« ForrigeFortsæt »
unusually high up and composed largely of bone. I am indebted to Dr. Outten, who was present, for a suggestion of great practical value in such cases, namely, that the scissors be constructed with the Henckel joint, like the powerful pair of plaster scissors I have here, the gliding motion of the blade adding immensely to their strength.
2836 Lafayette Ave.
The Indications and Modes of Drainage After Abdominal and Vaginal Section.
The following from the pen of Nicholas Senn, M. D., of Chicago, is interesting and valuable:
Drainage of the abdominal cavity is an expression of the present imperfect state of surgery. It is often an unavoidable evil. It should be limited to appropriate cases, and it is, therefore, well that the indications for it. should be laid down clearly, so that we may have eventually some definite rules that will guide the surgeon in his abdominal work. There are now no fixed rules. Some surgeons avoid drainage wherever possible; others drain as a rule. If I were permitted to pass my judgment on this question as a whole, I would say that the surgeon who has the ambition to operate quickly, to make an impression on the bystanders, should drain frequently; while, on the other hand, the surgeon who proceeds with his work carefully, step by step, with plans well laid out, with his practical knowledge resting on a firm pathological basis, will only drain in exceptional cases. After opening the abdomen the surgeon has frequently to deal with affections that absolutely call for drainage. There is no other course to pursue. He meets with pathological conditions that cannot be successfully removed; he meets with cavities, the walls of which it is impossible to extirpate, and consequently he proceeds to establish an abdominal fistula, a great consolation to the operator, because it enables him to do something, so that probably during the course of time Nature will come to his rescue, taking advantage of the temporary drainage, and eventually closing the cavity where drainage was established. One of these conditions is met with in a distended or diseased gall bladder. It is my firm conviction that the best success obtained in cases of disease of the gall bladder requiring opening of the organ, in the absence of a permanent occlusion of the common duct, is the establishment of an external fistula. This operation shows the greatest success, is attended by the least danger-in fact, it is almost devoid of danger if the sur
geon is careful to prevent infection of the peritoneal cavity during the operation.
The next condition-one that is not so frequently met with (but there are now forty or sixty cases on record)-is cyst of the pancreas. A few bold surgeons have made the attempt and in a few isolated cases have succeeded in extirpating pancreatic cysts with a mortality of more than 50 per cent. Statistics show that the formation of a fistula usually results in a permanent cure in the course of a few weeks, and that a permanent fistula is the exception.
Very often the surgeon makes a mistake in diagnosis, opens the abdomen for a supposed ovarian cyst or an ovarian tumor of some kind, and is astonished, when he has exposed the abdominal organs, to find a retroperitoneal cyst, a hydronephrotic kidney. Many surgeons under such circumstances have resorted to the formation of an abdominal fistula, thus draining the distended pelvis of the kidney-a very unwise procedure, because a lumbar fistula will accomplish the same object, the formation of which is attended by less danger, and eventually, if it should become necessary, a nephrectomy is attended by a great deal of difficulty if previously the organ has been attached to the abdominal wall. So that I should lay down the rule that in hydronephrosis, whether diagnosticated before or during the operation, the surgeon should make a lumbar nephrotomy.
Then comes that large class of pelvic abscesses without removable walls; abscesses which have had their origin in the pelvic removable walls; abscesses which have had their origin in the pelvic connective tissue, perimetritic abscesses; abscesses originating within the fallopian tubes, and abscesses within or around the ovary, but in which the careful surgeon will make the most scrutinizing examination before he attempts the work of enucleation. If he finds enucleation impossible it would have been vastly better if he had dealt in a more conservative manner with his patient, and had resorted to abdominal drainage as taught us by Mr. Tait.-Am. Gyn. and Obstet. Jour., March, 1896.
Novel Method of Disposing of Neuromata.
It has been found that neuromata after amputation almost always appear in scar tissue, and are especially fixed against the sawn end of the bone. Senn endeavors to obviate this by amputating the nerve high up in the tissue, and then cutting a V-shaped wedge out of the distal end, uniting the two flaps with sutures so that none of the interior of the nerve-trunk is exposed-all nerve tissue is covered in by the endothelial sheath.-The Medical Age.
We publish in other columns a good paper by Dr. Chaffee of Brooklyn, in which he discusses at length the Railway Employes' Hospital Association and its benefits, especially to the injured and sick employes. We hardly conceive the possibility of a difference of opinion among surgeons as to the desirability of the railway hospital system, and it seems to us that this paper of Dr. Chaffee's should be enough in itself to convince the most prejudiced railway man of the advantage both to the employe and to the management of such a scheme.
As Doctor Chaffee says, accidents upon the railway are inevitable, and we must have railway surgeons, and while we are all prepared to prove that good surgery can be done at the cross roads, there is no necessity for proof that railway surgery can be best done in well ordered hospitals, and if a road can own and manage its own hospital, or have a system of hospitals distributed along the line, all under one chief surgeon, and arranged and conducted after the same general plan, it must of necessity be productive of the very best work in the care of the sick and injured.
As to the economical side to the question, we believe it has been quite sufficiently demonstrated that, all things considered, this method of caring for those injured on the track is by far the best and cheapest.
While we are aware that on some roads the proposition to establish such a system and to assess employes for its support has met with opposition among the men, we believe it has always been due to a misunderstanding, because of faulty presentation of the plan and a misconception on the part of the employes of what was desired of them and what the benefits were to be.
Referring again to the paper of Dr. Chaffee, there is abundant proof such as he furnishes in the form of letters from railway men who have been patients in the hospitals, that when the system is fully comprehended and its benefits experienced by the men, all opposition on their part ceases and they are loud in their praises of the method.
We can conceive of nothing more desirable or more humane than the transfer system which Doctor Chaffee suggests, looking to the exchange of patients by various railway hospitals situated in the different parts of the country, and trust that the subject will be agitated until such a system is established. It is certainly a perfectly feasible thing, and, we believe, would so shorten the term of hospital life in many cases as to make it a real economy, as well as a true beneficence.
We have just received a reprint of an article by Dr. Frank H. Caldwell, chief surgeon of the Plant System, entitled "Transportation. of Injured Employes," in which he gives a very good description of the hospital car used upon the Plant System for transporting patients from one hospital to another, and also from the scene of an accident to the nearest hospital. This seems to leave almost nothing to be desired for the immediate and continuous care of persons injured upon the railway. He says:
"It has been conclusively demonstrated that injured persons, except when suffering from severe and extensive injuries to the head, spine, thoracic and abdominal cavities, or in a state of profound shock, may, when properly handled, be transported almost an indefinite distance without endangering life or increasing the extent of injury. And it has been further shown by actual experience that a large percentage of the exceptional injuries above men
tioned can be safely handled if proper transportation facilities are provided. In cases of lighter forms of injury, as a crushed limb, how should they be transported to the hospital in order that shock may not be induced or increased, or the already mangled parts be further injured?
"The nearest surgeon is sent for, and under no circumstances should the patient be carried to him. The messenger informs the surgeon as nearly as possible of the nature and extent of the injury, so that he may come prepared, for not all surgeons have emergency cases, ready for every kind of accident. The surgeon, upon his arrival, controls hemorrhage, anticipates or combats existing shock, and adjusts a temporary dressing. Briefly, he prepares the patient for his journey, whether it be long or short. After due preparation, the patient is lifted gently a few mches from the ground or floor, and a stretcher slipped under him, and he is lowered into it and made comfortable. He is then carried into a coach or baggage car of the first passenger train going in the desired direction. An injured man should never be transported by a freight train. If no passenger train is available in a reasonable time, "special" should be provided. If the surgeon in attendance fears for the safety of his patient, the chief surgeon should be notified of the fact, and he should instruct the surgeons along the line to visit the patient as the train passes their stations and renders any assistance necessary.
"As a rule, upon arrival at the hospital, you will find your patient in condition to submit to any operation required for his relief. The plan above outlined in this class of cases, is the one practiced on the system which the writer represents, and furnishes the patient almost constant attention from the receipt of injury until he arrives at the hospital; the greatest distance between surgeons being forty miles, and usually but twenty.
"The comfort and safety of the patient will depend very much upon the stretcher in transporting him. The writer spent several years experimenting before one was secured which answered the purpose to the satisfaction of himself and patients. Photographs of the ones that have been in use upon our system for the past eight years are submitted for your inspection. It is made of cypress; a light, springy, yet strong, native wood. The stretcher will pass easily through a car door, and two standard car cushions placed end to end, fit it exactly, and can be used as additional protection when required. The bottom of the stretcher is of wire netting, two-inch mesh, and is covered with eight-ounce duck. The netting and duck are fastened to the frame with strips of wood which are screwed on, and enabling us to easily clean or repair the wire
and duck. The legs fold under, and have heavy, corrugated rubber tips. This stretcher is light, strong, durable, and easily kept clean. It has sufficient elasticity to prevent undue jolting, but not enough to give pain. The writer has personally tested it, and can certify to its comfort.
"There have been several plans of ambulance cars proposed from time to time, but they have, in the writer's opinion, been too elaborate, entailing a large expense upon the company, the officials of which could not see a proportionate benefit; and in my judgment they have taken the correct view of the case. What we need is a strong, stiff car, with firstclass trucks, furnished in the simplest style, without upholstery of any kind. We need a transportation room, an operating room, and a small consultation room.
"The transportation room is furnished with wrought-iron beds, with woven wire springs. Heavy, corrugated rubber tips are on the legs, which prevents slipping, and breaks the jar to a great extent. When not in use, these beds are fastened against the walls of the car, and are entirely out of the way. In addition to these, we have an air bed, which, when not in use, is folded into a very small compass, and packed into a closet. It takes but a moment to inflate it with air. Lastly, there is a hammock arrangement made to suspend from the roof of the car by strong straps. This hammock has a device of short, strong, spiral springs, which absolutely prevents any jolt cr jar being communicated to the patient.
The operating room is supplied with an iron, glass-top table, and all necessary appliances for the treatment of shock, and for the performance of perfectly aseptic operations. Sterilizers, etc., are stored beneath the water tank, which is kept filled with sterilized water. All bedding, etc., are packed in the corner cupboard. Bandages, bottles containing chloroform, ether, etc., are in the center cup
The car is painted with a specially prepared paint, which may be scalded without injury, and will stand disinfection by means of superheated steam or air."
Notes of Societies.
The French Surgical Association will hold its tenth annual meeting in Paris during the week ending October 24, 1896, under the presidency of Professor Terrier. The two subjects for set discussions are "The Surgical Treatment of Clubfoot," to be opened by M. Forgue of Montpelier, and "The Treatment of Prolapse of the Genital Organs," to be opened by M. Bouilly of Paris. The secretary-general of the association is M. Lucien Picqué, No. 8 Rue de l'Isly, Paris.
The American Public Health Association will hold its twenty-fourth annual meeting at Buffalo, September 15 and 18. The following are the subjects proposed for discussion: The pollution of water supplies; the disposal of garbage and refuse; animal diseases and animal food; the nomenclature of diseases and forms of statistics; protective inoculations in infectious diseases; national health legislation; the cause and prevention of diphtheria; causes and prevention of infant mortality; car sanitation; the prevention of the spread of yellow fever; steamship and steamboat sanitation; the transportation and disposal of the dead; the use of alcoholic drinks from a sanitary standpoint; the centennial of vaccination; the relation of forestry to public health; transportation of diseased tissues by mail; river conservancy boards of supervision.
The American Electro-Therapeutic Association.
The sixth annual meeting of the American Electro-Therapeutic Society will be held in Allston Hall, Boston, Mass., September 29 and 30, and October 1, 1896.
Dr. Robert Newman, New York, president; Dr. R. J. Nunn, Georgia, treasurer; Dr. Emil Huel, 352 Willis avenue, New York, secretary; Prof. A. E. Dalbert, Tuft's College, Mass., chairman of the committee of arrangements. The following is the scientific program:
Address of the President, Dr. Robert Newman, New York City, "The Want of Education in Electro-Therapeutics in Medical Colleges."
REPORTS OF COMMITTEES
"On Induction Coils and Alternators," Mr. A. E. Kennelly, Philadelphia, Pa.
"On Meters," Dr. M. A. Cleaves, New York Citv.
"On Static Machines and Condensers," Dr. W. J. Morton, New York City.
"On Constant Current Generators and Controllers," Dr. W. J. Herdman, Ann Arbor, Mich.
"On Electrodes," Dr. C. R. Dickson, Toronto, Canada.
"Electro-Therapy in the Treatment of the Nervous," Dr. W. S. Watson, Fishkill-onHudson, N. Y.
"The Role of Electricity in the Treatment of Uric Acid Diathesis," Dr. J. G. Davis, New York City.
"Some Observations in Electro-Therapeutics," Dr. D. R. Brower, Chicago, Ill.
"The Physics of the Production of the XRays," Mr. Edwin Houston, Ph. D., Philadelphia, Pa.; Mr. A. E. Kennelly, F. R. A. S.. Philadelphia, Pa.
"Treatment of Strictures by Electrolysis versus Any Other Treatment," Dr. F. H. Wallace, Boston, Mass.
"The Newman Method of Urethral Electrolysis." Its advantages and reasons why some operators fail. Dr. Francis B. Bishop, Washington, D. C.
“Faradism in Gynæcology," Dr. R. J. Nunn, Extracts and Abstracts.
"The Motor Dynamo-Adapted to ElectroTherapeutic Work," Dr. W. J. Herdman, Ann Arbor, Mich.
Discussion by Mr. Edwin W. Hammer, E. E., New York City, and Dr. G. J. Englemann, Boston, Mass.
"The Application of Electricity to Surgery," Dr. J. W. Herdman, Ann Arbor, Mich.
"A Summary of the Ultimate Results in 86 Fibroid Tumors, Treated by the Apostoli Method," Dr. G. Betton Massey, Philadelphia, Pa.
"Some Experiences and Experiments in the Construction of High Tension Coils and Electrodes," Dr. Frank W. Ross, A. M., Elmira, N. Y.
"Electricity Considered in Its Relation to Surgical Gynecology," Dr. O. S. Phelps, New York City.
Closing Arterial Wounds by Suture.
Dr. Heidenhain, in the Centralbl. fur Chir., No. 49, 1895, cites two previously recorded cases, involving in one instance the common femoral, in the other the common iliac. also reports a case of his own, in which during the removal of some cancerous glands from under the armpit, and after necessary resection of a portion of the axillary vein, a wound about an inch and a half in length was accidentally made in the main artery. The bleeding was arrested by digital compression and the edges of the arterial wound were brought together by a continuous suture of catgut. The bleeding was thus completely arrested. The lumen of the vessel was not apparently diminished. The sutures held firmly in spite of strong arterial pulsation. The patient made a good recovery, and when last seen, seven months after the operation, was quite free from relapse. The axillary artery could be felt pulsating along the whole extent of the armpit.— The Medical Record.
How to Prevent Anæsthetic Vomiting.*
I think you might dispense with half your doctors if you would only consult Doctor Sun more, and be more under the treatment of these great hydropathic doctors, the clouds.-Beecher.
BY THOS. W. MUSGROVE, M. D., FAIRHAVEN, WASHINGTON.
"A Clinical Report of Case of Rectal Phlebitis Treated with Galvanism," Dr. D. B. D. Beaver, Reading, Pa.
"On the Electro-Therapeutics of the Constant Current," Mr. A. E. Kennelly, F. R. A. S., Philadelphia, Pa.
Title to be announced, Dr. M. A. Cleaves, New York City.
Title to be announced, Dr. Fred. H. Morse, resemble the throes of parturition. Melrose, Mass.
Of all creatures known to science man is the most given to vomiting. Every organ of his body is connected by alarm nerves with the vomit center. A sudden injury to any important or vital organ will produce vomiting. In many persons a disagreeable thought, a disgusting sight, a fright, a chill, or anything that impresses the vomit-center that there is something obnoxious in the system, produces a contraction of the diaphragm, reversed peristaltic action of the stomach, with ejection of its contents; or, if the stomach be empty an attempt to vomit the stomach itself. This safeguard of life is so finely adjusted-set with a hair trigger, as it were-that vomiting frequently becomes one of the most annoying and even dangerous complications of disease in many patients. Vomiting may be a simple regurgitation, or it may be of so severe a character as to
The vomiting of pregnancy, the nausea of intestinal disorders of children, the uncontrollable vomiting of meningitis, of intestinal obstruction, are all sufficiently distressing to the patient and troublesome to the physician, to try the courage and skill of the best of us. But none are more annoying and obstinate than the vomiting produced by anæsthesia.
by any of the popular anæsthetics suffer more Nearly all patients who are deeply narcotized or less from nausea and vomiting. I believe fully ninety per cent of all persons who are kept under an anæsthetic more than half an hour are made sick. If ether is used, about 60 per cent vorait. If chloroform, about 40 per cent. If nitrous oxide, not more than 10 per cent, but it is very seldom that anyone is kept under gas half an hour.
In abdominal surgery, the vomiting during and after the operation is often exceedingly troublesome, and sometimes dangerous.
These statements are so well known to the profession that I need not elaborate or quote authorities to prove them. We all know them unpleasantly well. The question is how to prevent anæsthetic vomiting. As both the etiology and process of vomiting is very complex it is plain that there is no simple method of preventing it. The only rational method is to keep in mind and etiology and physiological process of vomiting, and put the patient in a
*Read before the Washington State Medical Society, May 19, 1896.