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I have frequently noted the pain Original Contributions
of ligating the meso-appendix when it has not (EXCLUSIVELY FOR THE MEDICAL HERALD.)
been previously blocked with local anesthesia.
Solution, Syringe, Needles, Etc. THE LIMITATIONS OF LOCAL ANESTHE
Novocain one-fourth per cent. solution, or SIA IN SURGICAL OPERATIONS*
cocain one-tenth per cent. solution, is strong
enough for any operation. Adrenalin (1:10,000) LEIGH F. WATSON, M. D., Chicago.
five minims to the ounce of anesthetic solution Introduction,
is usually employed to give prolonged anesthesia. Local anesthesia has its limitations the same The drug must be sterile, and dissolved in sterile as any other method of anesthesia. It cannot
normal salt solution, being freshly prepared for be succesfully employed for every operation nor
each operation, and of a definite strength, that can it be used on all patients. In some instances the operator may know at any time the exact it is not suited to the temperament of the patient; amount of anesthetic that has been used. Coin others, the operation is one that should not
cain and novocain can be sterilized by heating be attempted by local alone. The variety of to 212 degrees Fahrenhiet; a temperature above major operations that is possible to be com
this, as well as repeated sterilizations, are inpleted by local, depend upon a proper selection jurious. of cases and the experience of the operator;
Different operators prefer various syringes. his patience, his gentleness in handling tissues,
I have found an all metal syringe holding ten and special training in the method.
c.c. very serviceable. The syringe should take
a slip needle to facilitate rapid refilling. The Essential for Success.
needles must be kept sharp and clean; the smallThe first requisite for the successful use of est size should always be used for the initial inthe local method is an accurate knowledge of the filtration of the skin. nerve supply and the ability of the operator to
Advantages. block off completely every sensation of pain. As there is no danger of post operative When the nerve supply cannot be entirely con- pulmonic, cardiac or nephritic complications foltrolled general anesthesia should be employed. lowing local methods, many emergency opera
The sensation of pain is confined to the skin, tions can be satisfactorily and safely performed nerve trunks, parietal peritoneum and synovial in the patient's home. Either at home, or in membrane of joints. Lennander has demon- the hospital, the patient should be made comstrated that all internal organs obtaining their fortable on the operating table, which should nerve supply from the sympathetic and vagus, be well padded with extra blankets or quilts; below the branching of the recurrent nerve, have a hard table will quickly cause him to become no sensation. For this reason the abdominal tired and restless. As there is no necessity for and pelvic viscera are insensitive to heat, cold, speed with the patient conscious and comfortable, pain and pressure, both in health and disease. fewer assistants are required than with general There is no sensation of pain in bone substance, anesthesia. bone marrow, cartilage, tendon, articular sur- Many patients will consent to operation under face of bone covered with cartilage, brain, lung, the local method who would not consider it if liver, heart, kidney, kidney pelvis, ureter, bladder it involved a general anesthetic; this applies serosa and intestine.
especially to those who have had a stormy and A slight twinge of pain is felt. when blood protracted convalescence after taking ether. vessels are cut. Traction on the ligaments of Allen sums up the advantages of the local the thoracic, abdominal or pelvic viscera will method as follows: Absence of fear of the cause pain ;'-traction on the mesentery, besides anesthetic; absence of post-operative disturroducing pain, will cause epigastric discomfort bances; no danger of post operative dilation of
the stomach or tympanities; no post operative *Read before the Medical Society of the Missouri Valay at Lincoln, Neb., Sept. 21, 1917.
backache; no vomiting and straining to weaken abdominal incisions; no necessity to starve the strangulated hernia in patients with lowered patient beforehand—the regular post operative vitality, the local method is a necessity, to elimnourishment of debilitated patients is not inter- inate the additional shock of general narcosis. fered with.
Interval cases of appendicitis, selected cases Contraindications.
of acute appendicitis can often be completed
under local if the mesenteric nerve block technic The local method is positively contraindi
is employed. cated in the patient who does not want it—who
In selected cases I have completed the folprefers for any reason to be asleep during opera- lowing operations under local anesthesia: Hertion. It is a mistake to urge local anesthesia niotomy, appendicectomy, nephropexy, cholecon the skeptical; and without exception, I ad- ostotomy, suprapubic cystotomy and prostatecminister a general anesthetic to this type of
tomy, gastro-enterostomy, colostomy, resection patient.
of the tubes and ovaries and shortening of the When there are intra-abdominal adhesions
ligaments. or when the condition is one in which the nerve. supply cannot be completely blocked, as is the
Perineum and Cervix. case in deep pelvic or abdominal operations, a Perineorrhaphy, trachelorrhaphy and cystogeneral anesthetic is indicated.
cele operations can usually be performed under Allen says, "local actually contraindicated local methods. only in children, epileptics, and highly nervous 30 N. Michigan Ave. or neurotic subjects. The loss of consciousness is not necessary for the successful performance of an operation, and with the patient's restless
GUN SHOT WOUNDS OF THE BRAIN* ness and possible anxiety allayed by a small
C. E. RUTH, M. D., F. A. C. S. preliminary dose of morphine or morphine and hyoscine, the fact that the patient is conscious
Gunshot wounds of the brain by pistol, rifle becomes a negligible factor for the successful
or shell fragments, have rightly been considered completion of the operation".
the most grave of all wounds. All such wounds
during the Civil War were expected to terminate Scope of Local Anesthesia.
fatally and out of the many hundreds all but In selecting the anesthetic for a major opera- about ten did so terminate. "Those not immedition, one must first of all consider the risk to ately fatal died later of cerebritis or meningitis. life of the patient. Local anesthesia adds greatly One notable exception to the rule was reported to the safety and comfort of the young and by Dr. Conniff in the Vis Medicatrix, published robust, and when the patient is handicapped by at Des Moines in February or March, 1892, in old age, shock, hemorrhage, pulmonic, nephri- which a patient post-mortemed by Dr. Conniff tic, or cardiac lesions, the local method is es- was found to have a connoidal lead bullet weighpecially indicated, if he is to be given the great- ing 126 grains, lodged in the left posterior lobe est chance for recovery.
of his cerebrum where it had remained for Operations on the Extremities
twenty-nine years. His death was due to other
causes. He retained a fair amount of physical In dislocations, fractures and amputations of
and mental vigor during all this period, but the fingers and toes, a simple infiltration around
complained of considerable pain at times and althe base of the digit is all that is required for
ways insisted that he could feel the bullet in his successful analgesia. For operations above the head. In this case the bullet had traversed four wrist and ankle, the regional nerve block method
or five inches of soft tissue and bones of the of Matas is most satisfactory and quicker than cheek before it entered the cerebral cavity and local infiltration.
had probably lost most or all of its grease and Operations on the Skull.
dirt before reaching the brain. Trephining, exploratory craniectomy, mas
This case at once indicated the possibilities of toidectomy and removal of depressed fractures
a tolerably good recovery resulting from clean are easily performed under local anesthesia,
wounds of a supposedly vital organ. greatly to the safety of the patient. The bone,
In the Journal of the American Medical Asdura, and brain substance, are insensitive. In
sociation of August 20th, 1892, was published filtration anesthesia of the skin, fascia, muscles
a report of two cases by myself of pistol shot and periosteum, is all that is needed.
wounds of the brain, by 32 and 38 caliber bul
lets fired at ranges so close as to produce powder Major Abdominal Operations.
burns. All forms of inguinal, femoral, ventral and In case No. 1, the patient was eighteen years umbilical herniae can be operated on under local old and the bullet had passed entirely through anesthesia. A general anesthetic is never indi
*Read before the Medical Society of the Missouri Valcated except in children and the neurotic. For
ley at Keokuk, Ia., March 21, 1917.
the right middle and posterior lobes of the brain quired from 2 to 3 ounces pressure to penetrate from before backward and lodged where it the normal brain, and therefore offered a defistruck against the occipital bone. The only nite, readily appreciated resistance so that a missymptoms present were slight slowing and ir- sile could be safely followed without danger of regularity of the pulse indicative of moderate making a false passage, and when such probe compression. These disappeared at once upon was metal tipped with shaft insulated according removal of a coagulum occluding the wound and to the plan outlined by Girdner, any metal endischarge of pulpified cerebral tissue and fluid countered would be at once detected. blood. Temperature, pupils, motion, sensation, We found that bullets fired into the brain and co-ordination were normal and for two take a straight course through the cerebral tisweeks he remained rational, had little pain, slept sue until bone is again reached or when far spent and ate well.
if they strike the falx or tentorium may be deAt the end of that time he begun to show flected. Bullets, whether conoidal or round, were evidence of septic trouble, some pyrexia, ano- not found to rebound, but if they failed to esrexia, and rapid failure of strength. Twenty days cape by repenetration of the opposite bony wall after the wound was received his condition was they remained where they struck or glanced from so desperate that an attempt was made to fol- the point of impact, at angles to the line of incilow the course of the ball by probe and if pos- dence of more than 90 degrees. We could on no sible locate and remove it.
account consider that a ball rebounded unless it A gum catheter with stylet was used as a repenetrated the brain by passing back from its probe, the bullet's track was followed to the in- point of impact at an angle to the line of inciner side of the occipital bone. Removal of a 58 dence of less than 90 degrees. If a ball having inch trephine disk over the probe's tip revealed a passed through the brain strikes the skull on rent in the dura made by the impact of the bullet the opposite side at a right angle to the surface and through this opening one or one and one of impact or within 15 degrees and does not penehalf ounces of pus were at once discharged and trate, the ball will lodge at the point of impact the bullet was secured. Death took place ten but will not rebound. days after operation or thirty days after the Case No. 3. Frank H., aged 13 years, living shooting.
at Farmington, Iowa, and referred to my clinic This case proved the possibility of recovery by Dr. Kirkpatric, in 1903, had been shot with a without serious damage to the individual done by 32 caliber pistol just to the left of the center of the transit of the bullet and destruction of a
the forehead and slightly above the orbital marlarge amount of brain tissue. He could not re
gin. We cleared the wound of entrance carecover, however, from the septic process develop- fully of spicluae of bone and dirt, but dressed ing about the infective bullet.
the wound with every care and as no unfavorThis patient was lost because we did not fol
able symptoms manifested themselves (see xlow the example of Fluhrer, remove the bullet ray) the ball was not searched for. This paand provide drainage at once. Fluhrer's case
tient is living now and well with the bullet resthad been operated upon seven years before and ing partly within and partly without the cranial was the only case I knew of at that time in which cavity proper. The missile is lodged in the horia bullet's track had been successfully followed zontal plate of the ethmoid bone. The patient and the bullet removed from the depths of the brain.
had some discomfort for a few years from atCase No. 2: May 4th, 1891, a sick, half tempts to lie on the left side, but this also disstarved man of 82 years, suicided by shooting appeared. In other respects he has been, and
now is, perfectly normal (see patient). with a 38 caliber pistol. The ball passed through
Case No. 4. Referred by Dr. Yates, Emerthe lower part of the right frontal and middle
son, Iowa. Toney De K., aged 22 years, single, lobes and lodged in the posterior wall of the Hollander, farm hand, was shot April 27th, 1914, pharynx. This patient lived sixty hours after by a 38 caliber pistol at about two feet distance. the shooting and was semi-comatose after the The injury occurred about thirty hours before first ten hours.
we saw him. The bullet entered through the cenIn this case the bullet's track was easily fol- ter of the bridge of the nose a little below the lowed, the ball located and removed. Owing naso-frontal articulation and passed to the right to his age and condition, comment on the result side in the direction of the inner side of the right is unnecessary and is only mentioned to show parietal eminence. the possibility of readily following missiles When we saw him first the right eye had althrough the brain, though such possibility was ready been enucleated because of sectioning of almost universally denied by authorities at that the optic nerve by the bullet in its backward and time.
outward course and because of hemorrhage beBy careful testing we found that properly hind the eye in the orbital cavity (see cuts and tipped probes of 3-16 to 74 inch in diameter re- x-rays). Powder marks are most numerous on left side of nose, cheek and sclera. His pulse was The most rigorous asepsis was observed in 54, respiration 14, temperature 99.5. He was this case and no constitutional disturbance took rational but suffering great pain which had re- place at any time. A large drain was also placed quired an opiate. He was brought to Des Moines in the orbit. Three per cent phenol in alcohol because there were no localizing signs and no re- was used as a dressing throughout the healing liable skiagraphic possibilities at hand. He was
process. transported by wagon and rail about 100 miles So much of the brain in both the parietal and to the Iowa Methodist Hospital, and x-rayed by occipital lobes had been pulpified by the passage Dr. Thos. A. Burcham. The main bullet mass of the bullet that the missile shifted its position was seen to be in the occipital lobe on the right with greatest ease. The pulpified brain tissue side while two large pieces were noted along the was of much the consistency of soft mush and bullet's track where the bullet had infringed the bullet eluded grasping by moving from heavily against bone of considerable strength. slightest contact. The mental processes were much obtunded
A small hernia cerebra developed at the sight by the frequent use of anodynes. Though rest
of the temporal drain, but this slowly disapless he understood simple commands, but could
peared and firm cicitrization took place. Daily give no account of subjective symptoms save the dressings showed the presence of necrotic cereincessant pleading for more relief from agoniz
bral substance about and within the drainage ing pain.
tubes, but gradually the discharge ceased from
both the orbital and parietal drains and the Operation was made at the M. E. Hospital tubes were removed on the 10th day without evion April 29th, with the pulse at 44 and respira
dence of the presence of septic material. · tion 12, temperature 99 3-5. He was still ra
The lantern slides of x-rays taken five days tional and had no neurological localizing symp- after operation show marked change in position toms of any kind. The pupil of his left eye re- of the missile, but the ball has remained fixed acted sluggishly to light. There was some stiff
since the first few weeks following the injug. ness of the posterior neck muscles. Reflexes were retained. Some pulpified brain tissue pro- cham, shows that not less than 35 tiny fragments
One x-ray recently taken by Dr. Thos. A. Burtruded from between the eyelids on the right side.
were separated from the bullet and strewn or
clustered along the bullet's track. Removal of a large horseshoe shaped scalp At no time was there the slightest disturband cranial flap, base downward, by trephine ance of sensation, motion, co-ordination, or menand ronguer from over and around the parietal tal function, save when under anodynes, and his eminence on the right side revealed the point recovery has been absolute in every way save where the bullet had struck and cut the dura and the loss of the right eye. from which point it had glanced into the right
For several months he suffered from slight posterior lobe. The exposed dura was tense and
headache, but that has disappeared for more than pulseless with much blood showing underneath. Removal of the large blood clot and discharge does all kinds of heavy farm or other work re
two years, though it was never severe and he of considerable broken down brain tissue quiring stooping or lifting without any trouble through the enlarged dural opening, resulted in
whatever. immediate return of pulsation to the brain, and increased frequency of pulse and respiration. left eye, as shown by the chart of his field, but
He was annoyed a little by heminopsia in the The bullet was touched twice, but escaped in the pulpified, mush like, cerebral detritis, and
that also has disappeared subjectively, though as we had accomplished what we set out for in
the chart of his field shows the outer part dethe main, viz., relief of pressure and providing
fective to color but not blind. drainage, it was not deemed wise to make fur- In cases 1 and 4 a large amount of the right ther effort to remove the bullet at that time. We parietal and occipital lobes were entirely depassed a 1/2 inch drainage tube well down into
stroyed and extruded from the cranial cavity, the softened brain tissue and brought the distal yet without symptoms. end of the drain out through the trephine hole In case 3, one cannot be surprised that recovat the lower posterior angle of the flap. Only ery was complete, yet there is small question the portion of the osseous flap left attached to but that the dura was cut and the bullet is certhe scalp was replaced. Along the course of tainly partly within the cranial cavity and restsome of the pial vessels was noted microscopic ing within and upon the ethmoid bone. It can evidence of the beginning of a meningeal in
be removed at any time, should occasion require. flammatory process. From the point where the In case 4, the main part of the bullet is within bullet cut the dura the track of the bullet could tolerably easy access and should its removel bebe easily followed forward and backward with come necessary it can be done by anyone capable a bullet probe.
of doing clean, careful, brain work.
These cases would seem to indicate that in as the scalp flap is deflected. gunshot wounds of the brain, our duty lies To prevent the otherwise almost certain enmainly in relieving compression and providing trance of sepsis into a draining cerebral wound drainage and maintaining asepsis where moist- 3 per cent carbolic acid in alcohol applied to the ure is unavoidable. That was possible of at- dressing is as yet probably unsurpassed. tainment by known methods only through No directions have been given for use of the phenol, alcohol until the advent of the so-called Dakin Solution for sterilizing actively or susCarrel-Dakin Solution. Recent experience in the piciously septic brain wounds. Presumably the world war shows that many recoveries may be nearest approach to it would be by carrying the expected from brain injuries provided they are solution to the bottom of the wound by a soft kept properly drained, clean, and dangerous com- rubber catheter and slowly irrigating from pression is not permitted from blood clot or de- within outward under almost imperceptible prespressed fracture.
sure. Removal of the bullet has become of secondary importance, though at times it becomes imperative.
PATHOLOGY OF INTESTINAL OBSTRUCTolerance of the brain to trauma enables us
TION* to make many explorations without damage, but
0. C. MORRISON, M. S., M. D., Carroll, Iowa. this fact must not lessen ones respect for certain areas of the brain or justify us in ignoring estab- The term obstruction as used in this paper lished laws in needle explorations.
means to convey the idea of a sudden, permanent Hexamethylamine was used freely in case 4, closure of the bowel lumen to the transit of as it has been in all our brain cases during the any material whatsoever. In health the perlast four years, because of its supposed protec- istaltic wave makes a transit of the entire bowel tion against meningeal inflammation.
about every four minutes requiring one minute I am indebted to my associate, Dr. T. B. for the wave to pass the entire length. This Throckmorton, for the report on the neurologi- is based upon the unstriped muscle beat. The cal tests, assistance at operation in case 4, and heart has its beat as it is an unstriped muscle. much of the after care; to Dr. Thos. A. Burcham Its normal beat is about 72 times a minute. The for the excellent x-ray work done on the case, placenta has its beat, the spleen its beat, the gall and to Dr. W. W. Pearson for the tests of the eye bladder its beat, the uterus its beat. By the fields.
term peristalsis we mean to include the double Conclusions—That bullets of large caliber action of the muscle fibers comprising the bowel may pass through one or more lobes of the brain wall. The action of the circular fibers cause and produce no cerebral, neurological, or physi- the food to move slowly down the intestinal cal disturbance.
canal keeping it in contact with the mucosa for That permanent lodgment of aseptic missiles the purpose of facilitating absorption of the in the brain may cause little or no pain or im- digested food and mixing the content of the pairment of function during long periods of time. bowel with the digestive enzymes. The long
That bullets may be followed along their itudinal fibers prevent stagnation within the tracks with ease and certainty without danger of lumen of the bowel and is known as the penduproducing a false passage.
lar movement. This combined movement of the That x-ray localization is now always indi- bowel called peristalsis travels normally from cated, when possible, before undertaking operat- the stomach toward the colon. A number of ive removal of a missile.
physiologists agree that the peristalsis is very Accurate knowledge of the resistance of the necessary in moving the lymph material and brain to probes of various sizes, Girdner's tele- partially absorbed food from the veins into the phone connection with probes, and Fowler's scale hepatic circulation. The subject of acute obto read pressure being used, while important, struction is intensely interesting since we may have lost much of their value since the x-ray has resect parts of the bowel; we may open its become efficient.
lumen and connect it with any other viscus within Relief from compression and providing of the abdomen; as a gastro-enterostomi or an suitable drainage are often the only operative entro-enterostomy and yet the peristaltic wave indications.
will transi the food in what seems to be a Removal of lodged missiles should only be normal manner but should a band of adhesion, undertaken after the most careful x-ray localiza- a kink of the gut or what-not suddenly occlude tion and because they are producing important its lumen, we immediately have a very definite
picture. It is unnecessary to repeat the classical All localization marks on the scalp must be symptoms of colicy pain, the cessation of bowel reproduced on the skull before the scalp is deflected or they become almost valueless as soon
Read before the Medical Society of the Missouri Valley at Lincoln, Neb., Sept. 21, 1917.