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muscles. The great toes are also drawn up. The arms are decidedly weak, and there is inco-ordination as well, which is increased when the eyes are shut, but there is no tremor. There is however some unsteadiness of the head at times. muscles are decidedly weak, and there is well-marked lateral curvature. The electrical reactions in the legs are unobtainable although the muscles respond to pinching, with the exception of the extensors of the left leg which did not respond. In the arms the reaction to Faradism was good with exception of the extensor groups of both forearms, and in these same muscles the reaction to galvanism was rather delayed on the left side, while in both forearms A.C.C. preceded K.C.C.
Thomas P., aged 10 years, was brought to hospital in April, 1892, for "St. Vitus Dance." No family history of nervous disease, except that a sister had a passing attack of chorea. Patient has had no serious illnesses-never measles or scarlet fever. He was quite well till August, 1891, and then, after a fortnight's absence, his parents noticed that he was unsteady on his legs, and that the least thing would knock him. down. He soon became clumsy with his hands, and about November it was noticed that his speech became slow and drawling. He also became irritable and fretful, and was at times silly in his talk.
On admission the boy was well nourished, with no muscular wasting. On the contrary, there was some hypertrophy of some of the scapular muscles, especially the infra-spinatus. and teresmajor. There was however no weakness of any muscles in this region, and no hypertrophy of the calf or other muscles. There was distinct weakness of the muscles of the back, as evidenced by his slight stoop when walking and by his attitude when standing, and by the slowness with which he regained an erect attitude when getting up from a recumbent posture. When standing, he holds his head and shoulders so far back. that a vertical line falls four inches behind the sacrum, He sways to and fro a good deal when standing, in spite of keeping his feet wide apart. His unsteadiness is increased somewhat
when his eyes are closed. His knee-jerks are increased, especially the right, which can be got on percussion above the patella, when the leg is straight. There is no ankle clonus, but the irritability of the calf muscles is a little increased. There is also a slight tendency to general extensor spasm of the legs, especially on the right side. These features make themselves evident in the gait, which has a little of the spastic character superadded to the typical choreiform unsteadiness.
He improved slightly during his stay in the hospital, and on leaving, there was no inco-ordination discoverable in his arms, and he was also rather steadier on his feet. The electrical reactions were similar to those of the other cases. Slight diminution of reaction to Faradism in the legs, especially in the right one, together with general diminution of the reaction to galvanism, especially in the anterior tibial muscles of the right leg, where A.C.C. preceded K.C.C.
In conclusion, I must express my indebtedness to two former resident medical officers at the General Hospital-viz., Dr. Short and Dr. Russell-for the careful notes they made of the above cases while in hospital.
THE TREATMENT OF WOUNDS.*
BY ALBERT LUCAS, F.R.C.S. ENG.,
ASSISTANT SURGEON TO THE GENERAL HOSPITAL, BIRMINGHAM.
THE subject of Wound Treatment is one which is ever before our minds in our practice as surgeons; it is one upon which there are many opinions. I have nothing novel to bring forward, no new antiseptic, no new gauze, or any other preparation which will alter the whole system of treatment. I intend to speak of the methods generally adopted, and then to give my own opinion upon them.
At the commencement I would emphatically say that I believe no wound can heal without inflammation, it is that process
* A Paper read before the Queen's College Medical Society.
Healing by "immediate
alone that causes a wound to heal. union" is an impossibility, and anyone who has any knowledge of pathology will see that it cannot take place. I know that the expression "primary union" is often loosely used when first intention is really intended. Inflammation is defined as "the succession of changes which occurs in a living tissue when it is injured, etc." It is our duty as surgeons to limit these changes as far as possible, and to see that we introduce no foreign body into a wound which will cause an increase of the inflammatory process. All clean wounds ought to heal without the formation of pus. In pure air and healthy surroundings a wound will heal of itself.
The causes which prevent healing by first intention may be divided into two groups. Ist. The presence of micro-organisms; 2nd. The presence of any foreign body or constant irritant; to which a further class may be added, viz., the failure to keep the wounded surfaces at rest and in apposition It cannot be too forcibly insisted that in order for a wound to heal by first intention the wounded surfaces should be brought together in their natural state and maintained there without disturbance. Not only should the skin surfaces be brought into apposition but the deeper parts should be brought accurately together. Many surgeons, and good surgeons too, merely stitch the skin edges together and ignore the deeper parts That this is essential is well shewn in the operation for hare-lip and other plastic operations where early union is necessary. It is sufficient now to mention the mere fact that micro organisms (staphylococci and streptococci) prevent wounds healing. I do not intend to enter into the bacteriological side of the question, but content myself with merely stating that these bacteria produce by a process of fermentation irritating chemical compounds, which in their turn. cause an increase of inflammation and finally the formation of pus.
I pass on now to the second cause preventing healing-viz., the presence of any foreign body or any constant irritant. Those of you who have had your hands in a solution of carbolic
acid, in 20 or 1 in 40, for some time, know to your cost how they tingle and smart. How much more so must the delicate wounded tissues of the body be affected by it; what an increase of inflammation, with resulting exudation, there will be separating the wounded surfaces and preventing that apposition of the divided tissues which is so necessary in order to obtain a good result. Think what an amount of peritonitis will be set up, what exudation there will be from the application of a 1 in 20 carbolic solution to its delicate surface. The application of a strong antiseptic to a clean wound is, with many surgeons at the present time, one of the most potent causes of suppuration, and one which is to some extent going out of fashion. There is at the present time no antiseptic known which is efficient in destroying bacilli and their spores which is not an irritant. If to a large wounded surface a strong antiseptic be applied, in order to be safe it is necessary to use a drainage tube to drain off the excess of exudation. The drain must be in the most dependent part of the wound; perhaps it will be necessary to make a counter-incision. Thus there is either the open end of the wound or the counter-opening to be healed up, thereby adding to the length of time taken in getting your patient well. If there is reason to believe that a wound is infected, it should be thoroughly irrigated by some strong antiseptic. Of what nature and strength should it be? I think corrosive sublimate, I in 1000, is the most efficient and reliable. Care should be taken to dry the surface well, and to leave none of the lotion behind. After this it is necessary to use a drainage tube. Good results will often follow the use of properly prepared decalcified chicken bones; they may be used more especially in those cases which it is undesirable to dress for some time, as, for example, after excision of the knee joint. Rubber tubes. are practically unirritating, and accommodate themselves better to the dressings than glass tubes. I do not believe in leaving a rubber or any other kind of tube, except a chicken-bone one, longer than three days at the outside in a wound. If there is any more discharge to come out, it will generally follow in the
track left by the tube. The rule should be to get rid of the tube as soon as possible, as at the best it is only a necessary evil.
Bleeding -When bleeding is controlled by the use of a ligature of catgut or silk, it is essential to see that the material used is properly prepared. It is not uncommon to see a wound which is suppurating prove, on careful examination, to have been infected by a foul ligature. On the other side, we must not forget the fact that too often this suppuration is caused by the surgeon's or his assistant's fingers. An absorbable ligature is no doubt to be preferred to all other kinds. "A perfect ligature must be sufficiently strong not to break, inelastic, round, pliable, and easily tied into a knot; not too bulky; absorbable, and not too readily so; and lastly, but most important, capable of being rendered certainly aseptic." (Ligation in Continuity. Ballance and Edmunds.) In order to answer these requirements, we must use for ordinary purposes either silk or catgut. If the latter fulfils the requirement of being absolutely aseptic, it is much to be preferred over silk. Silk in the form of Chinese twist, which has been prepared by boiling in carbolic acid (1 in 20), will remain in a wound for many weeks almost unaltered. It is not uncommon to find these ligatures coming away at a considerable period after the operation, much to the annoyance of all parties concerned.
Compression is one of the most salutary agencies in the treatment of wounds and generally in the treatment of injuries. In the words of the late Mr. Sampson Gamgee, "Compression is not constriction, this strangles and destroys, that soothes and heals. Constriction is hard, violent, and painful; compression, elastic, gradual, and comforting; nothing more soothing to an injured part, nothing more powerfully conducive to the balance of innervation and circulation; to the prevention of sanguineous and inflammatory exudation, and to its removal when it has taken place than gentle, equable, elastic compression." It is advisable to apply a certain amount of pressure to all wounds when union by first intention is desired, even if there is no