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step farther and I have finished. Take again an individual sustaining the same mental shock as the other, but, unlike him, has bruises about his body or a twist and strain of the ligaments and muscles along the spine. Here we have an actual pathological condition which conveys to the brain, already hyperæsthetic, the sensation of a bona fide injury, and which, by repeated suggestions from every motion and touch, keeps up the impression of grave injury on the cortex. If, however, at the time of the accident this person had not had a severe mental shock, and especially upon a brain not neuropathic, then the slight injury would in all likelihood go through the ordinary course of tissue repair, and we have no railway spine.
Much could be said along this line, but my time for preparation and yours for reception is limited. I have accomplished my object, if this brochure has any effect in changing the railway spine of Erichsen to the railway brain of Page, and while the damage done the individual by this transfer of title may be the greater, yet in our study of the subject or in our testimony in such cases, we are nearer the truth when we hold that the brain, and not the cord, is the seat of railway spine, and that the cerebral cortex may be so diseased by the injury and its consequent suggestions and repetitions of suggestions that a species of insanity or mental unsoundness may result.
Gunshot Wound of Spine.
In a recent number of Langdales Lancet, Dr. Jabez N. Jackson reports the following interesting case on account of the non-conformance of clinical symptoms with the location of cord lesion: E. W., colored, male, age 32. About 3 a. m., July 27, 1896, in a quarrel over a woman, was shot in the neck by a ball from a 44 calibre revolver. The ball entered the back of his neck on the left side near margin of occipitoacromial fold of trapezius muscle, about three or four inches above the acromion process, and ranged apparently downward and slightly forward. He was removed to All Saints' Hospital at once, and I was summoned to take charge of case. On examination found wound located as above in
dicated; man a magnificent specimen of physical strength and vigor. Closer examination showed complete motor and sensory paralysis from the level of the third intercostal space down. Also some priapism. No paralysis, either motor or sensory, of any portion of either arm. Complained, however, of some
tingling pain in tips of fingers. Pulse 60, full and strong; respiration 20, free and natural; temperature 100 F. Intellectual faculties unclouded. Abolition of all reflexes of limbs and trunk. The diagnosis of some cord lesion was readily made, and in the absence of disturbance of function of arms, together with the trunk circle of anesthesia, I located the lesion at about the first or second dorsal vertebra. Wound was dressed and patient put to bed. Prognosis extremely bad. By noon of same day temperature had risen to 104 F., and pulse to 100. At this time patient was examined in consultation by Drs. C. Lester Hall, John Punton and G. W. Grove. Diagnosis of cord lesion was confirmed by each, and probable location agreed as about first or second dorsal vertebra. In view of the hopelessness otherwise of the case, a laminectomy was advised, notwithstanding the usual advice to the contrary, this was agreed to, and assisted by the above named physicians and Dr. B. C. Hyde, our efficient police surgeon. The operation was made at 2 p. m. Without entering into the details of the operation, the laminæ from the sixth cervical to the third dorsal vertebra inclusive were removed, beginning below and working up. We only stopped with the sixth cervical on account of the condition from shock and anæsthetic. Nothing whatever indicative of traumatism of cord in this region was found. Wounds closed with drainage. In one hour after operation, at 5 p. m., patient had reacted from shock and seemed in favorable condition. Temperature, however, had gone up to 105, with pulse 120. At 6 p. m. temperature reached 106, pulse 140. Patient now began quickly to show signs of dissolution, and at 6:30 p. m. died, a little more than twelve hours after injury.
Post-mortem: The coroner's post-mortem showed that the ball entered left side of body at fifth cervical vertebra just internal to transverse process, and passed through body into spinal canal, where it was found less than one inch above the upper line of our operation. Unfortunately in removing ball the cord was so destroyed by the assistant that it was impossible to tell anything about the character of the original lesion.
The interesting feature of the case is the absence of those symptoms which would be expected from injury in this region, namely: (1) paralysis, almost complete in arms; (2) dyspnoea and diaphragmatic breathing; (3) difficulty of speaking and weakness of voice. The hyperpyrexia which occurred too soon after injury to be septic, is usual, however, in injuries to the lower cervical region, and should have been a partial guide.
Most physicians, as they grow greater in skill, grow lesser in their religion.-Massinger.
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The late James Adams Allen, many years Professor of Medicine in Rush Medical College and still familiarly spoken of as "Uncle Allen" by hundreds of medical men in the Northwest, used to say that he could not understand how so good and great a man as Moses Gunn, who occupied the chair of surgery in the same institution, could be satisfied to do the "carpenter work of medicine." In those days the surgeon was looked upon as a mechanic, skilled in cutting living tissues, while the practitioner of medicine, it was held, must be quite a philosopher in order to succeed; but the developments of modern surgical pathology have made it necessary for the man who would succeed in doing well the "carpenter work of medicine" should be even a greater scholar and a more profound philosopher than his confrere who declines the use of the scalpel, but wields the stethoscope and clinical thermometer.
One of the most important papers read at the last meeting of the National Association of the Railway Surgeons was that contributed
by one of Chicago's younger surgeons, Dr. Albert I. Bouffleur, which we publish in this issue. This paper is certainly a demonstration of the fact that operating is not all of surgery, and that many useful limbs may be saved by refraining from operation. It also demonstrates that the successful, conservative surgeon employs the highest skill and must possess the very best of judgment. He is, indeed, a philosopher and the work which he does is not the "carpenter work of medicine."
Dr. Bouffleur's paper contains, we think, several serious lessons, which all younger surgeons, especially, will do well to heed. We would particularly emphasize the following:
"One need not look far to find surgeons who are performing amputations on the same principles that were taught decades ago, when the effects of the ever-present suppuration made conservatism and attempts at restoration of function worse than useless-dangerous. The old argument that delay meant sepsis and that sepsis left death in its wake, should surely not be given much weight in these days of enlightenment. Antiseptics and drainage have eliminated all danger of serious results from the reasonable postponement of an amputation. The surgeon who practices on the basis of modern bacteriological knowledge, does not fear the slight toxæmia which results in all cases when dead or dying tissue is left in contact with the living.
"There can be no doubt, it seems to me, that an amputation is only indicated in traumatic surgery when the soft parts are so crushed and disorganized that repair of the injury is absolutely impossible, or if it should take place the injured member would be useless.
"While it is true that in many cases we can decide at once as to the necessity for amputation, yet in a large number of cases it is absolutely impossible to formulate a positive opinion until at least 24 and possibly 48, or even more, hours have elapsed. I desire to emphasize the fact that, while the general condition of a patient is manifested by signs and symptoms which admit of reasonably accurate interpretation, the indications as to the extent of the local injury are so uncertain and unreliable that a limb which presents all the clinical evidences of death may in a few hours glow with the warmth and color of life.
be held in Lexington, Ky., on the last Tuesday in October, 1897.
The annual meeting of the New York State Association of Railway Surgeons, under the presidency of C. S. Parkhill of Hornellsville, will be held on November 17, 1896, at the Academy of Medicine, New York City.
C. B. Herrick, Troy, N. Y., Secretary. Obligation of Professional Secrecy.
The Kitson-Playfair sensational suit continues to receive marked attention from the medical press of this country and England. Such a subject must always be of great interest, to physicians. The views expressed regarding this celebrated trial are almost as diverse as the writers.
The Northwestern Lancet of June 1, 1896, in commenting editorially, finds the best statement of the case to be that made by a writer to the Times, who maintains that the "knowledge gained by the doctor in the pursuit of his calling is not something confided to him to be used at his own discretion for the best welfare of society in general, but a confidence made to a physician by a patient as simple information furnished for one particular purpose; that is, that the physician may be able to give the disease, be it mental or physical, the best treatment." Here is a definition that may be commended to the medical profession. It covers the ground completely and without ambiguity, as far as the question of moral obligation is concerned. The legal obligations that apply to professional secrecy vary in different countries, and it goes without saying that they must be observed, and that there is no breach of confidence in disclosures required by law, such as the notification of contagious diseases, since people have no excuse for not knowing that such laws exist, and when they make their revelations to the doctor they do so with the understanding that he will give the legal notification. There are many situations where the physician must exercise his own judgment, but with such a leading principle in mind as that given above he is not likely to go far astray.-Medicine.
Medicine Up To Date.
Physician of the New School (after turning X-ray on the patient)—Your case is a somewhat complicated one. There is slight trouble with your left lung, and I observe enlargement of the liver and fatty degeneration of the heart. Kindly hand me that $2.54 in your right-hand trousers pocket and I will prescribe for vou.N. A. Medical Review.
Extracts and Abstracts. time to time. However this may be there are
so many sources of infection in these syringes (exploratory aspiration of pus, for instance), and absolute asepsis when making injections is so much to be desired, that I am certain that this simple procedure will find wide employment.-Medical News.
The Sterilization of Hypodermic and Other Syringes by Boiling.
BY CHARLES A. POWERS, M. D., OF DENVER, COLO.
However simple and efficient may be our present aseptic technic, there yet remain many minor details in which our methods fail to give entire satisfaction. We have hitherto been unable to sterilize injection syringes in which the piston and washers are made of leather. This difficulty is now, however, happily overcome by Hofmeister of Tübingen, who, in the Centralblatt f. Chirurgie, July 4, 1896, sets forth a method by which we may render these important instruments absolutely aseptic.
His procedure rests on the principle that leather may be boiled at will in plain water after previous hardening in a formalin solution. The plan is as follows:
1. Only such syringes may be sterilized as consist of glass, metal and leather. The metal parts must be united by solder or screws, rather than by cement.
2. The piston and washers are removed and freed from lubricating fat by ether.
3. They are then placed in a two to four per cent formalin solution for twenty-four to fortyeight hours.
4. After the formalin has been washed off, the syringe may be put together and is then ready for boiling.
5. All air should be removed by working the piston back and forth while under water; the syringe may then be boiled at will in plain plain water (thirty minutes should suffice).
I have thoroughly tested this procedure on a number of hypodermic, exploratory and aspiration syringes, and can verify Hofmeister's statements in every particular.
Apparently the only change which the leather undergoes is a darkening and a slight thickening. Previous to immersion in the formalin solution, it may be well rubbed with gauze, dipped in ether and after sterilization, it is to be again lubricated with sterilized oil. If the piston consists of two pieces of leather separated by an oil-space, I have found it well to insert the first of these in the glass barrel before boiling. A moderate swelling of the leather may necessitate trimming its edge with a sharp knife.
I have put an ordinary hypodermic syringe through this sterilization process four times, at intervals of two days, without apparent change in the leather. What its limitations are as regards repetition, time will determine. It may be that the leather will have to be removed from
Case of Traumatic Tetanus Successfully Treated With Veratrum Viride and Gelsemium.
In a recent issue of the Medical News Dr. Fordyce Grinnell of Pasadena, Cal., reports the following interesting case:
Guy B., a boy, aged six, while playing in his yard, barefoot, cut the ball of his left foot on a piece of glass. The wound apparently healed. Some nine days after (April 14), he complained of stiff jaws and difficulty in swallowing. These symptoms increased until, on the night of the 16th, tetanic spasms began to manifest themselves. The cicatrix of the wound was cleaned and scraped. It seemed somewhat tender on pressure, but no foreign body was discovered. The site was scarified, however, and turpentine and oil applied, and four-grain doses of ammonium bromid were given every two hours.
As no perceptible improvement was noted, on the 17th Norwood's tincture of veratrum viride was given, at first one drop every hour, then two drops every hour. As this did not seem to prevent the return of the spasms from time to time, fluid extract of gelsemium was given, at first in drop doses every hour, in conjunction with the veratrum, then in two-drop doses, and finally in three-drop doses. The veratrum was also increased on the 20th to three drops every hour, so that the child was taking three drops each of the veratrum viride and the gelsemium every hour, and it seemed to require this amount to control the spasms. This dosage was continued for forty-eight hours. Only once during this time did it produce active vomiting, or sufficient nausea to require an opiate to control it. When this relaxed condition was obtained, the drops were decreased to two of each on the 22d, and on the 25th to one of each, which was continued until the 27th, when the interval was lengthened to two hours, and gradually thereafter discontinued.
dies in such doses. It seemed to require these doses to control the conditions producing the tetanic spasms. The instructions were to decrease the amount and frequency of dose when distinct signs of nausea appeared or the signs. of convulsions abated.
I had been led to think that veratum viride might prove a valuable remedy in traumatic tetanus, as it had done in puerperal and other convulsions, and that gelsemium, in its peculiar action in causing relaxation of the muscles of the jaw, might prove a valuable adjunct, and in this case these remedies did not disappoint.
(380) Suture of the Heart.
Cappelen (Norsk Magazin for Lægevidenskaben, March, 1896), reports the following case: A man, aged 24, had some hours before admission received a stab from a knife in the left side. He went home alone, and about an hour afterward was found lying in a pool of blood. He was brought to the hospital in a cab, and on admission was found to be unconscious; the pulse could not be felt, but pure, though weak, heart sounds could be heard to the right of the sternum, on a level with the fourth rib; the impulse could not be felt. In the fourth left intercostal space, in the middle axillary line, parallel with the rib, was punctured, non-bleeding wound c.cm. long. After a camphor injection the patient began to breathe and the pulse could be felt. The left side of the chest did not move in respiration. Under chloroform narcosis a resection of the fourth rib was made after enlarging the wound. The pleural cavity was filled with partly liquid, partly coagulated blood, compressing the lung. After After evacuating the blood, which was estimated to be about 1,400 c.cm., the lung dilated and was found not to be wounded. By resecting 5 cm. of the third rib a wound 1 cm. long could be seen on the pericardium, bleeding freely. The sac was filled with coagula, and on enlarging the opening a wound 2 cm. in length was seen on the left ventricle, causing the bleeding. The wound was sutured and an artery tied, after which the hemorrhage ceased. The needle was brought half way through during a contraction and then dropped, and when the heart dilated after a second contraction the point was grasped and the needle brought completely through. The suturing was made very difficult by the rythmic movements of the lung, which covered the whole operating field, and by the heart contractions, which, however, were perfectly regular and quiet all the time. The pericardial cavity was emptied of clots as far as practicable. The pulse after the operation was very quick and feeble, but improved after a
subcutaneous saline injection. The patient sank gradually, however, and died two and a half days after the operation. At the necropsy it was found that a large branch of the coronary artery had been wounded; the wound had begun to heal, but there was evidence of pericarditis, and various bacteria were found in the fibrous exudation. The knife had passed through the pleura in front of the lung without wounding it, and again through the pleura and pericardium into the heart.-British Medical Journal.
The Treatment of Fractures.
The subject of fractures (says Dr. Andrew J. McCosh, Medical News, July 11) has in recent years, in this country at least, been somewhat overshadowed by the advances in operative surgery. American surgeons have however, always manifested a keen interest in the repair of fractured limbs, and many of the most important methods for the treatment of this class of cases have been devised and perfected by them.
For the treatment of fractures of the lower extremities two new methods, or, rather, modifications of old methods, have been recently proposed in Europe and have already been employed to a considerable extent in the United States. Each of these possesses features of novelty and also. of practical utility. Each is worthy of more extensive trial.
The first is the method of "massage and mobilization," which has been systematized and strongly advocated for the past six years by Lucas Champonière. He claims that this method is revolutionary and paradoxical, and one absolutely new and contrary to the theory and practice of surgeons. Such terms are, however, extreme, for the plan is not entirely novel, though it has never before been carried into execution in such a systematic and thorough manner as is advocated by this surgeon. According to this method, immobilization of the limb is avoided. Massage is begun at once the sooner the better-and employed daily until the bones have united. The seances, as a rule, last fifteen to thirty minutes. At first the manipulations must be gentle, and pressure should not be made directly over the ends of the fragments. In the intervals the limb is supported merely by a flannel bandage evenly, but not tightly, applied by sandbags alone. Splints or other immobilizing apparatus are not employed. The claims advanced for this method are: Rapid disappearance of pain and swelling, prevention of and more rapid absorption of the oedema and infiltration of the soft parts and of the effusion in the joints, preservation of muscular nutrition, and the more rapid formation of a firm callus. As a consequence, the fracture is followed by but little stiffness of either muscles, ligaments, or