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ADDRESS IN SURGERY.
By D. HAYES AGNEW, M.D., LL D.,
PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA
GENTLEMEN OF THE PENNSYLVANIA STATE MEDICAL Society :
Having been charged by your body with the honor of delivering the customary annual address in Surgery, I am before you to-day in obedience to that appointment.
If I apprehend rightly the legitimate sphere of such a task, it will be best discharged by taking a comprehensive survey of the field, and gathering, into a concise statement, whatever of importance has attracted professional thought in this department during the last twelve months, or since the last meeting of this organization. It is no trifling labor to analyze the work of even a single year, to eliminate the immense accumulation of rubbish from that which is worth preservation, and which will survive the fiery trial of observation and experience. It is no reflection upon the profession to say that much of its gatherings have no practical value; on the contrary, we find analogies on every side to show that in the domain of intellectual labor the law does not differ from that which governs in the ordinary processes of nature. The miner knows well that he is compelled to crush out vast quantities of auriferous-bearing quartz to secure the precious ore; the lapidary to cut away on his wheel much extraneous matter, before the brilliant is exposed ; and the husbandman to thresh an incredible amount of straw to obtain the golden grain.
No man can enter upon the work of traversing the field of our professional toil without being impressed by two facts: the intense activity which is manifest in every department, and the disposition to jostle old doctrines; to accept nothing, save on personal experience, and to challenge every problem for a new demonstration. This spirit of disbelief, of doubt, of want of faith-as theologians would term it-is not peculiar to medicine; it is rife everywhere; it is perhaps a feature of the century, and is often the subject of unsparing rebuke and condemnation. It, of course, has its legitimate bounds, especially when applied to subjects which are above
reason; but aside from such, and when animated by an honest desire to reach truth, it tends to advance, not retard, scientifie progress.
To enter, however, upon the work of the hour, it may be said that no branch of surgical study has made such rapid progress, within the last fifteen years, as Ophthalmology; and, in this department, the last year has not been barren of results. There have been earnest workers both abroad and at home. A new operation for the relief of that troublesome affection, entropeon, has been introduced by Professor Magni, by which it is thought a permanent correction of the superior eyelid can be maintained, by taking advantage of the well-known contractile property of cicatricial tissue, and which is effected by making an energetic cauterization of the integument, by means of the galvano-cautery. The corrugations produced in the skin of the upper lid by the underlying muscle, would, I suppose, keep so much of the lid in shade, that little, if any, appreciable deformity would be noticed.
Iridectomy, which may be considered a modern operation, at least in its application to cataract and glaucoma, has been somewhat modified in its execution by Mr. Brudenell Carter, when performed to remedy certain defects of vision, caused either by circuinscribed opacity of the cornea, or central opacity of the crystalline lens. It resembles the operation of Bowman & Weckers, and consists in making an incision at the sclero-corneal margin, with a pair of Dr. DeWeckers' scissors, passing in the blades, closell, through the opening, inclining the point toward the cornea ; and after passing a very short distance beyond the margin of the pupil, expanding the scissors, in the act of doing which, a fold or duplicature of the iris will pass in between the blades, the closure of which cuts out a piece, leaving a triangular-shaped opening, its base corresponding to the pupillary border of the iris. The method certainly attains a large and well-disposed opening, with the least structural disturbance to the iris or ciliary body. It might be supposed that there was no more room for corneal incisions in the extractions of cataract. DeWeckers, after reaffirming what are regarded as the important desiderata for a perfect cataract extraction, such as a proper disposi. tion of the cut for speedy union--that is, through the sclero-corneal junction, a point where the vitality is greatest; easy escape of the lens, and the prevention of a prolapsed iris-after considering these indications, adopts what he terms a new procedure in peripheric flap extraction. The eye is fixed by grasping, with a pair of forceps, the mucous and submucous tissues at the middle of the inner circumference of the cornea, and accurately detaching with a knife the upper third of the cornea. . After the counter-puncture is made, VOL. XI.
and when the iris can no longer bear upon the edge of the knife, the operator removes the fixation forceps and completes the section, without forming a conjunctival flap. This done, the lids are closed, and covered with a cold sponge for a few moments, after which they are again separated, and the capsule lacerated with the ordinary cystotome. The assistant now takes charge of the upper lid, and the operator, while pressing the lower lid against the ball of the eye, forces the lens into the wound, which he delivers by pressing with a delicate caoutchouc spatula the peripheral insertion of the iris, which tends to enfold the lens at the moment of its escape. Should the iris prolapse, the reduction is effected by moving the flat surface of an ophthalmic spatula over the eye, and the instillation of a solution of the Calabar bean, as used to produce myosis. After the lapse of some hours belladonna is used, as in ordinary cases.
To effect a rapid diagnosis of astigmatism, M. Bravais, of Lyons, has adopted a very simple ophthalmoscopic device. While examining the inverted image, if at the moment the optic papilla is seen at the centre of the glass, lateral movements are given to the objective lens, the ophthalmoscopic image moves also, but varying in degree according to the refraction. If the eye be myopic, the movement is less extensive; if hypermetropic, more extensive than that of the lens; and if emmetropic, the papilla continues visible at the centre of the lens, the displacement of the image and the glass being equal; so that by moving the objective lens in different directions it may be quickly determined which of the meridians is emmetropic, hypermetropic, or myopic.
In this connection may be mentioned a new astigmometer, constructed by Dr. Hay, of Boston, and originating in the demonstration of the regular increase in the refractive power of a simple plano-cylindrical lens, caused by rotating it about its axis. The practical application of the principles involved has been effected by placing a weak cylindrical lens in a tube so arranged as to admit of two movements, one on its own axis, and the other around the axis of the tube in which it is placed. By means of the movement around the axis of the tube the axis of the cylindrical lens can be varied so as to measure any desired meridian, the degree of rotation on its axis, or what is the equivalent, the obliquity of the curve of the cylindrical lens indicates the amount of correction required.
It gives me great pleasure also to notice, in this place, the ophthalmoscope and ophthalmometer, two instruments combined in one, invented by Dr. Edward 0. Shakespeare, of this city, and which is destined to fill an important place among the clinical
appliances of ophthalmology. The numerous applications of the instrument constitute its prominent characteristic. It enables the operator at the expense of very little time, and withi entire accuracy, to ascertain and correct anomalies of refraction. In high degrees of myopic or hypermetropic astigmatism, with posterior staphyloma, allowing only an exceedingly small surface for an accurate focus of the rays of light, and where in consequence of those rays which pass internal and external to the “yellow spot,” intersecting at different planes, the first anterior and the second posterior to the retina, and thus creating an anomalous refraction by the circles of diffused light; a condition which heretofore has not been correctable, because we have had no means of determining the anomaly; yet the instrument of Dr. Shakespeare supplies the void, and enables us to make the required correction, and gives the axial inclination of the correcting lens. By this same ophthalmometer the curves of the cornea in its different meridians can be determined on the principle of the formation of images by reflecting surfaces. So also any want of conformity in the coincidence of the axis of the lens with that of the cornea, may be detected. Nor does its multiform applications end here. We are enabled to determine the size and position of intra-ocular objects both actual and relative, to look into one's own eye and study its circulation; or as a camera it furnishes the means of accurately sketching the healthy and morbid appearances of intra-ocular structure.
In the department of otology there have been numerous additions to our knowledge of an important kind during the last year. Some of these beautifully illustrate the practical benefit to be derived from a careful study of the anatomy and physiology of special parts of the body. For example, it has been ascertained that in sounding either vowels, or words containing a vowel, the soft palate is so changed in its position as to divide the post-palatine space into an upper and lower compartment, much in the same manner, though not to the same degree, as when a fluid is swallowed. Taking advantage of this knowledge, Lucas, of Berlin, and Gruber, of Vienna, have added another means to that of Pollitzer, of forcing air into the Eustachian tube. In dealing with collections of matter, such as pus, or inspissated mucus in the cavity of the tympanum, we now take liberties with the membrani tympani which would, two years ago, have been considered rash, if not reckless. This course is due, in a great measure, to the practice of the late Mr. Hinton, of London, who boldly slits up the membrane of the tympanum, posterior to and parallel with the malleus, and, as is alleged, with great success.
also record the ingenious device of Dr. Blake, of Boston, for healing and improving the hearing, in cases of drum perforations, by the application of artificial or paper disks.
Our knowledge also of the diseases peculiar to the naso-pharyngeal region has been increased by the observations of Wendts, of Leipsic, and also of Pollitzer. Therapeutics sometimes reflect much light upon pathology. The success of Charcot, of Paris, in treating cases of aural vertigo by large doses of quinine, has drawn the attention of aurists from the semicircular canals to the muscular apparatus of the middle ear.
In certain forms of deafness dependent upon either defect in the nerve endowments of the organ, or the muscles of the middle ear, Dr. Hagen, of Leipsic, claims to have secured the most satisfactory results from the hypodermic use, over the mastoid portion of the temporal bone, of a one per cent. solution of the nitrate of strychnia.
Another subject of great interest to surgeons is the quick healing of wounds. The conditions which have been deemed necessary to secure this, are the complete arrest of all bleeding, the removal of foreign bodies, accurate adjustment, rest, limitation of inflammatory action, with a healthy state of the constitution. With all these indications fulfilled, by the use of the ordinary means known to the profession, yet it is nevertheless true that we are constantly doomed to disappointment by the occurrence of suppuration, which defeats or delays-often for a long time—the work of reparation. It is believed by some that this complication is due to the ordinary approved plans of dressing failing to remove all foreign matters from the wound. I do not mean by this that particles of matter, visible to the unaided eye, have been overlooked, but matter so extremely small as only to be seen by microscopic aid. The great exponent of this doctrine is Mr. Lister, of Edinburgh. It has been long known that the entrance of air constitutes a disturbing element, both in the healing of wounds and abscesses; and with regard to the latter, various incisions have been planned so as to exclude its presence; and in the construction of that beautiful instrument, the aspirator, this is the dominant thought. Just why the air should exercise a prejudicial effect, under the conditions named, was not determined; and is not necessary for my present purpose to detail the various speculations which have been entertained. It is sufficient to say that recent observations appear to show that neither oxygen nor any other gas is concerned in the complicalion; that it is not the air in its entirety, but to the presence of invisible organic particles which it contains. If urine is allowed to stand for a short time, it undergoes fermentation, and emits an