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The homoeopath uses bichloride and iodoform. in surgical work, and he uses quinine as we use it. There are few strict homoeopaths, and these few exclude themselves from consultation with other physicians on other grounds.
HOW SHALL WE SECURE THE BEST RESULTS IN TRAUMATIC SURGERY?*
BY HUGH JENKINS, M. D., PRESTON, IOWA.
It is presumed that there are no members of this association who do not practice aseptic or antiseptic surgery and who have not provided themselves with separable instruments with metallic handles which can readily be made surgically clean, a sterilizer by the use of which their suture material, dressings, aprons. etc., can be put in a sterile condition-that is, "like Cæsar's wife, above suspicion," and also a surgical emergency case which can be taken to patients unable to go to the office of the surgeon. These points have already received full consideration in our publication, The Railway Surgeon, and we will proceed to the consideration of a suitable place for operation. To those of our number who practice in the large cities this part of the subject will present but little interest. With the many well equipped hospitals, with their elaborate operating rooms, marble or tiled floors, provided with all the conveniences that genius can devise, the question with them of a suitable place for operation is easily solved. With those of us in small places it is often more of a question and has been to me one of considerable anxiety at times. I would not wish to be understood as taking the position that good work cannot be done under most unfavorable conditions, but it is a fact, that in severe traumatic cases the capability of the surgeon will often be put to a severe test under the most favorable conditions possible. So an operating room, which could be readily cleansed and rendered aseptic at a moderate cost was the end I had in view in constructing the room shown by the accompanying photographs.
I am sorry the light would not permit the
*Read at the fourth annual meeting of the C. M. & St. P. Railway Surgeons' Association, at Chicago, November, 1896.
best view to be taken, but I will pass them for examination. The inside of the room measures II by 13 feet, 9 feet high. The foundation is of stone, the sills of oak, 8 by 10 inches, secured by long iron rods running from side to side. Inside the foundation walls, and nearly up to the top of the sills, earth was filled in; on top of this broken stone was placed, on which was laid a portland cement floor, with a gentle incline to a trapped drain leading outside. Heat is provided by bringing a pipe to a register from the hot air furnace under the main office building. The construction above the foundation is frame; the roof shingle; the walls. plastered, and painted, with a mixture of two parts paint, one part best coach varnish, which stands out well on the wall. A base board was made of the cement on the wall, I inch thick and 12 inches high. The doors and windows shut against rubber-faced weather strips.
Here I have a room that can be thoroughly washed by taking in a hose, or can be sponged with a bi-chloride solution. No use is made of it except for surgical cases, and it is always ready for immediate use at any time. Perhaps it would be considered a practical point, by those thinking along this line, if I give the cost. It is as follows, including material:
way surgery. While, undoubtedly, the trend of modern surgical thought is toward asepsis, yet in the class of cases under consideration we will, in my opinion, attain the best results by antiseptic methods. Consider the conditions: The patients are usually at work at the time of the injury. The cutaneous surface has had no preliminary cleaning. Often, if it be a limb, it has been ground into the dirt. Nearly always grease and grime are in the wound. That such wounds can be
rendered entirely aseptic and ready for the dressings by simply washing and irrigating with sterilized water is, in my opinion, open to much doubt.
A case in point: A few days ago, C. M. aged 32 years, engineer on a steam thrasher, took the place of the feeder for a few moments; while there the band cutter was drawn over the back of his hand, cutting deeply three fingers. Hemorrhage being profuse, several chews of tobacco were contributed from their mouths by kind bystanders and
placed on the wound; the best-spared portion of some one's garment was taken for a bandage, and the patient brought to my office. The hand was covered with dirt and grease from the engine. It was washed thoroughly; irrigated with a 1-2000 bi-chloride solution, approximation secured by sutures and a sterile dressing applied. Result, primary union. I should not have had much confidence in healing without suppuration had I used for washing and irrigation simply sterilized water.
I am using the following routine measures in traumatic cases: On receiving the patient I estimate what dressings will be required and place them in the sterilizer in reverse order to that in which they will be needed; first bandages, next cotton, next gauze. Then needles threaded and quilted onto a piece. of gauze. Instruments are placed in a carbonate of soda solution and silk for ligatures in a small dish of water and all are boiled. The hands are cleaned afterward again and washed in a strong bi-chloride solution. The
injured parts are then washed clean and thoroughly irrigated with a 1-2000 bi-chloride solution, and all necessary operative measures carried out; the parts are again irrigated, the sterilizer opened, and the sutures and dressings applied with my own hands. With care in the details I then feel confident that all pyogenic germs are destroyed, and that the wound is in an aseptic condition favorable to prompt healing. To sum up: So far as contact with the patient is concerned
we should have our person, instruments, and dressings all aseptic. We should destroy sepsis in the wound by antiseptic agents, of which, in my opinion, the most reliable is bichloride of mercury.
DISCUSSION OF DR. JENKIN'S PAPER.
Dr. Thompson: I do not think it is necessary to have the room thoroughly aseptic in which we are working, and we country doctors do not get that kind of room in which to do our work. We get rooms in hotels that are sometimes laden with septic germs. Two years ago
I had a case of triple amputation; my work was done in one of those old hotel rooms, and in spite of the surroundings the patient was well at the end of the seventeenth day. Last winter a man was thrown off of the limited express; he lay in the cold for two hours before he was picked up. Both legs were crushed off at the ankle joint, and he was taken to one of the filthiest houses I know of. My work was done in a room in this house and complete recovery followed in twenty days. I do not think it is nec
essary to have everything in an aseptic condition at the time of operation. If it were, we would have poorer results than we do in our country surgery, and I do not think they have any better results in the city hospitals than we do in the country. Their cases are not of shorter duration than ours, and I know that the surroundings we have to contend with are not aseptic.
Dr. Egloff: I believe in Dr. Jenkins' paper in so far that we should make as strong an effort as possible to be aseptic. I congratulate
the doctor upon his success in his cases, and I believe with him that we country practitioners should have as good results in the country as do physicians in the city. But we have a great many advantages in the country that they do not have here. In so far as sanitary surroundings are concerned, I think we are better off, yet we should make every effort to have everything rendered aseptic, because we have enough loopholes that we would forget about, and I think we are working in the right direction in doing that. My idea has always been that if we uld have small hospitals distributed throughout the country it would stimulate us to do better work, and I believe our results would be better.
Dr. Johnson: There is something about this
in a boy who was hurt with a cornsheller. His father did the surgery himself, sewing the wound with common thread. The result was excellent. At the same time this would not be a safe rule to follow. The case occurred in a German family, and the boy was rugged and healthy. We must consider all these things. If we take some frail fellow and treat him in this way he will go to kingdom come.
Dr. W. T. Sarles: I think the whole subject resolves itself into this, that cleanliness is what we are after. If we have an unclean piece of dressing or a dirty instrument, however aseptic the room may be in which we operate, we will have bad results. It would be impracticable to have such a room as the doctor describes for emergency surgery. We
matter of asepsis that we do not fully understand. Sometimes our cases will recover under the most unfavorable circumstances and surroundings; nevertheless, we should try to be as aseptic as possible. A short time ago a boy in my immediate neighborhood tore his scalp very badly, and the father told me that he sewed up the wound himself with ordinary thread without the scalp ever having been shaved or cleansed and the treatment was followed by an excellent result. There was union by first intention throughout. I do not believe, however, that this is good practice to fol
Pump Sink Lavatory
Dr. McCoy: We cannot take too much. As St. Paul said, "Cleanliness is next to Godliness." In considering these cases must take into account the vitality of the patient. I know of a case of serious scalp wound
GROUND PLAN OF OFFICE AND OPERATING ROOM.
can have a surgical dressing case and can make our hands clean and keep everything about the wound and the wound itself clean, and aseptic with the resources we have at hand in any place, no matter how dirty, if we can get a clean sheet. If we render the parts absolutely aseptic we will get results accordingly. It is always well to have as nice and clean a room in which to operate as possible, as it lessens the chances of danger, but it is not so necessary as having the dressings and instruments in an aseptic condition. It is necessary to have such a room as the doctor suggests in places where we do considerable operating. This, I think, is conceded by all.
Dr. Jenkins: I desire to make one or two points in closing. I am living in a small country town where we have no hospital, and I have been operating in rooms in hotels, as the
gentleman describes, also in railway depots and different places, but I can do my operating in this room and take my patient to the hotel with very much less trouble and leave the patient in better condition than if I take my dressings and instruments over to the hotel and operate there with the inconveniences that would obtain. So I think it answers an excellent purpose in that way.
There is another point. I think we shou'd, if possible, remove our cases of accidental injury from the railway depot. If we are utilizing the waiting room of a depot for an operation we incommode the railway company to a considerable extent and it becomes noised around among the traveling passengers that an accident has cccurred and the waiting room is shut up because the doctors are in there performing an operation. If we take the patient away to a place where the surroundings are favorable, we will get better results.
Another point was the matter of cost. When I commenced this I did not know whether it was going to cost me $200 or $800. The cost, however, is within the reach of every surgeon on the system.
In regard to the sterilization of gauze, a physician who does considerable of obstetrical work and uses gauze will find it much more economical to buy his gauze in large quantities and sterilize it. This can be done by placing the sterilizer over a gasoline stove, or, better, a gas stove, and there is no more trouble in using it than a housewife would have in using her tea-kettle. After coming from an operation you can open up your emergency case, resterilize all of your dressings, pack them away and they are instantly ready to be taken to the next case to which you are called.
INJURIES OF BLOOD VESSELS.*
BY F. R. GARLOCK, M. D., RACINE, WIS.
The subject upon which I propose to make a few remarks is one of vast importance, as it presents itself in nearly every case which comes before the surgeon in his daily routine. There are wounded arteries or injured veins in every case in which there is solution of continuity of tissues. It is the most frequent injury which the surgeon has to contend with, and no one
*Read at the fourth annual meeting of the C. M. & St. P. Railway Surgeons' Association at Chicago, November 12, 1897.
can afford to ignore the results of injured blood vessels. Wounded vessels are of the greatest importance in all capital operations, although the various means which science has laterly devised have done much to obviate the danger of fatal hemorrhage. Wounded arteries claim greater attention than injured veins, as far greater danger results from their injury. The artery may be divided or it may be bruised and some of its coats weakened, either of which causes great inconvenience and at times great danger. When the coats of an artery have been injured the vessel has been rendered incapable to withstand the pressure of the heart's action and distension results.
In this short paper I cannot go into the discussion of the anatomical structure of arteries and veins, nor allude to all the injuries to which they may be liable, but will limit my remarks to a few cases which have come under my observation, both in railway surgery and in private practice. I have two cases to which I wish to call your attention. One occurred in railway service, the other in my private practice.
The first occurred while I was in the service of the R. W. & O. Railway in the state of New York. A workman, section hand, aged thirty-two, an Irishman by birth, while at work was struck by a lever in the popliteal space of the left knee, which caused an injury to the popliteal artery, and which resulted in an aneurism of that artery. The injury occurred at about 4 o'clock p. m., but he did not consider it of enough importance to discontinue work, and kept on till quitting time at 6 o'clock. After going home and sitting down he was disturbed by a constantly increasing pain in the region injured. Upon examination he discovered a small tumor, as he expressed it, of the size of a robin's egg. He applied a bandage moderately tight and cold water.
In the morning the pain had increased and the tumor was twice as large as the night before. He then sent a messenger for me, and upon my arrival I found a well-developed popliteal aneurism. For a temporary dressing a compress and bandage was applied. This failing to give relief, I decided to put the patient in bed and apply systematic pressure above and below, which was done by means of clamps applied, one just above the tumor, the other just below. The one above was applied for one