Miscellany.

Nerve Sutures and Other Operations For Injuries to the Nerves of the Upper Extremity.

At the last meeting of the Mississippi Valley Medical Society, Dr. A. J. Ochsner of Chicago read a paper of which the following were the conclusions; 1. Every severed nerve should be sutured even after years. 2. The earlier the operation is performed the better. 3. If neither sensation nor motion is established within a year, the nerve should again be exposed, the cicatricial tissue removed and the end again sutured. 4. The end should be clean cut, should contain neither crushed tissue nor cicatricial tissue. 5. Tension must be avoided. 6. The wound must heal without suppuration to secure the best results. 7. Hemorrhage should be perfectly controlled to prevent intervening clot. 8. Carefully prepared catgut is the best suture material. 9. After suturing the ends, either direct or "a distance," it is well to stitch a fold of fascia over the united nerve ends. 10. The extremity should be placed at rest. II. The external incision should be ample.

The Medical School of the Future.

The October number of the Edinburgh Medical Journal contains an address which was delivered by Dr. John Struthers at the Medical School, Edinburgh, in 1895, of which the following is the substance:

Abundant illustration, says the author, that our sciences are ever on the move, rising on the proverbial stepping-stones of their dead selves to better things, could be given from his own recollection if he had time. It has been a half century of extraordinary progress, an age of inquiry, in which all that had been accepted as truth, physical, metaphysical and historical, has been subjected to the crucible; an age of inventions that have revolutionized our locomotion and our means of communication with each other; and much has been done to alleviate suffering and for the saving of life. Sanitary science and preventive medicine. largely new developments, have produced great results and raise hopes of still greater. In therapeutic medicine one might have expected changes; less so in more matter-of-fact surgery, but in it the changes have been still greater than in the medical side of practice. Not only painless operation, but, as regards the saving of life, the still greater boon of aseptic practice. The progress in surgery reads like a

romance.

The ophthalmoscope and the laryngoscope have done much in their limited sphere; but it is mainly to the improvement and the general use of the microscope that we

owe the great progress, opening a new world to us into which the naked eye could not penetrate. Thus one new instrument may bring an era in medicine. In short, says Dr. Struthers, almost everything in surgery and medicine. has changed.

What, he asks, is the lesson of all this to teachers and to students? To teachers, is it not that our duty is to take our students to Nature, to what we call practical work, and there to train them to observe and to think for themselves, and that all our teaching should be imbued with the spirit of inquiry? To students, is it not that they should seek and appreciate that kind of teaching, in preference to the kind that feeds the memory with verbal knowledge; that they should keep an open. mind, and that whatever they hear should be received with what has been called the slow consenting academic doubt?

This training of the student to observe and think for himself, he continues, is by no means so easy a thing as may be supposed by those who know him only in the crowd or when he is somewhat advanced. It is the teacher of anatomy who is struck with that. Set the beginner down to a bone with his book, or let him hear a lecture of the usual kind; examine him and you will find he has not really seen anything. He has followed his previous habit at school, has learned his lesson and is ready to repeat what he has read, or more or less of what he has heard. He has to be taught to look and see at every statement that it is so. He has a sacrum before him and you ask him whether its length or breadth is the greatest. He had not thought of that before, but readily says its length. You put into his hand that useful training instrument, a little foot-rule, and ask him to measure. He finds that his eye has misled him, and learns the value of measurement. That may be of no moment for its own sake, but it trains him to observe, and he will have a sharp eye in his clinical work. At the first, fresh from his school method, he seems to think this a waste of time, but he soon discovers a new power within him, and he delights to exercise it.

Dr. Struthers impresses upon teachers of anatomy the responsibility that rests with them in giving the student the right start in method. It has been said, he says, that the value of anatomy is that it trains the memory, and that is an entirely erroneous method of teaching anatomy, for, although the dissection may be on the table or even in the demonstrator's hand, the teaching is too often verbal, addressed to the memory, and the students spin off answers from memory without being able to recognize the object when handed to them. The author thinks that much time is wasted in the anatomical lecture room in putting for the memory details for which the practical rooms

are the right place, and that the opportunity is lost of directing the student's eye and thought to the really important and interesting things of anatomy. In regard to the present system of the medical schools, he thinks there should be more practical work, more going to Nature, and less time consumed in the lecture room. In the last twenty-five years, he says, the amount of lecturing has been increased. Special departments have been split off, with the inevitable addition of special courses of lectures, while the general courses have not been shortened. Classes more or less practical have been added in nearly every subject in the curriculum of study, without the corresponding diminution that should have taken place in the time occupied with lectures. The result is, continues the author, that the student is pulled about from class room to class room; hardly settled to his dissection or to some other laboratory work when he is summoned off by the lecture room bell.

Dr. Struthers quotes the following definition of what practical work should be, which was delivered by the General Medical Council four years ago, when these questions were fully discussed and the resolution was taken to extend the period of study to five years:

"Due time should be set aside for practical work in the various subjects. By a practical course is understood one in which work is done by the student himself, under the direction of a duly qualified teacher."

Then as to the amount of lecturing:

"The regulations requiring attendance on systematic courses of lectures need not require attendance on more than three lectures weekly in any one course."

In regard to the work intended for the new fifth year, now impending, the purpose of the Medical Council was that it should be entirely devoted to clinical work, as thus expressed by

the council:

"The fifth year should be devoted to clinical work at one or more public hospitals or dispensaries, British or foreign, recognized by any of the medical authorities mentioned in Schedule (A) of the Medical Act (1858), provided that of this year six months may be passed as a pupil to a registered practitioner possessing such opportunities of imparting practical knowledge as shall be satisfactory to the medical authorities."

They are before us in France in having thought out these questions, and the system in Paris, started shortly, is: The first, the better, half of the day is set aside for the hospital and for practical work in the laboratories: no lectures allowed before two o'clock; and the number of lectures in any course are two or three a week, never exceeding three. No one will say that medicine is not well taught in Paris.

That, says Dr. Struthers, may be taken as his ideal of a medical school of the future. There

may be difficulties to overcome and the transition may be gradual, but it is manifest that the modern demand for more practical teaching in all the branches and for more clinical work will oblige the schools to move in that direction. It has been suggested to him, he says, that it would be well if all lecturing in our medical schools could be stopped for a couple of years, so as to throw us upon our resources for the giving and acquiring. of real knowledge. Lectures will always deserve to hold a high place in medical education when they are of reasonable number and of a high order; the teacher going before his assembled class not as grinder but as a commentator, guiding and inspiring his students, introducing more or less demonstration or experiment according to the nature of the subject and of a kind suitable before the crowd. In such a biweekly or triweekly lecture there will be more benefit from the living voice and more of the intellectual atmosphere than in the kind of lecture in which a stream of information, nearly all of it already in the student's hands in the printed page, is poured from day to day upon the memory.-N. Y. Med. Journal. Death Eighteen Hours After the Introduction of a Bougie Into the Urethra.

Muller (Centralblatt fur die Krankheiten der Harn- und Sexual-Organe, 1896, B. vii., H. 3, p. 137) has reported the case of a man, thirty-eight years old, with a history of gonorrhea in youth, who came under observation on account of some difficulty in micturition. He had previously been treated for stricture of the urethra. The urine was turbid, and passed in a small stream. A diagnosis of vesical catarrh, with moderate stricture of the urethra, was made, and to determine the degree of narrowing, metallic sounds were employed. A No. 21 conical instrument, with a long curve, was first gently introduced, with due antiseptic precautions, and an impossible obstruction encountered in the membranous urethra. With still greater care, a No. 23 sound was next used, but also without success. The examination was unattended with pain, and but little blood was lost. A prescription containing uvaursa and sodium bicarbonate was given, and the patient sent home. Three or four hours after the manipulations, and immediately upon taking his medicine, the patient was seized with vomiting and diarrhea, followed by chill, restlessness, general prostration, pains in the chest and in the sacral region, and excessive thirst. Eighteen hours after the use of the bougies the patient died, amid symptoms of cardiac failure. Upon post-mortem examination, the heart was found to be slightly fatty and the lungs edematous. There existed cloudy swelling of liver, spleen and kidneys. Portions of kidney were put aside for histologic examination, to deter

mine if nephritis existed, but were inadvertently lost. The ureters and pelves of the kidneys presented no abnormality. A tight circular stricture was found involving the membranous urethra, and, close by, several diverticular depressions of the urethral mucous membrane, one of which appeared to have been recently eroded. Copious greenish pus escaped from the prostate gland. The mucous membrane of the bladder was in a catarrhal state; the viscus contained a small amount of turbid urine. The opinion is expressed that the fatal issue in the case reported is to be attributed to an acute nephritis, induced, perhaps, through the introduction of pus from the prostate through the erosion in the urethra.-Medical News.

Fracture-Dislocation of Shoulder Reduced by McBurney's Hook-Traction Method.

At a recent meeting of the College of Physicians of Philadelphia, Dr. Thomas S. K. Morton reported a case which he had under care in December, 1895. A man, aged seventyfour years, of large frame and well preserved, was thrown from a trolley-car, striking upon his left shoulder, and was subsequently immediately admitted to the Pennsylvania Hospital. There the resident surgeon diagnosed dislocation of the head of the humerus and attempted reduction. Almost at once a snap was heard and evidences of fracture of the humeral neck presented. Dr. Morton was then summoned and found the head of the bone tightly wedged beneath the clavicle and almost complete paralysis of motion and sensation throughout the extremity. It was impossible to move in the least degree the head of the bone by external force. The man being apparently permanently disabled by the injury and probably destined to be a great sufferer from pressure symptoms incident to the head of the humerus resting upon the brachial plexus, and, furthermore, being in excellent condition for anæsthesia and operation, the latter was decided upon, with the idea of drawing the fragment into position by means of the hook-traction described by Dr. Charles McBurney (Annals of Surgery, Vol. XIX, 1894, p. 19), or, this failing, to excise it. Accordingly a hook similar to that of McBurney was improvised and anææsthesia by the ether-oxygen method induced. The deltoid was vertically split upon the outer aspect of the joint and the shaft of the humerus well exposed. It was then ascertained that a comminuted fracture existed. A number of small fragments laid externally while a long spicule, connected with the inner aspect of the head, ran downward in the axilla for two inches and a half. This could not be adequately exposed until a portion of the pectoralis major and the long head of the biceps muscles and been divided. Then a hole was

drilled in the fragment and the end of the hook placed in it. placed in it. But as soon as traction was made upon it, the bone, which was exceedingly soft and evidently the subject of fatty degeneration, gave way and the hook pulled out. Another hole was drilled at a point three-quarters of an inch below the head and traction again made. By very greatly increasing the traction force the head left its position beneath the clavicle and came to the edge of the glenoid cavity, here the hook again tore out, bringing away a considerable portion of the long, sharp spicule of shaft. But finger-pressure now easily directed the bone into the glenoid cavity. Silver wire sutures were employed to hold the head and shaft to proper position, all loose fragments removed, a large drainage tube introduced, and an aseptic dressing applied after suturing the skin margins. He reacted well and so remained, save for some weakness. Nevertheless the patient ate very heartily and did excellently until the eighth day. He was then permitted to sit up in a chair, but had not been out of bed more than a few moments when he went into a sudden collapse, from which it proved impossible to arouse him, and death ensued in a very short time. The wound had been dressed, found in perfect condition and the tube removed on the second day. No general post-morten could be obtained, but an examination of the wound after death found it to be in perfectly satisfactory condition, with no evidence whatever of infection or other complication.

Dr. Morton was unable to state definitely, but inclined to the belief that the resident surgeon had not produced an original fracture, but had simply separated the already broken and impacted bone. -Annals of Surgery.

Treatment of Ocular Traumatism.

Trousseau (Gazette Hebdom. de Med. et Chir., June 14, 1896) gives as general rules in injuries of the eye: (1) Render aseptic the eye and conjunctiva. (2) Cover it with a dry aseptic dressing.

The former is best accomplished by free lavage with a warm bichlorid of mercury solution 1-4,000. If free from alcohol and filtered, this solution cannot possibly do any harm. With the patient in a horizontal position, the lids are held apart with one hand while the solution is allowed to trickle into every corner of the eye from a mop of absorbent cotton. When thoroughly cleansed, the eye is covered with a dry, sterile dressing and a starch bandage.

Foreign bodies, if superficial, should be removed under cocain. Wounds of the conjunctiva are to be stitched with the finest catgut or silk. Wounds of the cilary circle are dangerous, and should not be touched.

Small wounds of the sclerotic heal readily; larger ones should be closed by a conjunctival flap. The author speaks against hasty enucleation, meantime watching carefully the other eye for sympathetic ophthalmia.

Traumatic Aneurism of the Posterior Tibia Artery; Notes of a Case.

The following rather interesting case is reported by Dr. C. H. Frazier of Philadelphia in the University Medical Magazine for No

vember:

The patient in question, a lad 11 years of age, came under observation in the out-patient department of the Episcopal Hospital. The history, briefly told, is as follows: Six weeks ago the boy was struck by a brick just behind the internal malleolus of the left foot. With the exception of a minute wound of the integument, there was no evidence of any external injury. Immediately blood flowed in a small jet from the wound, until mechanically checked by the application of some crude dressing. During the six weeks that have elapsed since the accident, a swelling about the size of a walnut has formed at the seat of injury, just behind the internal malleolus. The situation and size of the swelling prevented the wearing of a shoe, on which account chiefly the boy seeks relief.

An examination of the case revealed a swelling of size, shape, and location as above described. To the touch it was of semisolid consistency, and pressure thereon elicted no pain.

A diagnosis of hematoma was made and its removal recommended.

The patient consenting, a free incision exposed the tumor, which proved to be composed of blood-clots inclosed in a sac. On turning out the clots, free hemorrhage ensued. Pressure above the wound, however, promptly and effectually controlled it.

On close inspection it was seen that the hemorrhage had its origin from a tear in the walls of the posterior tibial artery. A catgut ligature was applied on the distal and proximal sides, and the external wound closed with silkworm gut sutures.

At the expiration of a week the stitches were removed, the wound healing by first intention. The subsequent history of the case is uneventful.

Remarks.--From the etiology of the case and from the fact that this aneurism had a sac, it properly belongs to that subdivision, the socalled circumscribed traumatic aneurism. This class is met with chiefly in the scalp, hands and feet. The treatment carried out in this case was that recommended, generally, in cases where the artery injured is small and easy of access, namely, evacuation of clot and application of ligatures on distal and proximal sides of the seat of injury. Left alone, the ane

urism may terminate in one of three ways. Either spontaneous cure may occur by extension of the organized clot into the vessel, or, the aneurism enlarging, may burst the sac, thus forming a diffuse traumatic aneurism, or, finally, possible infection with pyogenic microbes may result in the formation of an abscess, the bursting of which may be followed by the discharge of pus, blood-clots, and more or less profuse hemorrhage.

The Employment of Salol in the Treatment of Tuberculosis of the Bones.

The Journal des praticiens for April 4 contains a report of a recent meeting of the Société de chirurgie at which M. Reynier read a paper on this subject. In the presence of limited osseous tuberculosis, he said, which was just beginning, the surgeon often hesitated to interfere by trephining, as there was no exact information in regard to the limits of the field of operation. Grattage was practiced and continued until a more resistant osseous tissue was met with, and the period of time necessary for cicatrization was uncertain; usually it occurred slowly; consequently relapses, fresh abscesses, and persistent fistulæ were to be feared. Even when cicatrization was obtained, he said, the bone might remain large and hypertrophied, and become a cause of restraint in the movements of the limb. said M. Reynier, the surgeon was assured of the benignity of the operation, and if it was casy to clearly establish its limits beforehand, intervention should be immediate.

If,

In view of the difficulties attendant upon operations of this nature, M. Reynier employed a method of dressing which had been introduced by him in 1893. This dressing consisted of salol which was liquefied at a temperature of 104 degrees F. and mixed with naphthol. aristol, and iodoform. If, after having trephined the bone and cleansed the tuberculosis region, the cavity was filled with the melted salol, the latter would crystallize at 82 degrees F. and obliterate the cavity entirely. In this way, said M. Reynier, a complete and aseptic occlusion was obtained. Furthermore, union by first intention of the subadjacent skin might be effected with this method of closure, which was similar to plugging of the teeth.

M. Reynier stated that he had operated on six patients and employed this dressing, with the result that he had obtained a rapid recovery in a few days after filling the osseous cavity with this antiseptic mixture, and that immediate union of the skin and the subcutaneous connective tissue had taken place.-N. Y. Med. Journal

The tenth annual meeting of the National Association of Railway Surgeons will meet in Chicago, May 4, 5 and 6, 1897.

No. 17.

RESECTION OF ARTERIES AND VEINS INJURED IN CONTINUITY; ENDTO-END SUTURE; EXPERIMENTAL AND CLINICAL RE

SEARCH.*

BY J. B. MURPHY, M. D., CHICAGO, ILL.

The idea of suturing an artery after it had been injured was conceived by Lembert and a case is reported by Broca in 1762, in which suture of a longitudinal incision of an artery was successfully made. Assmann in 1773 treated of it in a dissertation at Groningen. The latter made two experiments on animals; both resulted unfavorably through an obliterating endarteritis. He then abandoned the work. Henry Lee of London in 1865 made some experiments with puncture to ascertain how large an opening could be made without fatal hemorrhage and described the method of repair in arteries without suture; Beale made an extensive microscopic examination of Lee's specimens, giving the pathologic histology of repair. (The Transactions of the Medico-Chirurgical Society, Vol. 50, p. 477). In 1883 Gluck reported nineteen experiments with arterial suture, but in all of these cases his efforts were futile, because he was unable to control the hemorrhage from the needle punctures through which the suture was introduced. He also devised aluminum and ivory clamps for the purpose of uniting longitudinal incisions in the vessel and succeeded with the ivory clamp in one experiment on the femoral of a large dog. (Langenbeck's Archives, 1883.) Von Horoch of Vienna had thrombosis in six experiments, including one end-to-end union (1887.) The most extensive and, indeed, the only work of true merit performed in this line was by Dr. Alexander Jassinowsky of Odessa. His first paper was read in Dorpat in 1889: his second was published in Langenbeck's Archives, 1891. Bruci in 1889 sutured six longitudinal incisions in arteries of dogs and was successful in four. Tansini of Modena in 1890 endeavored to close the arteries by absorbable horn clamps. Muscatello successfully sutured a one-third division of the abdominal aorta in a dog. Heidenhain,

*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., on May 1, 1896.