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abdominal incisions; no necessity to starve the patient beforehand-the regular post operative nourishment of debilitated patients is not interfered with.

Contraindications.

The local method is positively contraindicated in the patient who does not want it-who prefers for any reason to be asleep during operation. It is a mistake to urge local anesthesia on the skeptical; and without exception, I administer a general anesthetic to this type of patient.

When there are intra-abdominal adhesions or when the condition is one in which the nerve supply cannot be completely blocked, as is the case in deep pelvic or abdominal operations, a general anesthetic is indicated.

Allen says, "local actually contraindicated only in children, epileptics, and highly nervous or neurotic subjects. The loss of consciousness. is not necessary for the successful performance of an operation, and with the patient's restlessness and possible anxiety allayed by a small preliminary dose of morphine or morphine and hyoscine, the fact that the patient is conscious. becomes a negligible factor for the successful completion of the operation".

Scope of Local Anesthesia.

In selecting the anesthetic for a major operation, one must first of all consider the risk to

life of the patient. Local anesthesia adds greatly to the safety and comfort of the young and robust, and when the patient is handicapped by old age, shock, hemorrhage, pulmonic, nephritic, or cardiac lesions, the local method is especially indicated, if he is to be given the greatest chance for recovery.

Operations on the Extremities

In dislocations, fractures and amputations of the fingers and toes, a simple infiltration around the base of the digit is all that is required for successful analgesia. For operations above the wrist and ankle, the regional nerve block method of Matas is most satisfactory and quicker than local infiltration.

Operations on the Skull.

Trephining, exploratory craniectomy, mastoidectomy and removal of depressed fractures are easily performed under local anesthesia, greatly to the safety of the patient. The bone, dura, and brain substance, are insensitive. Infiltration anesthesia of the skin, fascia, muscles and periosteum, is all that is needed.

Major Abdominal Operations.

All forms of inguinal, femoral, ventral and umbilical herniae can be operated on under local anesthesia. A general anesthetic is never indicated except in children and the neurotic. For

strangulated hernia in patients with lowered vitality, the local method is a necessity, to eliminate the additional shock of general narcosis.

Interval cases of appendicitis, selected cases of acute appendicitis can often be completed under local if the mesenteric nerve block technic is employed.

In selected cases I have completed the following operations under local anesthesia: Herniotomy, appendicectomy, nephropexy, cholecostotomy, suprapubic cystotomy and prostatectomy, gastro-enterostomy, colostomy, resection of the tubes and ovaries and shortening of the ligaments.

Perineum and Cervix.

Perineorrhaphy, trachelorrhaphy and cystocele operations can usually be performed under local methods.

30 N. Michigan Ave.

GUN SHOT WOUNDS OF THE BRAIN* C. E. RUTH, M. D., F. A. C. S.

Gunshot wounds of the brain by pistol, rifle or shell fragments, have rightly been considered the most grave of all wounds. All such wounds during the Civil War were expected to terminate fatally and out of the many hundreds all but about ten did so terminate. Those not immediately fatal died later of cerebritis or meningitis. One notable exception to the rule was reported by Dr. Conniff in the Vis Medicatrix, published at Des Moines in February or March, 1892, in which a patient post-mortemed by Dr. Conniff was found to have a connoidal lead bullet weighing 126 grains, lodged in the left posterior lobe of his cerebrum where it had remained for twenty-nine years. His death was due to other causes. He retained a fair amount of physical and mental vigor during all this period, but complained of considerable pain at times and always insisted that he could feel the bullet in his head. In this case the bullet had traversed four or five inches of soft tissue and bones of the cheek before it entered the cerebral cavity and had probably lost most or all of its grease and dirt before reaching the brain.

This case at once indicated the possibilities of a tolerably good recovery resulting from clean wounds of a supposedly vital organ.

In the Journal of the American Medical Association of August 20th, 1892, was published a report of two cases by myself of pistol shot wounds of the brain, by 32 and 38 caliber bullets fired at ranges so close as to produce powder

burns.

In case No. 1, the patient was eighteen years old and the bullet had passed entirely through

*Read before the Medical Society of the Missouri Valley at Keokuk, Ia., March 21, 1917.

the right middle and posterior lobes of the brain. from before backward and lodged where it struck against the occipital bone. The only symptoms present were slight slowing and irregularity of the pulse indicative of moderate compression. These disappeared at once upon removal of a coagulum occluding the wound and discharge of pulpified cerebral tissue and fluid blood. Temperature, pupils, motion, sensation, and co-ordination were normal and for two weeks he remained rational, had little pain, slept and ate well.

At the end of that time he begun to show evidence of septic trouble, some pyrexia, anorexia, and rapid failure of strength. Twenty days after the wound was received his condition was so desperate that an attempt was made to follow the course of the ball by probe and if possible locate and remove it.

A gum catheter with stylet was used as a probe, the bullet's track was followed to the inner side of the occipital bone. Removal of a 5% inch trephine disk over the probe's tip revealed a rent in the dura made by the impact of the bullet and through this opening one or one and onehalf ounces of pus were at once discharged and the bullet was secured. Death took place ten days after operation or thirty days after the shooting.

This case proved the possibility of recovery without serious damage to the individual done by the transit of the bullet and destruction of a large amount of brain tissue. He could not recover, however, from the septic process develop

ing about the infective bullet.

This patient was lost because we did not follow the example of Fluhrer, remove the bullet and provide drainage at once. Fluhrer's case had been operated upon seven years before and was the only case I knew of at that time in which a bullet's track had been successfully followed and the bullet removed from the depths of the brain.

Case No. 2. May 4th, 1891, a sick, half

starved man of 82 years, suicided by shooting with a 38 caliber pistol. The ball passed through the lower part of the right frontal and middle lobes and lodged in the posterior wall of the pharynx. This patient lived sixty hours after the shooting and was semi-comatose after the first ten hours.

In this case the bullet's track was easily followed, the ball located and removed. Owing to his age and condition, comment on the result is unnecessary and is only mentioned to show the possibility of readily following missiles through the brain, though such possibility was almost universally denied by authorities at that

time.

By careful testing we found that properly tipped probes of 3-16 to 1/4 inch in diameter re

quired from 2 to 3 ounces pressure to penetrate the normal brain, and therefore offered a definite, readily appreciated resistance so that a missile could be safely followed without danger of making a false passage, and when such probe was metal tipped with shaft insulated according to the plan outlined by Girdner, any metal encountered would be at once detected.

We found that bullets fired into the brain take a straight course through the cerebral tissue until bone is again reached or when far spent if they strike the falx or tentorium may be deflected. Bullets, whether conoidal or round, were not found to rebound, but if they failed to escape by repenetration of the opposite bony wall they remained where they struck or glanced from the point of impact, at angles to the line of incidence of more than 90 degrees. We could on no account consider that a ball rebounded unless it repenetrated the brain by passing back from its point of impact at an angle to the line of incidence of less than 90 degrees. If a ball having passed through the brain strikes the skull on the opposite side at a right angle to the surface. of impact or within 15 degrees and does not penetrate, the ball will lodge at the point of impact but will not rebound.

Case No. 3. Frank H., aged 13 years, living at Farmington, Iowa, and referred to my clinic. by Dr. Kirkpatric, in 1903, had been shot with a 32 caliber pistol just to the left of the center of the forehead and slightly above the orbital margin. We cleared the wound of entrance carefully of spicluae of bone and dirt, but dressed the wound with every care and as no unfavorable symptoms manifested themselves (see xray) the ball was not searched for. This patient is living now and well with the bullet resting partly within and partly without the cranial cavity proper. The missile is lodged in the horizontal plate of the ethmoid bone. The patient had some discomfort for a few years from attempts to lie on the left side, but this also disappeared. In other respects he has been, and now is, perfectly normal (see patient).

Case No. 4. Referred by Dr. Yates, Emerson, Iowa. Toney De K., aged 22 years, single, Hollander, farm hand, was shot April 27th, 1914, by a 38 caliber pistol at about two feet distance. The injury occurred about thirty hours before we saw him. The bullet entered through the center of the bridge of the nose a little below the naso-frontal articulation and passed to the right side in the direction of the inner side of the right parietal eminence.

When we saw him first the right eye had already been enucleated because of sectioning of the optic nerve by the bullet in its backward and outward course and because of hemorrhage behind the eye in the orbital cavity (see cuts and x-rays). Powder marks are most numerous on

left side of nose, cheek and sclera. His pulse was 54, respiration 14, temperature 99.5. He was rational but suffering great pain which had required an opiate. He was brought to Des Moines because there were no localizing signs and no reliable skiagraphic possibilities at hand. He was transported by wagon and rail about 100 miles to the Iowa Methodist Hospital, and x-rayed by Dr. Thos. A. Burcham. The main bullet mass was seen to be in the occipital lobe on the right side while two large pieces were noted along the bullet's track where the bullet had infringed heavily against bone of considerable strength.

The mental processes were much obtunded by the frequent use of anodynes. Though restless he understood simple commands, but could give no account of subjective symptoms save the incessant pleading for more relief from agonizing pain.

Operation was made at the M. E. Hospital on April 29th, with the pulse at 44 and respiration 12, temperature 99 3-5. He was still rational and had no neurological localizing symptoms of any kind. The pupil of his left eye reacted sluggishly to light. There was some stiffness of the posterior neck muscles. Reflexes were retained. Some pulpified brain tissue protruded from between the eyelids on the right side.

Removal of a large horseshoe shaped scalp and cranial flap, base downward, by trephine and ronguer from over and around the parietal eminence on the right side revealed the point where the bullet had struck and cut the dura and from which point it had glanced into the right posterior lobe. The exposed dura was tense and pulseless with much blood showing underneath. Removal of the large blood clot and discharge of considerable broken down brain tissue through the enlarged dural opening, resulted in immediate return of pulsation to the brain, and increased frequency of pulse and respiration. The bullet was touched twice, but escaped in the pulpified, mush like, cerebral detritis, and as we had accomplished what we set out for in the main, viz., relief of pressure and providing drainage, it was not deemed wise to make further effort to remove the bullet at that time. We passed a 1⁄2 inch drainage tube well down into the softened brain tissue and brought the distal end of the drain out through the trephine hole at the lower posterior angle of the flap. Only the portion of the osseous flap left attached to the scalp was replaced. Along the course of some of the pial vessels was noted microscopic evidence of the beginning of a meningeal inflammatory process. From the point where the bullet cut the dura the track of the bullet could be easily followed forward and backward with a bullet probe.

The most rigorous asepsis was observed in this case and no constitutional disturbance took place at any time. A large drain was also placed in the orbit. Three per cent phenol in alcohol was used as a dressing throughout the healing process.

So much of the brain in both the parietal and occipital lobes had been pulpified by the passage of the bullet that the missile shifted its position with greatest ease. The pulpified brain tissue was of much the consistency of soft mush and the bullet eluded grasping by moving from slightest contact.

A small hernia cerebra developed at the sight of the temporal drain, but this slowly disappeared and firm cicitrization took place. Daily dressings showed the presence of necrotic ceretubes, but gradually the discharge ceased from bral substance about and within the drainage both the orbital and parietal drains and the tubes were removed on the 10th day without evidence of the presence of septic material.

The lantern slides of x-rays taken five days after operation show marked change in position of the missile, but the ball has remained fixed since the first few weeks following the injury. One x-ray recently taken by Dr. Thos. A. Burcham, shows that not less than 35 tiny fragments were separated from the bullet and strewn or clustered along the bullet's track.

At no time was there the slightest disturbance of sensation, motion, co-ordination, or mental function, save when under anodynes, and his recovery has been absolute in every way save the loss of the right eye.

For several months he suffered from slight headache, but that has disappeared for more than two years, though it was never severe and he does all kinds of heavy farm or other work requiring stooping or lifting without any trouble

whatever.

left eve, as shown by the chart of his field, but He was annoyed a little by heminopsia in the that also has disappeared subjectively, though the chart of his field shows the outer part defective to color but not blind.

In cases 1 and 4 a large amount of the right parietal and occipital lobes were entirely destroyed and extruded from the cranial cavity, yet without symptoms.

In case 3, one cannot be surprised that recovery was complete, yet there is small question but that the dura was cut and the bullet is cer tainly partly within the cranial cavity and rest ing within and upon the ethmoid bone. It can be removed at any time, should occasion require.

In case 4, the main part of the bullet is within tolerably easy access and should its removel become necessary it can be done by anyone capable of doing clean, careful, brain work.

These cases would seem to indicate that in gunshot wounds of the brain, our duty lies mainly in relieving compression and providing drainage and maintaining asepsis where moisture is unavoidable. That was possible of attainment by known methods only through phenol, alcohol until the advent of the so-called Carrel-Dakin Solution. Recent experience in the world war shows that many recoveries may be expected from brain injuries provided they are kept properly drained, clean, and dangerous compression is not permitted from blood clot or depressed fracture.

Removal of the bullet has become of secondary importance, though at times it becomes imperative.

Tolerance of the brain to trauma enables us to make many explorations without damage, but this fact must not lessen ones respect for certain areas of the brain or justify us in ignoring established laws in needle explorations.

Hexamethylamine was used freely in case 4, as it has been in all our brain cases during the last four years, because of its supposed protection against meningeal inflammation.

I am indebted to my associate, Dr. T. B. Throckmorton, for the report on the neurological tests, assistance at operation in case 4, and much of the after care; to Dr. Thos. A. Burcham for the excellent x-ray work done on the case, and to Dr. W. W. Pearson for the tests of the eye fields.

Conclusions That bullets of large caliber may pass through one or more lobes of the brain and produce no cerebral, neurological, or physical disturbance.

That permanent lodgment of aseptic missiles in the brain may cause little or no pain or impairment of function during long periods of time. That bullets may be followed along their tracks with ease and certainty without danger of producing a false passage.

That x-ray localization is now always indicated, when possible, before undertaking operative removal of a missile.

Accurate knowledge of the resistance of the brain to probes of various sizes, Girdner's telephone connection with probes, and Fowler's scale to read pressure being used, while important, have lost much of their value since the x-ray has become efficient.

Relief from compression and providing of suitable drainage are often the only operative

indications.

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PATHOLOGY OF INTESTINAL OBSTRUCTION*

O. C. MORRISON, M. S., M. D., Carroll, Iowa.

The term obstruction as used in this paper means to convey the idea of a sudden, permanent closure of the bowel lumen to the transit of any material whatsoever. In health the peristaltic wave makes a transit of the entire bowel about every four minutes requiring one minute for the wave to pass the entire length. This is based upon the unstriped muscle beat. The heart has its beat as it is an unstriped muscle. Its normal beat is about 72 times a minute. The placenta has its beat, the spleen its beat, the gall bladder its beat, the uterus its beat. By the term peristalsis we mean to include the double action of the muscle fibers comprising the bowel wall. The action of the circular fibers cause

the food to move slowly down the intestinal canal keeping it in contact with the mucosa for the purpose of facilitating absorption of the digested food and mixing the content of the bowel with the digestive enzymes. The longitudinal fibers prevent stagnation within the lumen of the bowel and is known as the pendular movement. This combined movement of the bowel called peristalsis travels normally from the stomach toward the colon. A number of physiologists agree that the peristalsis is very necessary in moving the lymph material and partially absorbed food from the veins into the hepatic circulation. The subject of acute obstruction is intensely interesting since we may resect parts of the bowel; we may open its lumen and connect it with any other viscus within the abdomen; as a gastro-enterostomi or an entro-enterostomy and yet the peristaltic wave will transmit the food in what seems to be a normal manner but should a band of adhesion, a kink of the gut or what-not suddenly occlude its lumen, we immediately have a very definite picture. It is unnecessary to repeat the classical symptoms of colicy pain, the cessation of bowel

Read before the Medical Society of the Missouri Valley at Lincoln, Neb., Sept. 21, 1917.

movements, the non-passage of gas, the rapid distention, the early vomiting, the increase in pulse rate, the critical picture with which the physician is confronted. The mere fact that the bowel is obstructed is not the determining factor in the prognosis. If the bowel is occluded by a thrombus in the mesentery or if all the circulation is in any way cut off from a section of the bowel, there is something added to the pathology that is not easily explained. Again, if the obstruction is low down the patient is not so seriously ill from the beginning nor are the symptoms as intense as when the obstruction is very near the duodenum. These two factors, namely, cutting off the blood supply to the lumen together with the proximity of the obstruction to the duodenum, serves as the basis of thought which I wish to present in this paper. I heard a very noted surgeon in New York make this statement that: "Obstruction is simply a sewage proposition. The nearer the top you obstruct it the more quickly does it overflow". I took issue with this statement because of the following facts: Should we obstruct the esophagus we know the patient will live for weeks and gradually die of starvation; should we obstruct the Pyloric end of the stomach and withhold food from the stomach, the patient will live for many weeks without the obstruction being

relieved.

Now let us place this obstruction in the first twelve inches of the jejunum or in the last portion of the duodenum and what happens? I will ask you to carry this for a moment and let us return to our thrombus proposition. Given a patient with the thrombus in such a position that the circulation is cut off from the bowel for a distance of one foot. We open its lumen above, establish drainage and forget the nature of the pathology. We all fully realize that we have an entirely different problem than where the obstruction is due to a band of adhesions. If that is true wherein do they differ? To me this is the very basis of all obstruction and its pathology. On examining the pathology closely, we have first, the hyperemia which is soon followed by the death of millions of cells or by gangrene of tissue extensively. Then upon this field is supra-implanted a bacterial infection which acts not only locally but generally by lowering the resistance of the patient. Over this mass of dead and dying tissue the pancreas pours its Trypsin constantly. We remember Von Furth's statement that an inflamed bowel will absorb faster than an un-inflamed one, would suggest that the cleavage products of this dying mass would quickly be absorbed into the lymphatics and thrown into the general circulation of the patient. Taylor, of Pennsylvania, says that the cleavage products of proteid tissue is always Amino acid. No matter with

which

what re-agents; steam, ferments, alkali or acids, the ultimate cleavage is Amino acid. The biological chemists have demonstrated that the poisonous substances in the cleavage of proteids is an organic acid which is built upon a well known base. Vaughn, after the long research in proteid, announces that the toxic acid is a benzine derivative in which any atom of hydrogen is replaced by an hydroxyl group. He further observed that the only oxy-phynol compound in the proteid molecule is Tyrosin.

It is very evident that before we will be able to solve the problem of synthesizing this toxic acid into a non-irritating compound, it will be necessary for us to separate each from its proteid radical, understand its position in that radical, how it would combine when liberated as a free acid and its toxic effects upon the tissue. We readily see that we are confronted with a problem that is not small. We are very conscious that the proteid molecule of every cell whether it be mammal or bacterial does contain this poisonous group. Besides this poisonous group from the proteid cleavage we have active within the cell, the cell ferment, as is evidenced by the autolysis of the liver after death. We also have the ferment which is extracellular as is evidenced in diphtheria. In thinking of this problem we must know something of the toxic acids derived from proteid cleavage aside from the action of the ferments produced by the cell. When the proteids are broken down their cleavage acid is liberated from the molecule within the cell. They are unstable compounds that are capable of chemical change and even affected by physical change. They unite when broken by cleavage as is evidenced by their formation of urea for elimination. If they are not so bound, they float free as poisons. an acid of negative electrical ions or corpuscles. Hence, we have a biological, physical, chemical and electrical imbalance. We know that through the study of Colloids, if a cell is hyper-acid it will swell with water until several alkalies are brought in to neutralize the acid. Hence, this automatic action seems to prevent the breaking up of the cell balance if possible, or in other tube the colloid may be found to be non-toxic. By waiting a few moments, shaking the test tube again and injecting the colloid into a guinea pig the substance is found to be exceedingly toxic. This alone would make us think that the proteid combination within the molecule might be exceedingly unstable and would be very prone to unite itself in combination with new organisms in case it was liberated. Many illustrations of the unstability of the parts of a molecule within a cell may be cited. A splendid analogy may be drawn from the physics of matter. matter. The positive and negative corpuscles of the gaseous ions are ever changing within

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