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Syme having left, there was again a difficulty in filling up the appointment, and I may say that party feeling ran exceedingly high, and—if all accounts are to be believed-there was a good deal of misplaced enthusiasm displayed by the students, so much so that it led on some occasions to the interference of the police. Another complication now arose because Mr. Cooper, feeling that his son-inlaw, Mr. Morton, had been unfairly treated, resigned his chair of surgery, and therefore for the moment the hospital was practically bereft of both surgeons. Mr. Quain was, however, promoted to the office of surgeon, and then came the question who should become the professor of surgery. In 1848 the Council solved the difficulty by asking Mr. Arnott, senior surgeon of the Middlesex Hospital, to be professor of surgery, and at the same time they selected two new assistant surgeons, Mr. Erichsen and Mr. Marshall, who were appointed on the same day in 1848. Things now quieted down a little, though disaffection yet. simmered, and there were occasional outbreaks; but still, as far as I can learn, affairs went smoothly till Mr. Arnott again found that the position was not quite satisfactory to him, and at the end of two years he resigned his post, and gave up the professorship of surgery and the surgeoncy at the hospital. The Council was now again in difficulty, but I am glad to say that it had the wisdom to appoint Mr. Erichsen to the office. He was appointed surgeon to the hospital, and also made professor of surgery. Order was restored, and the school began again to prosper. That appointment was not made, of course, without some trouble, and the fact was commented on that Mr. Erichsen was only 32, and therefore his experience was but limited. Mr. Quain, professor of anatomy for many years, thought the post ought to have been given to him, and therefore for the next fifteen years he revenged himself by never speaking to Erichsen at all. This seems a very small matter, but I have heard Sir John Erichsen himself say that he felt his isolation very much. There was no one about the hospital from who he could take advice or consult with, and he had to depend entirely on himself-in fact to play off his own bat. That was certainly somewhat trying, but it just shows what the man was, that he was able to overcome all the difficulties and to outlive all the trouble and all opposition, because before Mr. Quain gave up his post, on one memorable day, to everyone's great astonishment, Mr. Quain and Mr. Erichsen walked into this hospital arm-in-arm! How the rapprochement came about I do not know, but from that day forward those two men were friends.
THE FIRST ADMINISTRATION OF ETHER IN EUROPE.
We have so far traced the history of the hospital up to the appointment of Mr. Erichsen; let me pause to remind you of another great event which had taken place in the year 1847. On December 21, ether was administered in this theatre for the first time in Europe, and two operations were performed by Liston, amputation of the thigh and removel of a toenail, and from that time the use of anesthesia spread rapidly to other hospitals and became universal throughout the world.
The introduction of ether as an anææsthetic dates from October 30, 1846. A Dr. Morton, a dentist of Boston in America, who had been led to investigate and experiment on himself and others, found that with ether he could produce complete anæsthesia, as we now call it-for the word was not known then. spoke to Mr. Warren, the chief surgeon of the Massachusetts General Hospital, and offered to give the anesthetic for him there, and on October 16, in the same year, ether was administered by Dr. Morton to two patients of Mr. Warren's, and that was the first public administration of an anæsthetic in the world. I have here in my hand a paper recently sent me, inviting me to the commemoration of the fiftieth anniversary of that occasion at the Massachusetts Hospital on October 16, 1896, and it is an interesting historical document. From Boston the news of this entire reformation of surgical practice was sent to England by letter, which came into the hands of a Dr. Boott, who lived in this city. He spoke to Mr. Liston about it, and here, in this theater, on December 21, 1846, ether was for the first time administered in Europe. It is a curious fact that in the last edition of "Erichsen's Surgery" the 22d is the date mentioned, but I have found the correct date by referring to letters of the period. The introduction of anesthetics in this theater was the beginning of anesthesia in Europe, and I was only waiting for Sir John Erichsen to return to town from his holiday to suggest to him to come here on the fiftieth anniversary of that day, and address you all on the subject. Unfortunately that is now impossible, but I think you ought to remember that he was present when ether was first given, and that from that date anæsthesia was introduced into general surgery.
AN EPOCH IN ENGLISH SURGERY.
Erichsen's lectures on surgery were highly appreciated, and in 1853, three years after his appointment, he brought out the first edition of his well-known work on surgery. Now that book made, I may say, an epoch in English surgery. I was a student at the time it apppeared, and we were then as students obliged to get up our surgery as we could. There was no book really which was quite
satisfactory. There were some lectures by Astley Cooper and by Bransby Cooper. There was "The First Lines of Surgery," by Samuel Cooper; there was Cooper's "Surgical Dictionary," and there was a dreadful book by Miller of Edinburgh, in two volumes, one on the principles and the other on the practice of surgery as if it was possible to separate the two things. There was also a little book called Druitt's "Surgeon's Vade-mecum," which was then quite a new work. When Erichsen's book first came out it was a perfect godsend to the student; we could get what we wanted, written in good English, easily understood, and thoroughly well illustrated and up-to-date, and I can well remember the gratification which became general on the appearance of the work. The proof of its excellence is that the book has gone through ten editions, and that whereas the first edition, which I show you, consisted of 951 pages and contained 262 woodcuts, the tenth edition, published last year, consists of two volumes together, making 2,500 pages, with 972 woodcuts; and, as is mentioned in the preface, over 40,000 copies have been issued previous to the tenth edition in this country. Editions have appeared in every European language, and in America it has been not merely reprinted, but the American government, during the War of Secession, had a special edition printed and sent to every surgeon in its army, that every surgeon might have a good guide as to surgical practice. I am sorry to say they entirely forgot to remunerate the author, though he took pains to bring the fact under the notice of that gov
ERICHSEN AS A TEACHER.
Sir John Erichsen filled the chair of surgery here for fifteen years, and during those years he taught a large number of students, and I am quite sure that every one of them will say that his teaching was good and to the point. Of course new editions of the book came out, and if you think what the subjects are that Erichsen had to get up in order to keep his book up to date, you can estimate the ability of the man. We are apt to look on surgery at the present time as being almost perfect; every surgeon thinks that perhaps of his generation, and yet what improvements and alterations have been made since the time when this book of Sir John Erichsen's was first published! The whole of the surgery of the head has been altered; we know now more of the anatomy and of the physiology of the brain, and we are able, therefore, to bring surgery to bear much more on that organ. We have localized the centers of the different functions and are able to say exactly where mischief may be. Not only in cases of head injury, but in tumors of the
brain, we do not hesitate to open the cranium in a way that was impossible before the days of antiseptics, and with comparatively favorable results. The surgery of the chest is quite a different thing to what it was ten years ago. The surgery of the abdomen has made enormous progress during the last forty years. Why, in my student days, such a thing as ovariotomy was never heard of, and, though a few ovariotomies had been done, any surgeon who proposed to remove a diseased ovary would have almost been thought guilty of manslaughter. Now we open the abdomen for tumors, and to undo twists of the intestine, and to evacuate abscesses; in fact, to make not merely a diagnosis, but to carry out any treatment which may be necessary. The whole of abdominal surgery has been altered, and with it the surgery of the liver and kidneys. No one would have ventured to cut down on a kidney twenty years ago, and it is quite a recent thing that renal stones should be removed and the kidney operated on. Liston was a great lithotomist; he was also a good lithotritist. As to lithotomy, I will undertake to say there is no student here who has ever seen an operation of the kind Liston performed. He always preferred the lateral perineal operation. He was exceedingly dextrous. He could cut rapidly into the bladder and with his powerful hands extract large stones with astonishing celerity and with a fair amount of success. Now we have entirely altered matters as regards this class of cases. In the first place the lithrotrity which used to be done in many sittings with great pain to the patient, is now done in one sitting under an anæsthetic, and the whole stone is washed out; and even if we open the bladder now we most of us adopt the simple method of the suprapubic operation.
THE ANTISEPTIC SYSTEM.
All these things are improvements which have grown up since the first edition of Erichsen's book; and then comes the greatest improvement of all, brought about by an old student of this hospital, Sir Joseph Lister, the introduction of the antiseptic or aseptic treatment. When Sir Joseph Lister first began to experiment on antiseptics, the details were so disagreeable and so complicated that really I do not wonder at the hospital surgeons of that day being inclined to pooh-pooh the whole thing. Carbolic acid was used from the beginning, and it was first of all mixed with putty. One can hardly conceive nowadays using such horrible stuff, and yet it gave fair results, which improved when Sir Joseph Lister altered his method and took to the gauze and its modifications. There was another difficulty and that was the use of the spray. The spray was without exception the most irritating thing the sur
geon had to deal with. To be operating under a fizzling spray which wetted you completely, which whistled, and which gave out every now and then, worried everybody and made life unbearable, and rendered antiseptic surgery of those days anything but a comfortable proceeding. Now we have left off the spray, and with more cleanly methods we do with less carbolic acid, avoiding therby many dangers which carbolic acid gave rise
I merely want to point out to you that the whole of the antiseptic system has grown up since the days when Erichsen was professor of surgery here. At the end of fifteen years Sir John gave up the professorship of surgery and succeeeded Mr. Quain in the professorship of clinical surgery, and in 1875, having held the same wards which I have now the honor to hold for a quarter of a century, he gave up the position which he had occupied to the satisfaction of all and with great benefit to the school and the patients, and retired into private life. Now, gentlemen, I think you will, from what I have said, be able to appreciate a little more fully than you have hitherto done the difficulties which arose and which must necessarily arise in any new establishment, how they were overcome, and what a large part our dear friend Sir John took in the.work. I am quite sure that those who held office under him will agree with me that all found in him a kind friend and one who was always ready to lend a helping hand, and I know and feel that all his old pupils deeply regret that we have been deprived of his presence by death.-British Medical Journal.
Formaldehyde for the Disinfection of Railway Cars.
Extracts and Abstracts.
Fractures of the Margin of the Acetabulum.
BY EDMUND ANDREWS, A. M., M. D., LL.D., Professor of Clinical Surgery Northwestern University Medical School, Chicago, Ill.
A large portion of dislocations of the hipjoint are accompanied with a fracture of the rim of the acetabulum at the point where the head of the bone escaped from the cup. The head strikes with such violence against the thin edge of the rim, that the margin gives way, leaving fragments of various sizes attached to the torn edges of the ligament. Prof. Sims asserts that dead-house examinations show that a very large portion of dislocations of all parts of the body show analogous marginal fractures.
In the standard treatises on dislocations of the hip-joint this fact is scarcely alluded to, and the reader is left to suppose that after reduction the bone will stay where it was put and make no more trouble, whereas in a few cases there is such a gap in the side of the acetabulum that the dislocation is constantly reproduced.
As the patient does not usually die, no postmortem occurs, and no clear explanation is possible, so the unfortunate surgeon is quite likely to have the blame of a permanent lameness unjustly thrown on his shoulders.
In discussing this matter I do not allude, of course, to the blunders of diagnosis, where an ignorant practitioner mistakes a fracture of the neck of the femur for a true dislocation. Knowledge and care will always avoid this error. But there occur cases of true dislocation with all the symptoms clear and well marked, which either resist all efforts at a reduction short of a cutting operation, or else, being reduced and put into a good position, with the head of the bone squarely in the socket, it slips constantly out again. The standard treatises usually attribute all these cases to three causes, viz.:
1. The hooking of the head of the bone under the tendon of the obturator and adjacent muscles.
2. Hooking it under the sciatic nerve.
3. Flaps of torn capsule falling into the acetabulum in front of the bone and filling it up, thus excluding the head.
All these accidents may occur, and may render positive diagnosis of the cause of difficulty impossible, but I wish to call attention to the fact that in a considerable number of difficult cases the margin of the acetabulum is broken through and its retaining power destroyed.
The following case illustrates the subject:
striking his bent knee on the ground, while the wagon fell on top of him, driving his pelvis forcibly down on the femur and causing a dislocation of the hip upward and backward. He was sent into Mercy Hospital to the care of Dr. E. W. Andrews, but as the Doctor happened to out of the city the patient was temporarily brought to my clinic in the same institution. The diagnosis was perfectly clear. There was a dislocation of the femur upward and backward on the dorsum of the ilium. He was immediately etherized, and I made efforts to reduce by manipulation, using a variety of methods. Every effort failed. I then put on the famous old Jarvis' adjuster, without a particle of success. I next applied pulleys. I next applied pulleys, and could get an audible snap like that of reduction, but accompanied at times with something like crepitus. It was all in vain. The bone seemed to go into a correct position, or nearly so, but the trochanter projected out laterally too far, and the bone would not stay in place a single moment after the pulleys were relaxed. The patient began to show signs of dangerous shock and depression. [ therefore remanded him to bed and gave hypodermics of digitalis and strychnine.
The next day Prof. E. W. Andrews returned home, and as the patient was his by the hospital rules, I transferred the case to him and suggested that he make a cutting operation. He accordingly again etherized the patient, and after trying manipulation in vain, operated by a perpendicular incision between the outer border of the tensor vaginæ femoris muscle and the anterior border of the trochanter major, fully exposing the cavity of the acetabulum. The upper and outer wall of the cup of the joint was found broken. A large piece of bone was detached about an inch and a quarter in diameter. This fragment remained by one side to the torn capsular ligament in such a way as to shut up the gap like a gate whenever any effort was made to move the head of the bone into the socket. It was only by excising the fragment that he succeeded in reducing the dislocation, and then only by strong abduction of the thigh, thus prying the head of the femur back to its place.
Unfortunately the patient had received at the time of the accident some obscure contusion in the abdomen. In a few days, although there was no evidence of rupture of any of the hollow viscera, he developed a perotinitis and died.
I have met two other cases so nearly like this, that I believe the margin of the acetabulum was fractured. In one the bone would not stay in place a moment. In the other it would remain a few hours in correct position, but always slipped out unless retained by extension apparatus. I kept it in by weight, pulley and adhesive plaster for several weeks,
but it went out again as soon as the tension was relaxed. Both patients recovering, there was no autopsy.
My fourth case was different in character. A boy aged ten years came under my care with a hip disease of long standing. I suspected abscess. A few days later the hip went out of joint as he lay in bed, the dislocation being upward and backward, and fluctuation became distinct. I opened down upon the parts and uncovered the joint. I found a slightly tuberculous condition affecting mainly the upper margin of the acetabulum, and involving the head of the femur only very slightly. The tuberculous caries had thinned. and weakened the upper and outer margin of the socket until at last the remnant broke away under the pressure of the head, and a true dislocation ensued. I excised the head of the bone and gouged away all softened portions about the acetabulum. The patient made. a good recovery.-Fort Wayne Medical Journal-Magazine.
Fracture of the Pelvis; Acute Myelitis.*
By P. S. Rooт, M. D., MONROE, MICH.
I have thought to interest the members of this society by the presentation of two rather unusual cases; one surgical and the other medical. One will serve to exemplify the curious in surgery; the other the uncertainty of the element of prognosis.
Case I-Fracture of the Pelvis.-G. S., aged nineteen years, of athletic build and very healthy parentage, on the 9th day of October, 1895, while sprinting with a companion, felt something suddenly give way in his left hip. He fell to the ground and was assisted to his home, where I saw him a few minutes afterward. An examination demonstrated that he had fractured the pelvis. The location of the fracture was at the anterior inferior spinous process of the ilium. As you are aware, the straight tendon of the rectus femoris muscle has its origin at this process. This muscle is one of the four which form the quadriceps. extensor which has its attachment on the tibia. It was, then, the physiological action of this muscle that produced a fracture of this process. The piece of bone separated was about two inches long by one inch in depth.
As to the matter of treatment, two courses presented themselves; one to cut down and, wire the separated fragment to the body of the ilium; the other to attempt reposition by muscular relaxation. I found by flexing the knee and thigh the fragment could be quite perfectly replaced. I therefore placed the leg upon a double inclined plane, which afforded considerable relief to the patient. The young gentleman had just received an appointment
*Read before the Monroe County (Mich.) Medical Society.
to West Point and his father was extremely desirous that a perfect result be had; hence on the following day the case was seen by Doctors H. O. Walker of Detroit, and C. T. Southworth of this city. These gentlemen concurred in my diagnosis and treatment, but for greater comfort to the patient a long splint, with a double incline and a foot rest was advised. However, for the most perfect relaxation of the quadriceps extensor I think a triangular splint, perpendicular at foot and apex at gluteal region, would better fulfill the indication. It is possible such a splint would be somewhat tiresome. The splint we had constructed permitted of some up and down movement of the foot, which was greatly appreciated by the patient: The leg and thigh were protected by cotton and confined to splint by roller bandage. The limb was maintained in this position for nearly five weeks, when, upon removal of the splint, the union of the fracture was found to be quite firm and the patient able to walk with a slight limp.
The details of this case have been given because of the rarity of such fractures, when produced by muscular action. Hamilton reports one case in a man of seventy years who fractured the ilium while getting up from his seat in a street car. Ashhurst reports this case from Hamilton. No other cases are reported by such surgical authorities as I possess. Of course, fractures of the pelvis are common as a result of falls or mechanical injuries.
Case II-Acute Myelitis.-S. M., aged sixty-nine years, of Jewish nationality, well nourished and without history of any severe previous illness. I was asked to see the patient Oct. 17, 1895, and found him suffering with severe cystitis and complaining of painful sensations in the feet and spine. Temperature 100 degrees, pulse 96. The cystitis appeared to have been the result, or an extension of urethral inflammation contracted some months previously. An examination of the urine. showed it to be of acid reaction, pus and albumin constituting about one half the volume. Filtration and an examination for albumin showed about ten per cent. indicating the involvement of the kidneys in the inflammatory action. The microscope revealed pus, bladder and renal epithelia in abundance, also
We had, then, cystitis, with also a pyelonephritis from contiguity. I would call attention here to the acid reaction of the urine. Such reaction is found in pyelitis involving one kidney, but not in cystitis. Cystitis, especially if chronic, gives us ammoniacal urine or a urine of alkaline reaction. It must also be remembered that suppurative cystitis is liable to result in pyelitis by the simple process of extension. I cannot speak as to the nature
of the primal inflammation of the urethra, whether it was specific or simple. We will now revert to the nervous symptoms. The tenderness over the spine was accompanied by a bandlike restriction around the chest and marked formication and tingling of the feet. These last symptoms occasioned the patient so much suffering that the frequent hypodermic administration of morphine was necessary. Hot water applied to the dorsal region of the spine produced intense pain, but below this point very little sensation was manifest. In about four days the formication and tingling gave place to paraplegia with anæsthesia. Restlessness continued to be a marked feature. There were no special bladder or rectal symptoms, except constipation and some incontinence of urine. Temperature now ranged from 100 to 103 degrees; pulse from 75 to 90. About this time he began to complain of numbness of both hands, with tingling and an extension upward of the soreness over the spine. With the advent of these new symptoms the respiration became hurried-36 to 40-pulse, 120 and upward. The band-like sensation completely encircled the chest and was a source of great distress. There were indications of the formation of bedsores, but by great care and the use of air cushions this complication was avoided. The patient could move his hands, but otherwise he was absolutely helpless. He took nourish-ment in liberal amounts, but notwithstanding appeared to be failing. The exhibition of morphia was necessary in order to procure any sleep whatever. At this time, October 21, 1895, the case was seen in consultation by Doctors Heath and Masecar, who concurred in the diagnosis. Our prognosis was that he would live but a few days at most. He, however, continued in about the same condition, and on November 5 Doctor David Inglis of Detroit was called in council. He agreed perfectly both with our diagnosis and our prognosis; still the man lived on. His legs became edematous and his muscles underwent rapid atrophy. His hands were useless, though they could be moved.
As to the matter of etiology, it may be said. that the most common causes of myelitis are injuries, exposure, syphilis and diseases of the vertebræ. In the case under consideration I do not believe that any of these factors had a causative relation. I look upon this manifestation of disease to be the result of an infective process, which had its origin in the suppurative inflammation of the bladder and kidneys. Cases of myelitis due to septic infection are rare and by some are said not to exist at all. We have, however, the authority of Sir William Gull in confirmation of such a possibility. He reports several cases as being due to gonorrheal infection-the infection either being specific or purulent. He reasons that such infection