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condition as far from that which produces it as possible. Consequently, only by attending to all the details of preparing a patient for an operation can vomiting be reduced to a mini
1st. The preparation of the patient.
2nd The selection of the proper anæsthetic for each patient.
3rd. The method of giving the anaesthetic. 4th.
Every patient who has to undergo a severe operation, especially an operation of election, should be especially prepared, both mentally and physically, to withstand shock and pain.
Many surgeons have given years of patient and intelligent investigation to the best methods of preparing patients for operations under anæsthetics, yet we have not a system that is fully satisfactory and generally adopted by all surgeons. All agree on a few things. No surgeon will give an anaesthetic to a patient except in a grave emergency, soon after eating solid food. Six to eight hours is considered sufficient time after a meal. Twelve or more hours is apt to leave the patient hungry and less able to stand an operation. My own method is to empty the alimentary canal thoroughly the day before the operation, and give liquid food only the night before and malted milk or soup four hours before the operation. An especial effort should be made to have the stomach and bowels free from gas.
Few patients should have morphia in any form before giving an anæsthetic. Morphia often aggravates the nausea. Whiskey does the same thing and should not be given before the operation. In fact, all depressing anti-pyretic drugs should be avoided. Keep the patient's mind as cheerful as possible, and the strength as great as possible. Keep the patient warm. The rapid evaporation of all anæsthetic cools both the patient and the surrounding atmosphere, and many a lung complication has been produced by the great reduction of temperature rather than by any other factor in the operation.
A very warm room-about 80 degrees F.warm, dry flannel clothing, kept in close contact with the patient's skin, and as small a field. for the operation as possible exposed to the air, will prevent shock and chill and thereby counteract the tendency to vomit after the operation.
2nd. Selection of anaesthetic.
After using pure ether-as I was taught at Harvard by the renowned Bigelow-for ten years, and then having associated with surgeons who were educated in Edinburgh, under the influence of the celebrated Sir James Y. Simpson, I used chloroform mostly for five years, but the surgeons from whom I learned the use of chloroform having a very sad death from it in the hospital, the board of directors
passed a resolution prohibiting the use of chloroform in that institution, except in especia! cases. I began the use of the A. C. E. mixture about ten years ago, and have used it almost entirely ever since with the utmost satisfaction.
The A. C. E. mixture is composed of one part of pure 95 per cent alcohol, two parts of pure chloroform, and three parts of pure ether, by volume. This mixture keeps well in the dark. It should be given on a hollow sponge, covered with a leather case, with an opening in the top that can be opened or closed, as the surgeon giving the anesthetic deems necessary.
3rd. Method of giving an anæsthetic.
Begin with a half a drachm of the A. C. E. mixture on the sponge and let the patient inhale it slowly. The more through the mouth at first the better. Take at least ten minutes to bring the patient fully under its influence. During the operation give just enough of the anæsthetic to keep the patient quiet. Many patients are so saturated with the vapor that it is no wonder they vomit and have no rest for many hours after the operation.
If the method just outlined be skillfully carried out, there will be but few cases requiring special after-treatment.
Vomiting will be reduced to a minimum. But in the cases where shock and the anæsthetic have produced nausea and vomiting, there is nothing better than one drop doses of wine of ipecac on the tongue every half hour for two or three hours. If there be much pain a hypodermic of morphia will often relieve the patient, but in abdominal operations the less morphia used the better as a rule.
Ice has not been of much use in my experience. It does for a little while, but in one or two hours the tongue glazes and the stomach becomes uncomfortable. A mustard plaster on the back of the neck often relieves the patient. The skin should not be blistered. Over medication is sometimes the cause of vomiting. The hypodermic injection of digitalis, ether, strychnia and whiskey is often so heroically employed that the brain centers are driven to the utmost exertion of their power to expel so much poison from the system by vomiting.
The tendency of the surgeon is to conclude that so long as his treatment does not kill the patient, that nothing he does causes any harm. Unfortunately, the human mind is so constituted that any man is liable to fall into error regarding his most cherished work, consequently we fall into habits of dosing that are often unnecessary and sometimes injurious. The simplest medication is surely the most scientific, and the complex is so difficult to fully understand that no one can be absolutely sure
that he knows the post hoc from the propter hoc.
For the sake of brevity, I have not made. quotations or referred to authorities, but simply put the conclusions of my studies and practice of twenty-five years in as small a space as possible. I have never had a death in my practice, nor under my care from an anæsthetic. I have given anæsthetics in many cases, for all kinds of operations, and never had but one fright in all of them. A young woman came to me to have some teeth extracted. She disliked ether so much that I gave her chloroform, and if I had not been on the alert, she would have died in the chair. By quick work
The new building was erected by the funds of the A., T. & St. F. Hospital Association, completed and turned over to the board of trustees on May 21 of the current year, and by them immediately turned over to the chief surgeon, Dr. Geo. W. Hogeboom, for equipment and opening. It was partially equipped and opened on the 22d of June, in immediate charge of the superintendent of hospitals for the association, Dr. J. R. Fay.
Its construction is sandstone from Flagstaff, Ariz., for the first story, and for the stories above pressed brick. Its capacity is from 75
100 patients. There are three general wards with a capacity of 18 beds each, three
I lowered her head and pulled out her tongue, and she began to breathe again and soon recovered. So I would say never give chloroform to a patient in a dentist's chair, with his clothes on, and no preparation.-Medical Sentinel.
The New Santa Fe Hospital at Topeka.
The engraving presented herewith shows the exterior of the new hospital erected at Topeka, Kan., by the hospital department of the Atchison, Topeka & Santa Fe Railroad. This is the fifth hospital of the system. The other four are located at Ft. Madison, Ia., Ottawa, Kan... La Junta, Colo., and Las Vegas, New Mexico.
small wards of 4 to 6 beds, and the balance single rooms. This capacity can be safely increased one-third if necessary to do so. Its interior construction is of the most modern type. Its heating and ventilating is of the Sturtevant system, by fans propelled by electricity, by which the air in the entire building can be changed in 10 or 12 minutes, without the stirring of a feather held in midair in any room; and in each ward or room occupied by patients the heat is controlled by the Johnson automatic heat control, by which the temperature can be maintained at any desired degree. Since its opening it has administered to a daily average of from 20 to 25 patients, which is constantly increasing. Its patronage from out
side patients has been at the rate of $150 per month, which is also increasing. It is in universal favor with the profession, especially for its capacious and well-equipped operating
In reference to the utility of the Railway Employes' Association, the chief surgeon says that this association was organized in 1884 and since that time to date the evidence has been complete and conclusive of the good effects and results of such association, both to the employe and the railway company; and he earnestly urges all railway companies to favor such organizations.
Fracture of the Os Calcis, with Report of a Case of Comminuted Fracture with an Unique Method of Treatment.*
Dr. Henry M. Joy of Grand Rapids, Mich., reports the following interesting and instructive case in a recent issue of the Annals of Surgery:
Fracture of the os calcis of any variety, notwithstanding the peculiar liability of this bone to injury from its location, may, I think, be classed among the rare fractures with which the general surgeon has to deal, and there exists, I think, a corresponding scarcity of literature upon the subject.
The os calcis may be fractured either by muscular action, in which case the lesion is immediately below the insertion of the tendo Achillis and is accompanied with marked upward displacement of the fragment due to mucular contraction, or the injury may be caused by direct violence, as from a fall upon the foot. Fractures due to a fall are usually comminuted, and may be diagnosed by the flattening and broadening of the sole and heel, . which is observed when comparison is made. between the injured and the sound foot.
Crepitus may or may not be present, but if present is most readily obtained by rotating the foot and at the same time holding the heel, or by holding the heel and flexing the ankle. The treatment of these injuries will be referred to in connection with the following
Mr. B., aged twenty-one years, while suffering from an attack of delirium tremens, jumped from a second story window in his stocking feet to the frozen ground,—a distance of about twenty feet, he landed squarely on his feet, then fell forward onto his face.
Notwithstanding the injury sustained he succeeded in rising and ran some thirty or forty yards before being captured and returned. to the hospital.
Examination showed the presence of a transverse fracture immediately below the in* Read before the Grand Rapids Academy of Medicine. + American Text-Book of Surgery.
sertion of the tendo Achillis, due probably to muscular action in the attempt to prevent falling forward after striking the ground.
Evidence of flattening and broadening of the sole of the injured heel, when compared with the sound side, led me to suspect a fracture of the subastragaloid portion of the bone, though no crepitus could be obtained.
The action of the tendon was so marked that the upper fragment was separated about two inches from the lower portion of the bone, with the skin tightly stretched over it, and attempts at reduction either by manipulation or position with flexion of the leg and overextension of the foot being unsuccessful, an operation was deemed advisable. An incision was made in the median line of the plantar surface of the heel extending over the heel and about three inches along the course of the tendo Achillis, which was exposed by the incision. After the incision was completed, a large quantity of effused blood escaped from the wound, when it was seen that the subastragaloid portion of the bone was crushed into three fragments of different sizes.
The extensive comminution rendered the use of either nails or the ordinary method of wiring impossible, and a somewhat unique method of treatment was adopted. The tendon was first severed by an oblique incision, beginning at the outer side one inch above its insertion into the bone and ending on the inner side about two inches above the starting point. It was then easy to slip the upper fragment with its attached portion of tendon down into place.
A medium-sized silver wire was then passed through the tendo Achillis at its insertion, then through the tissues immediately surrounding the various fragments, returning to the point of insertion, thus fixing the fragments at the periphery of each, so that when the suture was completed the fragments were inclosed in a loop which, when drawn taut, brought the parts into perfect apposition. A few turns were then taken in the wire and the ends cut off. The severed tendon was next united with fine silk, the wound closed with silkworm-gut and dressed, and a plaster-ofParis cast applied with the foot in an over-extended position to secure as much relaxation of the tendon as possible, and thus avoid any tendency to separation of the fragments or of the ends of the divided tendon from tension.
The wound was first dressed and stitches removed on the eleventh day, when primary union of the cut surface was found complete. second cast was applied at this time with the foot still over-extended.
Fearing lest too firm adhesion might form between the tendon and the surrounding tissues the cast was removed at the end of two weeks, making in all about four weeks that the
foot had been immobilized. Much to my gratification, there had apparently been no inflammatory action whatever, as the function of the tendon was as perfect as in the sound foot, with no evidence of any formation of adhesions.
The treatment advocated for these fractures varies according to the location of the injury. In cases where the fracture is subastragaloid the use of splints will usually be unnecessary. The leg should be placed in a comfortable position and cold lotions applied until swelling has subsided, after which an immovable dressing should be applied and the patient allowed to get about on crutches (Agnew).
For fractures of the posterior portion of the bone (immediately below the insertion of the tendon), the application of a side or anterior splint with the foot over-extended or the use of Monro's modification of Thillaye's apparatus a device for securing this position, is sometimes used. When the injury is of this nature, I do not believe it possible if there be much muscular contraction to secure enough relaxation of the tendon by position alone to obtain sufficiently perfect coaptation of the fragments, and though there is danger of death of the fragment when tenotomy is practiced, the upper portion of the os calcis being largely dependent for its vascular supply upon the tendon, I believe the dangers of a useless foot are less when an open, oblique tenotomy is made and perfect coaptation of the fragments obtained followed by immediate suture of the tendon than when an attempt is made to keep the parts in position by the use of a splint or any apparatus which has as yet been devised.
(22) Massage in the Treatment of Joint Fractures.
Pello (Archiv. di Ortoped, An. 13, fasc. 3. 1896), draws attention to the value of early massage and passive movement in the case of intra-articular fractures. He believes that the usual method of treatment by prolonged fixation delays recovery, and only too often leads to ankylosis. He then reports three cases where massage was practiced at once, and where the only fixing apparatus was a starched bandage freely cut away so as to allow of the massage. The first case was that of a boy, aged 6, with intra-articular fracture of the trochlear process of the right humerus. Light massage was practiced at once, and gave much relief to the pain; the joint was put up in a starched bandage. The next day a good part of the bandage was cut off, and twenty minutes' massage practiced. On the fifth day slight passive movement of the joint was commenced. On the tenth day the bandage was discarded; at the end of a month the elbow was as free in its movements as before
the fracture. The second case was that of a man, aged 38, with Colle's fracture, treated. in a similar way and completely cured, with free movement and no deformity, on the fifteenth day. The third case was that of a man, aged 40, who fractured his tibia and patella. The tibial fracture was treated in the usual way; the patellar fracture was unrecognized. at the time, and after seventy days' treatment, when the patient was first seen by the author, although the tibial fracture was healed, the patient's limb was useless, as the patellar fragments were distant 2 centimeters, and only worked by weak fibrous union. Massage was practiced, and after fifteen days the patient could walk with crutches, the oedema disappeared, and flexion of the knee (previously rigid) could be obtained. At the end of a month the patient could walk well with a simple stick; in two months he could walk upstairs, so that no one would suspect any injury to the limb.-British Medical Journal. Changes in the Spinal Cord Following Amputation.
Dr. Alfred W. Campbell detailed the changes found in three cases, one an amputation below the knee and two amputations through the upper arm. For purposes of comparison sections of a spinal cord from a case in which the entire brachial plexus had been injured in early life were shown. In all cases marked changes in the spinal cord were found in those segments which receive the sensory nerves from the skin and give off the motor nerves to the muscles removed. These changes were hemiatrophy, with universal reduction in size of gray and white matter, without definite sclerosis of special tracts, and a numerical deficiency of the nerve cells in the cornua,, but especially in the postero-lateral group of the anterior cornu, all on that side corresponding to the amputation. In the case where the leg had been amputated there was a reduction in the number of the nerve cells in Clarke's column, in the lower dorsal and upper lumbar segments. The peripheral nerves above the site of operation revealed marked atrophic alterations and a filling up of the intervening spaces between bundles by large quantities of fat. The ganglia on the posterior roots presented atrophy of some nerve cells. In the brachial plexus case the hemiatrophy was not so marked and the posterior cornua were symmetrical, a condition which might be due to the skin being left intact. Reference was made to Sherrington, Head, and Thorburn's work on "spinal localization," and the wonderful accuracy of the results of these observers as confirmed by these cases was commented upon.-Universal Medical Journal.
some of our large systems have as many as 325 surgeons in their employ. Local surgeons are supplied with printed instructions, cover
Management of Cases Immediately Following ing all accidents that might occur, and in the
Sir Thornley Stoper (British Medical Journal) writes as follows: "If I may reduce to formulæ the matters I have referred to, I would put them thus: (1) That the tendency to prolong operations must be carefully guarded against, as it is a grave cause of danger. (2) That in the treatment of shock and vomiting following operation we get no help from the stomach, and must rely on the rectum as its substitute. (3) That heat, alcohol and opiates are our best remedies; and that the latter are well borne, and must be intelligently used to their full effect. (4) That drugs of the class ordinarily used to check vomiting are of little or no use in the cases under consideration. (5) That ice does not relieve thirst, and does harm by introducing water into the stomach and so provoking vomiting."-The Medical Record
The Management of Railway Hospitals.
It may not be uninteresting to the readers of the Fortnightly to give a cursory idea of the management of hospital departments upon railways as at present constituted. At the head of the department presides its chief executive, known as the chief surgeon, medical director or general surgeon. The chief surgeon has complete control and directs the management and disposition of cases, causes reports to be made, has charge of all hospitals and appoints all surgeons, renders personal injury reports to claim and legal departments, and causes to be kept a current history of every case treated. The chief surgeon directs the expenditure of bills incurred in conducting the department, vouching all accounts, selects experts for the company in damage suits and adjusts all disputed points pertaining to the department. The general manager is the only officer of the road to whom the chief surgeon reports and they alone are authorized to incur expense. The chief executive of the hospital department is held responsible for the proper performance of all its work and general efficiency, and therefore seeks to improve his department in every detail and being thoroughly cognizant of all that pertains to his department becomes an important factor in railway management. Local surgeons are appointed at every town of any importance and at large. division points, where many employes are engaged, two surgeons are stationed. Most roads average one local surgeon for every twenty-five miles represented.
The railways employ more members of the medical profession than any other industry;
event of an accident no misunderstanding nor confusion arises. All superintendents, train masters, conductors, engineers, brakemen, agents, road masters, section foremen and others have essentially the same printed instructions how to proceed in case an accident occurs and where to find the nearest local surgeon. All time-cards in force contain these directions and in addition thereto is printed the names and locations of all company surgeons of that particular division upon which they operate. When an accident occurs upon some portion of the road the chief surgeon or assistant chief surgeon is immediately notified by wire by the local surgeon and also by the superintendent, conductor or agent, detailing where, how and when it occurred, and the extent of injuries; the local surgeon is then directed regarding the disposition of the case and the advisability of transporting the same. Stretchers are placed at stations where local surgeons are stationed, and upon all baggage and wrecking cars, hence cases can be shipped with celerity. Notification is sent when a case is to be shipped and hospital ambulances meet the train. Should a passenger train be wrecked not only all local surgeons in the immediate vicinity are called, but invariably relief surgeons and surgical supplies are sent from hospitals. Instructions are likewise printed for the guidance of employes in case of sickness. Everything is explicitly stated regarding proper certificates of admission, character of cases admitted and requests for medicines and treatment through the mails. Records of all personal injury cases are filed in the chief surgeon's office. Thus, upon the Missouri Pacific the chief surgeon has over 30,000 reports of personal injuries on record for reference. At the hospital, a personal bedside history is taken daily by the attending surgeon. We have, therefore, not only a record of the injury, but a daily history from the time of the injury until settlement is made. These departments never lack patronage. The Missouri Pacific hospital department, including two hospitals and five emergency stations, treats nearly 30,000 employes annually, and it is computed that the various hospital departments of the United States treat from 165,000 to 185,000 annually.
A hospital department as at present constituted consists of the following medical officers: Chief surgeon, house surgeons, consulting surgeons and specialists, oculists, aurists, throat and lung specialists, dermatologist, neurologist, bacteriologist and pathologist and consulting electro-therapeutist.
The rapidity of growth of these departments