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with Miss Stoney's ideas of the responsibilities of the nurse and the ethics of the sick room. We can also heartily approve when she says: "A nurse must be cheerful and talk of cheerful things, she must not tell of her experiences in other families; all that she sees or hears in the family for whom she is working must be kept secret and revealed to no one. She has no right to speak of one patient to another in private or hospital practice or to criticise or discuss her patients' peculiarities outside of her report to the physician."
It is extremely unfortunate that such ideas are not impressed upon all nurses, for they are certainly among the most important things which she should learn. Sick people are so susceptible to environment and mental impressions that it is just as important for the nurse to be wise and discreet in what she says as that she is obedient and careful in what she does.
The general excellencies of this little book are so great that criticism will seem, perhaps, unkind, but there is room everywhere for honest difference of opinion, and we cannot approve of the practice recommended upon page 124, regarding the bathing of the baby's eyes immediately after birth with a solution of bichloride of mercury, no matter what its strength may be. We would advise that in its stead a weak solution of borax be used and that the lids be gently opened and the eye thoroughly flushed with it.
In these days, when graphic art plays so important a part in bookmaking, we expect pictures in every medical text-book, no matter what the theme. The volume under review contains many excellent cuts, illustrating methods and appliances employed in the care of the sick. They have been well selected and well executed and add greatly to the value of the book. One is disappointed, however, to find in this excellent treatise a picture on page 77 illustrating an antique and barbarous method of giving a hypodermatic injection. It is so much easier for the physician and so much less painful for the patient if the skin over the supinator longus is made tense, instead of being picked up between the thumb and finger and the needle quickly thrust through the tensely drawn integument.
The paper, presswork and binding make this a very attractive volume.
BOOKS AND PAMPHLETS RECEIVED.
Transactions of the Medical Society of the State of North Carolina for 1896.
"The Value of the Pulmonic Second Sound," by J. N. Hall, M. D. Reprinted from the Journal of the American Medical Association, June 27, 1896.
"Intussusception Treated by Colono-Enteric Irrigation," by Edwin Pynchon, M. D. Reprinted from Mathew's Quarterly Journal, January, 1897.
"Report of three cases of Phthisis Pulmonalis Following Scald of the Chest." by J. N. Hall, M. D. Reprinted from the Medical Record, August 15, 1896.
"The Modern Pathology and Treatment of Acute Otitis Media," by Norval H. Pierce, M. D. Reprinted from the Journal of the American Medical Association, December 19. 1896.
"The Study of Cicatrices, With Reference to Right and Left Handedness and Ambidexterity," by J. N. Hall, M. D. Reprinted from the Boston Medical and Surgical Journal, December 17, 1896.
"A Clinical Study of Twenty-one Thousand Cases of Diseases of the Ear, Nose and Throat," by Seth Scott Bishop, B. S., M. D., LL. D. Reprinted from the Journal of the American Medical Association, September 26, 1896.
"Acute Supperative Inflammation of the Middle Ear; Acute Suppurative Mastoiditis; Abscess of the Neck; Operation," by Seth Scott Bishop, M. D., D. C. L. Reprinted from the Laryngoscope, St. Louis, September, 1896.
A Rapid Procedure of Intestinal Suture.
Jaboulay and Briau (Lyon Medical, April, 1896) describe their perfected method of circular intestinal suture. It is an outgrowth of one performed for resection of the intestine in 1891, and for gastro-enterostomy in 1892. Two threads are passed through the divided ends of the intestine, one at the mesentery and the other directly opposite; pulling on these threads causes the intestinal walls to lie side by side. The posterior edges are then sewn together by a Glover continuous suture in two rows. The first row unites the serous and muscular layers to each other, and the second unites the mucous layers on each side. The anterior half of the circumference of the bowe! is then united by a double row of continuous suture, the first of which unites the mucous surfaces and the second or the outside the muscular and peritoneal coats. The two threads first introduced are then tied, and the operation is complete.-University Medical Magazine, November, 1896.
W. C. STATHERS, WHEELING, W. VA.
As my subject is an old one I fear I shall not be able to interest you, but feel that no apology is necessary for the attempt. It has been said that out of no other class of cases have arisen so many suits for malpractice as from fracture. The reason of this is not difficult to perceive. Disability in the upper extremity or lameness in the lower will fix the attention of the patient, and attract the notice of others. Therefore, in the treatment of fracture, it is a matter of great importance that the surgeon has an accurate acquaintance with normal anatomy, and no opportunity of examining fractures, whether in the living body or in the dead, in recent or in old specimens, should be neglected.
Every bone in the body is liable to fracture, but some bones are much more exposed and much more frequently broken than others. The bones of the extremities are nearly always the ones broken, and of these the radius is fractured oftener than any other. Fractures of the lower end of the radius are more numerous than of any other bone of the body, and the treatment of what is known as "Colles' fracture" seems to be followed by more unsatisfactory results than any other injury met with by the surgeon.
The history of the development of our present knowledge of this injury is so curious as to merit some notice. Poutan, in 1783, had thrown out the idea that fractures of the radius in the vicinity of the wrist, caused by falls on the hand, were "generally mistaken for sprains, for incomplete luxation, or for separation between the ulna and the radius," but the statement seems to have attracted no attention at
*Read at the meeting of B. & O. Railway Surgeons' Association in Philadelphia, Pa., June, 1896.
the time. The same view was promulgated by others at the beginning of this century, but to Colles of Dublin is due the credit of having given the first clear and practical account of these injuries and of their distinctive features in 1814.
Dupuytren and Nelaton realized the importance of the fracture in question, although they seem not to have been aware of Colles' paper.
Even Sir Astley Cooper makes no mention of Colles' name, and Prof. R. W. Smith of Dublin was the first to accord him the credit to which he was so justly entitled.
In this country attention was first drawn to the subject by Dr. Barlow of Philadelphia, in 1838. His views were based upon clinical observation and anatomical facts.
In 1870 Prof. Moore of Rochester advanced the opinion that "the fracture of the radius is a less important lesion than the luxation of the lower end of the ulna," which certainly is often a marked feature of these cases, and he suggested a plan of treatment based upon this view.
The observations of Prof. Moore and other writers brought about a very important change in professional opinion. Luxations of the wrist, which were formerly supposed to be of very common occurrence, have been relegated to a place among the rare lesions.
Colles' fracture is unique; it has no parallel in surgery; of the three cardinal symptoms of fracture, viz., deformity, increased motion and crepitas, we have but one, deformity. There is no motion at the seat of fracture and motion at the wrist joint is lost. We sometimes get crepitas at the seat of fracture after the fracture is reduced. Another point to which I wish to call your attention is that, as a rule, no noticeable callus forms in the healing. There is marked unanimity in the deformity in all cases of this form of fracture, and Velpeau's comparison of the deformity to its resemblance
to a silver fork is not an inapt one. This symptom, together with the pain and loss of power in the hand, is often in itself conclusive evidence as to the nature of the injury. The injury may and is sometimes mistaken for luxation of the wrist joint, but it is not complimentary to the profession that such is the
times an inch long, sometimes half an inch, quite forward to its place. If we fail to bring this piece of fractured bone into its proper position what will be the result? When we dispense with our dressing, and before absorption has come to Our we will find something like the following: The wrist will be straight, but the lower fragment will set diagonally upon the upper.
Another feature in this form of fracture that demands our attention is the dislocation forward of the head of the ulna from the triangular fibro-cartilage, and in addition to this dislocation is entanglement of the styloid process of the ulna in the fibers of the annular ligament, as described by Prof. Moore.
I have found this state to exist in the majority of cases which I have met. These cases can be reduced by means of extension and flexion, and by acting directly on the fragments and head of the ulna with the thumbs. If this maneuver fails it should be repeated, and ether used if there be much pain or muscular resistToo much stress cannot be laid on the importance of the perfect adjustment of the fracture, and reduction of the dislocated ulna, for the deformity after this accident is in many cases due to imperfect reposition of the head of the ulna. In aged patients who have a firmly impacted fracture, it is not advisable to break up the impaction, but deformity and impaired motion should be prognosticated.
In young persons the injury to the epiphysis may retard the growth of the bone in its long axis, cause a deflection of the hand to the radial side, and an abnormal projection of the styloid process of the ulna. To avoid the muchdreaded results, various splints and methods of treatment have been devised, but instead of reducing the number of unfavorable results, it is questionable whether they have not increased them.
The fracture of any bone is a serious injury, and we often are not able to attain the results we may wish. In this form of fracture there are a few conditions that render its treatment very difficult. The fracture is very close to the wrist-joint and to the bones of the hand that enter into that joint. Infiltration of the tissues and stiffness of the joints and general loss of power, associated with more or less pain and loss of those functions for which the forearm and hand have been so wisely designed, are, according to most writers and observers, very common as immediate results. One of the chief causes to bring about an imperfect result, in the treatment of this form of fracture, is that the fracture is often not properly reduced. A perfect coaptation of the fragments in this form of fracture is of more importance than in any other. Without this precaution we are apt to have a deformity that is always in sight. If the reduction is complete, a good result with a useful member is almost assured in any uncomplicated case. If we are not careful in bringing the parts together, there will be a slight deviation to the inner or ulnar side, destroying the sigmoid cavity, and the head of the ulna is crowded out and the want of perfect coaptation is apt to The head of the ulna, by being so displaced, infringes on the ulnar nerve, causing trouble in the ring and little fingers. In this particular form of fracture the muscles have but little tendency to displace the fragments when they are properly adjusted, but do we always have in mind the relations of the radius and ulna to each other, and to the surface of the wrist? The posterior surface of the radius dips toward the head of the ulna at an angle of three to five degrees.
Whether or not we have attained that knowledge of the contour of the bones of the wrist necessary, it is certainly a common error to leave the internal side of the lower fragment a little above the normal position. We do not bring this little piece of bone, some
A few who are careless observers have been led to rely on patent splints to reduce and correct the deformity and avoid the complications, rather than by a correct knowledge of the anatomy of the parts, and the forces producing the fracture, to appreciate the causes of the deformity and correct it before applying any splint, patent or homemade.
There have been numerous splints devised for the treatment of this fracture, and every deviser of a special splint recommended for this
fracture could cite cases in proof of the value of his splint, but the fact remains that if the fracture is completely reduced, almost any form of apparatus will keep the fragments in position.
SHOCK OR NEURO-PARALYSIS.*
BY W. L. DICK, M. D., COLUMBUS, OHIO.
Shock or neuroparalysis has been defined as a sudden or instantaneous depression of organic, nervous or vital power; often with more or less perturbation of body and mind, passing either into reaction or into fatal collapse, occasioned by the nature, severity or extent of an injury or by an overwhelming moral calamity. Its manifestations are through the nervous system and are exhibited more markedly by depressed action of the circulatory organs, vaso-motor paralysis. It immediately follows every injury requiring surgical attention, and is to be distinguished from the effects of hemorrhage, and in cases of surgical operation from the effects of anæsthetics, although in many instances it may be aggravated by either or both. The symptoms of shock are the immediate consequence of the injury sustained. The assumption of the possibility of a condition of delayed shock as often referred to by many surgeons is not consistent with the nature of shock itself. Whenever a condition of sudden and marked depression declares itself some time after the reception of an injury, it is always due to some distinct cause other than the original injury, and when recovery from shock is delayed, and we have distinct manifestations of improvement and retrogression present, a diseased condition, possibly resulting directly from the injury, is always the cause and should never be taken for delayed shock. For this reason the terms which are found in older textbooks and which are still often used in ordinary surgical parlance, viz., delayed shock, secondary shock and imperfect reaction from shock, may be misleading, as they tend to direct the attention from the real condition of the patient. The conditions which most fre
quently cause these symptoms of later depression are concealed hemorrhage, septic infection and fat embolism. Pulmonary cedema and renal congestion are also possible conditions
*Read at the meeting of the B. & O. Railway Surgeons' Association held at Philadelphia, Pa., June, 1896.
always to be looked for when a sudden and unfavorable turn occurs in the condition of the patient soon after an injury has been sustained, especially when ether has been used as an anæsthetic. The pathology of shock cannot be determined by the ordinary methods of research. In such cases death leaves no change which can be detected in any of the tissues. Sometimes, however, as seems to have been shown by Galtz, a marked distinction of the intra-abdominal veins exists.
The phenomena of shock must be accepted as the measure of the ability of the individual to resist hurtful influences from without, which is very different in different cases and at different times in the same individual; but the influence, from whatever source it may come, whether from an injury or from a mental emotion, is made manifest through the vaso-motor nerves, which have their origin in the medulla oblongata, thence their fibers pass down into the interior of the spinal cord and issuing with the anterior roots of the spinal nerves traverse the various ganglia on the præ-vertebral cord of the sympathetic, and accompanied by the branches from these ganglia pass to their destination. Secondary or subordinate centers exist in the spinal cord and local centers in the various regions of the body, and through these various centers the vaso-motor changes are effected. These centers may be affected very greatly by impressions descending from the cerebrum, as in shock from great mental emotion, of which a good example is furnished us by Dr. R. Harvey Reed in a paper read before the Central Ohio Medical Society. In a B. & O. wreck a man received such a shock from fright that his finger and toe nails, together with his hair and beard, had died, the influence. exerted through the vaso-motor nerves by the impression being so great as to impair nutrition to such an extent that the patient never recovered. In this case mental shock produced permanent lesions of the nervous system with its corresponding physical manifestations. We have, then, shock produced in three different ways, by injury, by mental emotion and by physical injury and mental emotion combined.
The symptoms are well known by every surgeon and need not be mentioned here. The most important points to us are how should shock be treated in railway injuries, and when is the best time for operation. The first duty
of the surgeon to the patient suffering from shock is to place the injured part in the most favorable position so that pain and increase of the already existing depression may be avoided as much as possible. If an immediate operation is not deemed advisable, perfect quiet should be secured, and every effort made to reassure the mind and allay the fears of the unfortunate victim of the injury. The patient should be placed in bed with hot water bags or bottles of hot water placed around him and covered with blankets to prevent radiation and restore the normal temperature of the body. The next important step is the judicious stimulation of the paralyzed and flagging nerve centers. I say judicious stimulation, for I believe there is often much harm done by constantly filling the patient's stomach with large draughts of whisky or other alcoholic drinks. Strychnia, sulphate or nitrate, with nitroglycerine or atropine, stands first on the list of stimulants and should be administered hypodermically in small and repeated doses until the desired results are obtained. Nitrate of strychnia and nitro-glycerine, aa 1-120th of a grain administered hypodermically every 15 to 30 minutes, is one of the best methods of stimulation. If, however, after a reasonable length of time, say 4 to 6 hours, the extremities remain cold, we may resort to the more diffusifee stimulants, such as alcohol, ammonia, hot milk, etc. We should not do too much but remember that time and physiological rest are important factors in the treatment of shock.
As to the time when the operation should be performed, there has been much discussion, and different surgeons differ in opinion as to when is the best time to operate. Ashurst says that in some instances, especially of compound fracture produced by railroad or machinery, the mangled limb seems by its presence to act as a continual source of depression, and in such cases he advises immediate amputation.
Bryant, as quoted by some writers, lays down the rule that in the presence of severe shock from slight injuries it is all right to operate, but in severe shock from severe injury it should not be done. Gross taught that the knife would often act as a stimulus favoring reaction from shock, but such has not been the experience of most surgeons of to-day. There can be no definite rule laid down by which a surgeon can be guided. Every case demands its own es
pecial treatment, but it is generally conceded by all surgeons that operative interference. should be delayed until reaction from shock be well advanced, except when we have a case of uncontrollable hemorrhage or one where the shock is kept up by some continuing cause.
Let me say in conclusion that when we are called to a railroad injury, the proper thing to do is to dress the injured part as quickly as possible with an antiseptic dressing and place it at rest, and if there be no hemorrhage, to administer the proper treatment for the relief of shock and await surgical interference until reaction is fully established.
The treatment of fractures of the femur by extension and counter-extension, making the weight of the body the counter-extending force as recommended by Dr. Buck of New York, has greatly simplified the measures necessary to fill the indication. The rule governing the treatment of all fractures by whatever method is the same, viz., "Place the ends of the fractured bone in apposition and retain them there till union has taken place." I pass all other methods by, and will only describe Buck's, as I have used it almost exclusively in my practice. It is more difficult to keep the ends of a fractured femur in apposition than of any of the other long bones. The femur is surrounded by a greater mass of muscle and soft tissue than any of the other long bones, hence the splints or other