OSTEOPLASTIC AMPUTATION OF THE ARM.
DR. MEYER presented a man, fifty-nine years old, who had been operated upon twice in another city for an epithelioma of the left forearm, which had recurred. When Dr. Meyer first saw him, there was an ulcerating neoplasm on the dorsal aspect of the forearm, and five weeks ago he removed the arm just above the elbow by Bier's osteoplastic method, which consists, essen tially, in covering the end of the amputated bone with a bone-flap, over which the skin-flaps are sutured. In this case Dr. Meyer removed a bone-flap from the humerus, sawing it convexly down ward and leaving it attached to the periosteum ; then, instead of dividing the humerus in a straight line, he sawed through it in a curved direction, so that the bone-flap fitted it snugly. A saw, which he had designed for these operations last summer, worked very well. The instrument was presented before the Society. Great difficulty was found in handling the periosteum on account of its extreme thinness and delicacy. The glands in the axilla were removed at a second sitting.
The wound healed without any drawback, and the man now has an excellent stump, which is entirely painless to pressure. An X-ray picture taken subsequent to the operation shows that the bone-flap has moved somewhat from its original position, but still seals the marrow-cavity.
DR. CHARLES L. GIBSON said that he had never had occasion to adopt the osteoplastic flap method of amputation described by Dr. Meyer, nor was he fully persuaded as to its advantages. He asked whether the method had ever been utilized to prevent the formation of a conical stump in young children. In such cases it might possibly be of real value ; although the usually accepted etiological factors would seem to preclude such a result.
DR. ROBERT H. M. DAWBARN said the Bier method of am putation did not entirely appeal to him. A good periosteal flap, if it lives, will accomplish the same results, namely, it will seal the lacunm of the severed bone and prevent pressure effects. Instead, in any amputation, of stripping back the periosteum with the usual blunt periosteal elevator, Dr. Dawbarn said he has for a long time used a strong sharp scalpel, scraping vigorously with it. By this method the periosteum is certain to live, however thin it may be. It does not have its circulation interfered with at all. The bone to be deprived of periosteum and the scalpel edge alone suffer. In a leg amputation, for instance, he makes his periosteal flap entirely from the front, and begins stripping it up at once, at the same level as the skin incision ; and not as a separate layer of periosteum alone.
DR. F. ICAMMERER said he did not quite agree with Dr. Daw barn. Bier's method of amputating the lower extremity gives a beautiful stump ; a better one, the speaker said, than he had been able to obtain by other methods. Whether the method was particularly indicated in amputations of the upper extremity he did not know, but in the lower extremity, where the stump should bear the weight of the body, Bier's modification has a distinct and decided advantage.
DR. DAWBARN said he could not ask for more satisfactory results than he has obtained by the method which he had de scribed, namely, scraping up the periosteum with a stout scalpel and then rounding the edge of the bone with a coarse file. With the periosteum utilized as a part of the flap, we get a strong stump upon which the weight of the body is borne without pain.
As regards the mooted question of using a periosteal flap, Dr. Dawbarn said it has one distinct advantage, and that is. if the patient should develop a mild form of sepsis during the first twenty-four or forty-eight hours, the periosteum will have prob ably adhered by then, and sealed the end of the bone; and thus there will be less danger of an ascending osteomyelitis.
DR. MEYER said that Bier had shown that the so-called pain ful stump is due to the fact that the marrow-cavity has not been sealed, unless, of course, neuromata are causing neuralgic at tacks. This fact, the speaker said, had induced him to resort to the osteoplastic method. Whether it is superior to the periosteal flap method advocated by Dr. Dawbarn could readily be demon strated by a practical test,—comparing two cases which have been treated by these different methods. Dr. Meyer said he was firmly convinced that with the osteoplastic method the resulting stump is entirely painless, while he was rather inclined to doubt that a periosteal flap would produce sufficient new bone to accom plish the same purpose. Bier has published a number of in stances where the bony flap was merely covered with skin, and still the stump was entirely painless, when the patients walked with it, uncovered, on a stone pavement. Dr. Meyer said he thought the osteoplastic method of amputating was preferable in all cases, excepting in senile or diabetic gangrene.
DR. CHARLES N. DOWD read a paper with the above title.
DR. DAWBARN said that during the past four or five years he has kept his needles immersed in a saturated solution of chemi cally pure washing soda in cold water, and believes he was the first to do this. This prevents the needles from rusting and does not dull them. The ordinary commercial washing soda should not be used for this purpose ; it contains some half a dozen salts beside the carbonate of sodium, and one of them is the chloride of sodium ; and such impure sodium carbonate quickly causes rusting. The following is a quotation from Montserrat's book on "Surgical Technics," published in 1898: "Soda solution for boiling instruments should be half an ounce to the pint. By its use, rust is altogether avoided and sharpness of knives and scis sors is unimpaired. The most resistant spores apparently cannot withstand a two-minute boiling, and the ordinary pyogenic micro organisms are killed in ten seconds." Now, the strength herein advocated is about five times what is customary with us, which is i per cent. of soda for boiling instruments. Perhaps, therefore, more soda would mean less dulling.
Dr. Dawbarn said that formerly he avoided boiling his knives for a longer period than a minute or so, lest the temper of the metal be injured. He had recently learned, however, from a metallurgical chemist, that the temper of steel could not be af fected by the temperature of boiling water ; and that it takes a much greater degree of heat to do this ; consequently, Dr. Daw barn now boils knives, scissors, and needles with the other instru ments.
DR. ALExANDER B. JOHNSON said that in sterilizing instru ments by boiling in soda solution, a sufficiently strong solution should be used, at least 5 per cent. or stronger. Even if the ordinary commercial soda carbonate is employed, the instruments will not rust if a very strong solution is made. In his office, Dr. Johnson said, he keeps his instruments immersed in a 5 per cent, soda solution for days, boiling them every time they have been used. Knives become dulled by boiling in soda solution. They preserve their edge better when laid flat upon a piece of gauze than when they are wrapped up in cotton, which must afterwards be pulled off.
Dr. Johnson said he sharpens his own knives, having taken lessons from a professional knife-sharpener. He uses a stone which is first made sterile by boiling, and employs lubrichondrin as a lubricant. As the knives are quite slippery when they are taken out of the soda solution, they should either be wiped on a piece of sterile gauze while they are hot or after they have been dipped into alcohol.
DR. GEORGE WOOLSEY said that for many years, at Bellevue Hospital, he has sterilized his knives in the flame of an alcohol lamp, which does not in any way injure the temper of the steel. Knives thus sterilized are decidedly sharper than those boiled in soda solution.