J. E. DAVIS: "Asepsis and Antisepsis," International Journal of Surgery, December, 1900.

HALBERSTADT: Journal of the American Medical Association, April

27, 1901.

7

HIRST: "A Text-Book of Obstetrics," page 299.

8 Medical Record, April 15, 1899, page 533.

Medical Record, April 15, 1890.

10 64 Discussion in Section on Obstetrics, British Medical Association," reported in Medical Record, August 13, 1898, page 245.

"Discussion in Section on Obstetrics, British Medical Association," reported in Medical Record, August 13, 1898, page 245.

12 J. E. DAVIS: Journal of the American Medical Association, June 26, 1901. 13 J. E. DAVIS: Medical Record, July 6, 1901.

831 FORT STREET WEST.

CONSERVATIVE TREATMENT OF EMERGENCY SURGICAL CASES.*

BY FRANK B. WALKER, PH. B., M. D., DETROIT, MICHIGAN.

DEMONSTRATOR OF OPERATIVE SURGERY IN THE DETroit college of medicine.

PUBLISHED IN The Physician and Surgeon EXCLUSIVELY]

By emergency surgical cases I mean those in which prompt attention is demanded through either accident or acute infection. They include a variety of injuries-contused, punctured, incised, lacerated and gunshot wounds, burns and fractures-complicated by a greater or less degree of septic infection. In discussing this subject it is not my intention to particularize with reference to the treatment of all these conditions, but rather to consider it in the light of results-that is, from the standpoint of the patient. It was a saying long ago that the Frenchman cured the disease, but the Englishman cured the patient. The distinction implied in that witicism is the subject of this paper.

In the "Memoirs of AMBROISE PARÉ" there is related the case of the King of Navarre, who was wounded with a bullet in the shoulder. When asked if the wound were mortal, PARÉ said "yes, because all wounds of great joints, and especially contused wounds, were mortal, according to all those who had written about them." The surgical skill and sagacity of that great man were highly esteemed in his lifetime and the dictum he uttered, on the occasion referred to, may be taken as the summum et bonum of the science and the art of surgery of that time. Since then the perfection of surgical methods, and especially amputations, did much, even before the discovery of anesthesia or of the principle of asepsis, to modify the established practice. Bold measures-amputations-became the order of the day by reason of their conservative effect. During the last decades, however, the necessity for radical procedures has dissolved in the clearer and full appreciation of surgical principles. Amputation as a routine measure in the treatment of emergency cases, is now only a

* Read before the DETROIT ACADEMY OF MEDICINE.

memory, and yet that it is even now too frequently and unnecessarily resorted to, I firmly believe. Cases are frequently met with which look at first exceedingly desperate, and to those not familiar with the possibilities of conservative methods, anything short of amputation seems like a waste of time and a lack of courage and surgical ability. I am not ignorant of the occasionally tedious healing of wounds, of the scars and contractures which sometimes result, and of the deformed and apparently useless members. I have seen these and still hold the opinion that amputation should be thought of only as a last resort. The saving of a foot, hand or arm is of far greater consideration than the petty annoyances which time and patient industry can usually overcome.

T. M., a marine engineer, came under my care July 13, 1901, and told me the following story: On July 4 a cannon firecracker accidently exploded in his right hand, badly shattering and lacerating it. He was taken to the nearest marine hospital, given an anesthetic and the thumb and first three fingers amputated at the metacarpo-phalangeal joints. The father of the patient, also an engineer on the lakes, visited the surgeon and was told, he said, that if he had known who the man was he might have saved some more fingers. This case is pointed enough to convey, without further comment, the impression I desire.

From a number of cases I have selected four intrinsically interesting ones which exemplify to my mind the art of conservative surgery.

Case I.-D. F., about fifty years of age, was sent by a physician to Saint Mary's Hospital, August 6, 1901, to have one or two fingers amputated and the hand otherwise cared for. While employed as engineer in one of the downtown buildings his right hand became engaged somehow in the machinery, as a result of which the thumb, index and middle fingers were crushed, broken and lacerated. The ring finger was also contused and cut but not severely. The wounds were grimy, large and jagged and the bones dislocated and comminuted. It must be confessed that hardly anyone except the patient would have thought the fingers of any future use. However, the wounds were soaked in several solutions of mercuric bichlorid, freed from dirt and loose particles of bone, trimmed up, sutured in places, drained, the phalanges put in apposition, separate finger splints and a larger hand splint applied and the whole hand dressed. After forty-eight hours the dressings were changed by the hospital interne. The patient remained in the hospital four days and the hand was dressed for the last time August 31, twenty-five days after the receipt of the injury, at which time the hand, with the exception of stiffness of the joints and a slight twisting of the distal end of the middle finger, due to careless early dressing, was a very presentable member and promised great utility. Passive motion has since rendered the joints more nimble and the patient considers he has still a good hand.

Case II.-H. J. E., on August 24, 1900, had his whole right hand

caught and squeezed between heavy rollers of printing machinery. He was soon in my office but even in so short a time the hand was swollen to twice its normal thickness. The thumb and fingers were split open in several places, chunks of muscle protruded and considerable portions had to be cut off, and crepitations could be felt in different parts of the fingers and among the metacarpal bones. The hand looked as though it might be saved from serious septic infection but the injury was so great that muscular function in every part of the hand seemed irreparably lost. seemed inevitable that tendon and sheath should be permanently adherent to one another. The hand was trimmed up and antiseptically dressed in splints and redressed from time to time during the next two months. Passive motion was begun between the second and third week and persisted in throughout the treatment. There was some contracture of the fingers and hand and contrary passive motion used as indicated. When last seen the hand was not of great use but the young man could hold a pen in it and the outlook justified the treatment.

Case III.-W. B., aged seventeen, while switching for the street railway fell on the night of November 26, 1901, in such a manner that a car wheel passed over the lower third of his right forearm. Skin and muscles were severely crushed and torn by the great weight, both bones fractured in comminuted form, dislocated, crushed and protruded from the wounds. A young surgeon who first saw the patient considered amputation as the only practicable method of treatment. The wounds were exceedingly dirty and acute sepsis seemed inevitable. As the family attendant I dressed the arm in the usual manner, using antiseptic solutions, sutures and splints as seemed to be indicated. The fragments of the radius were with considerable difficulty replaced and it seemed quite uncertain whether they could be retained in position. Anodynes were given and an ice bag ordered for immediate and constant use. Owing to the great swelling the edges of the skin could not be brought together at the first dressing. On the following day the dressings had become saturated and were changed. The bones seemed to be in proper relation but the arm had become more swollen so that all sutures had to be removed and the wound left entirely open. Drainage with gauze was provided from extensor to flexor surface. Temperature and pulse indicated sepsis and a second ice bag was ordered. The skin involved in the injury promised to slough, the hand and entire forearm were inflamed and pain was felt in the axilla. The arm was dressed daily and within ten days both ice bags were discontinued. The skin sloughed on the extensor surface over an area of about twelve square inches and over an area of eight square inches on the flexor surface. A large surface of the radius was at first exposed but at this date it is nearly covered. Skin-grafting was performed twice and the granulating surface is now pretty well covered over with good skin. The forearm is still enlarged. Phalangeal, metacarpal and wrist joints can now be moved passively and there is

slight voluntary control of the fingers and thumb. The treatment has been much more troublesome than it would have been by the method of amputation, but the results to the patient cannot be compared, for there is a certain promise of not only a whole but a useful arm and hand.

Case IV.-Miss M. V., twenty-four years of age, was admitted to Saint Mary's Hospital, February 7, 1899, with history and condition as follows: While engaged in laundry work, her left arm was caught in the gearing of a machine, by which all the soft tissues were torn from the humerus along the middle half of its anterior, inner and posterior surfaces. The integument of this region was chewed up and completely destroyed. Only a strip one and one-half inches wide was left on outer side of arm. The biceps, coraco-brachialis and brachialis anticus were lifted in part, the triceps was torn up and completely severed, the musculo-spiral and several smaller nerves divided, the median basilic and several other bloodvessels were torn into and their ragged ends hung in the wound. The brachial artery lay exposed, having been scraped by the machine but fortunately not divided by it.

I have scarcely seen a more hopeless condition than that arm presented, and had it not been that the brachial artery was still intact and that a feeble radial pulse could be felt I should have thought it little use to try to save the arm. The greasy bits of skin were snipped off, the muscles trimmed, the triceps sutured with long mattress sutures, bloodvessels ligated, the larger divided nerves sutured as well as possible, the healthy skin stretched and sutured to cover as much of the exposed surface as seemed prudent, the wound cleansed, dressed, and long straight splints applied to prevent tension on the sutured muscles and nerves. During the first twelve hours following this operation there was profound shock, and dark brown vomit, for which stimulants were administered hypodermically and normal saline solution repeatedly by enema. The wound was antiseptically dressed daily, for some time. Skin-grafting was performed three times, more than two hundred pieces having been used by Reverdin's method. The patient continued under my care until May 9, or about three months after the injury was received. At that time the arm was healed, contracture was inconsiderable in proportion to the wound, and by passive motion the several joints involved were gradually being loosened up. During the month of May the patient returned to work.

The foregoing cases exemplify conditions on account of which amputations are being made of fingers, hands and arms, and they demonstrate what I mean by conservative surgery. No one of the patients ever expressed dissatisfaction or had reason to be other than grateful for the result. In the treatment of them, repair and the normal relations of structures, drainage, the avoidance of excessive cicatricial tissue, the preservation of joint and muscle function, and the healthy condition of the body gener

ally were the main indications. The application of cold in the forms o solutions and of ice was of great service in arresting septic processes. Gutta percha tissue is in my opinion the least injurious protective dressing for granulating surfaces. Powders were generally discarded. As soon as the wounds became clean, irritating antiseptic solutions were displaced by mild antiseptics or sterile water. Passive motion of the affected joints was begun early according to their injury and patients were made. to feel responsible for their share in this part of the treatment. Fingers, hands, wrists, arms, feet and legs frequently become tightly anchylosed following serious injuries but patience and persistence will seldom fail in bringing about a good result.

THE LAWS OF MICHIGAN RELATIVE TO PUBLIC HEALTH.* BY HENRY A. HAIGH, LL. B., DETROIT, MICHIGAN.

MEMBER OF THE STATE BOARD OF HEALTH.

I BELIEVE "The Laws of Michigan Relative to Public Health" are the most important of any in our statute books. I also believe that the business of the health officers is more important than that of any other set of men in the State, and, I might add with truth, that failure to attend to this business properly and efficiently may entail more harm upon the community than a disregard of duty by any other class of officials.

The health officer's charge is "the greatest thing in the world," the care of the health of the people. It is greater than wealth, or property, or any other rights, and possibly even than life itself; because life without health has lost most of its value and much of its joy, and it is of short duration at the best. It is for this reason that "The Laws of Michigan Kelative to Public Health" give to the health officials larger and more absolute powers than are conferred upon any other class of public officers. And it is by the tactful exercise of these great powers, and the vigilant discharge of their important duties, that the health officers, more than any other class, may advance the public weal. I use the word "tactful" advisedly, because willing and intelligent cooperation is what the health officer most needs in order to make his work the most effective. While his duties are in the main executive, he should also, as it seems to me, strive to make his work educational. Though he has power to drive by force, he will accomplish more by leading through intelligence.

In no other department of human affairs does it seem that education will accomplish so much. It will, in large measure, do away with the necessity for coercive measures, and render resort to legal methods largely unnecessary. The ends to be attained by sanitation and preventive medicine are so paramount, and the results of neglect are so direful, that mere enlightenment will go far towards securing that willing and earnest coop* Abstract of a paper prepared for the CONFERENCE OF HEALTH OFFICERS which was held at Ann Arbor, November 21 and 22, 1901.