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of the joint often undergoes great contraction which if not counteracted by an appropriate mechanical support may result in a deformity difficult of correction short of operative interference. In cases of joint tuberculosis in which this treatment does not succeed in effecting a cure, it will prove to be the best possible preliminary treatment to a successful arthrectomy or atypical resection. Jodoform is absolutely useless in the treatment of tubercular affections complicated by suppuration. The antibacillary effect of iodoform in such cases only asserts itself after the pyogenic product and its causes have been eliminated by operative measures or chemical disinfectants or by a combination of these two antiseptic resources. In cases in which the iodoform treatment fails, or in which it is contraindicated, arthrectomy and atypical resection have been largely substituted for typical resection.
Malignant Tumors.-The imperfections of the art of surgery become very apparent in the treatment of far-advanced malignant disease of any part or organ. The essential cause of carcinoma and sarcoma remains to be discovered. The science of surgery must first divulge the true nature of tumors before we can expect a decided advance in their more successful treatment. The essential features of the modern treatment of malignant tumors may be summed up very briefly as follows: Operate early and thoroughly. The treatment of inoperable sarcoma by injections of the sterilized toxins of the streptococcus of erysipelas and the bacillus prodigiosus has not filled the expected results. In my paper on this subject read in the Surgical Section of this Association at the last meeting I gave the results of my experience with this treatment. An additional experience since that time only confirms my views expressed at that time concerning the utter lack of curative power of these toxins in the treatment of genuine cases of sarcoma. The microscope is no infallible means of diagnosis in differentiating between small round-celled sarcoma and some of the granulomata. The curative effect of a remedy can not be established unless an absolutely correct diagnosis can be made of the disease in the treatment of which it is employed. The discovery of some remedy, which by its local or general action would correct erratic cell growth and transform embryonic into mature cells might possibly change malignant into benign tumors, and by doing so deprive them of their malignant clinical tendencies. Experimental researches in this direction might possibly lead to a rational treatment of malignant tumors short of a resort to the knife or caustics. At the present time the surgeon's resources in the treatment of malignant tumors are
largely limited to an early and thorough use of the knife. Every surgeon deplores the fact that with the exception of carcinoma of the lip or of parts similarly exposed, the patients who apply to him for surgical treatment with few exceptions are suffering from malignant tumors which extend beyond the organ primarily affected and have given rise to regional dissemination, general metastasis or both. For instance, of the over 200 cases of carcinoma of the breast which have come under my own observation, I remember only one case in which, during the operation, the axillary glands were found unaffected, and in this case the columnar celled carcinoma, the size of a pea, had obstructed a duct, in consequence of which a retention cyst the size of a walnut developed, for which the patient applied for treatment. In cases of carcinoma of the uterus that come to me for examination and treatment, I find that only one out of every eight or ten cases is a proper case for a radical operation. In more than onehalf of my cases of carcinoma of the rectum, I refuse extirpation of the affected organ, and advise in its place an inguinal colostomy, because the disease has extended to the pelvic connective tissue, the retro-peritoneal lymphatic glands or adjacent organs. Of eighteen cases of pyloric carcinoma of the stomach subjected to operative treatment, I found the disease limited to the part primarily affected only in one case; in the remaining cases the disease had extended invariably to the lymphatic glands, and in some of them to the adjacent organs, liver, gall-bladder, pancreas, omentum and colon. It is the operative treatment of advanced cases of malignant disease that brings so little benefit to the patient and so much disappointment to the surgeon. Asepis and a greatly improved operative technique have done much to improve the results of operative treatment of malignant tumors, but they have not succeeded in doing away with well-recognized restrictions upon the art of surgery to which I now desire to call your attention. There is, perhaps, no other department in surgery which presents more diversity of opinions than the selection of cases of malignant tumors for operative treatment.
The conscientious surgeon looks as carefully for contraindications as for indications for radical operations. He is concerned more for the welfare of his patient than his own selfish interests. A prospective liberal fee has no influence in changing his decision. He makes a careful examination of his patient, the tumor and its environments, before he recommends an operation. He has learned from sad experience that aside from justifiable palliative operations for obstructive malignant affections, imperfect operations have proved as detrimental to his patients as to his repu
tation. He looks the ground over carefully before he decides to attempt a radical operation. The squeezing out of a fixed carcinomatous uterus between forci-pressure forceps is not likely to prolong the life of the patient or increase the reputation of the surgeon who ignores to such an extent the limits of the art of surgery. The removal of a carcinomatous breast without a thorough clearing out of the axillary space may increase, for the time being, the bank account of the operator, but it will surely prove a detriment to the patient. The partial or complete excision of the rectum for carcinoma complicated by regional infection is an operation attended by great immediate risk to life without a ray of hope of effecting a permanent cure. Such bold and reckless overstepping of the limits of the art of surgery is not calculated to increase the estimation of our profession in the eyes of the public or to receive the sanction of the conscientious, discriminating surgeon. The radical removal of a malignant tumor means more than the extirpation of the primary tumor; it means the removal of every malignant cell, whether in the immediate vicinity of the primary growth or in the same region. Evidences of distant metastasis furnish a positive contraindication to operative interference. Regional dissemination beyond the reach of complete removal of every vestige of tumor tissue, local and regional, without imminent risk to life, constitutes an equally forcible argument against a radical operation. Large surface defects made by extensive radical operations should always be covered by a plastic operation or by Thiersch's method of skin grafting. It has always been my aim to cover the wound with skin by either of these methods immediately after the extirpation of the tumor for the purpose of securing healing by the first intention, as I am satisfied that the slow process of healing of large surface defects by granulation, cicatrization and epidermization is conducive to an early local re
Surgery of the Three Great Cavities.--The systematic invasion of the three great cavities. of the body for the treatment of injury or disease is one of the great triumphs of modern founded dread for onerations which necessitated opening of any of the great serous cavities, knowing from experience their great susceptibility to septic infection. Recent experience has shown that any of these cavities can be opened for diagnostic or therapeutic purposes without much danger, provided the operation is performed under strict antiseptic precautions. The prevention of septic complications by asepsis has been the means of creating visceral surgery. The sense of safety in subjecting the different viscera to direct operative treatment which has taken
possession of the profession has enlarged to a wonderful extent the field of operative surgery, but it has carried at the same time the work of the ambitious, enthusiastic surgeon beyond the limits of his art. Many of the bold attempts upon the organs of the three great cavities are far beyond the legitimate restrictions established by the science of surgery. The mania for achieving new victories outside of the sphere of legitimate, rational surgery has neither brought lasting reputation to the adventurers nor benefit to suffering humanity. Many of the new operative procedures remind one more of sensationalism than the product of mature, deep surgical reasoning. The accounts of new operations that are being constantly devised have left operative surgery in a state of confusion. Works on operative surgery that left the press six months ago are obsolete or at least unsatisfactory to-day. The technique of nearly every operation is constantly undergoing changes by the addition of important or unessential modifications. Nearly every surgeon has a flaming desire to connect his name with an instrument of his invention, a new operation or a modification of an old one. A new operation is devised, a case is found upon which it is tried, and if the result is in any way favorable, an account of it is sure to find its way promptly into current medical literature. Many members of the medical profession are willing and ready imitators, who are always anxiously waiting for new discoveries and improvements, ever ready to apply them in their practice without questioning their utility or justifiability. This blind imitation of the practice of others has been the source of great harm to confiding patients and has exerted a powerful inhibitory effect on the true progress of surgery. This is an age of bold surgery. The surgeon who is careful in the selection of his cases, slow and painstaking in his work, need not look for recognition on the part of his students or colleagues; it is the man who lays the abdomen open by a single stroke of his knife, removes healthy ovaries and closes the incision and returns his patient to her room in seven minutes, who commands the attention of his audience and bears with self-confident dignity the proud distinction of being a bold and brilliant operator. In calling your attention to the limits of the art of surgery in the treatment of injuries and diseases of the organs contained in the three great cavities, time will only permit to point a few of the most flagrant transgressions of the established principles of surgery during the last few years.
Surgery of the Skull and Brain.-The use of the trephine in the treatment of fractures of the skull has had a varied experience since the time of Hippocrates. Trephining of the
skull for injuries is one of the oldest operations in surgery. From time to time strong arguments have been made against the indiscriminate operating for fractures of the skull. Stromeyer and his followers abandoned the operation of trephining, believing and claiming that the operation resulted in more harm than good to the patient. It is not difficult to conceive that at that time the conversion of a subcutaneous into an open fracture was attended by great risks from infection. The minimizing of the danger from infection by aseptic precautions again brought the trephine. into general use not only in the treatment of fractures of the skull, but also in the treatment of pathologic intracranial lesions of a nontraumatic origin. Many surgeons now advocate trephining in all fractures of the cranial vault, claiming that the operation would reduce to a minimum the dangers from remote complications such as obstinate headache, epilepsy and insanity. The question arises, is such a position in consonance with rational surgery? Every surgeon knows that such remote complications after fracture of the skull not subjected to trephining are rather the exception than the rule. It is evident that operative interference in such cases has been carried to extremes. Even under the protection of aseptic precautions, the transformation of a closed into an open fracture of the skull is attended by certain risks which no surgeon can afford to ignore and which must be taken into careful consideration before operative interference is determined upon. This advice applies with special force to the treatment of fractures of the skull in children, as in them spontaneous elevation of the depressed fragment or fragments is frequently observed during the process of repair. There is no rule in surgery without its exceptions, hence the advice to use the trephine in fractures of the skull with depression without regard to the age of the patient or the presence or absence of symptoms, lacks a moral as well as a scientific foundation.
(To be Continued.)
Simple Preparations for Aseptic Operations.
In The Corpuscle for February, 1896, Dr. A. J. Ochsner gives some simple directions. for preparing for aseptic operations under unfavorable circumstances. His methods are so simple that they deserve to be more widely known. Doubtless every surgeon of considerable experience has devised for himself very similar methods to be practiced in private houses where filth was an element to be contended with, and the less experienced operator will doubtless be interested in the study of his methods.
Dr. Ochsner says: Silk, silkworm-gut and horse-hair are enclosed in a few thick
nesses of gauze and placed in a closed vessel a tea-kettle or an ordinary tin dinner-pail with a lid will do. This is placed on the stove with enough water to thoroughly cover the material, and boiled for an hour. It is then preserved in a 5-per cent solution of carbolic acid in water. It becomes brittle after it is
a year old.
Cat-gut is prepared as follows: E violin strings and medium banjo strings are the most convenient sizes, and can be obtained at any music store. They are immersed in strong sulphuric ether in a tightly corked bottle for one week; in strong alcohol containing one grain of corrosive sublimate to the ounce for one week; then preserved in strong alcohol indefinitely. The alcohol should be changed once a month as it becomes weakened by absorbing moisture from the air, which diminishes its antiseptic power.
Any suturing material which has been taken from the preserving bottle and handled during an operation should be put through the original process of disinfection before it is used. Instruments are most readily disinfected by boiling in a solution of bicarbonate of soda, a tablespoonful to the quart of water, for half an hour. Knives should be made out of one piece of metal, so they can be disinfected by scrubbing thoroughly with strong alcohol. Needles are very common carriers of infection. By heating them in an alcohol flame and then dropping them quickly into strong alcohol, they can be disinfected without having their temper spoiled.
The hands should be kept habitually clean. It is an extremely bad habit to "puddle in pus" perpetually. Of course, one cannot always avoid touching pus, but one can easily dress suppurating wounds or open small abscesses without getting infectious matter upon the fingers.
The best means of making the hands aseptic is by the free use of soap, warm water, and scrubbing-brush, then washing with strong alcohol in order to dissolve any fatty material which may still adhere to the skin,* then cleaning the nails with a blunt pen-knife or nailcleaner, and then once more washing thoroughly with soap and warm water and scrubbing brush, in order to remove any loose material. The same method suffices for the preparation of the field of operation.
For the purpose of illustration, we will suppose that we are called to perform an operation for a strangulated hernia upon an exceedingly filthy patient in one of the dirtiest hovels in the country or in the city, with no one to assist us except a colleague who carries millions of microbes under his finger-nails. How shall we proceed to meet this emergency? We have in our surgical bag the necessary instruments
The alcohol has a marked germicidal power when applied to objects moistened with water.
-a razor, scalpels, dissecting-forceps, scissors, hemostatic forceps, a pair of long-handled sharp retractors, needles-these have been sterilized at home and enclosed in a clean towel or canvas bag. We also carry a nail-brush, soap, a pint of strong alcohol, two ounces of flexible collodion, a five-yard package of aseptic or antiseptic gauze, and a half pound of absorbent cotton, also half a dozen clean towels wrapped up in a towel and this again in a piece of strong wrapping-paper. We have the necessary suturing and ligature material, prepared in the manner already described. All of these things can be carried in a moderate-sized satchel.
Arriving at the house, we place a tea-kettle full of water on the stove to boil; then we place the kitchen or dining-room table near a window, spread a quilt over this, and place a pillow at one end. All of this is covered with an oilcloth, if one is at hand, and this with the cleanest sheet that can be obtained, or with one of our towels at the point where the operation is to be performed.
We next scrub our hands in the manner described, and treat the patient's abdomen and thighs in the same manner, carefully shaving the skin in. the vicinity of. the operation. For washing we use the water which has in the meantime been boiled.. A pad of absorbent cotton saturated with strong alcohol is placed over the area to be operated upon, and left in place until the beginning of the operation in order to dissolve the fatty material contained in the upper layers of the epidermis.
Four plates are now found and thoroughly scrubbed with soap and hot water and then with strong alcohol. On one of these plates. we place our instruments; on the second one, pieces of aseptic gauze to be used as sponges; on a third one, ligatures and sutures already threaded; on the fourth one, the dressings to be applied when the operation is completed. All of these preparations have occupied less than half an hour, and still they are as perfect as though the whole shanty had been turned upside down and every nook and corner had been disinfected.
The patient is now placed on the table and anææsthetized. The field of operation is once more scrubbed with water and then with alcohol, and surrounded with four clean towels. We wash our hands once more with alcohol and with boiled water, and ask our colleague to do the same. From this time until the operation is completed and the wound dressed, we touch nothing but our sterilized instruments, sponges, sutures and ligatures, and the wound. Should our colleague forget himself and touch any unsterilized substance, he must scrub again. The four plates with their aseptic contents are carefully placed where no one can reach them except the operator.
Our colleague is on the opposite side of the table and can assist us very materially by keeping the wound open with the long-handled retractor while we do everything ourselves. The operator is responsible for the wound and must see that no one else infects it. At the same time, he must not offend his colleague, because it will very materially enlarge his sphere of usefulness if he can gain both the good-will of his colleague and his admiration for skill and care.
After closing the wound it is well to seal it by placing strips of gauze two inches wide over the incision and fastening down the edges by applying an abundance of flexible collodion. A large absorbent-cotton dressing is applied over this and held in place with adhesive plaster and with a spica bandage in a manner which will prevent the patient and his or her friends from touching and thus infecting the wound.
Now the patient is ready to be returned to the filthy bed. Notwithstanding this and all other undesirable conditions, we can feel certain that the wound will heal primarily, and that the result of the operation will be perfectly satisfactory from the standpoint of aseptic surgery. The microbes in the bed, or on the ceiling or the floor, have not been disturbed in the least, but we are certain that no dirty hands or instruments have come in contact with the wound, and consequently it must be aseptic.-Medicine.
PRACTICE FOR SALE:-I offer for sale my practice in the county seat of one of the best counties in Iowa. Have been here for twelve years; am surgeon of the leading road entering the town; am medical examiner for six life insurance companies, etc. I simply require that my successor buy my office fixtures,-mostly new-worth $700. Purchaser must be reliable physician with few years' practice. Address "Z. V.," care RAILWAY SURGEON, Chicago.
Desiring to remove to the Pacific Coast, I offer my well-established practice of over 20 years to any physician who will purchase my real estate, situated in one of the most beautiful and thriving towns in Southern Michigan, and surrounded by a very rich farming country. The town is intersected by two important railroads, for one of which the subscriber is surgeon. The real estate consists of a fine brick house of eight rooms and two fine offices besides, attached to, and a part of, the residence. A fine well of the purest water, two cisterns, waterworks, etc. Fine garden filled with choice fruit in bearing, peaches, pears and apricots and small fruits, raspberries, currants, etc. Fine barn and other outbuildings, comparatively new and in the very best condition, all offered with the Address practice and goodwill at a very low figure for cash. 'MACK, Surgeon," care RAILWAY SURGEON, Monadnock Block Chicago, Ill.
By reason of failing health, physician wishes to dispose of real estate and practice. Practice amounts to nearly $4,000 per year. No charges except for real estate. Address WM. D. B. AINEY, Montrose, Pa.
Desiring to remove to a warmer climate, owing to poor health, I offer my well-established practice of 11 years to any physician who will purchase my real estate; situated in one of the most thriving towns in the Platte Valley, in Central Nebraska, on main line of Union Pacific R. R., on which road I am the assistant surgeon.
The real estate consists of 2 lots "on corner," on which there is a fine artistic "modern" frame house, 8 rooms; stable 20x30, wind mill. tower and 30-barrel tank: nice blue grass lawn, trees and fine garden (all new); and all offered with my 85,000 practice and good will. at a very low figure. A part cash, balance on time. A very thickly populated country. Address 'BOVINE," care RAILWAY SURGEON, Monadnock Block, Chicago, Ill
EYE SYMPTOMS OF BRAIN TUMOR.* BY JAMES MOORES BALL, M. D., OF ST. LOUIS.
The eye symptoms caused by brain tumor are numerous and include paralysis of the third, fourth or sixth nerves, uni or bilateral exophthalmus from pressure on the cavernous sinus, changes in the fundus oculi, diminution of visual acuity, concentric limitation of the visual field, and hemianopic contraction of the field of vision. It will be sufficient for our purpose to divide the topic into:
(1) Changes in the fundus oculi, and
(2) Derangement of sight.
At the outset, we must remember that there are a few cases of brain tumor in which there are no symptoms, ocular or other. These are rare cases in which a brain tumor grows slowly, without increase of intra-cranial pressure, and without irritation in the vicinity of the lesion.
CONTENTS OF THIS NUMBER.
Eye Symptoms of Brain Tumor-by JAMES MOORE, M. D.
An Address-by J. T. BROOKS, ESQ...... 149 Five Cases of Dislocation and Fracture of the Shoulder-by HOWARD J. WILLIAMS, A. M., M. D.....
Should We Have Pus in Railway Surgery -by LESTER KELLER, M. D..
Surgery at the Cross Roads..
NOTICES AND REVIEWS..
EXTRACTS AND ABSTRACTS:
On Some of the Limits of the Art of
Changes in the Spinal Cord After Amputation of Extremities...
Traumatic Neurasthenia..... 166 Roentgen Rays in Internal Medicine.... 166 The Fees of Medical Witnesses in Great Britain....
Officers of the N. A. R. S., 1896-7.
.F. J. LUTZ, St. Louis, Mo.
First Vice-President.. W. R. HAMILTON, Pittsburgh, Pa.
.C. D. WESCOTT, Chicago, Ill.
J.N.JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa.
I. CHANGES IN THE FUNDUS.
Of all the symptoms of brain tumor double optic neuritis is the most important in diagnostic value, because, (1) it is an objective sign, (2) it is present at some period in the great majority of cases, (3) the most common cause of double optic neuritis is brain tumor. While in the vast majority of cases of intracranial tumor the optic neuritis is bilateral, the degree of inflammation is rarely, if ever, the same on the two sides at the same time. Cases of one-sided optic neuritis in brain tumor do occur, however, and in these rare instances Dr. Hughlings Jackson believed that the disk on the side opposite to the brain lesion is the more frequently afflicted; but, as Bramwell has remarked, the number of these unilateral cases is entirely too small to permit us to draw definite conclusions.
*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May 1, 1896.