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half hour and then the one below tightened, after which the one above was loosened and by so doing there was no irritation of the skin and the circulation was effectually cut off in the aneurism. These clamps were operated by two enthusiastic medical students, who took turns in attendance upon the patient. At the end of eight days the tumor no longer gave forth the characteristic sound and no circulation could be demonstated in it. The clamps were gradually removed and at the end of two weeks the case was pronounced cured, or so far benefited that it was admissible for the patient to rise and sit in a chair, and he gradually got around about the house and at the end of four weeks from the time when he took to the bed he was able to resume work. I finally lost track of him for some time, but at the end of a year met and examined him, and the tumor was much diminished in size and causing him no trouble.
The next case to which I will call your attention is one of injury to a small recurrent artery on the posterior aspect of the ulna, and which is a branch of the ulnar artery. The point of injury was at a point about one inch below the point of the olecranon process of the left ulna. A gentleman, while taking a bath, in attempting to change his position in the tub, made a slight slip, and, falling, struck the left ulna against the edge of the tub in such a manner as to break or crush the coats of the recurrent artery found in this region. The skin of the arm at the point of injury was not broken. This artery being small and the skin not breaking did not attract his attention as anything of a serious nature, and he paid no further attention to it 'till some two hours after the receipt of the injury, when he noticed that there was quite a large tumor and fluctuation on the posterior part of the forearm Even then he did nothing for it, not considering it serious, but after taking his dinner he noticed the arm greatly swollen from the wrist to the axilla and about as full of blood as the skin would hold. He then applied for surgical assistance and had the arm bandaged so tightly as to prevent any further hemorrhage, which was successful in stopping the swelling. The bandaging and compression was continued for about three weeks, when the swelling was supposed to be about gone. Next day soreness appeared in the arm and upon examination an abscess was
discovered about the elbow with its origin at the point of the orginal injury. Warm applications were then applied and in about two or three days the whole arm was almost as much swollen with pus as it had been with blood at first. The arm was now freely opened at a point two inches above the point of the elbow and also two inches below. On the occasion of the first opening one pint of matter escaped of an unhealthy color and which I have no doubt had resulted from breaking down of the extravasated blood. A drainage tube was introduced and the discharge continued for more than a week thereafter. The swelling gradually went down and recovery was complete. In this case the blood extravasated burrowed between the muscles and when the pus formed it also followed this direction and filled the space which had been occupied by the blood.
DISCUSSION OF DR. GARLOCK'S PAPER.
Dr. Bouffleur: I want to call the attention of members to the fact that there has been a great deal said and written and a great many experiments are being conducted to determine the question as to the advisability of suturing injured blood vessels. You know for a great many years suturing of the veins has been practiced, but the suturing of arteries is a subject which has not received the attention which its importance deserves. Recently some experiments have been made in the end to end suturing of blood vessels of dogs, and little trouble has resulted even where the aorta is divided and sutured. The operation upon the human subject has not yielded, so far, the results we have been expecting-not the universally favorable results found in the lower animal. This can be accounted for, I think, in a large measure by the fact that the limb of a dog has very little to nourish and the obstructing of one blood vessel would not necessarily result in the necrosis of the limb. I know of one instance where an operation has been performed in which thrombosis followed, as we would expect in every instance. It is simply a subject before us at the present time, whether, instead of amputating the limb for the division of a principal blood vessel like the popliteal, it is not possible, by proper procedure, to save the limb by end to end anastomosis of the vessel. The technique has not been completed, but you will find it is well to keep in mind the particular steps now being taken.
The treatment of aneurism, of course, is very interesting. A great many of the older members have run across such cases. good many will terminate favorably, while others will result in absolute thrombosis, with necrosis of the limb. I am not familiar with any special improvements in the treatment of aneurism.
Dr. Spellman: It seems to me that if I had an injury of that kind I would expect the vessel to be destroyed as far as its circulation below that point was concerned, and if we were not skilled in anastomosis it would be better to cut down and tie the vessel and turn out the clot. It seems to me the suppurative process in such a case would be very dangerous.
Dr. Clark: Do I understand the doctor to say that compresses were applied upon the popliteal artery, both above and below the artery?
Dr. Garlock: Yes. I used what is known as clamps, one immediately above and the other immediately below.
Dr. Clark: I don't clearly understand what object the doctor had in placing the compress below. I don't understand what was to be gained by having a compress both above and below the tumor.
Dr. Garlock: The object in placing one below and one above is this: With only the one above, the continuous pressure might have resulted in injury and irritation to the skin and other soft parts. By changing them and maintaining the nutrition of the parts in a healthy condition we had circulation through the tissues.
Dr. Sugg: The point suggested was in my mind, whether ligation would not be better and safer than compression. As Dr. Garlock said, the object of the clamp was to cut off the circulation; if the lower clamp was applied before the upper one was relieved it seems to me the circulation was as immediately and permanently obstructed by the clamp as it would be by a ligature. Under the present knowledge in surgery I think I would recommend a ligature in preference to clamps.
Dr. Gardiner: As you are asking for testimony on this question it would not be out of place for me to relate a case here on the question of ligating the popliteal for a wound of an artery lower down. A boy stabbed himself accidentally about three and a half inches below the lower edge of the patella, on the inner side
of the leg close to the tibia and wounded an artery near the bifurcation of the tibia. The wound was dressed and a compress placed upon it to restrain the hemorrhage, which it did for about 24 hours, when the surgeon was called again and found it bleeding profusely; he put on a compress and after another 24 hours he and another surgeon were compelled to ligate the popliteal at about the usual place. Everything went on very well for three or four days; at that time I was called in consultation and found the artery had bled from the original stab wound and also the surgeon's wound, but it had ceased when I came; we re-applied the dressing. In 24 hours I was called again and it was bleeding again, more from the popliteal space than from the original wound. We were called again in 24 or 36 hours; it had been eleven days since the original injury, and we found altogether a horrible condition of things. That was about six or seven years ago. I had just returned from the city, from some postgraduate work, and was quite anxious to save the leg. It was very septic and the question of going down into the original stab wound and searching for the bleeding vessel if possible and of tying the femoral or amputating the leg was what confronted us. Finally we decided to amputate the boy's leg and did so and saved his life. We thought we were justified in not tying off any more vessels. Of course we could have tied the femoral but that was deemed unwise, considering the septic condition of the popliteal space above and below. The question was whether tying the popliteal originally was better surgery, or to have gone down and tied where the wound was originally made. It seemed to me useless to have the boy's leg sacrificed, yet at the time I did it it seemed utterly useless to do anything else. There were really some very important points in the case.
To Clean Rusty Instruments.
Brodie gives the following as an effective method of cleaning rusty instruments:
"Fill suitable vessel with saturated solution of stannous chloride (chloride of tin) in distilled water. Immerse the rusty instruments and let them remain over night. Rub dry with chamois after rinsing in running water, and they will be of a bright silvery whiteness."-Journal British Dental Association.
Advertising rates submitted on application.
Entered at the Postoffice, Chicago, Ill., as Second Class Matter.
Officers of the N. A. R. S., 1896-7.
F. J. LUTZ, St. Louis, Mo.
First Vice-President. W. R. HAMILTON, Pittsburgh. Pa.
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.
THE DOCTOR'S OFFICE.
The old saying that we can judge a workman by his chips has a broader and deeper meaning than would at first seem apparent. Unquestionably the character and appearance of a workshop always furnish a pretty good indication of the painstaking care and orderly execution of the workman, or the absence of these qualities. We have often been impressed with the fact that there is a marked individuality in doctors' offices, provided, of course, the offices are occupied individually and not by a number of different physicians at different hours of the day, as in Chicago and some other large cities. Illustrative of the impression which appropriate surroundings of the doctor make upon the laity, we once heard
a very eminent lawyer remark, upon going into the office of a young Chicago physician: "That office will get business for the doctor. It is just as neat and clean as it can be and the fittings are appropriate, even to the smallest picture. There is character in it; it is all right." It is an unfortunate fact that sometimes the doctor's office is simply a convenient or possible place for the reception of patients, little thought being given to cleanliness or comfort, to say nothing about the artistic and esthetic surroundings, which certainly do contribute to the daily and hourly life of the intellectual worker, and which form a part of his moral atmosphere.
In other columns we publish a valuable contribution from the pen of Dr. Hugh Jenkins of Preston, Ia., and incidentally a plan and illustrations of his office and operating room. His library and desk and pictures and rug are not shown, but we can easily believe that they are there and that all of the surroundings are appropriate and characteristic of a man who cares enough about doing the best work that can be done to provide an aseptible operating room and the very best, though possibly the simplest, modern appliances for doing surgical work.
Pain, sensation, impression and perception are but relative degrees of expression of one and the same process of functional life. They are all given to man for the broad purposes of self-protection, warning and information. The first (pain) comes with the idea of distress, the idea of injury. Sensation may be pleasurable or painful; impression the same, but more of a psychic nature, while perception refers to interpretation and reason. Distress is defined as extremes of pain or suffering, anguish of mind or body. Pain is undoubtedly an indication of higher organization and the higher man rises in the moral scale the more his sensibility increases, and it can be truly Isaid that the influences of civilization are all tending in the direction of an increased sensibility.
Man feels and notices more things and is more frequently the subject of pain than in the early period of his existence.
Pain appears to be a more important con
sideration to the surgeon of to-day than formerly. The highest ideal of the healing art is the avoidance of pain, and it should ever be the purpose of the wise surgeon to avoid inflicting suffering. Indeed, the most effective and the best function of his life is not to give pain but to relieve it, realizing fully the value of pain in a diagnostic sense, that it is ever a signal of distress, an outcry of suffering and injured nature, and demands relief.
Many advocate a kind of educational suffering for man, a forbearance of outcry, the supposed manly tolerance to pain. We have ever viewed this as nonsense. We once heard an old observing rural practitioner say: “The baby that cries quickest with the belly-ache gets cured the quickest." We believe that pain was intended to make man give vent to his suffering, and when any man fails to do so he suppresses his saving function. Physicians and surgeons should teach their patients to describe their pains and not to hide them as trivial. Intense pain may be the record of the torture of a single nerve, while the dull ache may involve a whole territory.
Again we venture to assert that the best and the most successful of surgeons is the one who never inflicts pain when it can be avoided and who pays most attention to the significance of pain. Many surgeons study pain in a somatic more than they do in a psychic way. It is as essential to study the various phases of psychic as of bodily pain. Mental shocks. in the weakened and suffering have debarred cure. It is not necessary to create a catastrophe to shock those mentally weak, but we venture to assert that the rough indifference of the surgeon and the display of instruments have, combined, killed more than the mere operation. Trivialities carefully studied lead to perfection. Picture, if you will, a weak, delicate, suffering woman, whose brain dwells in morbid sensibility. She comes to a surgeon for operative procedure. Our lordly man of the knife has not time to indulge in the ordinary amenities of life and examines his patient in orderly, business fashion, without the faintest show of sympathy or feeling, and tells in the shortest possible way what has to be done, and honestly says that he cannot tell what the result may be. He has not time to soothe, placate or encourage. The time comes for the operation. The patient
approaches the table in painful and nervous apprehension; nothing is said to encourage her. The chloroform is given without a soothing suggestion. Here is a mind that a mental shock can and will influence violently, and this mind goes under the influence of chloroform in a state where a morbid suggestion may be the means of causing grave results. It is a poor surgeon who cannot soothe and quiet a pained mind as well as a pained body. The surgeon is more often the unconscious, inflicting agent in operative work than he thinks.
A surgeon unacquainted with psychic pain is only half educated, and in truth the surgery of to-day becomes more mechanical and less soulful. Narrow, technique surgery makes most of its successes through the thoughts of other brains than that of the operator. If genius were required to make surgeons, then indeed they would be very few and far between. Technique is mechanical, not intellectual. The surgeon should not only be skilled in technique, but should have knowledge of every element of his art. He should be a student of the mind as well as of the body, and success only comes in its best form when we interpret every condition and surrounding of the patient aright.
Woman's Inferior Sensitiveness to Pain.
Dr. Ottolenghi (Centralbl. f. Nerv. u. Psych., No. 7) reports the tests made with Edelmann's faradimeter of the sensitiveness to pain and the endurance of pain in six hundred and eightytwo women. He finds that women are less sensitive to pain than men, and that this sensitiveness is less in early life, increases to the twenty-fourth year, and decreases after that. The higher classes are most sensitive and the degenerate least. He found the latter class very obtuse to the sensation of pain. Endurance of pain varies between much broader limits in women than in men, reaching a maximum far beyond the masculine limit, possibly due to the "greater suggestibility" of the female General sensibility reaches the highest point in the nineteenth year. He concludes that sensitiveness to pain stands in close relation to the "psyche," while "general sensibility" depends upon the peripheral nerves. He considers woman's comparative insensibility to pain as a sign of her inferiority to man, as the uncivilized and degenerates are least sensitive. He attempts to prove a connection between this characteristic and her longevity.-Medical Record.
Committee on Arrangements.-G. H. SimMitchell, M. D., Lincoln, Neb.
The Tenth Annual Meeting of the National Association of Railway Surgeons.
The following is a list of the members of the National Association of Railway Surgeons who have already pledged papers for the annual convention to be held in Chicago, May 4, 5 and 6, 1897, with the titles of their contributions as far as announced:
Dr. John Punton, Kansas City, Mo., "Treatment of Functional Nervous Affections Due to Trauma."
Dr. Frank H. Caldwell, Waycross, Ga., "Relief and Hospital Departments."
Dr. H. L. Getz, Marshalltown, Ia., title not announced.
Dr. Solon Marks, Milwaukee, Wis., title not announced.
Dr. W. T. Sarles, Sparta, Wis., "Traumatic Infections and Their Treatment."
Dr. Jabez N. Jackson, Kansas City, Mo., title not announced.
Dr. G. P. Conn, Concord, N. H., "Relation of Railway Companies to State Boards of Health."
Dr. C. W. Tangeman, Cincinnati, O., "An Exhibition of the Various Devices for the Determination of the Color Sense of Railway Employes."
Dr. A. L. Clark, Elgin, Ill., "A Case in Practice."
Dr. A. C. McClanahan, Red Lodge, Mont., "Plaster of Paris and the Difficulty of Applying it to Recent Fractures."
Dr. W. R. Hamilton, Pittsburg, Pa., title not announced.
Dr. Thomas H. Briggs, Battle Creek, Minn., "Problems."
Dr. A. C. Wedge, Albert Lea, Minn., title not announced.
Dr. Rhett Goode, Mobile, Ala., "A Case of Osteo-sarcoma from Railway Injury."
Dr. E. W. Lee, Omaha, Neb., "The Treatment of Burns."
Dr. A. I. Bouffleur, Chicago, Ill., title not announced.
Dr. W. A. McCandlass, St. Louis, Mo., "Brain Abscess."
Dr. T. O. Summers, St. Louis, Mo., "Shock in Its Relation to Permanent Injury.”
Dr. W. B. Outten, St. Louis, Mo., title not announced.
Dr. A. L. Fulton, Kansas City, Mo., "The First Care of the Patient in Railway Traumatism."
Dr. M. E. Alderson, Russellville, Ky., "Medicine and Surgery with Their Votaries of Today."
Dr. Geo. W. Hogeboom, Topeka, Kan.,