Andrews, Edmund

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REMOVAL OF NECROSED BONE BY IRRIGATIONSWITH WEAK HYDROCHLORIC ACID.Read in the Section on Surgery at the Thirty-Eighth AnnualMeeting of the American Medical Association, June,  88 .BY EDMUND ANDREWS, M.D., L.L.D.,PROFESSOR OF CLINICAL SURGERY IN CHICAGO MEDICAL COLLEGE; SUR¬GEON TO THE MERCY HOSPITAL, ETC.In almost all cases of necrosis the dead bone canbe removed without operation by the simple processof daily irrigation with diluted hydrochloric acid.This is especially important in spinal necrosis andcaries; but is also applicable to necrosis in otherparts of the body.Nearly all our authors are silent on this subject,for though Dupuytren and other older surgeons havespoken of brushing the cavity with strong sulphuricacid, they contemplated merely a caustic action tochange the condition of the diseased living parts,and not the dissolving out of the sequestrum. Oth¬ers, however, have proposed the solvent plan, butwithout gaining a serious hearing in surgical litera¬ture. Billroth, of Vienna, briefly alludes to the sub¬ject, but scouts the whole idea in the following strong,but ill considered language : "Chemical solution ofthe sequestrum is not to be thought of. If you weredaily to pour muriatic acid into the fistulous opening,it would affect the newly formed osseous tissue asmuch or more than it would the sequestrum, whichwould be very unfortunate, as it must replace thelatter. Hence, the mechanical removal of the se¬questrum is the only thing left. "In opposition to this high authority, I wish to stateas the result of actual experiments that, by a littleingenuity in the management of the irrigation, mostsequestra can be dissolved out; and if the solutionbe properly prepared it does not affect the livingbone, nor act upon the soft parts, except as a goodantiseptic ; neither does it cause any pain. In fact,by the addition of cocaine and morphine, it canbe made anodyne.So far as my investigations have yet gone, I findno solvent equal to a weak solution of hydrochloricacid. Sulphuric acid seems to limit its own actionby precipitating the insoluble calcium sulphate in theHaversian canals, and blocking the further access ofthe acid. Thin laminas of bone will lie in a dilutionof this acid for days with only a slight degree of de-calcification. Chromic acid is also inefficient, andstains the linen on which it happens to drip. Nitricacid decalcifies the bone rapidly, but I have not yetfinished the experiments for ascertaining its practicalusefulness.The proper strength of the hydrochloric solutionvaries with the tolerance of the patient, the objectbeing to keep it just below the painful point. Thiswill usually be found between one fourth and one-sixteenth of the strength of the officinal acidum hy-drochloricum dilutum, although it can be employedsomewhat stronger by the addition of cocaine andmorphine. The tolerance seems to be determinedlargely by the presence or absence of a good coat ofgranulations upon the living tissues. Directly afteran operation, the cut extremities of the nerves arepainful on the application of any acid, however weak;but after a few days, when covered by granulations,they bear comparatively strong solutions without dif¬ficulty.The length of time required will vary with thestrength of the solution, and the constancy of theirrigation. The following experiments were' madeoutside the body to get an idea of the rapidity of theaction of the acid. Fragments of actual sequestrawhich had been removed by operation were placedin bottles of acid of various strengths, and the timerequired for complete décalcification noted.TABLE SHOWING THE TIME REQUIRED FOR DECALCI¬FYING SEQUESTRA IN WEAK HYDROCHLORIC ACID,SOLUTIONS OUTSIDE THE BODY.mStrength of Solution. Dimensions of Sequestra.Time re-quir'd forDécalci¬fication. 1-162 I-IO3 1-10the strength of officinaldilute hydrochl. acid,do% -1adodododododododododododododododododododo4% cm. by 1 cm. by 3 mm.2% cm. by 14 mm. by 4 mm.very hard seq. from tibia.4*4 cm by 28 mm. by 20 mmVery spongy tuberculous trochanter.9 cm. by 32 mm. by 5 mm.mm. by 9 mm. by 4 mm.~/'¿ cm., very hard sequestr.5% cm. by 13 mm. by 1 cm.8 cm. long, whole thickness ofshaft of femur, diam. 2 cm.32 mm. by 13 mm. by 3 mm.64 mm. by 38 mm.Block of cancellated bone 16mm. diameter.Sundry small splinters.142 hoursT20 "24 "117120I 2.3I0296I0254Average time of solution, about 95 hours.These experiments show that old sequestra, whichhave lain long in putrid suppurating cavities, are notdeprived of their gelatiniferous animal basis. Inevery instance the decalcified animal matter remainedin full form, but, lying enclosed in granulations insidethe body, it is rapidly absorbed, exactly like the de¬calcified bone drainage-tubes when left in position..The method of effecting the irrigation is impor¬tant. If one simply pours a little acid into the fist¬ula, as Billroth evidently understood the plan to be,he will accomplish nothing. It is necessary to irri¬gate the whole sequestrum either frequently or con¬tinuously. If possible, one should have two open¬ings, so situated that the fluid may run into one, andthence along the whole length of the sequestrum andout at the other. When necessary, new openingsmust be made in suitable positions, and left pervious-by drainage-iubes. The next step is to fill a half-gallon fountain syringe with the acid solution, and',hanging it by the bedside, to let it run very slowly-through the diseased channel. If a "through andthrough" irrigation is not possible, we can often ob>-tain the same result by taking a small flexible cathe¬ter, especially of the kind having a curve near thetip, and called by the French sonde coudée. By alittle careful management this can often be carriedto the farthest corner of the cavity, and by attachingit to the fountain syringe it will deliver the fluidbeyond the sequestrum, and make it flow over it onits return outside the catheter. Whenever the seDownloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User  on 06/12/2015questrum can be thoroughly irrigated, its décalcifica¬tion is a matter of absolute certainty within a mod¬erate number of days. The hydrochloric solution isa perfect antiseptic of itself, and during its use noother is required.After the solution is completed there remains thegelatiniferous animal matter of the bone, which isidentical with the material of decalcified bone drain¬age-tubes, and like them is rapidly absorbed in anti-septicized cavities. I have commenced to investi¬gate the possibility of dissolving it out at once withpepsin, but have not finished that part of the subject.Billroth raises the objection that the acid will dis¬solve the living bone as rapidly as the dead, or evenmore so. So plain a point as this of course cannotfail to rise in everyone's mind, but I am sure thatgreat man spoke from mere theory, and not from ob¬servation or experience. Whatever one might fearin this respect, I find as a matter of experience thatthe weak solutions which I have used do not decal¬cify living bone. Apparently the granulations cover¬ing the living ¡osseous tissue protect it from contactwith the acid, except in spots denuded by ulcération,and even there the circulation of the alkaline bloodin the Haversian canals, and the constant exudation,of alkaline serum from all raw living surfaces, boneincluded, protect it from the action of such weak aciddilutions as I have hitherto used. At any rate, it isa positive fact that the sequestra are dissolved, andthe cavity heals, without any perceptible injury tothe living bone.No. 6 Sixteenth St., Chicago.THE INFLUENCE OF THE DURA MATER IN CAUSINGPAIN, REFLEX AND OTHER PHENOMENA, WHENINJURED OR DISEASED.Read before the Section of Practice of Medicine, Materia Med¬ica and Physiology, at the Thirty-Eighth AnnualMeeting of the American Medical Associa¬tion, June,  88 .BY W. B. FLETCHER, M. D.,SUPERINTENDENT OF THE INDIANA HOSPITAL FOR THE INSANE,.The dura mater, the mother membrane of thebody according to the ancients, is a much neglectedand most important organ, for organ it must be re¬garded in the human anatomy. To the averagestudent and general practitioner the dura is but atough inelastic, fibrous membrane of unusual thick¬ness, which plays the part of a scaffolding and sup¬port for the brain.A careful study of this part, however, shows thatit is not only the superstructure upon and in whichthe brain is built, but that it is an internal perios¬teum to the skull—a complex channel for the greatvenous currents through which course, not only thevenous blood from the brain, but much from outsidethe skull,—-likewise a soft, serous cover for the mem¬branes of the convolutions and sheath for the cranialnerves. It has, furthermore, a small arterial supply,which is gathered from branches of both the exter-nal and internal carotids, but is most peculiar inbeing a most sensitive organ with a greater combi¬nation of sensory motor and vasa motor reflexesthan any other part of the body. The nerves of thedura come from the Casserian ganglion direct, andfrom the three great branches of the fifth pair. Withthese are combined branches of the facial and anumber of sympathetic ganglia relating it to thespinal cord.Van Helmont and others of his school regardedthe dura mater as the seat of sensation. MarshallHall (1841) was the first to announce that its irrita¬tion caused reflex actions. In 1872, Dr. John C.Dalton showed that convulsions or contractions fol¬lowed irritation of the dura upon the same side.These observations have been confirmed by a largenumber of experimentalists, more particularly byDuret, who injected iodine and other chemical stim¬ulants between the cranium and the dura and pro¬duced fractuie of the skull at various points.All these experiments were upon lower animals—presumably dogs. That the same condition existsin an exaggerated degree when the dura in the hu¬man subject is either diseased or injured, is recog¬nized by Duret and others. This author, who haswritten most exhaustively upon the subject, inti¬mates that so much confusion may arise betweenreflected sense and motion arising from irritation ofthe dura, as to puzzle the advocates of cerebrallocalization. He says: "Certain opponents (of cer¬ebral localization) have adduced these facts to provethat the localized movements, which are determinedby the application of the electrodes on the pre¬tended motor centers of the cortex, were in realitydue to irritation of these.sensory conductors."I herewith submit a sketch of a few cases whichillustrate to some extent the function of the dura asan organ of sensation and reflected motor contrac¬tions, first premising my remarks by calling atten¬tion to the anatomical points of the scalp and cra¬nium. The scalp is not normally acutely sensitive;its cutaneous sensibility is less than other parts ofthe skin, notwithstanding its sensory nerves are fromexternal branches of the fifth pair of nerves. Theskull-cap, when examined shows many openings,through which emissary veins pass from without in¬ward, as can be plainly seen upon the dura by thenumerous spots where these veins have been brokenin tearing the fresh calvarium from the brain ; throughthese openings in the skull frequently, but perhapsin abnormal conditions the extremities of the duraibranches pass; it is from this, we have occasionallythose dreadfully sensitive tumors of the scalp, or themore dreadful tumors of the dura, which Abercrom-bie, Louis, Wenzel Brothers, Cruveilhier and others,describe as commencing in the dura and makingtheir way through the skull, lifting the scalp andfinally breaking into fungoid masses of the mostdisgusting and painful kind upon the surface. Theseexternal durai nerves, if I may so name them, alsoaccount for the excessively sensitive spots whichsome persons have upon the scalp, when they mustavoid the pressure of even a brush or comb, andarrange the hat for the particular spot. I doubtDownloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User  on 06/12/2015

REMOVAL OF NECROSED BONE BY IRRIGATIONS WITH WEAK HYDROCHLORIC ACID.: Read in the Section on Surgery at the Thirty-Eighth Annual Meeting of the American Medical Association, June, 1887.

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REMOVAL OF NECROSED BONE BY IRRIGATIONS WITH WEAK HYDROCHLORIC ACID.: Read in the Section on Surgery at the Thirty-Eighth Annual Meeting of the American Medical Association, June, 1887.

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