SURGICAL, MEDICAL, AND SANITARY NOTES.

By P. A. Surg. G. T. VAUGHAN,

I have the honor to make the following report of my recent visit to Europe:

October 24, 1894, I arrived in Bremen. Dr. Keenan, United States consul, took great pains to show me the facilities for detention and inspection of emigrants to the United States, including quarters, bathing apparatus, and steam disinfecting chamber. The consul informed me that he had just witnessed the slaughter of eight or ten horses for food, and that the number of these animals annually slaughtered in Bremen amounted to about 1,600.

The "Dome" is an interesting structure, not only on account of its thousand years of existence, but from the peculiar properties possessed by an anteroom, namely, that of preserving animal bodies indefinitely. This room, built of stone, is some 30 or 40 feet in length, 15 or 20 feet wide, with an arched ceiling about 15 feet high, and the air felt damp. and cool. Its peculiar properties were accidentally discovered about four hundred years ago, when a body placed there was found, after à long time, well preserved. Since then other bodies have been added, until there are fourteen in the chamber. The bodies are not specially prepared before being placed in the chamber. Every year the bodies of animals, as cats, dogs, and birds, are placed here in order to see if the preserving property is still retained, and they simply dry up without odor.

In Hamburg I had the pleasure of meeting Dr. Dunbar, director of the Hygienic Institute, and Mr. Schede, a former pupil of von Volkmann and surgeon in charge of the New Eppendorf General Hospital, a new hospital of 1,800 beds, on the pavilion plan, well fitted with all the apparatus for the modern treatment of diseases and injuries. I saw Mr. Schede do an operation, original with himself, for the radical cure of varicose veins of the lower extremity, which he told me he had done thirty or forty times, and in every case with a satisfactory result. The operation consists in making a circular incision, as if for amputation, 10 to 15 cm. below the knee, dividing skin, fascia, and all the superficial veins down to the fascia covering the muscles, then ligating both cut ends with catgut, usually requiring some thirty or forty ligatures. An Esmarch's or Martin's rubber bandage is used to make the limb bloodless.

On arriving in Berlin I decided to matriculate at the university in order to take courses under Professors von Bergmann, Virchow, Waldeyer, and Casper, besides visiting the clinics of Professors Martin,

Bardeleben, Hahn, Sonnenberg, Olshausen, and Dr. Schleich. Professor von Bergmann performed many operations, holding a clinic from 2 to 4 o'clock four times a week. Two operations on the rectum and two for congenital dislocation of the hip deserve notice.

The operation on the rectum consisted in resection of a portion just above the anus for carcinoma by making a flap consisting of the lower portion of the sacrum, muscles, and skin, by means of an incision beginning between the tuber ischii and anus, but a little in front of the latter on one side, and curving back like a horseshoe crossing the lower third of the sacrum to a corresponding point on the opposite side, sawing through sacrum with a chain saw and turning forward the flap of skin, muscle, and bone thus made, exposing the rectum from behind. About 4 cm. of the rectum were resected about 7 cm. above the anus, opening the peritoneum, and the two portions of the rectum united with sutures. Both cases recovered, though one had a fæcal fistula where the two portions of rectum were sewed together, which finally healed. The flap of skin, muscles, and bone was not fully replaced and sutured until the rectum had healed, a few stitches on the sides holding it in place while the rest of the wound was packed.

For congenital dislocation of the hip I saw him operate twice, as follows: He makes an incision from the anterior superior spinous proc ess of the ilium downward over the joint 10 to 15 cm. in a line with the external condyle of the femur, separates the muscles but does not detach from their insertion, opens the capsule, and scoops out with a special instrument—a kind of auger—a new acetabulum at the proper site, then pulls and manipulates the head of the femur into this depres sion and closes the wound with sutures through skin and muscle, but not through the capsule, and puts up with plaster of paris. Passive motion at proper time, ten days or two weeks.

Professor von Bergmann said that he had obtained good results from this method. Chloroform was the anesthetic almost universally used and often it was given to patients seated bolt upright strapped in a chair, as for reduction of dislocation of the upper extremity. I saw no bad effects.

A word must be said about Dr. Schleich's method of using cocaine in major operations, as laparotomies, where there are not many adhe sions to deal with, e. g., ventral fixation of the uterus, cholecystotomy, and in one case amputation of the forearm. His formula is sodii chloridi, 2 grams; cocaini, 1 gram; morph. muriatis, 0.25 gram; aqua distil., 1,000 c. c.; the maximum dose of the cocaine itself being 0.05 of a gram, or 50 c. c. of the above solution. It is injected into the tissue of the field of operation by means of a hypodermic syringe, layer by layer, first into the skin itself, then into the subcutaneous tissue, then muscle, and then periosteum (in case of amputation), using many injec tions, which are painless, the first one being made so by slight freezing with ether spray if desirable.

So much has been written about antitoxin that I will only mention here the opinions expressed to me in the different cities visited as to its value in diphtheria. In Berlin the opinion was almost unanimously in its favor in spite of the attack made by Hansel. In Leipsic the opinion was quite conservative, Professor Tillmanns, of the Children's Hospital, saying that it would require a year or more in order to establish its value, and in the children's division of the City Hospital (hospital at St. Jacobs) I was told that they had little confidence in its virtue and believed it acted injuriously on the kidneys. In Dresden the "heilserum" was held in high esteem. In Prague, Professor Weil, of the General Hospital, said that it was used there with excellent results, but did not believe the reduction of mortality on account of it was from 60 to 12 per cent, as was claimed in Berlin. In Vienna the opinion was generally favorable. Professor Widerhofer used it in the Children's Hospital and was well satisfied with its action. In Paris, it is scarcely necessary to say, there was great enthusiasm over this remedy, while in London they seemed ultraconservative and skeptical.

In Dresden Professor Leopold explained his method of determining the position of the child in utero by external examination alone, which he has systematized into a method which he calls his "four grips," explained as follows:

Grip 1 (the physician faces the patient).-Both hands are placed flat across the belly of the woman with the finger tips touching, and then gently and symmetrically passed over the womb to the fundus, determining its position in relation to the navel and epigastrium, at the same time feeling whether the child is straight or transverse, whether the head or breech lies in the fundus, the size of the child, and the stage of pregnancy.

Grip 2.—The hands separated, instead of with finger tips touching, are passed from the epigastrium to the sides, lying flat on the sides of the womb. Under one hand are felt the smaller parts, under the other the long cylinder which corresponds to the child's back. The recognition of the back may be facilitated by putting one hand on the middle line and pressing the womb gently back, thereby forcing the amniotic fluid to one side and the child's back to the other, where it can easily be felt by the other hand.

Grip 3.-With the thumb of the right or left hand, separated as far as possible from the fingers, clasp with the thumb and tip of the middle finger, close over the pelvic inlet, the presenting part of the child. If hard and round it can only be the head, and if not yet engaged may be moved as a hard ball. The breech feels much softer and more uneven. If the presenting part of the child is felt unusually covered, indistinct, and somewhat softer than usual, the presumption is that the placenta is situated in the lower part of the uterus. If no presenting part is felt, the head is sought in the side of the womb, and this is best done by means of the fingers of one hand striking the uterus gently with short strokes, thus causing the head to make short, springy movements. 5553-VOL I-11

This grip is of great value in all cases where the presenting part, head or breech, is still in or above the pelvic inlet. If it is further advanced, already in the middle or outlet of the pelvis, grip 4 is of value.

Grip 4.-The physician stands by the bed with his back to the woman's face, and with the finger tips of both hands presses slowly and gently over the groins deep into the sides of the pelvis. With a deeply engaged head, a hard round part of the child is clearly perceived to fill the pelvis and the arched forehead on one side is easily distinguished from the flat neck on the other.

In Vienna I found Professor Gussenbauer, who succeeded the cele brated Billroth as professor of surgery in the university, courteous and obliging. He is the inventor of the artificial larynx which bears his name, and a surgeon of great ability, being very slow and careful in his operations. In removing most of the thyroid gland for goitre he had the patient propped up into the upright sitting posture and thus gave chloroform, showing the usual fearlessness with which the German surgeons use anæsthetics. On one occasion he showed a young man 18 or 20 years of age in which the right femur was 2 cm. longer than the left, causing a decided limp which had come on recently. There was some enlargement of the right trochanter with pain on deep pressure. Otherwise the patient seemed in perfect health. The professor thought it a case of osteomyelitis, the inflammation having stimulated the bone to overgrowth so that it exceeded its fellow in length.

I have recently seen a case somewhat similar in a man 40 years old, who suffered severe pain in the right hip and thigh for a period of two years with short intervals of relief, and was treated for sciatica and rheumatism. At the end of two years he had developed a decided limp, although there was no pain, and on measurement the right femur was found to be fully 3 cm. longer than the left. The limp was relieved by a shoe on the left (sound) foot with a sole 3 cm. thick.

It would seem from these two cases that osteomyelitis may cause sufficient increase in the length of the bones affected as to require some orthopedic apparatus for its correction and at the same time not seriously impair the functions of the limb.

In Padua Prof. Edward Bassini was very pleasant and courteous. He is apparently 55 years of age, tall, slender, quick, and alert in his movements, with brown eyes and black hair and beard about equally mixed with gray. He speaks German quite well and English a little. He did five hernia operations and took the trouble to explain them thoroughly.

Description of operation.- He makes an incision over the inguinal canal through skin and fascia down to the aponeurosis of the external oblique, tying each vessel with silk as divided. He then divides the aponeurosis of the external oblique, exposing the spermatic cord from

the internal to the external ring, separates the hernia sac from the cord to a point within the internal ring, twists the sac and pulls it out well, ligates with silk, or sews, if large, and cuts off. He then hooks back the tissues, including the divided aponeurosis, removes the cord to one side, and sews the conjoined tendon and rectus muscle to Poupart's ligament from the spine of the pubes to the internal ring, using interrupted silk sutures. Then the cord is replaced and the aponeurosis united over it from above downward to the external ring. Last, the skin and fascia are united with a continuous lock stitch of silk, without drainage, and dressed with sterilized gauze (no iodoform), cotton, and a gypsum bandage. He usually found the wound healed in eight or nine days.

Professor Bassini was extremely careful about his asepsis, giving his personal attention to the disinfection of instruments and the sterilization of the dressings. He informed me that he first did this operation in 1884, and that he had now performed it seven hundred and fifteen times without a death, and knew of only nine relapses.

In London I saw Dr. Granville Bantock, Mr. Skene Keith, Mr. Lucas, Mr. Collins, and Mr. Treves. Dr. Bantock's views as to germs causing disease are well known. He claims that we do not distinguish between "post hoc" and "propter hoc;" that the germs appear on account of the disease, and not the disease on account of the germs. In his opera tions he uses no antiseptics, does not boil his instruments nor sterilize anything, nor boil the water for flushing out the abdominal cavity, but uses silk and gauze just as it comes from the manufacturer or dealer, and water as it comes from the tap. He uses only soap and water for cleansing his hands and the field of operation.

Professor Sänger, of Leipsic, informed me that he used water from the tap, without any antiseptic, and for the year during which he had used it had no case of sepsis. Dr. Bantock believes in drainage, and requires visitors to his operations to sign a declaration in a book kept for that purpose that they have attended no case of infectious disease, peritonitis, nor post-mortem for two days before his operation. His results are good.