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joints, and as soon as the bone is united the function of the limb is fully restored and the patient thus saved weeks or months of pain, stiffness and disability. In certain cases, however, the originator of this plan grants that his treatment cannot be carried out in all its details. When the mobility of the fragments is so great that there is danger of a permanent deformity, or when the ends are so sharp that manipulation is apt to produce repeated trauinatisms of the soft parts, or where the vitality of the skin has been endangered on account of the severity of the injury, the use of massage should be postponed for a week or two and the limb may be even confined for a few days in splints. There can be no question but that in certain cases this plan of treatment possesses advantages over the recognized treatment by complete immobilization. For example, in fractures of the radius or of the fibula, the period of inability will probably be considerably shortened. It is not, however, a safe method to employ in every case of fractured leg. The risk of bony deformity is probably increased, and it is very doubtful if either the patient or surgeon will be satisfied with a crooked limb even at the expense of a shorter and an easier convalescence. In many cases this method must prove a dangerous one, and it therefore cannot be recommended for routine practice.
The other method is the so-called ambulatory plan of treatment for fractures of the lower extremity, but especially of the leg. The method is not entirely novel, for at different times it has been used by surgeons in this city, though perhaps not in the systematic manner in which it is now practiced in Holland, Germany, and in our own country. Plaster of paris has always been largely employed in this country, and has been especially popular in New York and Boston, in which cities, indeed, its use has been for many years almost universal in the treatment of fractures of the leg. The fracture box has happily disappeared, and in most of our city hospitals is not to be found in the surgical armamentarium. According to the ambulatory plan of treatment, the use of the plaster splint is carried to a still greater state of perfection. It is claimed that the patient can get out of bed a few days after the accident, and can walk at the end of the first week, with the assistance of one crutch or a cane. About twelve years ago, it became the custom of several surgeons in this city to encourage their patients to get out of bed as soon as possible, and often they would be able to walk on the injured limb at the end of a week or ten days. This plan, however, which only differed in a few details from the method now called the ambulatory, seemed to have fallen into disuse, in part, perhaps, due to the custom in our hospitals of handing over
the treatment of fractured legs to the hospital internes, many of whom have habitually enveloped the limbs in rolls of cotton underneath the plaster. The ambulatory treatment, as systematized at the present day, consists in the use of a plaster splint snugly applied, without the use of cotton on the leg, but with this addition: that on the sole of the foot, underneath the splint, is placed a pad of cotton about threequarters of an inch thick and slightly deeper at the heel. This splint grasps the leg firmly about the bony prominence, especially at the upper part of the leg and head of the tibia. The leg thus hangs suspended to a certain extent in the splint, the greater weight being borne on the bulging part of the leg below the knee, the sole of the foot being separated from the splint by the pad of cotton. The principle is the same as that taken advantage of in the use of an artificial limb, though, of course, the avoidance of pressure at the end of the limb is less perfectly accomplished. In a few cases this splint can be applied immediately before swelling has resulted. Generally, however, this is impossible, and it is then wise to delay its application for four or five days, so that it may not be rendered unserviceable by the shrinkage of the limb. The short period of confinement to bed and the preservation of muscular nutrition are the main advantages of this plan of treatment, and as a result the general condition of the patient remains good and his period of invalidism is much shortened. It is not, however, a method adapted for all cases. In a considerable number the pain is so great that the patients cannot walk; in others, the weight of the splint or timidity prevents locomotion. In some cases the shape of the upper part of the leg prevents proper support; in others, the obliquity of the fragments is such that there is considerable risk of overriding and ultimate shortening, and in still others, the laceration and contusion of the soft parts is too severe to warrant the early application of the splint. Experience seems to show that the ambulatory splint can be used with distinct advantage in from 30 to 40 per cent. of simple fracture of both bones of the leg and in nearly all cases of fracture of the fibula. The same principle may be occasionally employed with advantage in the treatment of fracture of the knee, though, of course, the apparatus must be of a different pattern.
One fact must not be forgotten in the trial of new methods—that is, that there is no class of cases, either in surgery or medicine, where the medical attendant is liable to meet unjust criticism or suits for malpractice as in cases of fractures where a perfect result has not been obtained. Caution, therefore, should be exercised in the employment of methods which have not received the general sanction of surgical authorities.
The Hippocratic Oath.
Under the above title Dr. W. S. Brown of Stoneham, Mass., writes as follows of the Kitson-Playfair case in a recent issue of the Times and Register:
The recent trial in London, Kitson vs Playfair and wife, opens up a serious question for the medical profession to answer, namely, is a physician justified, under any circumstances, in revealing a secret confided to him? The defendant, Dr. William S. Playfair, is a professor of obstetrics in King's College, London, with a lucrative practice in fashionable circles; and the jury has awarded the plaintiff, Mrs. Kitson, damages amounting to $60,000, for betraying a professional secret. The circumstances are briefly these: Mrs. Kitson is an Australian lady, wife of Mr. Arthur Kitson, the husband's reputation for morality being rather below par. At all events, the lady has had four or five miscarriages, and has been under some doctor's care most of the time since her marriage. She came to England alone, towards the end of 1892. Latterly she was attended by Dr. Williams, who called Dr. Playfair in consultation. On February 23, 1894, she was placed under chloroform, and examined by both practitioners. Dr. Playfair, during the legal trial, testified that "he found the neck of the womb dilated to the size of a five-shilling piece." He found a spongy mass inside, which "he at first took to be an intra-uterine cancerous growth. The mass was not growing from the interior of the womb, and it was easily scooped out and removed. On removing the mass, he specially examined it, and found it to be a small portion of fresh placental tissue, of a spongy consistence, and containing fresh blood in its interstices. He said to Dr. Williams, 'she must certainly have had a recent miscarriage.' The mass removed was not a blighted ovum."
This last remark referred to a statement by Dr. Spencer, professor of midwifery in University College, London, who was "of opinion that the body removed in February, 1894, might have remained in the uterus since October, 1892. What witness was shown was a piece of a dried blighted ovum."
Dr. Playfair also testified that "the plaintiff had told him, prior to the operation, that she had not menstruated since December, or thereabouts, and that menstruation had always been regular." During the cross-examination he stated that "he had formed an opinion adverse to the honor of the lady on February 23, and still holds it."
I do not propose to discuss the legal aspect
of this case; but, there are two or three points which require to be taken into account in forming an opinion as to its medical bearings. The husband, Mr. Arthur Kitson, is a brother of Dr. Playfair's wife. The sum claimed as damages was only $25,000, and the jury gave a verdict for $60,000. On account of relationship, Dr. Playfair made no charges for his professional services.
I do not know whether Dr. Playfair ever took the Hippocratic oath or not. Oaths (except profane ones) are going out of fashion nowadays, and with good reason. They are a remnant of barbarism. For no honest man is more likely to tell the truth after swearing to do so than before; and dishonest men do not usually stick at trifles. Here is a verbatim copy of the Hippocratic Oath, taken from the Sydenham Society, edition of the works of Hippocrates:
"I swear by Apollo, the physician, and Esculapius, and Health, and All-Heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation-to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and, in like manner, I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Just whatever houses I enter I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, if freemen and slaves. What-ever, in connection with my professional practice, or not in connection with it, I see or hear in the life of men which ought not to be spoken of abroad, I will not divulge as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all men, in all
times! But, should I trespass and violate this Oath, may the reverse be my lot!"
The Hippocratic Oath (minus its Pagan and local features) is no longer administered to medical graduates; but its essential principles are as worthy of observance to-day as they ever were. Is a physician justified, under any circumstances, in revealing a secret confided to him professionally? I reply, no, emphatically no! And there are at least two good reasons which seem to me to settle the question.
First, the uncertainty of histological and pathological evidence. Here we have two obstetricians, occupying chairs in celebrated London colleges-not tyros, but experienced, talented teachers-one of whom testifies that a spongy mass, removed from the uterus, is a piece of fresh placental tissue, and the other that it is a piece of a blighted ovum! Since the trial, a writer, in the British Medical Journal,
"Chorionic villi are very prominent, prettylooking objects, when seen in microscopic sections, but it is not always that we can swear to them. Other structures may simulate them. Admixture with blood may partly destroy the villi, and greatly modify their appearance. The very nature of the placenta offers great difficulties for evidence of the kind required for legal evidence."
* * *
I admit that cases occur in which the proofs of conception are decisive; but it is surely our duty, in all doubtful cases, to give our patient the benefit of the doubt, and keep the suspicion. to ourselves I think that a physician is not even justified in expressing his suspicions to a consultant He should first be absolutely sure. A woman's moral character should not be impugned on the doubtful evidence of microscopic sections.
Second, the notorious uncertainties of the law itself. This very trial demonstrates the unreliability of legal opinions. The lawyers on both sides wriggled through a quagmire of doubt. In every case, a conscientious man must make up his own mind what his duty is, and be governed by that, regardless of legal consequences. It would be better to go to jail for "contempt of court," than go to Coventry for betraying a patient's secret. During this trial, the question was raised whether Dr. Playfair was not privileged to tell his wife, as a family secret. I hold that a secret ceases to be a secret at all when told to anybody; and the last person a physician should gossip to is his own wife.
The essence of the Hippocratic Oath is embodied in the French law, which makes "the betrayal of professional confidence a punish able offense." In the state of New York, the law says, "No person duly authorized to practice physic or surgery shall be allowed or
compelled to disclose any information which he may have acquired in attending any patient in his professional character." I am told that there is no special law in Massachusetts anent betrayal of professional secrets; but the injured party could prosecute under the common law.
In this comparatively enlightened period, physicians do not need an oath to induce them to keep professional secrets; most of them do so. If a medical practitioner is not prompted to remain silent from a sense of honor, he is likely to do so from a sense of pocket; for a man must be a fool who habitually lets out his patients' secrets.
As far as law is concerned, I do not see why we are not as much entitled to professional privilege as lawyers or Catholic priests. A lawyer is not compelled to divulge his client's confession; neither is a priest. I claim that our profession is as necessary to public welfare as either law or religion-in some respects more so—and that it should be our privilege, as it is our duty, to keep the essence of the Hippocratic Oath.
To Drive Away Flies.
Dr. H. S. Baketel of Derry, N. H., writes: "Many practitioners of medicine among the poorer classes are greatly annoyed by flies in the sick room. The annoyance to the patient is doubly great. Such, at least, was my experience not long since on New York's great east side. An excellent safeguard against these pests is the sweet-pea flower. The Lathrus maritimus, the purple variety, grows near the seacoast from New Jersey around to Oregon, and beside the coasts of the Great Lakes. The Lathyrus ochroleucus is found on the hillsides from New England to Minnesota, and even further West. It is distinguished by its small, yellowish-white flower. Either of these varieties can be grown in the sick room, and the sweet odor emanated seems very offensive to the ordinary house fly."
Silver in Surgery.
Although the ophthalmic surgeon has long recognized the efficacy of silver as an antiseptic, Professor Credé of Dresden has recently presented the further claims of this metal to the attention of the general surgeon. Lactate of silver is an excellent germicide, but its easy solubility (in fifteen parts of water) renders it rather dangerous as a dressing. The citrate, however, is only soluble in 3,800 parts of water, and is therefore quite safe. It is found that a dilution of silver of even 1-80,000 still retains appreciable antiseptic qualities, while a solution of sublimate weaker than 1-20,000 is worthless. A novel suggestion is the use of
thin sheets of metallic silver spread upon linen cloth as a protective dressing in surgery. It is claimed that even in the occurrence of suppuration, the action of the products of the bacteria produces a lactate of silver, which prevents their further development.-Medical News.
The Employment of Asbestos for Dressings.
The Union médicale for July 18 contains an abstract of a review of a report made by Mr. Volintzeff to the Surgical Society of Moscow, which was published in the Gazette des hôpitaux. The results of the author's investigations are summed up as follows: The density of this product is much greater than that of cotton or of tarlatan; it is less porous than either of them and less hygroscopic. The escape of vapors takes place more slowly under a dressing of asbestos than under all others. It is not as good a conductor of heat as cotton is, but on this point, says the writer, the results of the investigations are not yet perfectly satisfactory. Asbestos absorbs the albuminoid solutions better than absorbent cotton or tarlatan does. In regard to the clinical observations, says the writer, M. Volintzeff thinks they are yet too small in number to enable him to give a definitive judgment. The product is not expensive, because it may be used several times.
The Right to Practice in England on an American Diploma.
An English court has recently decided that an American physician with a genuine diploma from a recognized medical school is at liberty to practice medicine in Great Britain, but must not assume any titles implying that he is a registered British practitioner. The case was that of an American who appended to his name the letters, "M. D., U. S. A.," and the court held that there was no attempt to claim qualifications other than those implied. The Medical Defense Union, which undertook the prosecution, was condemned to pay costs amounting to about £800.-The Medical Record.
lodide of Starch in Surgery.
Majewski (Wiener med. Presse, 1896, No. 19; Centralblatt für Chirurgie, August I, 1896) recommends iodide of starch as an excellent application in suppurating and neglected wounds, phlegmons, panaritia and venereal sores. A mixture of one part of tincture of iodine and two parts of starch, he says, exceeds iodoform in antiseptic action and in controlling suppuration. It is exceedingly hygroscopic, almost odorless, and very agreeable.
Notices and Reviews.
The Stomach; Its Disorders and How to Cure Them. By J. H. Kellogg, M. D. Battle Creek, Mich., 1896. It perplexes one to know just how to take this book, whether as a book intended primarily for physicians or for patients. If for the former it is in most respects a failure. The crude cuts, the crude and half-complete description of physiological processes, the condensed quiz-compend style used in relating the symptoms of disease, make it of no value to a physician who has studied physiology, anatomy and the rudiments of practical medicine. Some of the hints as to treatment and the more accurate diagnosis of digestive failures of the stomach, are not without value to the practitioner. Nor is the book much more of a success if it is intended for the patient as a "home physician." In the preface the reader is evidently regarded as a layman: "The individual who wishes to make use of this work as a means to his own recovery, must first of all carefully read the entire work. He should then seek, either with or without the aid of a physician, to arrive at a correct diagnosis of his case. If possible, the services of a skilled physician should be employed, a test meal taken and the methods of examination described on pages 134, 320 and 352, utilized. *** The nature of the disorder being determined, it will be easy, by the aid of the table of contents or the index, to turn to the section which deals with this form of digestive disturbance; and then having become familiar with the causes of the trouble, and the means of preventing its aggravation, such rational methods of treatment as will be efficient, and it is believed, successful in a majority of cases, may be carried out at home." We predict that if the average dyspeptic reads these pages he will be sure that he has in turn, ulcer of the stomach, cancer, all the forms of dyspepsia, five, we believe, are described, dilated stomach, etc., etc., and that the only sure way of saving his life is to rush to the Battle Creek Sanitarium and have Doctor Kellogg put in charge of his case.
Many of the directions, e. g., the diet lists, the use of baths, the simpler massage movements, will be valuable in the home treatment of patients. Some, e. g., many of the mechanical Swedish movements, and the low tension sinusoidal current, will be extremely perplex
ing, to say the least. He will have some difficulty, too, in understanding what is meant by the elaborate methods of examining the stomach contents, "coefficients of digestive work," the classification of functional disorders of the stomach (p. 144), etc.
Some of the cuts are good, particularly those showing massage and Swedish movements. Others are wretched, e. g., the ones on pages 50 and 30. The plate opposite page 128 intended to initiate the layman into the mysteries of bacteriology, shows twenty-eight kinds of micro-organisms. If the plate is taken from someone else, it should have been so stated, for as it is, we have to make Dr. Kellogg responsible for giving us representations-and not very good ones at that-of "micrococci arranged in groups of four, found in the sputa of consumptive patients," the "bacteria termo," "bacterial termo" and "bacterium aceti," the "bacillus of malaria, found in the blood in cases of malarial fever."
On the whole, the book will, we believe, add to Dr. Kellogg's reputation with the laity. But it will add little or nothing to the respect in which he is entitled to be held by the great body of practitioners because of his unusual natural ability, the good scientific work he has done, his wonderful versatility, his far-reaching and whole-souled charity. J. B. H.
A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D. Philadelphia, Penn.: W. B. Saunders, 1896.
This is one of Saunders' New Aid Series, and is a credit to both author and publisher. Upon the whole, it is one of the best manuals of obstetrics we have seen and should prove of value to students and practitioners alike. Instead of the usual arrangement into chapters, the work is divided into two parts, Part I being devoted exclusively to physiologic obstetrics, and Part II to pathologic obstetrics. To the former is given 200 pages, while the bulk of the work, about 500 pages, is devoted to pathologic obstetrics. In each part the subjects are systematically arranged, and “reference is made easy by a system of paragraphing, italicizing and numbering." The author has introduced into the text quite a number of tables for differential diagnosis, which add considerable value to the book. The illustra
tions and diagrams, of which there are a large number, are in the main very good. We notice a number of excellent cuts, showing the various positions and presentation, which are reproductions, reduced in size, of original drawings used in Doederlein's manual, published in 1893, and for which no credit is given. We cordially recommend Dr. Dorland's manual as one that is up to date, and that would prove of value to students as a guide to the study of obstetrics, and to the busy practitioner as a reliable work of refer
At the last meeting of the American Neurological Society, Dr. Bert G. Wilder presented the report of the Committee on Neuronymy.
Among the recommendations of the committee were:
1. That the adjectives dorsal and ventral be employed in place of posterior and anterior as commonly used in human anatomy, and in place of upper and lower as sometimes used in comparative anatomy.
2. That the cornua of the spinal cord and the spinal nerve roots be designated as dorsal and ventral rather than as posterior and anterior.
3. That the costiferous vertebræ be called thoracic rather than dorsal.
4. That the hippocampus minor be called calcar; the hippocampus major, hippocampus; the pons Varolii, pons; the insula Reilii, insula; pia mater and dura mater, respectively, pia and dura.
5. That, other things being equal, mononyms (single-word terms) be preferred to polyonyms (terms consisting of two or more words).
A Remedy for Black-Eye.
There is nothing to compare with the tincture of strong infusion of capsicum annuum mixed with an equal bulk of mucilage or gum arabic, and with the addition of a few drops of glycerine. This should be painted all over the bruised surface with a camel's hair pencil and allowed to dry on, a second or third coating being applied as soon as the first is dry. If this is done as soon as the injury is inflicted, this treatment will invariably prevent blackening of the bruised tissue. The same remedy has no equal in rheumatic sore or stiff neck.— Medical Progress.
The honorary degree of Doctor of Medicine has been conferred upon Bismark by the University of Zena.