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"The Beneficial Influence Exercised by Railway Hospital Associations Upon the Morals of Employes."
Dr. C. B. Stemen, Fort Wayne, Ind., “Accidental or Railway Surgery."
Regeneration of the Axis-Cylinders of Divided Peripheral Nerves.
Ziegler has published in the Archiv f. klin. Chir., vol. li, part 4 (abstract in Centralbl. f. Chir., No. 46, 1896), an account of his laborious investigation into the subject of regeneration of divided nerves in dogs, rabbits, rats and frogs. According to most histologists and embryologists, an active growth from the divided ends of the axis-cylinder ushers in the regeneration of the cut nerve. Ziegler claims, on the contrary, that the old axis-cylinder plays merely a passive part, and that the real regeneration is a neuroplasma rich in nuclei, which sends out protoplasmic fibrillæ, which later become differentiated into axis-cylinders and the other essential components of a nerve.
After division or constriction of a nerve, degeneration takes place in its peripheral and, to a less extent, in its central end. This degeneration is really a vital act, and predisposes to the absorption of the material of the degenerated fiber; meanwhile the sheath of Schwann-the neurilemma-is stimulated to active growth, and from this springs the protoplasm rich in cells, which absorbs the degenerated fibers and by the growth and differentiation of which the new nerve is formed. This sheath of Schwann cannot, therefore, says Ziegler, be of connective-tissue origin and nature.
The formation of new nerve-fiber takes place only in the central stump of the divided nerve, in intimate connection with the border of the degenerated area; and the union of an old fiber with a new one is accomplished by means of a nucleated drop of protoplasm, which appears in the end of the old nerve-fiber in close association with the sheath of Schwann.
The differentiation in the new protoplasmic strings appears early. First, as the finer fibers are recognizable, the axis-cylinder makes its appearance. Sometimes two or three of them appear side by side in a single fiber. Their union with the old axis-cylinders is a secondary process. After the axis-cylinder appears in the new protoplasm, the medullary sheath. becomes differentiated about it, and the nuclei assume a more superficial position, giving the appearance of a surrounding membrane to the newly formed fiber. This grows thinner and becomes the sheath of Schwann.
Notes, News and Personals.
It is reported in the daily press that Dr. G. W. Hogeboom has been removed from his position as chief surgeon of the Santa Fe system. We sincerely hope that there is some mistake.
A special dispatch to the St. Louis GlobeDemocrat from Sedalia, Mo., and bearing date of March 2, says that Dr. E. F. Yancey, who has been connected with the Missouri, Kansas and Texas hospital department since 1885 and who has been chief surgeon for the company since 1890, has been appointed to the position of chief surgeon of the Atchison, To peka & Santa Fe railway, with headquarters at Topeka, Kan. He will take charge of his new post on the 15th inst. and will have five hospitals under his supervision.
A later dispatch to the St. Louis Republic says that Dr. Yancey, at the earnest solicitation of the officials of the Missouri, Kansas and Texas Railway, has withdrawn his resignation as chief surgeon of the system and he will not accept the offer of the Santa Fe.
We are also indebted to the daily press for the following: Dr. J. P. Kaster of Albuquerque, N. M., now chief surgeon of the Atlantic and Pacific, has accepted the same position with the Santa Fe, and will make his headquarters at Topeka. It is probable Dr. Worth of Albuquerque will succeed him on the Atlantic and Pacific.
Dr. W. C. Gibson, chief surgeon of the G. S. & F. Railway, died recently at his home in Macon, Ga., in the thirty-ninth year of his age. He was an extremely active and busy man and his untimely death is attributed to overwork.
At a recent meeting of the board of trustees of the Jefferson Medical College, Philadelphia, Dr. J. Chalmers Da Costa was elected clinical professor of surgery. Dr. Da Costa has been connected with the college for many years, and has recently been demonstrator of surgery and chief of the out-patients' department. The new appointment is made in recognition of his long service and valuable contributions to surgical literature.
Sir Spencer Wells, the well-known surgeon and ovariotomist, died at Cannes, France, on the first day of the present month. He was the eldest son of the late Mr. Wells of St. Albans, Hertfords, his mother being the daughter of the late Mr. Wright of Richmond, Surrey. He was born in 1818 at St. Albans, and educated at Trinity College, Dublin. His first medical experience was in the infirmary at Leeds, but he subsequently studied in the Anatomical School at Dublin and at St. Thomas' Hospital, London. In 1841 he be
came a member of the Royal College of Surgeons, and three years later was elected one of the honorary fellows. At the close of the Russian-Turkish war, in which he officiated as naval surgeon, he returned to England and revived the operation with which his name has been chiefly associated, and ultimately became surgeon to the Samaritan Hospital for Women. In April, 1883, in acknowledgment for "distinguished services rendered to the medical profession and to humanity," Her Majesty conferred upon him the honor of a baronetcy.
Under the auspices of the railway branch of the Young Men's Christian Association at Utica, N. Y., the local surgeons have been given a series of lectures to railway men upon the subject of "First Aid to the Injured." Dr. J. G. Hunt, surgeon for the Ontario & Western railway, recently gave the men a very practical talk upon the dressing of wounds and the treatment of shock and hemorrhage in the absence of a surgeon, or until his arrival.
Dr. Haldor Snévé of St. Paul, Minn., has been appointed chief surgeon of the Chicago & Great Western Railway, to succeed Dr. Perry H. Millard, recently deceased. Dr. Millard died at Johns Hopkins Hospital in Baltimore, February 1, of pernicious anæmia. He was born in the state of New York in 1848 and was graduated from the Ogdensburg Educational Institute. He studied medicine in Rush Medical College and graduated in 1872. He then spent several years in the practice of his profession at Stillwater, Minn., afterward removing to St. Paul. At the time of his death he was Dean of the College of Medicine and Surgery at the Minnesota State University. He was an aggressive advocate of higher medical education and it was mainly through his efforts that the present laws regulating the practice of medicine in Minnesota were enacted. The following resolutions were passed by the Faculty of his college:
The faculty of the College of Medicine and Surgery of the University of Minnesota records with sincere regret the untimely death of its dean, Dr. Perry H. Millard. In his death, a ioss is sustained, not by this faculty alone, but by the medical profession of the state of Minnesota and by the cause of medical education throughout the country. He was a self-made man of large natural resources, of indomitable energy and perseverance, of unswerving devotion to his chosen purposes. And those purposes had, at heart, the good of his profession. To that profession he devoted twenty-five years of his life, achieving an enviable success in its service. He filled many positions of trust with faithfulness and places of honor with modesty. His services to the state of Minnesota are written upon her statute books and
in the history of her medical institutions. He was the author and the inspirer of the laws which have governed the practice of medicine in the state and particularly of that progressive measure known as the Minnesota Medical Practice Act, which has become the type of legislation for over half the states of the Union. He was one of the most active organizers and promoters of the American Medical College Association, a body which has done much to elevate the average standard of medical teaching in this country. His most signal service was in the projection, organization and development of the Department of Medicine of the University of Minnesota. It was in his brain that this institution, which has taken rank among the foremost professional schools of America, first took shape. It was his influence which secured the surrender of the charters of those private colleges which united in its establishment. It was largely through his unceasing labors and his persistent enthusiasm that it was placed upon the university campus beneath the roof of Medical Hall. It was his first ambition, his daily duty, his well justified pride, to forward its interests throughout the years of his fatherhood of its faculty. He passed from its immediate service under the inevitable compulsion of a death-warning he had too long refused to heed, to a death-summons which commands the sorrow of his associates and inspires this memorial "to the duty he has wrought."
Cyrus Northrop, LL. D., Prest.
R. O. Beard, M. D.
Incisions of Face.
Incisions made in the skin of the face should be placed where there is a shadow, or in the bottom of the furrows produced by the habitual expression of the patient. When this cannot be done, the incision should be parallel to the facial line rather than across it. A slightly curved incision makes a less conspicuous scar than a straight or abruptly curved one.-Rob
A Lawyer on a Physician's Diagnosis.
A referee in habeas corpus proceedings for the release of a patient in one of the state hospitals for the insane recently reported to the Supreme Court that the man is not insane. A physician in the hospital stated that the man was suffering from acute mania, but the referee asserted that the diagnosis of the witness was worthless.-Medical Record.
Extracts and Abstracts.
Amputation With Periosteal Flap in the Lower Third of the Leg.
At a recent meeting of the Practitioners' Society of New York Dr. Joseph D. Bryant presented an illustrative case of amputation with periosteal flap in the lower third of the leg, according to a method which he had practiced in more than a dozen cases in this locality. flap was made a little longer than a fourth of the circumference of the limb at the point of amputation, and included the periosteum attached to, not d'sected from, the soft parts. In suturing the flaps no stitches were put into. the periosteal portion, this being simply folded over the end of the bone. The advantage of the method lay in the fact that it gave a freely movable and painless stump, which allowed the patient to wear an artificial Imb with comfort. Some of the fourteen patients whose legs had been amputated in the lower third in this manner had worn an artificial limb within a month after the operation. In the case presented, the operation was done for necrosis of the tibia. A diagram was shown of the condition found at autopsy in the first case which he had operated upon in this manner, the patient having subsequently died of malignant disease. What little cicatrix which the method of operating had left had become almost entirely absorbed.-Medical Record.
Hypodermo-Clysis in Severe Railway Injuries
Requiring Multiple Amputation.*
BY JAMES EVANS, M. D., FLORENCE, S. C.
Wounds inflicted by railways are always serious, inasmuch as the various tissues involved are irreparably injured and usually require removal. It is difficult to form a correct idea of the extent of the injury as the external appearance of the wounded part does not always indicate the loss of vitality it has sustained, and the damage to the tissues is only revealed afterward by the more or less extensive sloughing which takes place in them. Sometimes in the examination of a limb, more especially when the bones are but slightly injured, only a trivial wound may be seen, yet the cellular and muscular tissues beneath the skin may be injured beyond the possibility of repair, and free hemorrhage is taking place from their torn and lacerated vessels. Considerable shock always accompanies these injuries, and when attended by hemorrhage the depression of the vital forces is often so profound that the condition
*Read before the Southern Surgical and Gynecological Association, Nashville, Tenn., November 10-12, 1896.
becomes one of exceeding gravity. If the injuries are multiple and of a character so serious as to require an operation for their repair, or removal, the condition is much intensified, and correspondingly greater difficulties must be encountered in our efforts to preserve life. To save life under these circumstances requires prompt and decisive action on the part of the surgeon, and there is nothing which occurs in practice more difficult to determine than the right course to pursue in an emergency of this kind. The victim of one of these railway accidents is brought to the surgeon in a state almost moribund, with cold extremities, and a weak, small and rapid pulse, almost imperceptible to the touch; he is restless, covered with clammy perspiration, and has sighing respiration and is in a condition of semi-unconsciousness. Formerly it was a difficult matter to decide what course to pursue in regard to patients in this condition. The combined effect of the anesthetic, and the shock which would follow an operation of any description, added to the existing profound depression of the heart and nervous system, would almost inevitably prove fatal, yet to defer it death would certainly take place from the more or less hemorrhage that was continually sapping the patient's strength. Usually when operations were performed under such circumstances, a fatal result followed. Now, however, a very different termination of these cases can confidently be anticipated by a timely resort to hypodermo-clysis. There are cases where the hemorrhage has been so excessive that the system drained of the minimum amount of blood compatible with life that the only remedy that offers the slightest prospect of preserving life is the speedy and direct transfusion of the blood of another person or an animal into the veins of the sufferer. But in the great majority of instances which come under our notice in practice, the transfusion of normal, warm saline solution into the subcutaneous cellular tissue answers every purpose and is attended with the happiest result in saving life while it is free from many dangers inseparable from the use of the former. Another advantage it possesses is the materials for its preparation are always available and can be easily obtained in almost every locality, and be prepared in a few minutes. It is not necessary to weigh the salt or take the temperature of the water, all that it requires is to put a teaspoonful of salt into a pint of warm water, as hot as can be well borne by the hands when immersed in it. There is some choice to be made in the selection of the spot for the injection, and for some reasons the left side of the chest, in the subaxilary space, is preferable to any other, as it is near the heart, and the injection acts as a powerful revulsive and counter-irritant to that organ, increasing rapidly the force and volume of the pulse, caus
ing deeper respiration and restoring sooner than when injected elsewhere, warmth and color to the surface of the body. The injection should be given either for the relief of shock or hemorrhage, as it will relieve the one and stanch the other, preventing further loss of blood. As soon as reaction occurs give the anææsthetic and proceed with the operation if one is necessary, and continue the injection from time to time until it is concluded, if there is any faltering of pulse. As much as 40 ounces or more may occasionally be used with advantage. As yet, the mode of action of the injection of hot saline solutions on the economy has not been studied with the care and industry such an important subject deserves, and we are not in a position to form an opinion of the metabolic changes wrought in the cells of the body which enable them to afford such speedy relief to nervous shock and hemorrhagic depression. Sir George Johnson attributed the stage of callapse in Asiatic cholera to the contraction of the cells of the lungs caused by the specific poison of that disease circulating in the blood, and it may be that the semi-conscious state, the weak heart and shallow perspiration are due to a poison generated by deficient metabolic action caused by shock and a deficient blood supply, and that the relief afforded by hot saline solutions is, owing to the restoration to the circulation, of a normal quantity of fluid, and also the dilution of the poison circulating in it. Whichever it may be, there cannot be any doubt that it is incomparably superior to any other remedy for the relief of the depressing effects of shock and hemorrhage.
The narration of a few cases which have recently occurred in my practice will convey a better idea of the prompt relief of all distressing symptoms which follows the use of this remedy.
Case I: A healthy boy, aged 14, in attempting to jump from a railway train, while in motion, was thrown down and his left arm and hand horribly crushed. As the accident occurred some distance in the country, three or four hours had elapsed before he was brought to me. The hemorrhage had been quite free and was still going on to some extent. He was restless, unconscious, cold to the hips, with a small flickering pulse and sighing respiration. A rubber band was thrown around the limb to restrain further hemorrhage and a hot saline injection administered. In a short time the body regained its warmth, the pulse acquired considerable force, and consciousness was restored. An anæsthetic was then administered, the limb amputated, the pulse remaining fair and respiration good until the completion of the operation. About six ounces was injected. Speedy recovery followed.
Case II: Negro man, aged 28, run over by a locomotive, crushing the left foot and the right foot and leg. Saw the man an hour and a half after the accident. The hemorrhage had been quite profuse, the lips and tongue pale and exsanguined, pulse exceedingly rapid, small and scarcely perceptible. There was considerable embarrassment of respiration and the mind wandering and unable to tell anything about the circumstances of the accident. As soon as a warm saline solution could be prepared it was given by transfusion into the subcutaneous cellular tissue in the subaxillary space of the left chest. Nearly sixteen ounces were administered before reaction took place and the pulse had recovered sufficient volume. and force to make it safe to proceed with the amputation of the limbs. Chloroform was administered and the limbs amputated, the left just above the ankle, and the right at the point of election below the knee. Several times during the operation the pulse became extinct and the respiration so much embarrassed that it became necessary to continue from time to time the injection until the operation was completed and the wounds dressed. More than 40 ounces were injected into this man, with the happy effect of maintaining in him a pulse of fair force and tension, during the operation. Rapid convalescence and recovery followed in this case.
Case III: A negro man, aged 19, of fine stature and robust constitution, jumped from a rapidly moving train at midnight, was thrown on the track and run over, crushing the toes and metatarsal bones of the left foot, the bones forming the right ankle were, crushed, the posterior tibial artery severed, and the muscles of the subcutaneous tissues of the entire limb below the knee were torn and lacerated and black from the infiltration of extravasated blood. This man was not seen till several hours had elapsed from the time of the accident, and was found in a state of profound collapse, due to shock and the enormous amount of blood which he had lost. Further hemorrhage was somewhat controlled by rubber bands thrown around the limbs just above the wounds, and a hot saline injection given in the subaxillary space on the left chest. Twenty ounces of the solution was transfused subcutaneously before reaction occurred. It was continued until warmth was restored to the body, consciousness had returned and the pulse had recovered sufficient force and steadiness to make it safe to administer an anæsthetic and proceed with the amputation of the limbs. Syme's operation was performed on the left foot, while the destruction of the soft tissues of the right leg was so extensive as to make it necessary to amputate just above the knee. In this case it became necessary to continue the injection of the warm saline solution until the close of the oper
ation in order to maintain the strength of the patient and prevent threatened heart failure. It required 32 ounces or more to do this.
Anyone who has witnessed the marvelous effects of the subcutaneous transfusion of warm saline solution in the relief of the collapse from shock and excessive hemorrhage can no longer doubt that it is incomparably the best remedy ever suggested for this condition, and that it has been instrumental in rescuing many from impending death that otherwise would have perished. Soon it will be required of every physician who accompanies an emergency ambulance in our large cities to be provided with the necessary appliances for the administration. of this simple remedy in the event it becomes necessary. It should likewise form a very close essential part of the armamentarium of the military surgeon and the men under his charge in the rear of the line of battle who render first aid to the wounded should be taught when and how to use this remedy and be provided with some simple contrivance for administering it. Each one could be provided with a small alcohol lamp, a few feet of rubber tubing with a large sized hypodermic needle and in an emergency even an ordinary canteen could easily be improvised for use. It is pleasant to contemplate how many lives will be saved in future wars by this simple and effective remedy who in the past were left on the field of battle to die without assistance.-Medical Review.
A Case of Foreign Body in the Ear.
BY FREDERICK N. C. JERAULD, M. D., NEW YORK.
Although clinical statistics show that foreign bodies in the external auditory canal are not so frequent as might at first be supposed, they are common enough to be frequently met with in general practice. In fact, the general practitioner is called upon to extract the foreign body as frequently if not more so than is the specialist.
The ones that usually fall into the hands of the specialist are those cases in which the foreign body has been in the ear for some little time, and has not given rise to any very active symptoms in the beginning. Let a man get a bug in his ear, he will not stop to look for a clinic or a specialist, but will go at once to his family physician.
In twenty-seven hundred and eighty-four cases treated in the New York Eye and Ear Infirmary, a foreign body was found in only thirty cases, and Dr. Albert H. Buck, clinical professor of diseases of the ear in the College of Physicians and Surgeons, New York City, says his records show only about one-half of one per cent.
These are, however, the records of the spe
cialist. Could we get a record of all ear cases treated in New York City, both by specialists and general practitioners, the percentage of foreign bodies would undoubtedly be much greater.
All forms of foreign bodies found in the ear might be divided into three classes, according to the character of the foreign body.
The first class consists of sticks, pebbles, peas, beans, beads, lead from pencils--in fact, anything with which a child might play. This class is the one most frequently met with, and the patient is usually a child. The foreign body may have gotten into the child's ear while the latter was at play, or, as frequently happens, been put in by the child of his playmates.
The second class consists of wads of cotton, which are put into the ear by the patient as a protection. This class is usually found in old people. They put one wad in the ear; then, forgetting that it is there, put another on top of the first. The first wad is thereby pushed into the auditory canal, forgotten, and may remain for a longer or shorter time, until finally the patient begins to grow deaf.
The third class consists of various forms of insects, such as the fly, bedbug, waterbug, etc. They may be found with equal frequency in children and adults, and usually gain access to the ear while the patient is sleeping.
A patient with a bug in the ear would naturally be aware of its presence, and would go at once to a physician; whereas an old man with a wad of cotton in his ear would not be aware of its presence, and would not consult a physician until he began to notice that he was growing deaf.
A child is apt to go for months with a foreign body in the ear, provided it is out of sight and gives rise to no pain. As the earwax collects on the foreign body, the canal becomes filled, and then it is that the mother notices that the child is growing deaf and consults a physician.
It is exceedingly rare for an adult to get a foreign body of the first variety in the ear and not be aware of its presence. Such cases do, however, occur, and I refer below to one of that kind which came to my notice a short time ago.
Mr. L., aged 26, until this fall had never had any trouble with his ears, and his hearing had always been perfect. He noticed in September that he was growing rather hard of hearing in his left ear. The deafness increased to such an extent that he decided to consult a physician, and came to me on October 24. He had suffered absolutely no pain or discomfort other than the deafness. The latter had increased to such an extent that a person standing on his left side and speaking in an ordinary tone was heard with difficulty.
On examination I found a ball of wax tightly