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antiseptic or aseptic precautions, healing by first intention is not obtained in one case out of ten-yes, we can almost say not one in twenty cases." Can this be so? Hardly. Particularly must we object to the assertion in regard to the amputation of lower extremities. Our experience has not been such and others with whom we have talked confirm us in our opinion. We should have as good results here as in any case where traumatism is the cause of amputation. Were I to have pus in a wound of that kind I would think I was to blame.
When I speak of having pus in railway surgery I mean in all cases, large and small. I fear that we, as a body, devote too much time to the consideration of the severer cases and not enough to the more trivial ones. Our reports of an operation after fracture of the spine are very complete. Being very careful of our asepsis, we would have been much chagrined to have had pus; in fact, it would have been disastrous to our case. We are prone to dismiss a brakeman with a mashed finger with much less ceremony. I once heard a most eminent surgeon deliver a very fine lecture on the use of antiseptics in surgery, and within a month saw him apply a dressing to a mashed finger which I should have been ashamed to have seen coming from my office. Our crying evil, as surgeons, and particularly as railway surgeons, has been the lack of attention to little things. A mashed finger may be a small thing in the surgeon's estimation, but it is a large one to the man who owns it.
We must not depend on asepsis alone; we must use antiseptics if we would succeed. There are many of them, and good ones, too, and it matters not so much which one we use as how we use it. We must not undo the good work of our antiseptic by using a suture not properly prepared. We might get our operating field in good condition by using soap and water. Surely, these are important, but how much more certain of good results are we when they are supplemented with some efficient antiseptic. The half-read and illy understood writings of the great Tait have caused more suffering than he has ever saved by his wonderful skill. I do not know of a general practitioner who attemps to do surgery and makes failures, because he is not careful of his asepsis and ignores his antiseptics (and notice, I associate the two conditions), but quotes Lawson
Tait and excuses his failures because he has followed "the very best." I have no idea that Tait ever intended to be so interpreted. He, no doubt, would use antiseptics if he were doing railway surgery away from his hospital and under the conditions with which most of us have to contend. The avenues for the infection of a wound are so many that it keeps us constantly on the lookout to keep from spoiling the work well begun and almost perfect. I have seen a surgeon, very elaborate in all his details in preparing for an operation, careful of his hands and all, and then, after the operation was carefully done, make one last wipe across the stump with the cleaning-up towel.
I have seen a man, who thought he was careful, put his silk ligatures in a carbolic solution for fifteen minutes and think they were sterile. This same man often complained that he had a little "stitch hole" suppuration.
Often the meddlesomeness of a patient or his friends spoils our good work. It is next to impossible to make a man believe you are not neglecting him if you put up a small injury and tell him to report at your office in a week. The chances are, if he has had no experience with an antiseptic surgeon, that he or his friends will find some excuse for opening it, if only for a peep. To sum up, if we have a correct idea of the principles underlying antiseptic surgery, will follow them out in the minutest detail and will control the curiosity of the patient and his friends, we will have no occasion to think pus is any more necessary in railway surgery than anywhere else—and that is very seldom.
You need not doubt; you are no doctor.
Science is knowledge and art is skill; or, more fully, science is organized knowledge, while art is educated skill. The same ideas are expressed by the terms theory" and "practice." This is the fundamental distinction. Here art is actual skill, practice or doing, but art has a second meaning; it signifies, also, a body of rules, or precepts, that guide skill, practice or doing. This is the sense of art in the statement that science teaches us to know and art to do, or in the statement that the two differ, as the indicative mode differs from the imperative, the first making declarations, the second issuing commands. Hinsdale.
the doctor's snug little office, there was a knock at the door and the swarthy section boss entered, closely followed by a man with his left hand bound with a bandanna, from the de
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falling. We smiled inwardly and said to ourselves: "Now is our opportunity to see some cross roads surgery." After a few words of cordial and sympathetic greeting, the patient was asked to be seated and the doctor went quietly and quickly about his preparations for the care of the wound, first uncovering the hand to learn the extent of the injury. The hand had been caught in the hasty handling of a hand-car and there was an ugly, lacerated and contused wound of the palm, involving tendons, vessels and nerves of the ring and little fingers. A rubber sheet was produced and spread out upon the table, which served as operating table and gynecological chair in this simple office; a clean hand basin was placed upon the table, some crystals of washing soda thrown into it, and the basin filled with boiling water. As soon as the solution had sufficiently cooled, the injured hand was immersed and allowed to soak until other preparations were completed. A scalpel, a pair of scissors, two or three needles of different size, some tissue forceps and two pairs of snap-forceps were placed in a pan upon the oil stove, covered with hot water containing more of the sodium carbonate and boiled for several minutes. We had noticed that the doctor's hands were clean, that the finger nails were closely trimmed, and that the subungual spaces gave evidence of frequent attention; also that the hands were soft and not as brown as the doctor's face and neck, eloquent testimony that he knew the value of gloves. When everything else was in apparent readiness, he took from a jar of 5 per cent., a stiff brush, carefully scrubbed his hands and covered them with alcohol, and the work began.
W. B. OUTTEN, M. D.,
C. D. WESCOTT, M. D.,
HUGH M. WILSON,
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SURGERY AT THE CROSS ROADS.
Apropos of the statement that aseptic surgery can be done anywhere where hot water can be obtained, we have a little story to tell.
Not very long ago, during one of our outing trips, we visited an old friend and classmate whose lot has been cast in the country, or almost in the country, at a little railroad town, a center from which the farmers ship their produce, and in the company of this genial country doctor we spent some very pleasant hours. Born and bred among the people whom he serves, he began the study of medicine about fifteen years ago with a common school education and the robust health of a farmer's son as his capital. College life in the metropolis failed to spoil him or to make him discontented with the home which he had left, and he determined to return to his people and to do better work, if it was possible, for those whom he knew and who had always been his friends. That he has succeeded was abundantly demonstrated during our short stay with him by his large following of trusting friends, the good work which we saw him do and by glancing over the carefully selected books in his library. While we sat chatting early one morning in
The patient's hand was carefully scrubbed, not with soap, but with the soda solution in which the instruments had been boiled. These were now placed upon a clean towel and spread upon the table. After the hand had been soaked a few minutes in a solution of lysol the edges of the wound were carefully trimmed, partially detached masses of tissue were dissected out, bleeding was stopped by pressure and the occasional use of snaps, and the deep
proportions of the wound more carefully examined. It was found that two tendons had been drawn from their sheaths and one partially, another completely torn across. These were carefully adjusted, the torn ends approximated with fine catgut sutures, the catgut having been sterilized by the doctor himself, as he afterward told us, by boiling in alcohol. The wound was then adjusted with greatest nicety with silkworm gut sutures, the hand dressed with borated absorbent gauze, and placed upon a Palmer splint.
The next day we drove together into the country in answer to an ordinary call, the messenger simply saying that Farmer Hicks was ill. Upon arriving we found a case of welldeveloped appendicitis, which evidently called for an early operation. When our friend had so pronounced and explained in simple terms. the nature of the trouble, the patient simply replied: "All right, Doc, you know best and we know you'll do what's right."
Immediately the same simple preparations were made that we had witnessed in the office, save that a number of towels and soft clothes were sterilized by boiling, to be used about the field of operation and for sponges.
When the patient had received a bath, all other preparations had been made and a clean bed prepared for his reception after the operation. The doctor proceeded with the chloroform himself, using an Esmarch inhaler and the drop method, and while the patient was gently yielding to the influence, he quietly instructed one of the good angels of the neighborhood who had been sent for in the hour of need, how to continue its use when he was otherwise engaged. When the patient was asleep the good doctor again sterilized his hands and the field of operation, by first scrubbing with soap and hot water, then with pure hot water, and finally with alcohol. The incision was quickly made, the bleeding vessels twisted, the peritoneum opened, the inflamed and swollen, almost necrotic, appendix brought to the surface, cut off, the stump invaginated and sutured, and the abdominal wound closed with a small gauze drain.
These two operations were performed with as true a regard for asepsis, as if they had been done in the tiled operating room of the most modern hospital and with as perfect results, as subsequent events proved, yet how simple the
outfit and the preparation! But the secret of such work lies in the man and the elements of such success are a knowledge of the latest facts of our science and the genius and courage to apply them.
Mississippi Valley Medical Association-Meeting at St. Paul, Minn.
The following letter has been received from the secretary:
St. Louis, July 30, 1896.
My Dear Doctor:
I desire to announce to you that the date of the meeting of the Mississippi Valley Medical Association has been changed to September 15-16-17-18, in order to permit the members and their families to take the opportunity accorded by this change to make a pleasant tour through the Yellowstone Park, so justly celebrated as the Wonderland of America.
Prominent resident members of our association in St. Paul and Minneapolis are formulating plans for the special Yellowstone Park excursion trip, to leave on the evening of September 18, arriving in Mammoth Hot Springs in the Yellowstone Park about noon on the following Sunday, and devoting the following five days to the wonders of this remarkable region, returning to St. Paul, Sunday, September 27.
The cost of the trip, including all expenses west of St. Paul, will be announced in due season, but we are authorized to say that the figure will be a very favorable one, and we simply wish at this time to make the preliminary announcement of this most enjoyable feature of the St. Paul meeting, so as to give members the opportunity of making their plans in advance to join the party. It is desirable that there be a party of 100 or more, in order to obtain the benefit of the special train service in both directions.
Extracts and Abstracts.
On Some of the Limits of the Art of Surgery.
Delivered at the Forty-Seventh Annual Meeting of the American
The art of surgery has its well-founded limits in the treatment of fractures of the skull. In my opinion, operative interference is absolutely indicated in fractures of the cranial vault under the following circumstances: 1. All open fractures, including gunshot and punctured fractures. 2. Depressed fractures attended by well defined symptoms caused either by the depression or intracranial complications. 3. Rupture of the middle meningeal artery with or without fracture of the skull. The use of the chisel or trephine is superfluous and often harmful in the treatment of subcutaneous fractures of the vault of the skull with or without depression, more especially in the case of children. The operation of trephining in the prevention of remote complications of fracture of the skull is often powerless, owing to the existence of visceral lesions which it can neither remove nor render harmless. The indiscriminate use of the chisel and the trephine in the hands of the inexperienced practitioner is fraught with danger and should not be encouraged by teachers and expert surgeons. Such teachings and practice are in conflict with the correct principles which should govern the true art of surgery. Brain surgery is of recent origin. It is in this department of the operative work of the surgeon that art has gone far in advance of the science of sur gery. Cerebral localization and aseptic surgery have made it possible to treat a few intracranial lesions successfully by direct operative interference. Cerebral localization in its infancy and the minutest aseptic precautions do not absolutely protect against infection. A few years ago the columns of the medical press brought glowing accounts of the removal of brain tumors. Patients were exhibited at the meetings of different medical societies with enormous cranial defects and ghastly depressions marking the place from whence a large glioma had been removed successfully. Such cases aroused the most intense attention and interest at the time, but where are they now? Subsequent reports failed to appear, and an ominous silence remains regarding their ultimate fate. Many of the cases of tumor of the brain operated up
on who never recovered from the immediate effects of the operation were never reported, and those who were fortunate enough to survive the fearful ordeal, after a longer or shorter interval joined the silent majority. One of the well defined limits of the art of surgery is the operative treatment of malignant tumors of the brain. Tapping and drainage of the lateral ventricles as taught and practiced by Dr. W. W. Keen may and undoubtedly will become in the future a useful and legitimate surgical resource in the treatment of inflammatory affections of that part of the brain, but so far it has not yielded encouraging results. When Lannelongue devised linear craniotomy for the liberation of the undeveloped, imprisoned brain in the skull of infantile idiots, his doctrine was received with open arms by many surgeons who occupy the front rank in the profession. The lay and medical press vied with each other in bringing before the general and medical public the wonderful results following the use of the trephine, chisel and rongeur forceps in opening the skulls of such unfortunate children. Many of these little innocents, of course, succumbed to the immediate effects of the operation, but this did not subdue the ardor of the surgeon, as he had been instrumental in transferring an object of pity to that happy home where microcephalus is unknown, and had relieved the family of a troublesome trust. Where are the cases that have been permanently benefited by the operation? Ask Lannelongue whether his hopes have been realized. I am free to confess that I have never been able to muster my courage to attack the skull of a poor, innocent and yet happy microcephic child, because I have always regarded the operation as useless in promoting brain development. The responsibility of the surgeon is not limited by the defective mental development of the child nor the importunity of the parents in demanding the operation at all hazards. The surgeon should stand guardian over such a charge, mindful of the limits of the art of surgery. Have we a right to estimate human happiness? The driveling idiot has many enjoyments and pleasures that you and I know nothing about. His responsibilities to God and man are limited, and his existence on earth is a long, happy dream, which only ceases when the soul leaves the imperfect body, and returns from whence it came, where mental distinction is unknown. The operative removal of inflammatory products from the cranial cavity and the brain has yielded the most satisfactory results, and constitutes one of the most important achievements of modern surgery. This part of cerebral surgery will reach perfection with the progress of cerebral localization, and should be encouraged and cultivated by all
who are desirous of extending the present limits of the art of surgery.
Surgery of the Chest.-Modern surgery has done much toward the alleviation and cure of injuries and diseases of the organs of the chest, but it is here also that we are confronted by well defined limitations of the art of surgery. The successful treatment of hydrothorax and empyema of the pleural cavity is the result of a better knowledge of their etiology and pathology, and an improved operative technique under strict aseptic precautions. Tapping of the chest for tubercular hydrops, followed by iodoform glycerin injection has done more for this class of patients than counter irritation and the internal administration of digitalis, squills, acetate and iodide of potassium. Free incision of the empyemic pleural cavity after resection of one or more ribs, followed by efficient tubular drainage, has become an established practice by almost universal consent. The treatment of chronic empyema with thickened pleura and collapsed adherent lung by Estlander's multiple rib resection or Schede's thoracoplastic operation has yielded brilliant results. The treatment of abscess of the lung by rib resection, free incision with the knife point of the Paquelia cautery and tubular drainage, has been the means of saving many a precious life, which, without the aid of the surgeon, would have been doomed to a premature death. With few exceptions this is about all that has been accomplished by the surgery of the chest. It is true that a few surgeons have been fortunate enough to cope successfully with a few affections of the heart and its serious investment, the pericardium. Tapping of the pericardium for serious effusion has become one of the established operations in surgery. A very few cases of pyopericardium have been brought to a successful termination by free. incision and drainage. We are familiar with isolated cases in which bold surgeons exposed the heart by a free incision for the removal of a foreign body, or sutured a visceral wound, and their effort was crowned by success, but, on the whole, we are painfully conscious of the fact that the art of surgery has done very little toward the successful treatment of injuries and diseases of this organ. Many have been the efforts of surgeons to supplant the physician in the treatment of pulmonary tuberculosis, the results of such efforts are familiar to you all. In the very nature of things, such trespassing upon the legitimate field of the physician has been fol lowed, without exception, by an ignominious failure. It is unfortunate, but true, that the surgical treatment of pulmonary tuberculosis by direct surgical intervention is beyond the legitimate limits of the art of surgery. Surgery has done very little during the last two
decades toward a betterment of the treatment of penetrating stab and gunshot wounds of the chest. The careful surgeon knows that the hermetic sealing under aseptic precautions of the wound of entrance and exit, if such exists, affords the greatest degree of safety in arresting hemorrhage and in preventing septic complications. Free incision of the cavity of the chest with a view of arresting hemorrhage by ligature, or tamponade from any of the organs which it contains is attended by such great immediate risks to life that the possible benefits to be derived from it are more than overbalanced by the immediate dangers which attend such an aggressive course of treatment. The removal of malignant tumors of any of the organs of the chest is beyond the present limits of the art of surgery.
Surgery of the Abdomen.-For reasons that we do not require an explanation here, the abdominal cavity was largely a terra incognita to the surgeon of less than half a century ago. To-day it is the favorite battle-ground of the average surgeon, and the select field of the so-called abdominal surgeon.
The bold surgery of to-day upon the organs of the abdominal cavity is largely due to the comparative safety with which the peritoneal cavity can be invaded under proper aseptic precautions. This new field for the display of surgical talent and ingenuity has been diligently cultivated in a legitimate way by the honest progressive surgeon, but it has also been made the playground of unscientific sensational surgery by men who are ignorant of the legitimate limits of the art of surgery. The simple fact that any of the abdominal organs, in part or in whole, can be removed successfully without much danger to life does not establish the legitimacy of the surgical procedure. Billroth, one of the greatest and certainly one of the most honest surgeons of this age, did not realize the expectations he entertained in regard to the benefits to be derived from direct surgical intervention in cases of carcinoma of the stomach, justifying surgical interference. Notwithstanding the wonderful improvements in the technique of operations upon the stomach, partial gastrectomy and pylorectomy have yielded anything but encouraging results. In nearly 50 per cent. the patients subjected to radical treatment for malignant disease of the stomach succumbed to the immediate effects of the operation. In all of the cases which survived the operative ordeal, the patients succumbed to a relapse in from a few months to several years. I have opened the abdominal cavity for the surgical treatment of malignant disease of the stomach, nineteen times, and only in one case did I find the disease limited to the organ primarily affected, and in this case