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time on, Joseph receives instructions from the Lord and a year later again visits the place where the plates lie concealed. This time, he even has the plates in his hands, puts them down, turns and finds them gone; prays fervently, and is again shown the plates under the stone but is instantly hurled back and comes to himself, as before, lying upon the ground. He returns to the house weeping with grief and disappointment.

It was just after this occurrence that Joseph entered the employ of Josiah Stowell, who sought his services in locating a silver mine, having heard that Joseph that Joseph "possessed certain keys by which he could discern things not visible to the natural eye." After a month or two, he gives up the search and is reprimanded by the angel of the Lord for his worldliness.

(To be continued.)

THE ELECTRIC DRILL, SAW, REAMER AND TREPHINE IN BONE SURGERY.* CHARLES GEIGER, M. D., St. Joseph, Mo. Professor of Orthopedic Surgery, Ensworth Medical College

For some time those who are engaged in the practice of surgery have realized the necessity of modernizing the instruments and methods employed in operating upon the head and large bones. The old crude methods of employing the chisel, hammer, and hand drill, are unscientific procedures, requiring too much valuable time, and exhausting the patient. Even the expert operators observed during the recent Clinical Congress of the Surgeons of North America, that they were handicapped by a lack of suitable instruments, consuming too much time with their chisel and hammer and hand instruments.

In modern bone work, it is absolutely necessary in some case to remove bone grafts varying from two to ten inches in length. The only correct method to do this, is with the electric circular saw.

In

the latest treatment for Potts' disease, a bone graft is taken from the tibia of the individual suffering with this disease, the length of the graft depending upon the number of vertebra that are diseased. The graft extends into at least one healthy spine of the vertebra, above and below the diseased member or members. In fractures that cannot be held in apposition by methods commonly used, and also in ununited fractures, in place of Lane plate, bone *Read before the Academy of Surgery, St. Joseph, February 2, 1914.

grafts are used. The grafts are always taken from the tibia. After the ends of the fractured bones have been reamed out with the electric reamer, the graft is inserted into the ends of the fractured bones. All bone grafts must fit snugly, otherwise they are liable not to grow. The operator should always keep in mind the importance of preserving the periosteum on the graft, as the periosteum has much to do with the blood supply, and the life of the graft.

Surgeons have found that handling, manipulating and trauma are the causes of infection in bone grafting, operating on ununited fractures, or any plastic bone work, and the slightest infection is destructive and hazardous to good results. The above causes of infection are eliminated by the use of this set of instruments.

Any surgeon who has had much experience with bone work, appreciates the great difficulty of enlarging holes in bone with the ordinary hand reamer or chisel. In making holes or wiring bone, the electric drill is unsurpassed, as it penetrates without pres

sure.

The electric saw will be found of great service in removing plaster casts; only onetenth the time being required, as compared to the old method, and the operator is relieved of all work.

The object of this instrument or device is to supplant the cable, which usually conveys the power from the motor to the instrument; the cable has been used by all other motor bone sets. It is always in the way, and if bent at right angle, or at any acute angle, while it is running, it will generate heat, and its action be retarded. The Geiger device, motor and all, is held in the hands of the operator and gives firmness and rigidity to the instrument on account of the weight and firmness with which it can be held. The operator, by a motion of his thumb, turns on or off the electricity, without any efforts, as it is always at his thumbs end.

The Geiger electric surgical bone set comprises a 1-15 horse power, 110 volts universal motor. The housing is aluminum; the motor is wound with an enameled wire. The enameling is baked on with a temperature of 1000 F., and all connections are insulated with a special insulation (bakalized fibre). The switch is made of delecto. There is nothing about the motor that can burn or be melted with a temperature lower than 130 degrees C., which gives us an assurnace that the motor can be thoroughly sterilized with dry heat without harm.

The speed of the motor is 7000 RPM.,

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The handle and hand piece are at right angles with each other. The hand piece is four inches long. At the outer end of the hand piece is a ball bearing, which receives the outside thrust or the inward thrust of the instrument, so that any pressure brought to bear upon the instrument will not interfere with the power of the motor.

The chuck, which is a special one, is simple and effective, giving absolute rigidity and firmness to the instrument while in operation. The instruments are interchangeable in the universal chuck, and the instrument to be used by the operator can be quickly adjusted or released as will be seen by a glance at the construction of the chuck. The motor complete, weighs about four pounds.

1913, and he stated as follows: "This is a first-class device, and by the use of this instrument we simplify and modernize bone surgery, also reducing the time and labor, both of which are essential factors in this important branch of work. The great power and efficiency of this small instrument, as a motor, saw, electric drill, reamer, and trephine, deserve the highest commendation of the profession."

This set of instruments is also used and recommended by Drs. William and Charles Mayo.

The risks of pylorectomy can be reduced by performing it in two stages-first the gastro-enterostomy, later the resection.

THERAPEUTIC PROBLEMS. GEORGE F. BUTLER, A. M., M. D., Kramer, Ind.

Man is a componud animal whose health and functions are constituted by a system of balance. This balance is secured by a system of conflict between various organs regulated for the benefit of the body as a whole by the central or cerebro-spinal system. Like an invertebrate, each organ has its own nervous system, which but for the central nervous system, would imbibe nutriment at the expense of the system as a whole or in conditions of extra work, would excrete unduly at the expense of the organism as a whole. This would result in that disturbance of balance which occurs from undue use or disuse. If there be undue use there results undue appropriation of nutriment followed by undue creation of

waste.

To balance elimination there are two great functions carried on in common by different organs. The first great func

tions, oxidation both for the creation of energy and for the conversion of waste into its most eliminable form. Elimination of the waste thus converted is the second great function. Accumulation of waste in the system implies interference with oxidation, creating the so-called suboxidation conditions and also imperfect elimination. Before accumulation there is generally strain on the oxidizing organs or on the elimina tive organs taking the line of least resistance.

Under normal circumstances the toxic elements produced in the organism are eliminated by various channels. Some of these products are transformed in the alimentary canal into innocuous substances. Gases are eliminated by the lungs, other compounds are intercepted and decomposed in the liver, and others eliminated by the kidneys and skin. When any of these emunctories is interfered with, in the discharge of its duties, phenomena of autointoxication, such as alternate pale and high colored urine, headache, pallor, nosophobia, etc., occur.

The liver, which from an embryologic and functional standpoint resembles two organs one an eliminative and poison destroying. the other a sanguifactive can by the pecuilar intrinsic action due to the specific activity of its cellules, diminish the toxicity of substances with which it is brought into contact. Such action is manifested not only in the case of poisons introduced through various channels into the organism, but likewise in the case of toxic products elaborated within the organism

itself in consequence of changes in products due to tissue activity. The liver suffers from general instability of the organs. It has extra work to perform but has not sufficient balance to do its ordinary work. Through this, the toxic product of oxidizing organs are thrown back on them.

The kidneys present a point of least resistance where there is an undue proportion of sodium chloride in the circulation. Under certain conditions either of insufficient dilution or of imperfect organic combination, sodium chloride may play an important part in the production of autotoxic states of which scorbutus is the type. The influence here exerted is due more properly to interference with elimination and its precedent oxidation. The presence of a pale urine indicates the absence of proper elimination by the kidneys which may be due to strain on the kidneys themselves, which strain may result from the presence of intestinal products like indican, which again may be the expression of intestinal fermentation, together with imperfect poison destroying power of liver. This may be due to excessive polyuria through which liver, spleen, skin and the oxidizing organs are imperfectly supplied with the necessary water which has to be drawn from the tissues increasing the difficulty of elimination, through the imperfect metabolic products thus formed.

The therapeutic problem presented is first, to secure the proper balance of elimination and next to secure proper oxidation. The elimination problem is the first, because the materials to be eliminated are already formed and must be expelled in their present character. A hint of the procedure to be adopted is given by the methods successfully employed in ascites and anasarca. and anasarca. Here, diuretics and hydragogue cathartics balance each other. In many of the states to which these conditions are referable, the strain on the kidneys is secondary to the imperfect action. of the liver and bowels, and the renal strain is best relieved as in anasarca through agents which act on both the liver and the intestines, producing a moderate, almost natural hydragogue catharsis.

Among the agents which have a marked but much neglected action in this particular is a drug not now official, which appears in the pharmacopeia of the Massachusetts Medical Society of 1808. This is aesclepias. It has a slight diuretic action secondary to an action on the liver and the upper intestines; its action is on the heart, liver, pancreas and intestines. It is somewhat cumulative when given for some

time alone, and hence, like the group to which it belongs, requires modification by combination. Another drug which after falling into comparative disuse has again become widely used in these conditions is apocynum and cannabinum. This, like aesclepias, is a marked hydragogue cathartic and diuretic, but in addition more of a respiratory and cardiac stimulant in its primary action.

Like aesclepias, it exerts some influence through its cardiac action secondarily on the liver and also slightly influences the spleen and the adrenals. The disuse of aesclepias and apocynum by the regular medical profession, was due to the disuse of green root and leaf preparation in tinctures. The clinical results in the use of apocynum cannabinum indicate not only that the adrenals, but other oxidizing organs are stimulated since patients gain strength and flesh when they get well under the influence of apocynum. The tendency to slight nausea present at times from the cumulative action of aesclepias is corrected by apocynum to a large degree. The chief untoward effect of aesclepias, is psychic nausea which is the first indication of its cumulative action, and which being due to over-stimulation of the pneumogastric rather than of the vomiting center, may be corrected readily by a heart stimulant of the strychnia type.

While both these remedies have undoubtedly beneficial action in true nephritis, still the disappearance of albumen and casts produced by them, is due to the removal of renal strain rather than to any directly beneficial effect on the kidney itself. Through the hydragogue action of the two drugs, it is possible not merely to control anasarca but likewise to control polyuria to such a degree as to direct aqueous elimination to the liver and intestines, this increasing the action of both these organs and thus removing the elimination of heptho-intestinal products from the kidney. The procedure is furthermore aided by the stimulation given oxidation, as shown in the gain in strength and flesh, even in nephritis, from the use of these two drugs in combination.

Another remedy acting in a similar way as a tonic, hydragogue cathartic, and diuretic, is chionanthus. The action of this is primarily tonic and secondarily slightly hydragogue aperient rather than cathartic and latterly diuretic. It has some influence on the oxidation system, secondarily to the influence on the liver followed by an influence on the pancreas. Its general tonic action adds to that of the two remedies first mentioned and tends to relieve the strain

produced by them on the general system which is most potent in the case of the aesclepias and less in the case of the apocynum. The other drugs which conjoin similar properties with greater cathartic action are leptandra and podophyllum given in combination with the three previous remedies and with iris a certain intestinal action is added to the effects already described. Iris is the most tonic, least irritant and most strongly stimulant to the oxidizing system of the three, but the combination affords better balanced results with less untoward effects than any of the three given alone, and the combination with the three remedies first described, adds to the general efficiency. Colocynth in the form of a compound extract, adds to the efficiency of the combination by its action on the lower bowel. In this prescription the evil effects of aloes upon the hemorroidal veins does not occur and scammony adds to the general oxidizing tendency, so far as the fats and stretches are concerned.

My attention was first directed to this combination by Dr. Jos. G. Kiernan of Chicago, who recommended that the prescription be prepared from tinctures made from green plants, dispensed in capsules with licorice powder as an excipient.

I have devised a formula containing the active principles of these drugs save in a case of the last ingredient, put up in tablet form, each tablet containing the following: Chinnanthin... Apocynin . Leptandrin. Podophyllin. Irisin ....

Asclepidin

Powdered extract

comp....

.gr.

.gr. 8

gr.

gr.

.gr.

gr.

colocynth

gr.

These tablets are now prepared by the Abbott Alkaloidal Co. under the acrostic name calpia. One tablet may be given three times a day when free elimination is desired.

The conditions underlying intestinal frementation involve both elimination and oxidation since fecal resorption is a frequent consequence. Fecal resorption, as Sir Andrew Clark pointed out, is a frequent cause of an obstinate type of anemia such as today is too often regarded as pernicious anemia. There is here a pathogenic circle since the true pernicious anemia (which consists as P. O. Owsley has pointed out in a resumption of reproductive powers by the red blood cell, fatal to the organism as a whole) is intensely aggravated by non-elimination and non-oxidation. Fecal resorption plays here in a vicious circle nearly as

great a part as in fecal anemia. The elements entering into fecal resorption are much more complex than is usually stated. Starchy elements of the food play a more important part in even the seemingly proteid results than would be assumed from the ordinary statements on the subject.

Accumulation of starch in the intestine from excessive use of potatoes, bananas and other starchy vegetables leads to an acetous fermentation with great disengagement of gas and likewise to chemical combinations with proteid contents of the bowel. The resulting combinations are much more easily absorbed than are either the starch or the proteid alone of their absorption, indican is the index. This is the toxic material which plays such a destructive part in the cachectic condition. To overcome the conditions the attempt must be made to secure natural regulation of intestinal changes. In this the secretion of the liver and that of the pancreas both play a part. A combination (also at the suggestion of Dr. Kiernan) which I have found of value in meeting all these indications consists of the following:

Creosote (beechwood)...minims 36
Oil gaultheria (Merck's) minims 18
Oil cassia (Merck's).... minims 18
Eserine salicylate (Merck's).. gr.
Pancreatin....

.gr. 72

Cascarin (Merck's).

Po. ext. colocynth co. Bilein (Abbott).

.gr. 36

.gr. 18

M. ft. tablets No. 72.

gr. 36

Sig.: Take one after each meal. The creosote and the essential oils play a large part in determining proper fermentation, while the bilein and the pancreatin give this a physiologic direction. The influence of scammony on oxidation of fat and starch has already been pointed out. Eserine has a more decidedly regular influence on the peristaltic action of the intestine than strychnine so long the stand-by in this particular. The late development of the rectum and anus in embryogeny, has naturally exposed these two organs to influences tending to arrest of development. The cloacal type persists quite late in fetal life even in the placental mammals. The ovi-parous mammals retain this type permanently. With the rise in evolution of intra-uterine development the cloaca is less dominant and its relations to the neurenteric canal are less easily determined. The neurenteric canal is an open communication between the archenteric cavity and the medullary. The terminal portion of the intestinal canal the premative anus receives in early stages of fetal life the urogenital

ducts; a condition which is permanent in the Sauropsida (birds and reptiles) and the monotremata (egg-laying mammals). The portion of the archenteron common to these ducts is the cloaca. The ectoderm forms very early a small anal invagination which. grows in toward the cloaca until the ectoderm come into contact. The membrane formed by the two epithelia breaks through and the cloaca thereby acquires an opening to the exterior. This opening subsequently divided into two: 1, the urogenital opening; 2, the permanent anus. The complex development here outlined results in various complications of elimination consequent on the struggle for existence between the organs which are affected by the various periods of intra-uterine stress precedent to the complete development of the anus. This may effect not only organic development, but likewise functional potentiality and innervation. It is for this reason that the lower bowel has such a marked relation not only with pelvic but with the general constitution.

The increasedly complex system of lymph spaces in connection with cerebral development show that the trophic functions of the neuron imply waste which requires oxidation and elimination in greater proportion as the animal rises in the scale of brain development. In proportion as the waste at the place of formation is properly oxidized, do the chances or arrested elimination lessen not only at the point of formation, but likewise at the points of elimination. As elimination like sensation, is a balance between different organs, the chances lessen of improper elimination everywhere. The problem of intellection involves, as Meynert long ago pointed out, proper supply of oxygen to the brain cells. In the event that an excess of oxygen was furnished, excessive emotional states are produced whose products fail of proper symbolization because of the rapidity with which they occur. The reverse state of depression arises from the imperfect supply of oxygen and the consequent imperfect elimination of the products of nerve action rapidly removed through the ordinary elimination centers. It is for these reasons that elimination has played such a large part in mania the type of emotional exaltation; melancholia the type of emotional depression and the confusional mental states, where there is no emotional basis. In these last states, a condition may be present somewhat resembling toxic amblyopias before the change in nerve structure occurs. What is true of the cerebral nervous system is likewise true of the cord and still more

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