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posure, was about two days later than that of the abdomen.
The surface left was "raw" and "weeping," but not very painful. It was kept well dusted with powdered talc and protected from the friction of the clothes by a pad of wadding.
The author states that the discharge next became sero-purulent, and that he had now lost some thirty square inches of cuticle, and must have been daily losing considerable amounts of albumin in the discharge, and it was with difficulty that he, attended to his laboratory duties.
However, by twenty-seven days the surface was dry, and in thirty-three days quite healed. On January 11, 1897, there was no vestige of hair left upon the chest, and he has not been troubled with the shaving of his chin for the last six weeks, the hair having come out by the bulbs to the touch of the razor twentytwo days after the chest exposure, after a slight preliminary erythema of the skin not followed by loss of cuticle.
The time of the appearance of the symptoms in this case, he says, agrees fairly closely with that observed in two cases reported by Dr. Drury and Dr. Radcliffe Crocker.
In Dr. Drury's case there were vesicles on the tenth day after the first exposure (fourth day after second exposure), and there was a profuse discharge by the twenty-fourth day (the eighteenth day after the second exposure). The skin, however, was not sound sixteen weeks later, a fact possibly associated with the state of the health of the patient (kidney affection). In Dr. Crocker's case vesicles were seen on the eighth day, the epidermis began to separate on the fourteenth day, and peeling was complete by the eighteenth day. The skin was not sound sixty-seven days after the exposure.
The fact that about a week elapses before any serious symptoms of dermatitis appear, he says, suggests that the surface cells are destroyed by the rays, and that the inflammatory phenomena are associated with the removal of necrosed tissue.
The author thinks it possible that the early application of the skin's natural fat may have had something to do with the fact that he was well in a month.
The interesting point, he thinks, is the apparent immunity of structures deeper than the skin, for, although he had a sore on his chest and pimples on his back, his lungs, so far as he knows, are not affected. It is conceivable, he thinks, that this may be connected with the fact that the gas mixture in immediate contact with the skin is richer in oxygen than that in the pulmonary alveoli, and that the rays produce "active" oxygen, which is capable, when present in sufficient amount, of destroying the cells, were it not
that there is no evidence that the X-rays do produce "active" oxygen.
Skin structures, continues Professor Reid, and possibly the conjunctiva, at present appear to be the only tissues on which action has been noticed. Passage of the rays for an hour through the head of a boy of medium intelligence did not, in his hands, cause deterioration or improvement thereof.
Dr. Crocker, he says, makes the suggestion that as a prophylactic workers with these rays might wear red cloth gloves or coat their hands and face with red paint, which could easily be washed off, but he adds that the waistcoat within which he suffered was lined with scarlet flannel.-N. Y. Med. Journal.
Libel and Slander as Affecting Physicians.
Henry Leffman contributes to the Philadelphia Polyclinic of January 30, 1897, a syllabus of the law relating to this important subject: Libel consists in the utterance of any communication otherwise than by oral speech unjustifiably accusing private individuals, officials or governments of anything tending to make them ridiculous or injure them in reputation or public etseem. Slander is an oral statement unjustifiably accusing a person of a crime, a loathsome disease, incapacity, or dishonesty, or of any fault which tends to injure the person or his business. The courts have decided that an accusation may be slanderous or not according to the vocation of the accused. To accuse a physician of general professional ignorance or malpractice is actionable per se, but to state that in a special case he was at fault is not slanderous, unless special damage is proved. A retired physician, since he no longer gains his living by his profession, may be accused with impunity of what would "slander" a man in actual practice. Slanderous words uttered in one state may not be actionable in another state unless proved to be so also in the place uttered. person uttering slander to a second party who repeats it to the detriment of an individual may escape responsibility if the damages result from the utterance of the second party and not from that of the originator. In case of libel, any accusation holding a person up to scorn or ridicule, whether professionally or as a private person, is actionable. A physician who attempts to achieve notoriety by puffing himself cannot recover damages from those who further his attempts. It is slander to falsely attribute a contagious disease to a person, unless a statement was necessary and there was a mistaken diagnosis. A physician condemning any article used in medical practice is liable to the manufacturer, if the said physician's statement be incorrect.
siderable. Fortunately the larger vessels were intact. The patient was informed that there would be no difficulty in obtaining a good result in the case of the left leg, but an effort to save the right leg might result disastrously. He was very anxious to have the effort made and agreed to hold me blameless in case of failure.
In order to divide the responsibility I sent for a neighboring surgeon, who, on inspection of the injury, decided that an amputation was absolutely necessary. After stating the patient's proposition to him he decided to join me in an effort to save the limb. The left leg was put up in the ordinary lateral splints with a light splint anteriorly and posteriorly, and gave us but little trouble. The right leg was put on a double inclined splint that had been carefully padded. The foot was bound to the foot-piece and the leg to the splint, an opening being left through which the wounds. might be dressed. For the first week there was considerable pain, but after that time he suffered little. The wounds of the soft parts healed kindly and at the end of ten weeks the left leg had so far recovered that he could bear his weight upon it. The right leg was swollen, but otherwise seemed in good condition, so I put it in a plaster dressing and allowed the patient to take moderate exercise on crutches. By observing the photographs you will notice on the right leg, about five inches above the ankle, a slight bending of the bone from before backward. This marks the point
to which fracture extended above.
This slight angle is evidently responsible for two conditions remaining as a result of the fracture. The gentleman informs me that after walking all day the "heel string" in this leg feels as though it were a little short. He has also noticed that he stumbles more frequently with this foot than with the other, a condition evidently brought about by a slight relaxation of the tendons, due to the bending of the bone backward. It will be noticed that as he stands, the great toe especially has a tendency to drop down. The above slight deformities, with an enlargement two inches above the inner malleolus of the right leg, and a few scars where the soft parts were penetrated by pieces of bone, are all the evidence we have of the ordeal through which this patient passed. He is strong and reasonable ac
tive, occasionally plays baseball and informs me that he can do as much work in a day as before the accident, with the exception of putting hay in a press, a work which he now does in a slower but safer way. When I first viewed this limb I presumed there might be one chance in a hundred of saving it. I am doubly thankful we took the one chance.
41 S. Locust street.
FIRST ATTENTION THE AUTOCRAT OF FINAL RESULTS.*
BY J. L. WIGGINS, M. D., E. ST. LOUIS, ILL.
The story of the newly arrived Hibernian who refused to pick up a silver dollar which he saw lying in the street because he had been told that in America five-dollar gold pieces were as thick as blackbirds in a meadow,' finds his prototype exceptionally plentiful in the medical profession. The tendency of our profession is to ignore small injuries which do not threaten the life of the individual, or too markedly interfere with his comfort, and trust too much in the reparative power of nature to bridge chasms and overcome deformities unguided by the hand of man, who, from special education and experience, has opportunities to learn methods by which natural repair can be assisted. I do not mean that the majority of physicians wilfully ignore certain stereotyped rules which they have perfected after a more or less rigid apprenticeship in the school of experience, but I do mean that after certain methods have proven in a manner satisfactory in their hands, there seems to be an arrest of development, lack of desire to further advance or incorporate new and improved ideas. There seems to be a line of demarkation between our treatment and preparation in minor and major surgery. When the higher stratum is reached, every sense is quickened and every opportunity embraced, either by study or observation, to reach the higher point of perfection. A man will travel hundreds of miles to see how Jones ties a knot and Smith makes his initial incision, and think himself well paid in catching one new idea. If you gentlemen will permit your memories to carry you back over your experience in medical societies, and at the same
*Read before the Association of Big Four Railway Surgeons, at Indianapolis, Ind., Nov. 10, 1896.
time scan your journals, it will surprise you. to find the great amount of space and time which has, and is, being devoted to those operations which not one physician in one thousand ever has to perform, and how little attention is given to those known as minor injuries which daily fall to the lot of the general practitioner.
The presumption is that every physician is competent to ciasp hands with nature, interpret her signs and aid her efforts, but is this presumption proven by results? Are not half the cases followed by deformities, traceable to our own incapacity? If we should do our full duty in all cases, would not the dockets of our courts be less burdened with suits for damages against individuals or corporations under the general head of permanent disability? Is there really any injury which we can classify as being simple-that is, is there any injury so slight that a careful aseptic and antiseptic first attention can be ignored with safety to the patient or credit to the surgeon? We have all seen illustrations of the results of carelessness in these simple cases. Two of them occur to me at present. One a slight abrasion on the cheek caused by falling in alighting from a car. The injury was so slight that had it not been that the rules of the company for which he worked made it obligatory, the man would have sought no medical advice. As it was, the physician barely glanced at the injury and sent the patient home. Perhaps none of us would have done differently. A few days later I was called to see case. Erysipelas had been contracted and continued to spread, involving head, neck and chest. The case terminated in death.
The other case was one of contusion in the palm of the hand. Abscess resulted and after great damage had been done by aglutination of tendons a slight puncture was made. The inflammation extended, necrosis of the soft parts occurred, and the hand had to be sacrificed. These may be extreme examples of cases of this kind, but the bare possibility of such cases occurring should make us doubly careful in all cases. Let us take the first case. Suppose the abraded surface had been cleansed with some simple wash-Thirsch's or normal salt solution, covered with gauze and absorbent cotton and sealed with collodium. Does anyone here think we would have had the
above result? Again, in second case, suppose a free incision had been made and the cavity packed with gauze, and proper drainage provided after antiseptic or even simple irrigation. Would not the individual have retained his hand and the community have escaped the penalty of a possible dependent?
Of course, after certain conditions have been provoked, any and all treatment proves unsatisfactory. I hold that no matter how advanced or appropriate after treatment may be, initial, or first, attention, will govern results. The knowledge, reputation or opportunity of any surgeon does not absolve him from the penalty visited upon all who violate the basic principles of modern surgery. He must suffer in common with his victim. The charge that medicine is not an exact science loses its force when applied to the department of surgery. Starting with a certain condition we all know if we violate no rule either by omission or commission ordinarily certain results will follow. Following this line of thought we are led to ask in what manner is a man influenced in permitting himself to be led in error. In answer I would venture the assertion that the greatest obstacle most men have to contend with is that of habit encouraged by a spirit of laziness. If we subject humanity to a careful analysis we will find that the animal nature in man finds no greater surface indication than in that proclaimed by the force of habit. By daily devotion at this shrine, the physician more than all men creates a code which, right or wrong, becomes an index in all cases which experience has been the teacher. It is useless to argue the Common sense theories are combated with reported successes by means untenable and almost prehistoric and mechanically all of us follow certain lines unguided by reason, simply because our environments have been such as to encourage the formation of a fixed code, or because the broadening influence of association has not permitted unprejudiced comparison. Let us take as an illustration a point with which we are all familiar: Twenty years ago we were taught that in wounds, when possible, the finger was the only reliable means for exploration; that fact still remains. Later on we were taught that the finger must be thoroughly aseptic, otherwise more harm would be done by infection
than would be balanced by the information gained. Yet the latter instruction, although more valuable than the first, is still by many unhonored in its observance.
If habits, environments and associations have such an influence upon our successful treatment of cases, it would seem that it would be profitable to direct our attention to means whereby habits and other conditions may be turned to our advantage rather than to our detriment. I know of no means which aid in the advancement of our profession so much as a well-regulated hospital. In this matter we find both the surgeon and the hospital mutually benefited; one regulates the other. As a result we will now find a large number of good surgeons in our land when formerly there were but few. This is certainly a great advantage, not only to our people in general, but to corporations and individuals requiring surgical attention, who, from force of circumstances, are dependent upon a local surgeon and must be benefited or suffer in direct ratio to his knowledge and skill and the means which he can command for proper treatment and observation.
If the hospital is a good thing, and I hardly think anyone will question the fact, why not encourage its more general adoption in preference to its centralization?
If the principle will survive general criticism why not be more specific and apply it to our own system and let our local surgeons and employes share in its advantages?
In this connection, I would suggest the advisability of each division having from three to five hospitals, located at points where the co-operation of other companies could be invited. I take this stand in opposition to the proposition now so prevalent, to centralize the patients of an entire division or system at one point. I believe it would be cheaper and would yield better results. It is not necessary that a separate building should be maintained, but wards or a series of rooms in some hospital already established, or which could be established by slight encouragement of the company or companies. Not only this, but the company should see that the character of the service in these hospitals is in keeping with the latest practical developments in surgery, sanitary science and nursing. To this end, the trained nurse should be the starting
The expense item would be of small moment in comparison with the benefits which would accrue from better service. The avoidance of bad results in but one case, would more than pay the entire bill, with a large balance to the credit side of humanity.
Take either of the cases cited in the foregoing. Had the surgeon insisted that their well-being depended upon their careful observation until such time as the danger period had passed, is it not reasonable that both would have suffered but slight inconvenience and the courts would not have been called upon to adjust a death claim in one case and a permanent disability in the other?
In conclusion, I would re-echo the sentiment expressed at our last meeting, that no man should hold a commission on our system, who, with "malice aforethought," ignores our society. I know the time and money required by many of us to keep in touch with all our societies is no small item, but the rule is, that where a man fails to take an interest in a society with which he is directly connected, he takes an interest in none. Neglect always begets neglect. He fails to scan his journals and his textbooks become covered with dust. Trusting to luck, he moves onward, justifying conscience by ridiculing the heights which he fails to attain.
A SUGGESTION IN THE TREATMENT OF THE CENTIPEDE'S BITE.
BY W. B. OUTTEN, M. D., ST. LOUIS, Mo.
A party of gentlemen had gone out for recreation and a hunt. They had stopped at B-S-, Tex., and the hunting in that vicinity being good, they determined to stay there for several days. As usual, they had learned, upon inquiry, that Dr. H. of that place was an in