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Notices and Reviews.

The American Year-book of Medicine and Surgery. Being a yearly digest of scientific progress and authoritative opinion in all branches of medicine and surgery drawn from journals, monographs and text books of the leading American and foreign authors and investigators. Collected and arranged with critical editorial comments by J. M. Baldy, M. D., C. H. Burnett, M. D, Archibald Church, M. D., C. F. Clarke, M. D., J. Chalmers Da Costa, M. D., W. A. N. Dorland, M. D., V. P. Gibney, M. D., Homer W. Gibney, M. D., Henry A. Griffin, M. D., John Guitéras, M. D., C. A. Hamann, M. D., H. F. Hansell, M. D, W. A. Hardaway, M. D, T. M. Hardie, B. A., M. B., C. F. Hersman, M. D., B. C. Hirst, M. D., E. Fletcher Ingalls, M. D., W. W. Keen, M. D., H. Leffmann, M. D., V. H. Norrie, M. D., H. J. Patrick, M. D., William Pepper, M. D., D. Resman, M. D., Louis Starr, M. D., Alfred Stengel, M. D., N. G. Stewart, M. D., and Thomson S. Wescott, M. D., under the general editorial charge of George M. Gould, M. D. Profusely illustrated with numerous wood cuts in text and 33 handsome half-tone and colored plates. Philadelphia: W. B. Saunders, 1896. Pp. vi-17 to 1183. Price $6.50.

In the preface to this magnificent summary of the year's progress, the editor says: "The general design of the work is to give physicians in a compact form an annual epitome of the new and progressive medical truths or suggestions published during the months of the preceding year from July to June inclusive. It is at present almost or entirely impossible for the specialist, even as regards his own department, to keep himself conversant with the tremendous literature in all languages and in a thousand periodicals." The editor goes on then to draw a distinction between a “summary of medical progress" and the "literary review of all published matter," and adds briefly that he has not attempted the latter problem. Indeed, he says, "Thousands of excellent articles have not even been mentioned, because our task has been to epitomize our knowledge. not to review text-books (unless containing original researches, new suggestions, and so on) or to abstract articles not written for the sake of new truth. We have aimed only to mention those ways that are or may be contributory to the progress of medical science and art." That the design has been fully and satisfactorily carried out goes without saying when we have said that Dr. George M. Gould is the editor and that the following gentlemen have assisted him:

General medicine is cared for by William Pepper, M. D., and Alfred Stengle, M. D., both of Philadelphia; surgery by W. W. Keene, M. D., and John Chalmers Da Costa, M. D., both

of Philadelphia; obstetrics by Barton Cook Hirst, M. D., and W. A. Newman Dorland, M. D., of Philadelphia; gynecology by J. M. Baldy, M. D., and W. A. Newman Dorland, M. D.; pediatrics by Louis Starr, M. D., and Thompson West, M. D., of Philadelphia, Pa.; nervous and mental diseases by Archibald Church, M. D., and Hugh J. Patrick, M. D., of Chicago, Ill.; dermatology and syphilis by William A. Hardaway, M. D., and C. Finley Hersman, M. D., of St. Louis, Mo.; orthopedic surgery by Virgil P. Gibney, M. D., and Homer W. Gibney, M. D., of New York City; ophthalmology by Howard F. Hansel, M. D., of Philadelphia, Pa., and Chas. F. Clark, M. D., of Columbus, O.; etiology by C. F. Burnett, M. D., of Philadelphia, Pa.; diseases of the nose and pharynx by E. Fletcher Ingalls, M. D., and T. Melville Hardy, B. A., M. D., Chicago, Ill.; pathology and bacteriology by John Guitéras, M. D., and David Riesman, M. D., of Philadelphia, Pa.; materia medica, experimental therapeutics and pharmacology by Henry A. Grffin, M. D., and Van Horne Norris, M. D., both of New York City; anatomy by C. A. Hamann, M. D., of Cleveland, O.; physiology by J. N. Stewart, M. D., of Cleveland, O.; hygiene jurisprudence and chemistry by H. Leffmann, M. D., of Philadelphia, Pa. The departmental editors have not only made wise and judicious selections of material, but have in most cases given careful and studied criticism of the new suggestions and have passed the needed judgment upon matters in dispute. The department of general surgery, under the skilful handling of Drs. Keen and Da Costa of Philadelphia, is wonderfully complete and well written, and the critical comments of these able teachers make it delightful reading. The entire work is well illustrated, but chiefly with simple wood cuts. The paper and press work are excellent and no physician can afford to be without the book. The chapter on general surgery alone is worth twice the cost of the book.

Rhymes of the States, by Garrett Newkirk, M. D., with drawings by Harry Fenn, after sketches by the author. New York: The Century Co., 1896. $1.00.

It is with peculiar pleasure that we acknowledge the receipt of this little volume for review, for every physician will certainly be glad to know that one of our number has written so

helpful a book for our children. Dr. Newkirk says in his preface: "It is no easy task to fix in mind the location, outlines, physical features and historical record of all the states of our American Union. The author has tried to reduce all these distinctive facts into the form of

simple rhymes, easily impressed upon the memory, and accompanied by pictures which illustrate the ideas contained in the verses."

The verses are extremely simple but wonderfully descriptive. The sketches are truly artistic and many are particularly apt and suggestive and will undoubtedly aid greatly in impressing the geographical and historical facts upon the minds of the youngsters for whom they are intended. Besides an outline map of each state, making prominent the name and location of the capital and other chief cities, there is given a caricature sketch of some animal or other object which the state might be said to resemble in form. In addition to the verses and pictures, which have appeared in St. Nicholas during the past two years, certain prose statistics are now published, greatly enhancing the value of the work for instructive purposes. Among the facts given in regard to each state are the area, the population, the rank of the state according to population, the number of counties, the representation in Congress, the number of electoral votes, date and location of first settlements, when admitted to the Union, value of chief industries, popular name, etc.

The whole idea is quite unique and the book will be found equally attractive both to old and young. When we consider the number and quality of the illustrations we wonder how it is possible to publish the book for $1.00, for it is handsomely and durably bound and well. printed on heavy calendered paper. The little volume will make an elegant and appropriate gift book and we predict for it a very large

sale.

Blood Lavages in Surgical Infections.

P. Walton (Belg. Med., July 16) reviews this question. Dastre and Loye have shown that a venous injection of salt solution, amounting to even two-thirds of the animal's weight, may be made without accident, provided the entry be slow and well regulated.

At 7 per cent, or even 10 per cent, there is no

toxic dose, but merely a toxic speed of introduction. Bosc and Vedel have shown that the addition of sodic sulphate to the solution has no advantages. By some surgeons enormous venous injections have been practiced. Lejars, in a septicæmic patient, injected 26 litres in five days without grave sequelæ. Michaux injects doses of 1,000, 1,500 and 2,500 grains a day. Péan and the author regard these as the maximum doses to be reached without serious risks, and Péan insists on the superior safety of subcutaneous injections in prudent doses as opposed to intravenous injections. The question of their mode of action is difficult and complex. The first result of either method is to restore arterial tension to the normal, and to lessen the frequency of the heart beats. Secondly, diuresis is markedly increased. Michaux has seen a few slight and immediate consequences, dyspnoea and pain in the side, and in one case, where 2,000 grains were thrown in at once, abundant serous vomitings. Sometimes complaint is made of a feeling of heat and tension. For venous injections, which are preferable if a large quantity of fluid is to be introduced, Michaux uses a glass funnel furnished with a rubber tube, to which cannula No. 2 of Potain's aspirator is fixed. The skin is cleansed antiseptically, a cut made over the median cephalic or basilic vein, which is then laid bare, and its peripheral end closed with Péan's forceps. The cannula, previously freed of air, is introduced into a V-shaped opening made by scissors in the vein. A forcipressure forceps keeps the vein tightened over the cannula. The temperature of the injection varies between 38 and 40 degrees C. As to hypodermoclysis, unless very slowly performed, a painful swelling may be produced in the subcutaneous tissue. By introducing only about a litre an hour this is avoided. The skin of the abdomen is suitable, and a very fine trocar should be used. Colson has used the latter method in two desperate cases with great success. Case I: Male, 28, with articular abscess of right knee, temperature 40.7 C., dry tongue, delirium constant. Free incision, drainage and daily sublimate irrigations, a purgative, alcohol, quinine. After two days the temperature, which had fallen to 38.6 degrees, rose to 40.2 degrees C. Dry tongue, pulse 130, skin dry and burning, urine scarcely a pint daily. Subcutaneous injection of 1 litre of 7 per cent salt solution. Two hours later abundant sweating, sensation of comfort, more abundant urine. The next day the disquieting condition returned. Fresh injection of 1 litre. Renewed improvement of symptoms. The injection was repeated for five days, and recovery ensued. In Case II the results were equally gratifying. Here 16 litres of salt solution were injected in the space of three weeks.-The British Medical Journal.

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VOL. III.

CONTENTS OF THIS NUMBER.

ORIGINAL ARTICLES:

Why the Railroad Surgeon Should Not Try to Practice Aseptic Surgery-By EMORY LANPHEAR, M. D., Ph. D......

Inflammation of Bone-By ANDREW L. FULTON, M. D......

EDITORIAL:

CHICAGO, DECEMBER 1, 1896.

Remarks on Traumatic Neuroses Resulting From Railroad and Other AccidentsBy JOHN PUNTON, M. D...

The Tenth Annual Meeting..

COMMUNICATIONS

NOTES OF SOCIETIES.

NOTES, NEWS AND PERSONALS...

NOTICES AND REVIEWS

PAGE.

MISCELLANY:

The Marine Hospital Service.... Irritable Stump.

313

319

325

331

332

EXTRACTS AND ABSTRACTS:

Persistent Traumatic Dislocation of Both
Hips......

334

Treatment of Rupture of the Kidney..... 334

335

333

333

336 336

Officers of the N. A. R. S., 1896-7.

President.........

.F. J. LUTZ, St. Louis, Mo.

First Vice-President.. W. R. HAMILTON, Pittsburgh, Pa.
Second Vice President....J. H. LETCHER, Henderson, Ky.
Third Vice-President......JOHN L. EDDY, Olean, N. Y.
Fourth Vice-President....J. A. HUTCHINSON, Montreal, Canada
Fifth Vice-President...... A. C. WEDGE, Albert Lea, Minn.
Sixth Vice-President...... RHETT GOODE, Mobile, Ala.
Seventh Vice-President...E. W. LEE, Omaha, Neb.

Secretary..
.C. D. WESCOTT, Chicago, Ill.
Treasurer.....
...E. R. LEWIS, Kansas City, Mo.
Executive Committee:-A. I. BOUFFLEUR, Chicago, Ill., Chair-

man:

J. N. JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa.

No. 14.

WHY THE RAILROAD SURGEON SHOULD NOT TRY TO PRACTICE ASEPTIC SURGERY.

BY EMORY LANPHEAR, M. D., PH. D., ST. LOUIS, MO.

The railroad surgeon should not try to practice aseptic surgery in accidental work! This is perhaps an astonishing position for a surgeon to assume in these days of ultra-asepticism; but I believe it is the correct one. By the term "railroad surgeon" I do not refer to those few men who have all the resources of a modern hospital and who can choose the time, the surroundings and perhaps the field of operation for the cases they are called upon to treat; but to the common, every-day surgeon whose work is forced upon him in emergencies at the time of injury and who is even compelled to attend to his duties at the very place of accident. Under such circumstances is it right for him to rely upon asepsis alone? I answer emphatically, No!

I do not mean to insinuate, as a somewhat facetious member of this association remarked on hearing the title of my paper: "He shouldn't try because he doesn't know how." Far from it. I believe the progressive, earnest workers of this great body are thoroughly familiar with the fundamental principles of asepsis and most of them are competent to carry out the details so essential to success. To be sure there are doubtless a few who occasionally so far lose their presence of mind as to make serious mistakes now and then, such as using an instrument that has been contaminated by handling by somebody whose hands have not been sterilized; stopping to take a chew of tobacco and forgetting to thoroughly cleanse the hands after insertion in dirty pockets; allowing unwashed hands to touch the gauze to be applied to the wound

-a most common source of infection; feeling the pulse in a critical case and neglecting to again sterilize the hands before resuming operative work. All these and other similar derelictions may be noted here and there, for the technique of perfect asepsis such as seen in the work of Joseph Price, for example, is a habit which can only be acquired by long and patient toil, and maintained only by the most careful watchfulness. But I take it for granted that such operators are the exception, not the rule, and that consequently the reason assigned by my friend why the railroad surgeon should not try to practice aseptic surgery is not the correct one.

Further, I do not wish to condemn cleanliness in surgical work. It is, above all other things, the secret of success in our most hazardous undertakings. Indeed, under certain conditions and in certain classes of cases the surgeon must rely solely upon perfect, ideal asepsis to secure perfect results. Notably is this the case in abdominal and cerebral surgery, where, after the incision through the skin has been made, antiseptic agents must be ished. But to obtain the best results in most cases of acute trauma, something more than simple surgical cleanliness, something more than mere hot water, is essential. It is not right to depend upon asepsis alone; and in most of his operative work the modern surgeon has gone too far in attempting to depend upon asepsis alone. Antiseptics of known and tried value have been too hastily discarded in the desire to use nothing but hot water or normal salt solution, "the best antiseptic in the world," as has been erroneously said by some enthusiastic crank. In other words, we have been trying to do "aseptic surgery" where "antiseptic surgery" should have been practiced. Indeed, it has seemed as if in following the fashion set by Lawson Tait and Joseph Price, that is, in trying to apply the rules of abdominal work to general surgery, antiseptics were about to be relegated to "the glories of the past."

I myself have the greatest faith in antiseptics. The reason is not hard to give. I have seen too many cases get well, and without trouble, in the work of surgeons who were positively filthy in their methods, yet who used strong antiseptic solutions, to allow any doubt as to the efficiency of the medicinal

agents employed. Antiseptics and prayer have saved many patients who would have died if the operators had relied upon asepsis alone. More than this, I have seen many times the most favorable termination in cases where dirt was ground into the wound, where death would inevitably have occurred had it not been for the life-saving properties of the antiseptic agents used. An instructive case in this connection was this:

George E., 24 years old, was struck upon the head on the morning of April 2, 1891. During the day he was seen by at least three prominent surgeons of the city, each of whom refused to operate because there seemed to be absolutely no hope of recovery. At about 4 p. m., six or eight hours after the injury, he was still breathing and partially conscious, and Dr. W. S. Allen asked me to see him as I had a reputation for doing operations against desperate odds,-if there was even one chance in a thousand, regardless of my "death rate;" or, as Dr. Allen put it: "You are noted for fixing up a mangled body so it will look well at the funeral." So I saw him at 6 p. m. At that time his appearance was frightful in the extreme. The whole scalp and pericranium were torn away, hanging by a narrow strip less than three inches across near the occiput. In the wound were cinders, earth and grease in such quantities that it appeared as if it never would be possible to clean the surface. The flange of the drivewheel had struck near the coronal suture on the right side, driving the bone down into and badly mangling the frontal convolutions. A fracture extended downward into the orbit gaping widely, and blood was oozing from eye and nose. It was one of those cases of "diffuse injury" in which the text books direct not to operate. Nevertheless he was given a little chloroform by Dr. Callaghan and we proceeded to clean the wound. After scraping off as much as possible of the dirt and blood we industriously scrubbed with soap, water and a stiff brush, dried it and washed with sulphuric ether, then with turpentine, and finally with sublimate solution I to 1,000. We next washed the bone and brain for at least ten minutes with boiled water and then with saturated solution of boric acid. After removing all fragments of bone we trimmed up the brain and dura with scissors, cauterized such bleeding points as would not check on the application of hot water, 115 degrees, applied a very large quantity of iodoform, replaced and sutured the scalp and inserted large drainage tubes. About the orifices of the tubes and along the line of sutures an immense amount of iodoform was dusted and gauze wrung from 1 to 1,000 bichloride

solution used as dressing. Recovery was remarkable. The next evening, April 3, his temperature was 99, pulse 100, no paralysis and but little mental disturbance. The drain was removed on the fourth day, when his temperature and pulse were normal. The next day he insisted upon sitting up and on the fifteenth day after operation he was discharged in perfect health, although there was a very large opening in the skull. There was not a drop of pus visible at any time.

From such cases as this (and this is not an isolated instance) I draw the conclusion that when the operator is not sure there will be no break in the chain of surgical cleanliness, or where there is known infection of the field of operation, in every capital operation antiseptics should be employed in such quantities as to guarantee the safety of the patient. The lesson is more firmly impressed when, in a ward common to several surgeons, I see my patients treated in the manner this one was recovering without a symptom of local infection or inflammation, while upon adjoining beds are patients with wounds reeking with pus as the result of the attempt upon the part of some misguided and careless man who is relying upon so-called "asepsis."

Now do not misunderstand me. I do not mean the exclusion of attempts at perfect asepsis, or as near approach to it as possible in every operation of any magnitude. I believe it the duty of every operator to: Ist, boil all instruments in a strong solution of washing soda (sal soda) before every operation of importance; second, to sterilize his hands by thorough scrubbing for five minutes, drying them and trimming the nails down to the quick; then scrubbing again for another five minutes, then immersing them.

for at least one minute in alcohol, or if that be unobtainable, in turpentine, and finally in bichloride solution for a minute; or by the permanganate of potash and oxalic acid method familiar to most of you; and, third, to prepare the field of operation by practically the same cleansing process. Any surgeon who goes into a major operation without taking these precautions should be deemed guilty of malpractice and held responsible in case of an unfavorable result dependent upon septic processes. I repeat that this process should be gone through even for already infected wounds, but that in addition to it the operator should make use of certain antiseptic solutions

during the progress of operation, for sponging purposes, for repeatedly washing the hands, for irrigation, etc., in every case where the wound is already infected or the possibility of infection during operation may arise.

But, says the skeptical one, why use all these precautions for a wound that is already infected, that already may be filled with pus? There are two reasons, one scientific, the other practical. As to the first, there are two classes of micro-organisms chiefly concerned in the production of inflammation and in pus formation: the streptococcus pyogenes and the staphyllococcus pyogenes aureus, or other variety of staphyllococci. These are entirely different in their mode of action, danger to life of the tissues and in other ways. Now if we have a simple staphyllococcus infection it may amount to little, possibly only to the appearance of what the old authors called "laudable pus" in the wound, and a slight amount of systemic disturbance; but if upon this, by careless methods or want of antiseptic agents, we engraft a streptococcus infection we render the inflammation more spreading in its character and far more dangerous in degree because we have added to the wound that peculiar germ which under certain circumstances gives rise to erysipelas, under others to puerperal sepsis, and other grave disorders. On the other hand if we already have a streptococcus infection, and by our unsurgical measures permit conjoint infection with some of the staphyllococci, which possess strong peptonizing properties, the extensive infiltrate depending upon the streptococci will melt down into pus with wholesale destruction of tissue, perhaps with the development of a fatal septicemia. So the use of strong antiseptic or even germicidal agents is distinctly indicated in wounds produced by accident. As to the second, it gives better results than can be obtained by any other course; as in this case:

George R., of Independence, Kan., was admitted to the Baptist Sanitarium some three weeks ago, suffering with an old, discharging ulcer of the leg, due to trauma. Many ineffectual efforts had been made to heal it, but no cure seemed possible. Examination showed a large amount of dead tissue lying in the bottom of the indolent ulcer, infiltrated edges, a stinking discharge, etc. The ulcer was about one inch wide by two inches long. Under chloroform I shaved the leg, scrubbed the surrounding area and the ulcer itself, after curet

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