« ForrigeFortsæt »
covery followed with a good stump. Dr. Hamel operated.
FRACTURE OF THE SKULL THROUGH THE ORBITENUCLEATION OF THE EYE.
Wm. M., section laborer for the Missouri Pacific Railway, was injured by falling on a pick, the sharp point passing through the orbit up into the brain. He entered the hospital July 4, 1895. On examination nothing could be seen but a slight wound of the left lower eye-lid and ocular conjunctiva; this was followed the next day by hemorrhage into upper lid with oozing of blood. The patient being unconscious, no history could be obtained and the diagnosis of fracture of the supra-orbital plate was made. The patient was placed under the influence of chloroform and on examination a probe was found to pass between ocular conjunctiva and the eye-ball up into the brain. It was decided to remove the eye-ball in order to get free drainage. The contents of the orbit was then removed by Dr. J. H. Thompson, after which Dr. King made a further examination and found that the inner half of the supra-orbital plate was fractured and pushed up into the brain for fully an inch. The bones were then removed, bringing away a portion of cerebral substance. A drainage tube was inserted in the brain and the orbit packed with gauze. The wound was redressed upon the third day, at which time another small piece of bone was removed. The discharge was persistent and quite free for some eight or ten days. The patient's mind gradually cleared up and he was discharged four months after the injury, seemingly well and in good mental condition.
A CASE OF SECONDARY HEMORRHAGE.
I. B., a brakeman for the Missouri Pacific Railway, aged 32, was admitted to the hospital February 22, 1895. His left leg was crushed up to the knee joint. An amputation of the thigh was performed at the junction of the lower and middle thirds. The patient did well until eight days later, when secondary hemorrhage occured; the flaps were opened up but no particular point could be discovered from which the hemorrhage came. The arteries ligated showed that they were intact. Blood seemingly oozed from bone and muscle. Each muscle was ligated separately with a circular ligature passed around the entire mass. The flaps were
closed without drainage, and pressure made with a gauze compress. This stopped the hemorrhage, but suppuration followed and the parts healed by granulation. Dr. Rule amputated.
Traumatic Rupture of the Biceps Muscle of the
At a recent meeting of the Philadelphia Academy of Surgery, Dr. John B. Roberts presented a man, twenty-eight years of age, who was admitted to the Methodist Hospital on December 11, 1895, with a longitudinal wound six inches long in the middle line of the front of the left arm just above the bend of the elbow. The limb had been injured by being caught between the bumpers of two railroad cars. The ragged end of a torn muscle, evidently the biceps, was seen through the wound, and the bicipital fascia was laid bare. Careful examination showed that the internal condyle of the humerus had been split off by an oblique line of fracture running into the joint. It was evident that the injury had torn nearly the whole thickness of the biceps muscle, and that the muscular fibers so torn had retracted into the upper part of the arm. The incision was extended upward for six inches to uncover the retracted fibers. The small portion of muscle untorn, which was about as thick as a little finger, was found to be the central portion of the biceps. The main mass of the muscle was drawn downward and sutured to its tendon with catgut. These sutures were applied very much as in the ordinary method of teno-suture. A counter opening was made on the back of the arm and a drainage-tube inserted because of the probable septic character of the wound, though sterilization was attempted. The wound was then sutured and the limb placed with the elbow flexed and the hand supinated so as to relax the biceps.
The next day it was necessary to remove some of the stitches because of the swelling due to sepsis. A plaster of Paris splint was applied to the back and internal surface of the arm in such a way as to keep the hand and arm in the position just described.
The patient has done well, the wound at the present time, January 17, being a superficial ulcer, and the patient having considerable action at the elbow-joint.-Annals of Surgery.
A Philadelphia paper once announced the arrival of the Siamese twins in that city in the following manner: One of the Siamese twins arrived here on Monday last, accompanied by his brother."
THE RAILWAY SURGEON will be published bi-weekly on every alternate Tuesday.
Surgeons and others are requested to send items, articles and notes of news which will be of interest to railway surgeons. All communications will receive prompt and respectful attention.
Address all communications intended for the editorial department to the Editor, at 1453 Monadnock Block, Chicago.
Address all communications intended for the business department to THE RAILWAY SURGEON, Monadnock Block, Chicago.
"SINS OF OMISSION."
Under the title of "Some Surgical Sins of Omission," Dr. Charles B. Nancrede, professor of surgery in the University of Michigan, than whom there is no more careful and painstaking surgeon, has written a most excellent paper, which was read before a recent meeting of the Detroit Medical and Library Association, and published in the Physician and Surgeon for August, 1896.
His paper was inspired by the thought that interest in head injuries, especially so far as the general practitioner is concerned, seems to have died out, and he quotes Nussbaum, who says truly that the fate of a wounded man is in the hands of the surgeon who first examines him. It is the family doctor who is naturally first consulted about injuries to the head and other parts of the body, as well as about diseases of the eye, womb or liver, and what a wise and good man he should be! He should be wise enough to recognize all known ailments, and true enough to himself, his profession and his patient to decline the care of cases which he is not prepared by training and experience to manage with skill; for no one man can be skilled in internal medicine,
surgery, obstetria, gynecology, ophthalmology, and the other specialties of modern medicine. The general practitioner, however, is almost daily called upon for advice in regard to some case requiring the care of one skilled in some special field, and if it be a case of injury he must at least be able to apply a temporary dressing in accordance with the dictates of modern surgical art, even if the injured part be an eye. That due care is not always observed in the ordinary handling of scalp wounds and more serious injuries of the head, even by those professing to be surgeons, is the reason for the excellent paper from which we shall quote. Dr. Nancrede says:
"The first evil practice to which I desire to call your attention is the natural sequence of the fundamental error that a scalp wound is a trivial affair, demanding neither specia! care nor skill in its treatment, because the scalp is such a vascular structure that open traumatisms will nearly always heal by the first intention, or by a rapid granulating process. This, like all half truths, sometimes proves more disastrous than the most serious error. Dangerous consequences from ordinary scalp injuries are doubtless the exception, but they are needless exceptions in nearly every instance, and when human life is at stake are not to be tolerated. If all believe firmly as I do, that every scalp wound, however trivial, is one menacing life, the exceptional--that is, dangerous-cases, will be few and far between. Whence comes the danger? From infection. But why should infection be so dangerous in structures from which their vascularity should be best able to cope with germs? Because of the vascular relations existing between the most superficial vessels and the intracranial circulation. Did time permit, I could demonstrate the very numerous routes of direct and indirect vascular communication between the scalp and the vessels of the brain. Suffice it to say that the vessels of the scalp, surrounded with their perivascular lymph sheaths, communicate with those of the aponeurosis of the occipitofrontalis muscle, the latter's with osseous vessels, and the diploic in turn with the great venous sinuses of the cranium. Hence, in those cases which are in reality at the outset nothing more than simple scalp wounds, a cellulitis, septic puelo-phlebitis, osteo-myelitis, infective meningitis, or even pyemia may, and too often does, result from unfortunate environment or unskillful treatment of a scalp wound. I have seen death from pyemia follow a mere abrasion produced by a blow with the bare fist on the forehead, and tetanus from an insignificant head wound. But what war
rant exists that the smallest scalp wound is nothing more? Let me give a few illustrations of simple scalp wounds, as they were termed by those who first treated them."
He then recites the case of a youth who came complaining of a sore on the left side of his head, which had existed for over two months, the result of a blow which had not caused unconsciousness or other brain symptoms, and which had been treated as a "simple scalp wound." A penknife blade was found in the "sore" which had penetrated the brain substance for over an inch and had caused an abscess from which the boy subsequently died. He describes another case as
These cases abundantly illustrate the fact that no wound or injury about the head is so trivial as to be treated without care and thoroughness, and, as Dr. Nancrede says:
"The best way to illustrate the 'sins of omission' committed in such cases as we have been considering will be to contrast the proper course with that too commonly pursued.
"After thorough sterilization of the hands and instruments a compress wet with some efficient germicidal solution should be placed over, or lightly packed into, the wound. Next the scalp should be shaved and disinfected for at least one inch around the wound, preferably much farther. Agents calculated to remove all oily materials should be employed to enable the germicidal solutions to act. Renewed disinfection of the hands must precede the disinfection of the wound itself, which should now, for the first time, be explored. Should the slightest doubt exist as to the presence of a fracture, the wound must be sufficiently enlarged to determine this and secure disinfection. Passing by, for the present, omissions of important measures in the treatment of fractures, let me contrast the two methods commonly employed during an examination of a scalp wound. The attendant takes off gloves, which have been used for
months perhaps, while attending all sorts of contagious diseases, as erysipelas. Oftentimes, without washing the hands, or after a perfunctory attempt, without cleaning the nails, removal of the hair around the wound. or sterilization, the wound is explored and infected, if it has not already become so, when, finding a fracture exists, the physician if surgically inclined proceeds to attempt such disinfection as will give him least trouble, or salve his conscience, after which he operates. If not willing to operate, after infecting the wound and thus doing all the damage he can, he sends for a surgeon or has the patient conveyed to a hospital. I have said "the practitioner uses such measures of disinfection as will give him the least trouble or will salve his conscience," because a man proceeding as I have described, either does not believe in asepsis at all, or is not honest enough to do what he knows is his imperative duty."
"Again, a boy having been knocked down by a snowball thrown by a man, received a small wound in the frontal region. He came It takes a little more time to be thorough under the charge of one of the out-surgeons more care and to the same hospital. in our work, it requires Until serious intracranial mischief became manifest no suspithoughtfulness always to be clean, but a little cion of the real nature of the injury was en- more time may save a life and a little more tertained. One of my colleagues explored care may save a limb, and we have no right the wound, as should have been done at first, to do less than our best for every case for discovering a small pebble imbedded in the bone, a compound fracture, infection, etc. which we become responsible. The man who The case terminated fatally in a few days by is habitually clean about everything can most diffuse intracranial suppuration and brain easily and surely sterilize his hands for an abscess." operation; he who is thoughtless about putting his fingers into pus and unclean places, without immediately sterilizing his hands, will see many suppurating wounds and some cases of septicemia in spite of corrosive sublimate and carbolic acid.
He believes in actively interfering in all cases of compound fracture of the skull, and
"As an operation, properly conducted, should lessen the immediate risks to life rather than increase them, and as it is the sole prophylactic means at our disposal to lessen the chances of grave sequelæ, I contend that it is out duty to intervene. False notions relative to the pathology of compound fractures, together with certain statements which are still allowed to remain unchallenged in our standard surgical works, explain the antiquated practice too often still in vogue. Some of my own writings are obnoxious to the charge of incorrect pathology likely to give rise to errors in practice, but my practice was better than my pathology, and I have since endeavored in my various public utterances to correct any misapprehensions left. *** The modern and sole reason in many cases of compound fracture which induces the surgeon to operate is not intracranial hemorrhage, compres
sion by depressed bone or irritation produced by sharp osseous spiculæ, for often none of these exist, as for instance in such fissured, undepressed fractures with imprisoned hairs, as I have already mentioned, but to secure disinfection and drainage, if disinfection cannot successfully be effected. Immediate danger to life from a broken skull does not reside in the mere injury to the osseous tissue, the depressed spicule of the same, or the lacerated brain substance, unless the latter involves centers essential to life, but from infection. Doubtless infection is more likely to prove effective if the vitality of the encephalic contents is lowered by the damage inflicted by the continued pressure of bone spiculæ or a foreign body, but unless infection has occurred recovery will ensue. The opportunity for disinfection by the removal of infected bone fragments, hairs, and foreign bodies, with drainage in case the efforts at disinfection fail, are the real indications for trephining in compound fractures, and not to do so is a serious "sin of omission" which such teachings as I have been combatting tends to perpetu
"The late headaches from dural irritation, epilepsies, insanity and other sequelæ of compound fractures are additional and valid reasons for immediate prophylactic trephining in all such cases. If neither depressed bone, spiculæ or infected foreign bodies be removed, no harm should result from a properly conducted operation, but in the vast majority of instances some or all of these conditions exist and will be only remediable by operation."
The Sterilization of Catgut.
At a recent meeting of the Berlin Medical Society Saul (Wiener Klinische Rundschau, 1896, No. 9, p. 154) described a method of sterilizing catgut by means of boiling alcohol, that he has found efficacious and satisfactory. A combination of alcohol 80 parts carbolic acid 5 parts, and water 15 parts effected the purpose best. Hofmeister (Centralblatt für Chirurgie, 1896, No. 9, p. 193) has employed the method of Saul, but failed to secure satisfactory results. His own method consists in first hardening the crude catgut, wound upon rolls, by immersion for twenty-four hours in a 4 per cent. solution of formalin; then boiling in water for ten minutes, and subsequent hardening and preservation in alcohol, to which have been added 5 per cent. of glycerin and one-tenth per cent. of mercuric chlorid.— Medical News.
Physicians, when they have found out the cause of a disease, consider they have found out the cure.-Cicero.
Notes of Societies.
Association of Erie Railway Surgeons.
The annual meeting of the Association of Erie Railway Surgeons will be held at the Kent House, Lakewood, N. Y., on September 21, 1896. Matters of great importance are to come before the association, one of which is the relief and hospital system for disabled railroad men, which will be presented to the association by Chief Surgeon C. M. Daniels.
Mr. E. B. Thomas, president of the Erie Railroad System, has accepted an invitation and will be present at this meeting. Surgeon F. J. Lutz, president of the National Association of Railway Surgeons, and W. B. Outten, chief surgeon M. & P. R. R., St. Louis, have both promised to be present. Dr. J. B. Murphy of Chicago has promised also to attend.
There will be a larger attendance, and for several reasons a more interesting session than at any previous one.
John L. Eddy, M. D., Olean, N. Y., President. W. W. Appley, M. D., Cochecton, N. Y., Secretary. Medical Society of the Missouri Valley.
7. "Treatment of Burns of Conjunctiva," Dr. D. C. Bryant, Omaha.
8. "Breech Presentations," Dr. A. D. Wilkinson, Lincoln, Neb.
9. Two Cases-(1) "Gastrorrhaphy for Dilatation of the Stomach and Ptosis of the Transverse Colon; and (2) “A Successful Gastro-enterotomy with the Murphy Button," Dr. J. E. Summers, Jr., Omaha.
10. "Treatment of Hydro-Thorax and Empyema." Dr. J. M. Emmert, Atlantic, Ia.
II. "Congenital Dislocation of the Hip." Dr. B. B. Davis, Omaha.
12. A paper-title not given, Dr. R. Hanna, Red Oak, Ia.
13. "Retrogade Catheterization," Dr. A. F. Jonas, Omaha.
14. "Mental Dynamics and Psycho-Therapeutics," Dr. W. B. Lawrence, Red Oak, Ia. 15. "An Instructive Case of Labial Cyst," Dr. R. M. Stone, Omaha.
16. "Typhoid Fever," Dr. M. C. Christensen, Council Bluffs.
17. "Remarks on Appendicitis," Dr. F. W. Porterfield, Atlantic, Iowa.
18. "Meningocele"-with Report of Case, Dr. J. P. Lord, Omaha.
19. "Pulmonary Tuberculosis: Etiology," Etiology," Dr. C. Engel, Aspinwall, Ia.
20. "A Case of Gunshot Wound of Rectum," Dr. V. L. Treynor, Council Bluffs.
The B. & O. Railway Surgeons' Association.
The semi-annual meeting of the Baltimore and Ohio Association of Railway Surgeons was held in Philadelphia, June 23, 24 and 25, at the Hotel "Hanover." The committee of arrangements had very wisely prepared the various parts of the programme, so that ample time was given to the reading of all the papers and their free discussion. The intervening time was taken up with interesting and instructive clinics at several of the city hospitals.
The meeting was called to order at 8:30 p. m., June 23, by President J. M. Spear of Cumberland, Md. Papers were read that evening and the following day by Charles A. Oliver, M. D., Philadelphia, "A Clinical Study of the Ophthalmic Symptoms in a Case of Fracture of the Anterior Portion of the Base of the Skull." W. E. Slathers of Wheeling, W. Va., "Fractures." B. J. Byrne, M. D., Ellicott City, Md., "Treatment of Fracture of the Olecranon," read by the secretary. C. M. Frissell, Wheeling, "A Case of Mal-Practice brought Before the West Virginia Courts. In this case the defense is utterly deprived of all chance to defend, on account of the rejection of all professional testimony. Dr. Charles A. Oliver read a paper on "Some of the Inefficiencies of the Methods Commonly Employed by Railway Surgeons for the Detection of Subnormal Color-Perception." J. M. Thorne, M. D., of McKeesport, Pa., read a paper on "The Proper Amputation, with Reference to the Adjustment of Artificial Limbs." Dr. J. J. Hamilton of La Paz, Ind., read a short article on "Tablets and Tablet-Making." Dr. W. L. Dick, Columbus, O., read a paper on "Shock or NeuroParalysis.
The discussions on the several papers were conducted in a very spirited manner throughout, which lent much to the interest of the several sessions of the association. An amendment to the constitution was introduced,
to be acted on at the next meeting, changing the meetings of the association from semi-annual to annual meetings.
The committee on necrology reported the death of three members of the association during the past year: Drs. T. F. Barton, D. P. Aldrich and T. C. Martin.
The following were elected to membership: L. G. Thacker, M. D., Defiance, O.; W. S. Powell, M. D., Defiance, O.; M. Campbell, Parkersburg, W. Va., J. W. McDonald, M. D., Benwood, W. Va.; Charles A. Oliver, M. D., Philadelphia, Pa.; J. A. Ellegood, Wilmington, Del.; W. A. Shuey, Piedmont, W. Va.; G. B. Masters, Rockwood, Pa.; W. M. Dealty, Newark, O.; H. G. M. Kollock, Newark, Del. All the various sessions of the association were well attended and the interest in the work was attentive and at times quite enthusiastic, so that all who took this pilgrimage to the City of Brotherly Love could feel themselves fully repaid. Not the least interesting part of the programme was the flying visit made by many of the members with their wives to Atlantic City. The next meeting will be held in December at Chicago.
JA. M. Kean, Secy. The papers read at the above meeting will be published in future issues of The Railway Surgeon.
Mississippi Valley Medical Association.
President, H. O. Walker, M. D., Detroit, Mich.; Ist vice-president. B. Merrill Ricketts, M. D., Cincinnati, O.; 2nd vice-president, W. F. Barclay, M. D., Pittsburg, Pa.; secretary, H. W. Loeb, M. D., St. Louis, Mo.; treasurer, H. N. Moyer, M. D., Chicago.
Executive Committee: W. T. Belfield, Chicago, Ill.; C. S. Cole, New York, N. Y.; Geo. J. Cook, Indianapolis, Ind.; I. N. Love, St. Louis, Mo.; J. M. Mathews, Louisville, Ky.; A. M. Owen, Evansville, Ind.; C. A. L. Reed, Cincinnati, O.; X. C. Scott, Cleveland, O.; R. Stansbury Sutton, Pittsburg, Pa.; W. N. Wishard, Indianapolis, Ind.
Judicial Council: W. N. Wishard, Indianapolis, Ind.; T. E. Holland, Hot Springs, Ark.; A. P. Buchanan, Ft. Wayne, Ind.
Chairman Committee of Arrangements, C. A. Wheaton, St. Paul, Minn.
Headquarters, Windsor Hotel, St. Paul,