A RETROSPECT OF THE PRINCIPAL AND MOST INTERESTING PAPERS AND DISCUSSIONS PRESENTED AT THE RECENT

ANNUAL MEETING OF THE AMERICAN MED

ICAL ASSOCIATION.

(Written by our Special Correspondent.)

We wish to call the attention of our readers to a new departure which we inaugurate with this issue, namely, a reportorial essay, if you please, or retrospect of American Medical Society gatherings. We here publish a retrospect of the recent meeting of the American Medical Association at Chicago. The article aims to present to those of our readers who were not fortunate enough to attend this meeting a bird's-eye view of the principal papers and topics discussed at that time. The programme was carefully studied, and the papers which seemed to present the most interesting phases of medicine were carefully listened to, and an abstract in some instances, almost a verbatim report in others, taken down by our special correspondent at the meeting. While it is true that all of these papers will be published in their entirety in the journal of the association, it sometimes takes quite a while before these papers get into print in that publication. Our readers will thus have the benefit of an "advance copy" of these papers, presented in what we trust is a condensed and intelligible form.

The weekly medical papers usually attempt to make a society report of this kind, but monthly medical papers, as a rule, do not. We believe that the monthly medical journal can give a condensed report of the entire meeting, and keep its readers abreast of the times just as well as the weeklies. It is our aim to continue to make this a feature in the future, reporting all the principal national meetings in this way.

TECHNIQUE OF CRANIAL SURGERY.

One of the most interesting matters brought out at the association meeting was the "Symposium on the Technic of Crania! Surgery," presented at the surgical section. This was participated in by the three masters of cranial surgery in America, viz., Harvey Cushing, of Baltimore; Frank Hartley, of New York City, and C. H. Frazier, of Philadelphia. There was a lantern-slide demonstration with each paper, which enhanced the value of the papers considerably. Cushing spoke first of the administration of the anesthetic, deciding that the inhalation method was better than rectal anesthesia. The skull is shaved, and the patient put in the most comfortable position for the operator to work well. A protective sheet is tied around the head, after the lines of incision are scratched in the scalp. The sheet alluded to is tied around the head with tapes. Cushing then showed a picture of a special table for operating upon the base of the skull, which permits the patient to lie prone, with

his shoulders resting upon an elevated rest above the table, head projecting beyond the table, forehead resting in a head-rest, supported upon a stand which is placed upon the floor in front of the table. Mention was here made of the author's method of continuous auscultation of the heart during the anesthesia, which gives the anesthetist a continual idea of how the circulation is behaving, instead of having to be guided by occasionally feeling the pulse, according to the ordinary method. It might be added that this continuous auscultation of the heart could well be practiced with all anesthetics, no matter what the operation may be.

Cushing then went on to describe his method of going into the head, using the trephine and the Gigli saw and drill. He also showed his method of closing the wound.

Mention was then made of the so-called "decompressive" operation for relieving intracranial tension. For early decompressive operations we are indebted to Jaboulin and Broca. The speaker called attention to a method of performing decompressive operations through the temporal muscle, first described by him in 1905. He advocated this operation for relieving intracranial tension in unlocalized tumors within the cranial cavity. This temporal decompressive operation occurs in the "silent area,” and if there is any cerebral protrusion, it does not matter.

Cushing emphasized the point that in cases of internal hydrocephalus a decompressive operation does not do any good. He mentioned the fact that of the hundred or more decompressive operations that he had performed in the last three or four years for unlocalized cranial tumors, many of them are now coming back with their tumors localized. Paradoxical as it may seem, the best patient for operation in the field of cranial surgery is the one with unlocalized cranial tumor, upon whom the decompressive operation is performed, for later they come back with the preliminary symptoms relieved, but with well-localized symptoms indicating the exact situation of the tumor, which can then be intelligently dealt with and, perhaps, removed.

Cushing mentioned that there are some cases where the decompressive operations are good; for instance, in uremic states, as in one case reported by him. Secondly, they do good in cases of basal hemorrhage. He reported one case of basilar fracture, with paralysis of both sides of the face, which later cleared up.

A most important point brought out by Cushing was in regard to the performance of lumbar puncture in cases of cranial increased tension: There is great danger in performing lumbar puncture in cases of brain tumor which lie below the tentorium. In these cases you will find that there is somewhat of a "hernia" of the brain matter pushed through the foramen magnum, and if you do a puncture into the spinal column, with the outflow of serous fluid, there is an immediate ramming down of the edges of the cerebellum into the foramen magnum, pinching of the cere

bellum by the edges of the foramen, and fatal issue. It is in the nature of things the production of a local anemia of the cerebellar tissue which is thus pinched, followed, of course, by death.

Frank Hartley, of New York, then showed his method of operating upon the skull. He uses an electric motor for drilling. This motor is so made that it can be taken apart for sterilization. He laid stress upon the necessity of a knowledge of the topography of the head, and said that in operating the flaps should be made with some definite purpose. He showed the various flaps and "bone windows" for going into the head, with preservation of the bony flap, which is left adherent to the scalp. In cases of extensive fracture of the skull, with comminution of bone, he showed a method of putting in an artificial bony flap by means of at piece of celluloid, with perforations through all parts. Hartley makes his windows in the skull by drilling six holes in a square, or rectangular fashion, connecting them with a saw-incision. The flap is then raised with a Macuen osteoclast.

C. H. Frazier, of Philadelphia, contributed the last chapter upon the technic of cranial surgery. He showed a very good table for operating upon these cases. He went over his individual technic, which differed in some minor particulars from that of Cushing and Hartley. The ultimate results of all three operators seemed to be equally good in these cases. The field of cranial surgery has certainly been thoroughly worked out by these operators and their followers. There is now no longer that feeling of hopelessness on the part of surgeons when they are brought face to face with the subject of intracranial new growths and basilar fractures, as was the case not so many years ago.

ARTIFICIAL RESPIRATION,

Another paper read before the surgical section was that by Edward A. Schäfer, of Edinburgh, Scotland, on "Artificial Respiration in Its Physiological Aspects." He reviewed the various methods of performing artificial respiration. He said that, as a result of experiments upon dogs, he proved that the pressure method is the best for performing artificial respiration, with the subject in the prone position, lying upon his belly, with pressure applied vertically over the ribs. Pressure upon the abdominal walls forces the viscera against the diaphragm, which is forced upwards, driving the air out of the lungs. On relaxation, the elasticity of the lungs causes them to distend naturally. Pressure should be performed gradually and slowly, each pressure lasting about three seconds. Then it can be worked up to lasting but two seconds. Schäfer calls this method the "prone-pressure" method. During actual working, it should be perforced twelve times per minute. The operator squats down alongside the patient, who lies face downwards upon the floor. Place the hands along

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the ribs and swing the body forward and backward. In this way hardly any muscular exertion is required.

The efficiency of the pressure method of artificial respiration depends upon the fact that after ordinary expiration, the thorax still contains 1,500 c.c. of air, which can be expelled by forcible expiration. It also contains 1,000 c.c. of air which can not be expelled. This is called the "tidal," or residual air. It can be expelled by artificial respiration. More than this amount can be expelled when the pressure is applied in the prone position, and by alternate relaxation you can get an air exchange of six liters, which is more than the average normal amount per minute required.

It is somewhat curious to hear that up to the time of Schäfer's experiments but little was definitely known as to the actual amount of air that could be expelled from the lungs with use of the various methods of artificial respiration. In other words, methods were used without any mathematical calculation of just what good they were doing, i. e., just how much air, measured accurately, could be pushed out of the lungs with the sundry methods. In order to determine this point, Schäfer undertook to measure the air content of the lungs by means of a kind of spirometer. By means of this instrument he showed, for instance, the air displacement in the lungs with all the artificial respiration methods, arriving at the statement of facts that the prone-pressure method displaced a great deal more than the Sylvester or the Marshall Hall methods, which are so commonly used. The prone-pressure method is the best because it is the most efficient, because it can be performed without effort, even by a woman or by a child. It is also very simple and easily learned. It allows the tongue to fall forward, with the escape of mucus, water, saliva, etc., from the mouth. Its field of usefulness is not only for the resuscitation of drowned persons, but also for those suffering from overdosing with chloroform or ether. There is great danger of patients succumbing to chloroform because of its influence upon the vagus, which danger can be obviated by a preliminary injection of atropine, which also is a good measure, because it prevents the excessive flow of saliva.

Schäfer showed, also, if you keep the mouth closed and introduce a tube into one nostril, behind which you have a bellows, that the lungs can be distended with air by this bellows-arrangement.

Schäfer showed that with the use of his prone-pressure method of artificial respiration it is not even necessary to remove the clothing, corsets, etc., of persons overcome by drowning. You can proceed with the pressure with all the clothes on the person.

POSITIVE VERSUS' NEGATIVE PRESSURE IN OPERATIONS UPON THE CHEST.

The next discussion before the surgical section was upon the best method of performing thoracotomy, whether the operation with positive pressure was the better or whether that with negative pressure surpassed

it. Dr. F. Sauerbruch, of Marburg, Germany, spoke of the present status of surgery of the thoracic cavity, and showed his method of preventing pneumothorax by means of a negative-pressure contrivance. He discussed the development of the use of his pneumatic cabinet in intrathoracic operations, and pointed out the fact that it minimizes the danger of such operations, lessens the frequency of the occurrence of complications, and favors healing. Operations formerly looked upon as impossible can now be performed with every assurance of a successful issue. He showed this cabinet, which is simply a small operating room, with the patient's head outside, the body and operator inside. He bases his technic upon the difference that exists between the pressure in the bronchial tube and that upon the outside of the lungs. When the normal relationship between these two is disturbed, then you have trouble. He elaborated his technic by placing dogs in glass cylinders, with the head projecting through one end and the legs through the other. Placing his hands inside the cylinder, he found he could open the thorax without any trouble or disturbance to breathing. For practical purposes, he devised the rarefied air chamber just alluded to for performing these chest operations. Under this negative pressure the thorax may be opened, and the lungs will be found approaching the edges of the wound, instead of receding and retracting, as you see it in the ordinary thoracotomy. This also prevents the aspiration of foreign material into the remote parts of the lungs, pus, etc. Sometimes this forcing of pus and foreign material into the ultimate parts of the lung, before the days of operating under negative pressure, resulted in serious complications and death. Another indication for operation upon. the lung is where we have a tumor involving but one lobe. Primary carcinoma of the lung is rare, said Sauerbruch. He has operated upon but one case of this kind. In that case he made a resection of the lung.

This method of operating under negative pressure is used by Sauerbruch in operations upon the oesophagus, as well as upon the lungs. In cases of deep-seated carcinoma of the cardia, resection of the costal arch is recommended by Myer, of New York.

Sauerbruch then referred to the advisability of performing more exploratory thoracotomies. He said that failure to make enough exploratory thoracotomies is responsible for many errors in diagnosis. He pointed to the great advances in diagnosis and surgery of the abdomen by means of frequent exploratory laparotomies, and said that equal progress could be made in surgery of the chest with more exploratory thoracotomies.

The "positive pressure" school of operating upon the thorax was then ably represented in the paper read by Samuel Robinson, of Boston, who spoke upon "Artificial Intrapulmonary Positive Pressure, Experimental Application in Surgery of the Lung." He said, first, that the negative