first question. If we are uncertain or unable, from any circumstance, to decide, we have only one thing to do, that is, to wait. We should never sacrifice any portion of the body when there is reasonable ground for hope of restoration to a fair degree of usefulIt is unnecessary for me to dwell upon this part of the subject, for the reason that so much has been said of late regarding it. It has been thoroughly considered at various times in different societies by experienced and competent surgeons.
Let us suppose that we have decided the first question affirmatively, and that an amputation is necessary, we will then proceed to consider the second question, which is:
Will my patient survive if I proceed now? So little has been said regarding prognosis in the case of severe injuries, at least, as bear
*Read by title at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, May 1, 1896.
ing upon the ability of the patient to survive an important operation, rendered necessary by traumatism, that a few suggestions upon this point may not be inappropriate. In deciding this question the surgeon will have ample opportunity for the exercise of his best judgment, even if aided by considerable practical experience and thorough professional professional knowledge. He will still feel the need of the opinion and advice of those more experienced than himself. Any general principles, rules, suggestions, or opinions from those having the widest range of actual experience would no doubt be read with the greatest interest. An eminent authority in gynæcology states that skill in the diagnosis of abdominal tumors can only be attained by repeated examinations and many failures. The same is true, to a great extent, as to acquiring skill in deciding the question we are now considering. By availing ourselves of the knowledge gained from the experience of others, we should aim to make the failures as few as possible. Whether an injured patient can survive an operation will depend largely upon the following conditions:
Ist. The severity of the injury. 2d. The degree of shock. 3rd. The amount of blood already lost. 4th. The habits of the individual, and 5th, his constitution.
Ist. As to the severity of the injury, care is necessary in the examination of an injured patient in order to ascertain the extent of injury, especially in railway cases. So deeply has this been impressed upon my mind, that I invariably search for multiple injuries. For example, a patient has a crushed lower extremity. If able to speak, I would not fail to inquire: "Do you think you are injured elsewhere?" We may also find fractured ribs and an injured lung or other severe trauma complicating the case. Before deciding whether our patient will be able to survive an operation, we should be as certain as possible that we have ascertained the number and extent of the injuries present.
While it would be impossible, in a paper like this, to do more than offer a few suggestions that may aid in prognosis, we may safely say that, as a general rule, the average individual will survive the loss of a single extremity; any portion of the forearm or arm, even at the shoulder joint; any portion of the
leg and also an amputation of the thigh; but as we advance above the middle third, the danger is immensely increased. To this rule there are, however, exceptions. Probably all experienced railroad surgeons have seen patients succumb when but one lower extremity was crushed. I can recall three such cases. There had been but little hemorrhage in either case and no operation was performed. One was a patient of my own, the others I saw in consultation. In the case of my patient the laceration of the integument was not extensive, but a large portion of the soft parts were pulpified. The external hemorrhage was slight, but considerable occurred subcutaneously and into the intermuscular spaces. The patient soon became pulseless and remained. so until his death, thirteen hours later. Many cases are on record where slight injuries and slight operations have resulted fatally. It has been related that a man in a hospital, not a case of railroad injury, was being prepared for an operation. The surgeon drew his finger along the proposed line of incision to explain to the assistants and students present what he intended to do. The patient evidently thought he had commenced the operation and immediately died, apparently from shock. This illustrates how difficult it is to determine whether a patient will survive an operation. Some cannot endure a comparatively small operation, while others survive double, and in rare cases, even triple synchronous amputations. Where the injuries are multiple and severe it is, no doubt, better to be cautious, to wait and ascertain whether the patient is gaining or losing; to wait until we can answer affirmatively the question: Will my patient survive if I proceed with the operation now?
2nd. Shock is an important factor to be conisidered in deciding whether an injured patient will be able to survive an operation. The degree of shock is, to some extent, an index to the severity of the injury. If the shock is quite profound, it is absolutely necessary to wait for some degree of reaction. To wait for further reaction when the patient has a fair pulse is a fallacy. The force, frequency and volume of the pulse is the best guide as to the severity of shock. The continuance of some degree of shock, for a time, is to be expected in all severe injuries and should not deter the surgeon from proceeding with a necessary
operation. As to the influence of anaesthetics upon the condition called shock there is a difference of opinion. I will not attempt to discuss the subject here. Further investigation and observation are required to elucidate this point. The surgeon who believes that they relieve or diminish shock will be inclined to proceed earlier with his operation than the one who holds the opposite opinion.
3rd. The amount of blood lost at the time of injury, or before the arrival of a surgeon must necessarily have a marked influence on the condition of the patient. The chances of surviving a serious operation are diminished in proportion to the hemorrhage, but the loss of a moderate amount of blood is no contraindication to an early operation. It is well known that contused wounds do not bleed freely. Most wounds in railway service are of this class. The amount of blood contained in a crushed extremity is, of course, lost. This alone would be sufficient to produce quite severe shock in some persons. The amount of hemorrhage can only be estimated approximately and must be described by such relative terms as slight, moderate, severe, profuse, etc. If the surgeon is quite certain that the hemorrhage has been severe, he should be cautious about proceeding at once with an operation. No fixed rule can be established, but due consideration should be given to the loss of vital fluid, in determining the question of prognosis.
4th. Habits. It has been said; "Happy is the man whose habits are his friends." This is true and, perhaps, never of more significance than when the individual has sustained a severe personal injury. It frequently happens that the railway surgeon meets his patient for the first time when called to render his assistance, and knows nothing of his habits. Careful inquiry will often fail to elicit the desired information. If, however, the marks of dissipation or syphilitic disease are plainly manifest, they should serve as notes of warning, indicating that the patient is in poor condition for an operation. Although these circumstances are unfavorable, they should not be allowed too much weight. Such patients are poor subjects upon which to practice conservative surgery. They are the very cases where it is important to proceed, with any required operation, as soon as the second question I have indicated can be answered in the
affirmative. Any habits tending to impair vitality or lower the tone of the system are unfavorable for sustaining a serious operation.
5th. Constitution of the individual: Strength of constitution is not determined by the weight or stature, or even muscular strength, but by the vitality or powers of endurance. Previous acquaintance with the injured person will enable the surgeon to form a sufficiently accurate estimate of his patient's stamina or vitality; in other words, his constitution. Without such acquaintance, the surgeon should search for organic disease of all important organs, especially for renal disease. The person with weak constitution succumbs, while the one possessed of good powers of endurance survives an important operation. The importance of a correct opinion regarding the patient's constitution should be duly appre ciated by the surgeon. Having intimated to our president that my paper would not exceed ten minutes, I must close, having but briefly indicated the chief points that should be given. consideration in estimating the prospects of an injured patient surviving an important operation. Having decided that an operation is necessary and that it appears quite probable our patient will survive, if we proceed at once, there is but one thing for us to do, and that is to operate. I do not mean that we should be hasty and operate wherever we may. We should take what time is necessary to remove the patient to a suitable place and make suitable arrangements, but should not delay unnecessarily. With the conditions I have just indicated all complied with, I can imagine no cases to which the rules I have formulated do not apply.
It is a common saying: "There are exceptions to all rules," but I would urge you not to seek for exceptions. I am fully satisfied that it will be better for your patient and will save you much anxiety and mental strain, if, having decided that an amputation is required and that your patient will probably survive, you follow the advice suggested in this paper and proceed.
Order a purge for your brain; it will there be much better employed than upon your stomach.-Montaigne.
One asking a Lacedæmoniann, what had made him live so long, he made answer: "The ignorance of physic."-Montaigne.
A COMPLETE EMERGENCY OUTFIT.
BY ARTHUR DEAN BEVAN, M. D., CHICAGO. Professor of Anatomy at Rush Medical College; Professor of Surgery at the Women's Medical College; Surgeon to the Presbyterian, St. Luke's and St. Elizabeth's Hospitals.
The introduction of asepsis and antisepsis has SO completely revolutionized the technique of operative surgery, that the general surgical operating cases formerly used are now practically worthless. Experience has taught us that, with proper preparation and proper precautions, aseptic surgery can be done as well in a farmer's kitchen as in the most modern operating room.
To accomplish such results, however, a surgical outfit is required which is so complete
that with the addition of water and a place to boil it, the surgeon has at his disposal everything necessary to perform an aseptic operation. The value of aseptic or antiseptic surgery has been so fully demonstrated that the operator who neglects to full carry out its essential principles is to be held negligent. This fact is generally admitted and yet how few surgeons possess and have ready for instant use a complete aseptic surgical outfit with which they can go at once to an emergency operation as fully prepared as a fire company is when it answers a fire alarm. Such an outfit must be recognized as a necessity by all men doing surgical work.
Many surgeons and instrument makers have pondered over the problem of devising the best complete emergency outfit, but as a rule their attempts have failed because of
their efforts to make very small and compact cases, and as a result the outfit is incomplete and not suited to grave emergencies. After devoting some considerable time and thought to this subject I have devised an outfit so complete, that I could handle with it any emergency surgical case and practically all surgical operations, except such as litholopaxy, osteoclasis, etc., which require cumbersome instruments and which are of a nature requiring ample preparations.
A considerable experience with this outfit in cases of appendicitis, strangulated hernia, tracheotomy, mastoid disease and brain abscess, laparotomy for intestinal obstruction, ovarian cysts, stone in the bladder, retention demanding external urethrotomy amputations, osteomyelitis, fractures of skull and long bones, and in all general surgical cases performed outside of my hospital operating room, has taught me its great value. The outfit consists of two cases one containing the instruments, ligatures, sutures, anæsthetics and antiseptics; the other containing the dressings, sponges, bandages, aprons, towels, laparotomy pads, etc. The list of instruments is based upon a careful study of the instruments required for all the various operations described in one of our most complete text books on operative surgery. The list of dressings, bandages, etc., contains the essentials as found in our modern hospital operating rooms.
The outfit is very complete and rather expensive, but it contains practically all the instruments required by a general surgeon and in such shape that they are ready for instant
Not a little reputation may be gained for the surgeon by demonstrating to his patients and fellow practitioners that he is possessed of such a complete surgical outfit and is at all times prepared to meet any surgical emergency. But far above such considerations is the fact that such an outfit will enable the surgeon to give his patient the benefit of aseptic surgery under practically all circumstances, which means often the saving of life and suffering by the prevention of wound infection.
My experience in railway surgery, both as local and chief surgeon, has demonstrated to me that very few railroad surgeons are equipped as they should be with a complete emer