« ForrigeFortsæt »
Notes of Societies.
Association of Military Surgeons of the United
The following are the officers of this association for 1896-97: President, Com. Albert L. Gihon, Medical Director, U. S. N. (retired), New York City; first vice-president, Brig.Gen. Edward J. Forster, Surgeon-General, M. V. M. (deceased), Boston, Mass.; second vicepresident, Maj. John Van Rensselaer Hoff, Surgeon, U. S. A., Fort Vancouver, Wash.; secretary, Maj. Herman Burgin, Surgeon, P. N. G., Philadelphia, Pa.; treasurer, Capt. Jas. J. Erwin, Surgeon, O. N. G., Cleveland, O.; editor, Maj. Charles C. Foster, Surgeon, M. V. M., Cambridge, Mass. The seventh annual meeting of the association will be held at Columbus, O., May 25, 26 and 27. 1897. The local committee of arrangements consists of Maj. Henry M. W. Moore, chairman, Assistant Surgeon, O. N. G., Columbus, O.; Capt. James E. Pilcher, secretary, Assistant Surgeon, U. S. A., Columbus Barracks, Columbus, O. Western Ophthalmological, Otological, Laryngological and Rhinological Association.
This society meets in St. Louis, Mo., first Thursday and Friday, April, 1897. Physicians desiring to read papers are urged to send subject to secretary soon. Programmes will be mailed February 1, the profession cordially invited to attend. The Railway Association will give one and one-third fare on the usual certificate plan. Hal Foster, secretary, Kansas City, Mo.
The tenth annual meeting of the National Association of Railway Surgeons will be held in Chicago, May 4, 5 and 6, 1897.
The Treatment of Burns.
Kelly (New York Polyclinic) describes his method of treating burns. He regards the inefficient results obtained so often as due to the non-recognition of asepsis in the management of this class of cases. Indeed, he would make asepsis the fundamental principle in the therapy of burns. He mentions the dry dressing to condemn it as impracticable, for the reason that asepsis cannot be maintained and
that toxic effects are prone to follow. The author's method (for which he claims no originality) is simply a moist dressing, for which he claims the following advantages, namely, that "the materials are all easy of procurement, easily sterilized or impregnated with antiseptics, if required, and are easy of application." Furthermore, the dressing is more efficient in controlling or at least mitigating sepsis, is comfortable to the patient when applied, and its removal is absolutely painless. Asepsis is preferable to antisepsis. Shock is met by using morphia hypodermically. The wound is first irrigated with sterile water (110 degrees) or Thiersch's solution if there be no sepsis present, with bichloride solution (1-1,000) where infection has already occurred, to be followed with sterile water when the surface irrigated is large. Unbroken blisters are never ruptured, as the epidermal covering protects the surface beneath from infection. When tense and threatening rupture they are aspirated subcutaneously with a sterile needle. The dressing proper is adjusted to the different degrees of severity; portions simply hyperæmic are anointed with a five per cent solution of phenol in sterile olive oil, which reduces heat and itching when present; strips of gutta percha tissue previously kept in a two per cent carbolic acid solution. This material may be applied over unbroken blisters to protect them from rupture. Over areas where slough is impending a moist gauze compress is applied, covered with rubber tissue to prevent evaporation. Over all a large thick layer of sterile cotton is laid and held in place with a well-fitting bandage.
The author at this juncture emphasizes the necessity for the same scrupulous cleanliness of hands and instruments as in any aseptic operation, and the maintaining of these precautions throughout the conduct of the case. He advises changing the dressings daily during the first week, after which time every second or third day will suffice. As to iodoform, he regards it as useful but dangerous when applied over extensive surfaces. Grafting may be done after the separation of the sloughs. Where deep losses of substance have occurred, plastic operation by flap with pedicle may be best employed. Few cases require much more than a month for their satisfactory completion.-Buffalo Medical Journal.
Professor Roentgen was the recipient, on November 30, of a medal awarded him by the Royal Society of Great Britain, for his discovery of the X-rays.
Extracts and Abstracts. bumin. The quantity of urine passed in
Successful Abdominal Nephrectomy for Rupture
of the Kidney.
At a recent meeting of the Clinical Society of London, Wallis (Lancet, October 31, 1896, p. 1,229) reported the case of a man, twentytwo years old, who had fallen a distance of twelve feet from a ladder upon a spiked railing. Though collapsed and evidently in pain, consciousness was not lost. The abdomen was rigid and rather distended. On examination it was found that one of the spikes-three inches in length-had pierced the abdominal wall nearly an inch below the tenth costal cartilage on the right side. The opening in the skin ran downward and inward, and the finger passed into the wound could be pushed on into the abdominal cavity. Soon after admission to the hospital the patient passed a pint of healthy pure blood by the urethra. He was at once prepared for operation, and an incision made from the lower end of the punctured wound downward to the right semilunar line. A lacerated wound of the peritoneum came into view, through which the bruised intestines presented. The peritoneal wound was enlarged and large masses of blood clot were turned out of the abdomen. Sponges were inserted and the sides of the abdominal wound held apart by two long silk ligatures. The under surfaces of the liver and the gall bladder were exposed and found intact. The intestines in the track of the wound were bruised and one piece of small intestine presented a tear in the external coats, through which the mucosa bulged. At the bottom of the cavity the kidney could be felt, torn almost in two; blood welled up through the wound at a great rate. The left kidney was found intact in its normal situation. The peritoneum was now divided along the outer edge of the ascending colon, and this portion of the gut pushed in toward the middle line. The left hand was passed in behind the colon, the kidney rapidly freed and brought out of the wound. The ureter was clamped, tied and cut, the vessels were treated in the same way, and the kidney was removed. The deep muscles were considerably lacerated and bled freely. Sponges were temporarily inserted and the abdominal cavity was washed out with saline solution. The wound was packed with iodoform gauze in strips and dressed with cyanide gauze, blue wool and bandaged. The patient was greatly collapsed after the operation, but reacted well during the following twenty-four hours. The wound healed without complication, and the ultimate recovery was perfect. For two days following the operation the urine contained blood, and for twelve days al
twenty-four hours averaged between forty and fifty ounces. It was pointed out that in the past rupture of the kidney has been attended with a mortality of thirty-five per cent.—Medical Record.
Subcoracoid Dislocation of the Humerus in a Man 92 Years of Age-Reduction, With Perfect Recovery.
By H. D. WALKER, M. D., OF FRANKLINVILLE, N. Y.
The following case is thought worthy of reporting, for two reasons: First, I am unable to find the report of anyone of that age with a dislocation of the humerus; and, second, I failed to reduce by Kocher's method, but easily accomplished reduction by other means. oldest person I can find recorded with a dislocation of the humerus is eighty-six years of age. Guterbock reports one, both humeri being dislocated in an old lady by falling from her bed,' and Dr. H. B. Sands reports another in a lady, also aged eighty-six years.
On December 23, 1894, I was called to see Mr. M. S., ninety-two years old, on the seventh day of the preceding September. While emptying a pail of water he had slipped on a stone covered with ice and fallen heavily, striking on the left shoulder. He was picked up by his friends, carried into the house, and I reached him about half an hour after the accident. I found him sitting in a large rocking-chair supporting his left arm with his right hand. He was very pale, and at intervals would lose consciousness from the pain and his weak condition.
On removing his clothing to the waist and examining him, I noticed that the left arm was abducted from the body about thirty degrees. There was an abrasion of the skin on the left shoulder at the upper posterior and outer part, showing plainly where the force of the fall was received. On placing the hand on the opposite shoulder it was impossible to bring the elbow down to the chest. The acromion process was prominent, and on rotating the arm the head of the humerus could be plainly seen and felt beneath the coracoid. After giving him a glass of hot whisky, I laid him on his back on a lounge, and, with an assistant to hold down the opposite shoulder, proceeded to reduce the dislocation by Kocher's method, as modified by Dr. C. A. Powers.
Four times I faithfully tried to reduce the bone in this way, but failed. In performing the second movement, i. e., rotating the arm outward, so much resistance was met that it was not fully rotated, the patient exclaiming each time that I would break his arm. I did 1 Medical News, vol. xlvii, page 541. Medical Record, vol. xix, page 45.
not deem it prudent, in his condition, to give an anæsthetic; moreover, I have always succeeded in reducing a dislocation of the humerus without one. After a short rest, I placed a towel through the axilla and directed an assistant to take hold of the hand and make moderate extension, first, directly downward and forward, then gradually across the body to the right.
While the extension was being made in this way I drew upward and outward on the towel, when the head was felt distinctly as it slipped back into place. This is the first time I have failed to reduce a subcoracoid dislocation by Kocher's method, and it may be well to inquire why I did not succeed. I attribute the failure to a lack of rotating the arm sufficiently outward, being fearful, on account of the age of the patient, the great resistance met, and the cries that I would break his arm, that fracture would actually occur. What was the cause of the uncommon resistance met with on rotating the arm outward? I am of the opinion it was due to degeneration of the muscles and ligaments about the joint, consequent upon old age, so they would not permit full rotation of the arm outward. I notice there are contractions of the palmar fascia in both his hands, also a want of freedom of motion about the right shoulder and the joints generally, such as we usually find in old persons. At the present time, about one and a half years after the injury, I find the arm in as perfect a condition as the right one.-Medical News.
Eucain in Minor Surgery-Report of a Case. BY ARTHUR L. FULLER, M. D., HOUSTON, TEXAS.
While cocaine has been of undoubted value in minor surgery, its use having enabled the surgeon to dispense with general anaesthetics in lesser operations, many cases have been reported in which its exhibition, even in very small quantities, has been attended with serious and even fatal results. If these accidents were due to the use of excessive quantities of the drug, they could be guarded against; but they seem to have occurred quite independently of the amount used, and this uncertainty of action has undoubtedly caused many surgeons to employ it less than they otherwise would have done.
It is claimed that in eucain we have a drug which is practically innocuous and which produced a local anesthesia fully as effective as that of cocaine. While the reports of its use in ophthalmic and dental practice show that it has a very strong claim on our attention, very few reports of its use in general surgery have so far come to hand, and this emboldens me to report a case which is interesting, solely from its employment as an anaesthetic.
Miss J. L., aet. 18, came to me with a large mole on her neck. The mole was so situated as to show above the back of her dress, and caused her much distress on account of its un
sightliness. After After injecting endermically twenty minims of a ten per cent solution of eucain, I made an elliptical incision through the skin and removed the mole, together with a little surrounding skin. The piece removed was somewhat larger than a quarter dollar. The edges were then brought together with two sutures and a simple dressing applied. On the third day the sutures were removed and the wound covered with collodion. The place is now, eight days after removal, quite healed, only a thin red line marking the site of the operation.
In this case the anesthesia, which covered an area as large as a half-dollar, was rapidly induced and absolutely perfect, the patient not even knowing when the incisions were being made or the sutures introduced, though the tissues were so hardened by the eucain that it was only with difficulty the needles could be made to pierce it. Such perfect anæsthesia I have never seen induced by endermic injections of cocaine. I observed no bad effects on the circulation, though from the position of the mole there was no means of preventing the whole amount of eucain entering the circulation in a very short time, and there were no bad after-effects, the wound healing well and quickly.
This case has given me a very favorable impression of eucain, and I shall in future almost entirely substitute it for cocaine in my practice, reserving the latter for those cases in which sutures are required, for while eucain seems to be the superior in the thoroughness of the anææsthesia induced, it so hardens the tissue that it is only with the greatest difficulty that sutures can be introduced, a drawback which may possibly be overcome by the use of weaker solutions, if such are found to act as well as the one used in this case.
Since writing the above, my friend, Dr. E. N. Gray, of this city, has described to me a case in which he used eucain. The patient was suffering from a tubercular ulcer, and he wished to scrape away the diseased tissues. He tried painting the surface of the ulcer with a four per cent solution of cocaine, but it had so little effect that the patient could not bear the scraping. Some days later he tried an eight per cent solution of eucain and was able to curette the ulcer freely with no discomfort to the patient. He states that the anesthesia was perfect, that it was induced more rapidly, extended more deeply and lasted longer than that of cocaine. His experience coincides with mine as regards the hardening of the tissues. and he informs me that the eucain coagulated the pus so that it came away like lumps of cheese. International Journal of Surgery.
REMARKS UPON FRACTURES.*
BY SOLON MARKS, M. D., MILWAUKEE, WIS.
I will acknowledge that in an unguarded moment I promised our secretary that I would say something upon fractures. I regret it very much now. The treatment of fractures is as dangerous to a surgeon's reputation as anything. connected with the practice of surgery. As you are aware, fractures are often followed by more or less deformity or impairment of functions. You are well aware of that, but unfortunately it is very hard to convince the non-professional that anything like deformity or impairment of motion is not the fault of the surgeon, especially in railroad
To illustrate, something like the following came under my observation:
A man was injured on a railroad; he was neither a passenger nor a workman and the railroad company was not in any way at fault. Notwithstanding that the officers of the company, out of sympathy for a poor man, ordered one of the surgeons of the company to take charge of the case and give him every care possible at the expense of the company. It was a compound comminuted fracture of the thigh. Other surgeons were called in who
did not belong to the company at all, and they all agreed that it was possible a very imperfect limb might be saved, but it would be more dangerous to leave it than to amputate it at once. They informed the injured man of their conclusion and he settled the matter at once. He said he wouldn't have it amputated; he would die first, no matter what they said. The limb was dressed and month after month the surgeon attended to the case. After nearly six months the man was able to begin to move around on crutches, very much pleased with
*Made at the fourth annual meeting of the C. M. & St. P. Ry. Surgeons' Association, at Chicago, Nov. 13. 1896.
the attention he had received and perfectly satisfied with the limb. Finally he was able to walk out in the open air. One day while he was out walking he met an old gentleman who claimed he had had great experience in the treatment of wounds and in nursing them. After a while he asked the patient to step in and rest and seemed to take a great interest in him, and finally asked him to show him the leg. The patient was only too willing to show it to anyone taking so much interest in his case and the limb was laid bare. The old gentleman wiped his glasses with great care, took a fresh chew of tobacco and was ready for the inspection. He looked it over with great care, up and down, and finally shook his head and asked the patient if the doctor that "set that there leg thought it was set right." The response was: "As well as could be in the condition in which it was found after the injury."
Again the old man examined the limb and measured it with strings and was horrified to find that it was an inch and a half shorter than the other leg. He changed his quid to the other side of his mouth, raised his spectacles to his forehead, sat back in his chair and said: "That there doctor what set that there leg didn't know anything about his business." He also said that the leg wasn't set
right, and if he would call on Dr. Cimicifuga
he would agree with him that the leg wasn't set right and could probably set his leg out to the full length. Up to this time the patient was perfectly satisfied, but as he returned home he was somewhat disturbed by what the old gentleman told him, and finally concluded he would go and see Dr. Cimicifuga. As soon as the doctor looked it over he declined to have anything to do with it or to prescribe for it. This disturbed him still more and finally he called on Dr. Ethics, who treated him with great dignity, but told him nothing could be done with it, and that he
had no right to express an opinion. That disturbed him more and he called on other doctors from time to time. Some wouldn't express any opinion and others told him it was a bad case. He finally concluded he had been treated very badly indeed, and called on a lawy ly with a view to prosecuting the doctor. The lawyer inquired into the case and found that the railroad company had employed the surgeon. He thought it would be foolish to prosecute the doctor-he had never collected a cent from any doctor-so he would sue the company for malpractice. The lawyer went around to see the different persons who had expressed an opinion, but wasn't satisfied with the reputation of the men. He was very anxious to get a man with some reputation who would have influence with the court. He then had the patient call on Dr. Old Reliable. He told him what to say and how to act, and said: "That doctor is pretty rough; he may swear at you, but never mind, he won't hurt you." The doctor, however, treated him with kindness, asked him into the consulting room and asked him when he was injured. When he found it was nearly a year before, he discovered the odor of a colored gentleman and saw the fence in the distance. The patient finally asked the doctor if he didn't think it was a bad case of surgery. Then the doctor told him the truth, that considering the nature of the accident it was one of the best cases he had ever seen. The man went back to the lawyer and he changed his course entirely. He commenced writing the officers of the company, asking them for humanity's sake to do something for the poor man who had been crippled for life, and I understand that in that way he got a few dollars, but how much it was the unfortunate man got you can judge for yourselves.
I have no doubt that most of you, who have been connected with the railroad for some time, have seen a great number of cases where you were thoroughly satisfied that the patients have been exaggerating their troubles. I am not prepared to say that this is always intentional, for I can well understand that any person who has been through a railroad wreck would have his nerves shaken up to a considerable extent and be very apt to conscientiously believe he was seriously injured; but we also have a class who are blackmailers and
who will attempt to deceive us in every way possible for the sake of getting money out of the railroad company that doesn't belong to them. But we should not, because the majority of them are not quite fair with us, conclude that they are all so, because there are some who are conscientious and tell us the truth in every particular. We find a man sometimes who has been on a wreck in a railroad in a car which is not thrown from the track and nobody in it is injured. He says he is not injured and gets out and helps others out of the wreck and goes home and feels very much pleased to think he was not injured. In the course of eight or ten days he learns that the railroad company is paying some of those who were injured, and he finally concludes that he was among the most severely hurt, and at once informs the company of his deplorable condition.
Now the company must rely upon the surgeon to know or to find out how severely injured he is. And what is the duty of the surgeon toward his company? It seems to me to be very plain. He should guard the company's interest the same as he would guard his own, but while he is doing that he should not forget to be just toward all. There is no way in which he can serve his company better than by being just and truthful. He should observe his case attentively, so that in case he is called upon to testify he can do so intelligently and conscientiously, and if called upon to testify he should try to appear before the judge and jury as an expert who is there for the purpose of telling the truth. I think I have seen surgeons called upon to testify who in their anxiety to favor the company have done the company more harm than good. I think there is a doctor here who will recollect a case where I was called. Quite a number of surgeons were called to testify in the case where there had been a dislocation. The dislocation was reduced and I believe to this day the man had nursed his arm for the purpose of getting money out of the railroad company. He carried it for months in a sling. The judge ordered an examination of the case by both his surgeon and the railroad's. One of the gentlemen that was with me didn't see anything the matter; he didn't see that there was any atrophy around the shoulder. There was quite a good deal of atrophy around the