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ing, the blood should be squeezed out of the joint. The whole operation should not take more than five minutes. By this method a firm limb is said to be obtained with good flexion and extension and apparently bony union. In cutting off the wires, ends half an inch long should be left, which are to be passed back into the opening and spread out in the soft parts. The broken ends of the bone should be well rubbed together before operating, so as to clear the separated parts of all clots and fibrous tissue.-The University Medical Magazine.
Remarks on Wounds of the Heart, With Notes
BY WILLIAM TURNER, M. A., M. D., Surgeon to the Colonial Hospital, Gibralter.
There unquestionably exists in the popular mind a firmly implanted belief that the heart of the animal organism is its most vital structure, that in order to attain the destruction of a life with the utmost certainty and with the utmost rapidity attention should be directed toward the destruction or disablement of this portion of the circulatory system. The deerstalker, for example, recognizes that his best chance of promptly securing his stag is to aim well on the shoulder as being the best landmark for reaching the heart; and so with big-game sportsmen generally. The bull-fighter maps out in his mind's eye a little area on the surface behind the shoulder blade through which his sword must penetrate en route to the heart, if he is to succeed in quickly dispatching his adversary. Military regulations direct that when an offender has to be executed by shooting, the firing party must point their weapons at the heart of the culprit, obviously with the idea that the extent of his suffering will thus be minimized. Indeed, it has even been supposed that if the substance of the heart be touched in any way by a foreign body its action must necessarily and immediately cease.
Most surgeons, however, can of their own experience abundantly disprove such notions. I recently saw a child, aged two years, with a sewing needle driven into its heart. The whole needle had disappeared into the chest, but I could feel its head underneath the skin tapping against my finger with each beat of the heart. and I was thus enabled to cut down upon it and extract it, no evident harm resulting to the heart or to the child.
A case which much impressed me at the time in regard to the degree of laceration.
Read at a meeting of the Gibralter Branch of the British Medical Association.
which the heart is capable of undergoing before it is brought to a standstill occurred some years ago in my practice as police surgeon. The dead body of a young man was discovered by the police lying in a secluded spot with a series of some ten or twelve wounds over the region of the heart. A large butcher's knife lay buried in one of these wounds to the depth of four inches, and the right hand, covered with blood, grasped the handle of the knife. No doubt could be entertained that these wounds had been self-inflicted. At the necropsy it was found that no fewer than three of the wounds had penetrated the cavities of the heart, and had caused considerable laceration of its walls. It follows, therefore, that after the heart had in this case been at least twice run into by a large butcher's knife, and much damaged, the subject of the suicidal attack had retained the physical strength and mental determination necessary to inflict a third wound in the same organ.
Although the records of such cases are not numerous, they mostly point to the fact that wounds of the heart are seldom if ever immediately fatal. Out of the 29 collected cases of injury to the heart, only 2 were fatal within forty-eight hours."
Of gunshot wounds of the heart some interesting examples are recorded. A stag ran 60 yards after being shot through the heart, examination of the heart showing that the left auricle had been practically annihilated, and the left ventricle completely torn through by the bullet.' There is a well authenticated case in which a bullet was found embedded in the substance of a soldier's heart six years after he had been wounded, he having died from quite another cause.*
The following examples of penetrating wounds of the heart, in which life was not immediately extinguished, may be interesting:
A soldier fell on his bayonet, which passed into his left side between the fifth and sixth ribs. Death took place on the fourth day. At the necropsy the wound was found to have penetrated the pleura costalis, passed over the thin edge of the lung, apparently without injuring it, perforated the pericardium, entered the left ventricle of the heart about one and a half inch from its apex, and passed out through the mediastinum into the vertebral column.*
with the pericardium by old adhesions, and the pericardium was intimately adherent to the heart throughout its whole extent. A rounded opening was found on the inner surface of the right ventricle admitting the little finger, and a corresponding hole in the interventricular septum leading into the left ventricle.
The heart in the case which I am about to describe shows a cicatrized wound over the interventricular septum, and will be interesting as furnishing additional proof of the fact that the heart may be the subject of laceration from external violence, and still be amenable to the healing process.
The patient, a young Maltese, was admitted to hospital on October 21, 1895, in a state of extreme collapse, bleeding freely from a wound in the left side of the chest over the region of the heart. I ascertained that during a quarrel with another Maltese he had been stabbed, probably with a large knife, and had almost immediately dropped on the ground. On examination in hospital, I found a horizontal wound in the chest the cartilage of the fifth rib, and the cartilage itself was penetrated longitudinally by a slit one and three-fourths of an inch long. Bright arterial blood in considerable quantity was issuing in jets from the wound synchronously with the heart's contractions, and air was also passing with loud hissing noise on each movement of respiration. The heart sounds were muffled, and the pulse at the wrist was almost imperceptible. There appeared to be little hope of the patient's rallying, and his dying deposition was taken without delay. The surface of the body and extremities remained cold, and the pulse collapsed for twenty-four hours, when signs of returning warmth began to be observed. Breathing was very rapid, and the whole of the left side of the chest was absolutely dull on percussion.
A week later the patient's condition was stil! very critical. A sero-sanguinolent fluid was escaping in large quantity from the wound, and a cavernous resonance over the upper portion of the left lung indicated that pneumothorax had supervened. A month after the infliction of the wound the discharge from it was still abundant, and had become purulent. The pleural sac had become converted into a large suppurating cavity, and in spite of frequent antiseptic washings the character of the discharge did not improve. The fifth rib was therefore resected posteriorly so as to permit of a thorough drainage of the cavity, and a large rubber tube was inserted. The immediate effect of the operation was marked and satisfactory. Progress, however, was slow and fitful, and it was only after four and a half months that the patient's condition allowed of his sitting up in bed and being moved about the ward in a wheeled chair. One morning while he was sit
ting up and having his wound dressed he suddenly threw back his head, went into a convulsion and remained insensible till the evening, when he died.
Post-morten examination revealed deep congestion of the posterior surface of the brain, and an apoplectic clot of some size resting upon and compressing the occipital lobes. No evidence of embolism was apparent. The immediate cause of death, therefore, was clearly apoplexy. On opening the chest the left lung was found to be collapsed and retracted upward against the spinal column. The pleura. was adherent to the pericardium, the interior of the pericardium and surface of the heart were granular, and some serous fluid was found in the pericardial sac. There was a cicatrix in the pericardium corresponding in position to the external wound, and immediately subjacent to it was discovered a cicatrix in the anterior surface of the heart itself. This cicatrix was three-quarters of an inch in extent, horizontally placed, and was situated over the interventricular septum, about one and one-half inch from the apex of the heart. It was found on section to have penetrated to a depth of fiveeighths of an inch into the muscular substance of the heart. The left coronary artery and vein had been cut across. Apparently therefore the wound of the heart, although it probably had a remote influence in determining the fatal issue in this case, was not the immediate cause of death, and evidence to this.effect was given at the coroner's inquest and at the trial.
It appears almost certain, and yet almost incredible, that after the infliction of the wound the pericardium must have been filled up with blood from the division of the coronary vessels, and yet the heart's action was not thereby brought to a standstill, but even entirely recovered from so gross an impediment.-British Medical Journal.
Roentgen's Rays in Gunshot Wounds of the Head.
Max Scheier (Deut. med. Woch., October 1) relates a case where by means of the Roentgen rays it was possible to prove the presence of a bullet in the brain and approximately to localize its position. A man, aged 27, had a gunshot wound five years ago, just above the outer end of the superciliary ridge on the right side, followed by unconsciousness. No exit wound was to be found. Later, amaurosis in the right eye, swelling and prominence of the eyeball, and dilatation and immobility of the pupil were observed. The right face was anesthetic. The bullet was thought to be present in the orbit where a large blood effusion had taken place. The bullet could not be found there, but the inner and upper part of the orbital wall was ascertained to be
splintered. Five years later there was complete paralysis of the right fifth nerve except its motor branch, and paralysis of the olfactory and optic nerves. Buka took a Roentgen photograph of the head. A shadow of 5 mm. in diameter, 18 mm. from the root of the nose and 8 cm. from the back of the skull, was distinctly seen. The position of the bullet was somewhere in the neighborhood of the right Gasserian ganglion. If a photograph could have been taken immediately after the injury the exploration of the orbit would have been found to be unnecessary. A fracture of the base of the skull must have occurred, and thus the paralysis of the optic and olfactory nerves was brought about. Perhaps an operation undertaken immediately after the accident might have relieved the pressure on the trigeminal nerve, and thus also the paralysis.
The Use of Formalin in Infected Wounds.
BY A. L. CORY, M. D., Gynæcologist to the Englewood Hospital and Surgeon L. S. & M. S. Ry., Chicago.
My attention was called some time since to the use of a mixture of formalin and gelatin in infected wounds. A German firm placed the mixture on the market under the name of "glutol." Formalin is mixed with gelatin, which forms a solid mass; this is grated, forming a fine gray powder, in which state it is sold, to be dusted on the wound as we have been doing heretofore with iodoform or boric acid. An American firm have recently put the same thing on the market under its proper name, "formal-gelatin." It was claimed for it that when pus was present the gelatin would gradually dissolve in the secretions and liberate the formalin, which is a strong disinfectant, and thus keep up a continual action while any of the powder remained. On trial I failed to realize the good results, except in superficial injuries, for instance in two cases of scalp wounds. At the second dressing, 48 hours. after the injury, the skin around several of the stitches looked quite inflamed and seemed about to suppurate, but on the application of the powder and fresh gauze at the next dressing, four days after, the wounds were found entirely healed. In cases where the infection was deep and pus already formed I could see no benefit from the powder. At this time I had under my care one of the nurses of Englewood Hospital who had been operated upon for appendicitis. The external wound had by some means become infected and I had opened it widely down to the peritoneum. In spite of all the measures I could apply, including the
glutol, the wound surface continued to suppurate, and a pocket formed under the skin, beyond the wound but communicating with it, from which pocket I could press out at each daily dressing about two drams of pus. It then occurred to me to try the formalin in solution. Knowing it to be very strong, I without any special reason chose to make it of the strength of 1 to 200, formalin 1 dram, water 25 ounces. After the wound has been washed with sterile water until clean, I packed both it and the pus pocket with plain sterile gauze dipped in the above solution, and what was my surprise on the next morning to find no pus whatever. I again dressed it with the formalin, and at the end of another twenty-four hours removed it and dressed with iodoform, and the wound healed promptly without further formation of pus. At the same time I had under care a woman who had an Alexander operation for shortening the round ligaments, and in whom one of the wounds had become infected so that I had opened it widely for drainage. Two dressings of the formalin, I to 200, stopped pus formation, and the wound healed under iodoform without further suppuration. Since that time I have dressed all infected wounds, and we get many of them in railway surgery, because of dirt ground into the wound at the time of the injury, with plain gauze thoroughly wet with a solution of formalin 1 to 200, and have not had pus occur where the formalin could get to all parts of the wound.
I have had some wounds irrigated with the same solution, but do not get as good effects as where applied on gauze packed into the wound. In an amputation of the arm for railway injury suppuration occurred in the track of the drainage tube; here it was not possible to pack the entire tract with gauze, and irrigation seemed to reduce but not entirely stop pus formation. It would seem from my experience that the formalin must be held in place so that it may act on every part of the wound for several hours. In an acute case of gonorrhea in a woman, as proven by finding the gonococcus in great abundance, I had the vagina thoroughly douched, then packed it through a speculum with gauze wet with formalin I to 400. This was renewed for four days in succession, and the gonorrhea was cured.
My experience with the formalin has been so satisfactory that I desire others to try it and see if they can get the same good results.
I believe that with gauze dipped in the solution and the powder applied we have an ideal non-toxic dressing. With gauze wet with the solution packed in "pus pockets," and in gonorrhea in the female applied on gauze, we can get better results than with any other dressing used at present by the profession. I would not expect as good results in gonorrhea in the male, for there the formalin could not be re
tained long enough in contact with the diseased surfaces. In making my solutions I have used the formalin 1, as it is really a 40 per cent. solution of the gas called formaldehyde. I have continued the formalin as a packing material in my pus cases only long enough to stop the pus secretion. I do not know that it would be injurious, but knowing that it is being used as a fixative of fresh specimens for microscopic specimens, I have feared that its continued use would harden the granulations and delay the cure, so as soon as the suppuration has stopped I have used iodoform in powder and plain gauze as a packing to stimulate the growth of granulations.-Journal of the Am. Med. Association.
4101 State Street.
Within the distinct memory of a considerable proportion of the membership of this association, the technique of surgical dressings has passed through a vast and varied programme of changes. It would be tedious and unprofitable to inflict upon this audience an exhaustive review of these earliest and loyal efforts toward the devoutly to be wished-for goal of perfection. A more profitable and appropriate attitude, it seems to me, is one of inquiry as to whether there is not even yet something left to be desired; something to be accomplished; something to be hoped for in this common, everyday, all-important department of surgical work; and in our struggles forward and onward in this field the thought is irrepressible and undeniable that the whole past history of the subject coincides in impressing this one great fundamental lesson, namely, that just in proportion as the methods and procedures have become simplified our results-immediate and remote-have be
* Read before the Detroit Medical and Library Association.
come more and more satisfactory. So far as the mental condition of the public in general is concerned as regards matters medical and surgical, I feel happily confident in the belief that in our time there has been a very material improvement. Especially is this true as regards matters surgical. There is, I am convinced, more of scientific reasonableness and less of medieval superstition and prejudice among the people everywhere than there was when I was young, and still it would be absurd to claim that there is not plenty of room for still further improvement in this respect. It is more easy and safe now for the surgeon to preach and practice faith in simple and unostentatious methods than it used to be; so that if a surgeon feels safe in resorting to extremely elementary appliances in the treatment of wounds, either accidental or surgical, or in treating fractures with very primitive dressings, splints or supports, or even discarding these entirely as he well may in certain cases, he is not so likely to be met with a storm of orthodox and most devout protestations based on the inherited experiences and legends of all the grandmothers-male and femalewho have lived and left their impress on their posterity.
For my own part I have established as an important article of my surgical creed the doctrine that the oftener we are able to dispense with dressings or appliances of any kind the better for our patient as well as for our own peace of mind. In operations about the lip, the face, the scalp, the external genital organs, and in superficial wounds generally, anything beyond sutures of absorbable material, and just of sufficient strength to give proper support, I consider unnecessary, and of course if unnecessary, improper. In circumstances in which some additional cover
ing or support may be required, then the plainer and less complicated the technique and the material used the better.
My attention has recently been attracted to asbestos as a possible addition of merit to our list of surgical dressings. A paper by Surgeon Kane, of the United States army, has set forth in suitable terms the claims of this material to our thoughtful consideration, and from what little thought and observation I have been able to devote to the subject, I feel justified in calling the attention of this association to it. It is at the present time prepared for the use of surgeons by a well-known wholesale manufacturer in New York who professes his perfect willingness to listen to and follow out any suggestions which may come to him from practical surgeons. I here present a few samples illustrative of the forms which this material may be made to assume, and these will at once suggest the uses to which it may be possible to apply it.-Physician and Surgeon.
The following from a letter to the Boston Medical and Surgical Journal, from the pen of William Henry Thayer, M. D., is of interest at this time:
"In 1846 I was Admitting Physician to the Massachusetts General Hospital, saw the first administration of ether there, and have a vivid recollection of the professional interest in the successful experiment. If Wm. T. G. Morton had presented the subject to the medical profession in the manner in which scientific men and physicians are accustomed to publish a discovery or an invention-as something that belongs to science-making no concealment or false pretense, the credit of his discovery would have been unanimously awarded to him,
"But his experiments were purely in mercantile interests. He wished to conceal the nature of the substance he was using. He came to the hospital surgeons with a false statement. He had colored the ether and stated that it was a composition, whose ingredients were his own secret. He called it "letheon." He wished to secure the endorsement of the medical profession, but reserve for himself control over its Medical men surmised that it was simply sulphuric ether-which he was obliged to allow.
"There is no question that the use of sulphuric ether as an anesthetic at that time was due to the enterprise of Morton, and he would never have found it necessary to make any claim for the credit of it, if he had conducted himself honorably in relation to it."
Quite in contrast with Dr. Thayer's opinion. of Dr. Morton is that of Dr. I. T. Dana of Portland, Me. In his "Reminiscences of Distinguished Physicians and Surgeons," in speaking of John C. Warren, the eminent New England surgeon, he says:
"When the anesthetic use of ether was discovered by Dr. W. T. G. Morton, Dr. Warren at once became interested in it and afforded Dr. Morton opportunity to test it at the Massachusetts General Hospital during his service.
"I saw Dr. Warren perform one of the earliest operations made under ether at the Massachusetts General Hospital, Dr. Morton giving the ether. I well remember the great and anxious interest with which the numerous physicians and medical students present watched the patient, all unconscious of the knife, and the subsequent safe progressive recovery of consciousness. The profession and the people are undoubtedly under large obligation to Dr. Warren for his hearty and generous support extended to Dr. Morton, when the great discov
ery of ether anæsthesia was being established, in the face of opposition, suspicion and great jealousy. It is much to be regretted that the discoverer and donor to the race of so great a boon, should have been allowed to die without receiving more competent credit, and gratitude and pecuniary reward for the unspeakable blessing he had conferred upon his race."
The First Operation Under an Anæsthetic in England.
The first operation under ether in England was performed by Robert Liston in University College Hospital, on December 22, 1846. Among those present on the occasion the late Sir John Erichsen, Sir Joseph Lister, Mr. William Cadge of Norwich, Dr. W. H. Ransom of Nottingham, and Dr. William Squire. Mr. William Cadge sends the following interesting note on the subject to the British Medical Journal:
"I have no written notes of what took place on that memorable occasion, and I must trust to my memory, which may betray me into mistakes as to some minor details, but as to the main incident of amputation of the thigh, the scene was too startling and dramatic ever to be erased from my recollection.
"Dr. Boot of Gower street had reported to Mr. Liston the definite and authentic information of the effect of ether inhalation that he received from Dr. Bigelow of Boston in December, 1846. Two days after this communication was the operating day at University College Hospital, and Liston resolved to put the matter to the test. In the interval Mr. Squire, the well-known chemist of Oxford street, prepared the apparatus, and Mr. (now Dr.) Squire administered the ether.
"On December 21, 1846, at two o'clock, the operating theater was filled with students and spectators; Liston addressed a few words to them as to the nature of the experiment about to be tried, and it was manifest that he had but faint hopes of its success.
"The patient was a man rather below middle age, who, to the best of my recollection, had malignant disease of the skin and tissues of the calf of the leg, for which amputation of the thigh was deemed to be necessary. He was a man of courage and of intelligence above the average of hospital patients, and he expressed his willingness to try the inhalation of ether. The apparatus comprised a large bell-shaped glass reservoir containing ether and a long tube and mouthpiece. Fortunately the vapor caused no bronchial irritation or nervous excitement; the patient passed easily into complete insensibility, and Liston removed the thigh as rapidly as possible; a gentleman present, watch in hand, declared that the cutting operation lasted thirty-two sec