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PUBLISHED EVERY OTHER TUESDAY BY
The Railway Age and Northwestern Railroader (Inc.), THE MONTREAL MEETING OF THE BRITISH MEDICAL ASSOCIATION.
MONADNOCK BLOCK, CHICAGO, ILL.
Officers of the N. A. R. S., 1896-7.
F. J. LUTZ, St. Louis, Mo.
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.
earnestness and interest in the affairs of the association by the membership at large, and never before has the association been such a compact and workmanlike body as it is to-day.
As this issue of The Railway Surgeon leaves the press the Tenth Annual Convention of the National Association of Railway Surgeons is coming to order in Chicago, and there is sent with this, in the form of a supplement, a copy of the first issue of the daily edition of this paper, which is to be published each morning during the convention. All indications point to a successful and profitable meeting. The attendance will probably not be as large as at some former conventions, for the long-continued hard times have made themselves felt in a diminution of the membership of the association. It is likely, however, that, while absolutely smaller, the attendance will relatively represent a larger percentage of the total membership of the association than has the convention of any former year. The decrease in membership has not been among the active workers of the association. On the contrary, never before has there been shown so much
The Canadian committee of arrangements for the coming meeting of the British Medical Association at Montreal is giving itself much needless anxiety in regard to the fancied danger that the meeting will be invaded by physicians from the United States who are not members of the association. The New York Medical Record, it would seem, has been engaged to sound a note of warning urging all persons not honored by special invitations to stay away from the meeting. A circular letter has also been sent to other journals explaining that a few noted persons are to be invited and that the committee is quite unable to accommodate others. This is all very amusing, and to say nothing of the narrowness and selfishness of the thing, it strikes us as very impolitic and from a business standpoint a blunder. From our experience in preparing for the entertainment of the members and guests of our it National associations ridiculous to suppose that so large a number of physicians from the United States would care to attend the meeting of the British Medical Association as to become a real source of embarrassment in a city the size of Montreal. As is well said by the editor of the Journal of the American Medical Association: "The British Medical Association, like our association, should be free and independent, and its management should be capable of controlling any crowd of members and visitors who may come. Every section should be independent to adapt itself to the conditions of the meeting. The Montreal committee are not making their duties less nor winning respect from the profession by sending out vaguely worded circulars to keep people away, even from the States. States. While the profession at large have only a general interest in this association meeting, it seems lamentable that any journal in the States should notice, or even publish any letter conveying the morbid fears of the committee, which to say the least are implied insults to the honor of the profession. The
Montreal meeting should be a most notable Extracts and Abstracts.
event in the medical history of the year, but it should be managed as all other meetings of physicians are, and as it is always managed when it meets in England, that is, on broad scientific and business principles. It should be for the members alone and invited guests and the presence of a crowd of visitors and listeners should never create the slightest apprehension, but rather be considered as a compliment. A wise committee would seek to enlarge the membership from this crowd and not repel them, but impress upon them the value and need of belonging to such an association."
THE PHILADELPHIA MEETING OF
The coming meeting of the American Medical Association at Phildelphia during the early days of June promises to be the most largely attended and the most interesting from both a social and scientific point of view of all the meetings of this great association. The committee of arrangements has arranged for the accommodation of at least 5,000 persons and every effort has been made to induce the members and their families from all parts of the country to attend and celebrate the semi-centennial of the association. It is to be hoped that every physician in the land who can will attend the meeting, and if he is not a member that he will join the association and help to carry on the good work which it is doing in uniting the profession of our country; for surely, never in history has there been a greater need of a united professional brotherhood and never was there greater necessity for harmonizing our ideas, scientific, ethical and legislative.
All who must pass through Chicago in order to attend the meeting are invited to go by the Journal's special over the Pennsylvania lines, which leaves Chicago at II a. m., Sunday, May 30. For circular giving full information in regard to this train, write to H. R. Deering, assistant general passenger agent of the Pennsylvania lines, 248 Clark street, Chicago.
Now is the time to join the National Association of Railway Surgeons. Volume IV of The Railway Surgeon begins June 1.
Traumatisms of the Liver.1
The following review of an exhaustive paper by Dr. Schlatter on the "Treatment of Injuries of the Liver," originally published in the Beitrage zur Klinischen Chirurgie,' is contributed to the editorial columns of the Annals of Surgery by Dr. H. P. de Forest:
In most modern text-books of surgery but little space is devoted to injuries of the liver, and even in cases where the injury to the parenchyma of the organ is comparatively slight the prognosis is regarded as very grave. Thus is perpetuated the old idea that injuries involving the liver are necessarily fatal. Fortunately, a review of recent literature reveals the fact that here as elsewhere, modern surgery has done much to lessen the gravity of the prognosis.
As has been shown by Mayer, all surgeons up to the beginning of the present century united in regarding injuries of the liver as practically hopeless. The famous surgeon of the Napoleonic wars, Larrey, writing in 1812, says: "Laceration of the liver will always prove fatal if the wound communicates with the abdominal cavity;" in another place he states, "The escape of bile into the abdominal cavity is fatal." As late as 1864, Pirogoff' asserted that wounds of the liver were more frequent than of the stomach or spleen, and, in his experience, were always complicated and fatal. At the present time, however, it is a satisfaction to know that this region no longer is characterized by the phrase noli me tangere, and that the surgeon familiar with modern technique may act energetically in the face of apparently fatal injuries.
Few cases are recorded in comparison with the injuries which actually occur. The most complete statistics are those of Edler, in 1887, of 543 cases, including those of Mayer (267) and of Nussbaum, 1880 (251). This is easily accounted for, since many persons so injured die before medical assistance is ever obtained, and in other cases the prognosis is so hopeless from the time of injury that there is little inducement for publication.
The prognosis has materially changed within the past decade. Formerly, physicians based their views almost entirely upon their personal experience. Nowadays medical literature is so extensive that a much wider field can be covered in the formation of an opinion. The mortality shown by the statistics of Edler is 66.8 per cent; in ruptures 85.7 per cent; in
I Beiträge zur klinischen Chirurgie, Bd. xv, Heft II, Tübingen, 1892.
2 Die Wunden der Leber und Gallenblase, Munich, 1872. 3 Memoiren der Militärchirurgie, 1812.
4 Kriegschirurgie, 1864, p. 576.
gunshot wounds, 55 per cent; in incised wounds, 64.6 per cent. Since these reported Since these reported cases are only those of more than ordinary interest, or those in which the prognosis was especially favorable, these figures show a better condition of things than really exists.
A small minority of patients recover, and sometimes do so without external interference, for it occasionally happens that, at an autopsy there is found an old and healed scar in the parenchyma of the liver. This fact is alluded to by Nussbaum, who adds that "it should strengthen our hope that in a few cases something can really be done."
As early as 1795 Theden' states that "the primary danger in wounds of the liver lies in the hemorrhage that occurs, and this danger is increased if any large bile-ducts are opened. As both blood vessels and bile-ducts are larger on the under surface of the organ than elsewhere, wounds in this region are more dangerous than those of the convexity." These views correspond practically with those of the present day. Were it not for the complications of loss of blood primarily, and secondarily cholæmia, wounds of the liver would not be dangerous in themselves. It is now known that the escape of bile into the peritoneal cavity is not of necessity a source of danger. The mechanical irritation caused by its presence may give rise to a serous exudate, but bile is markedly antiseptic in its nature, and many cases have been reported in which bile remained free in the abdominal cavity for days or even weeks without giving rise to peritonitis.
The task, then, which the surgeon is called upon to perform in cases of traumatic injuries. of the liver is to check the hemorrhage as soon as possible, and to prevent the retention of bile in the peritoneal cavity on account of its liability to cause cholæmia. Various methods have been used to produce this desired result. Rest was, of course, the method earliest employed. Later came the era of antiphlogistic treatment with the accompanying vesication and venesection, and to-day one wonders at logic which could support such remedies. Of direct applications compression by means of tamponnade was the simplest, most primitive and quickest method used. Then came the thermo-cautery, and, within recent times, direct suture of the wound as in other parts of the body.
It is to this latter method that Dr. Schlatter especially directs his attention.
The literature on the subject is not very extensive. Postempski, in 1892, reported five cases in which recovery occurred after the wound in the liver had been sutured. Operations by Adler," Smits, and von Eiselberg gave good results
with this method. Burkhardt,' however, regarded the method of suture as available only in those cases where the wound is a superficial one; if too deep to be included in the track of the needle he advocates the use of iodoformgauze tampons, so arranged that fibrinous exudate after a few days would form a canal leading to the surface of the abdomen for the escape of bile and wound discharge. Langenbuch performed the operation of fixation of a "wandering liver" by passing a row of sutures through the entire thickness of the right lobe and then fastening them to the costal cartilages. Adler reported a case of stab-wound of the liver where, in spite of the use of sutures, hemorrhage still continued, and tamponnade was finally necessary. Hochenegg, after the removal of a tumor from the liver, perferred to treat the wound extraperitoneally, and supported the upper and lower edges of the wound by sausage-shaped rolls of iodoform gauze, held in place by deep mattress sutures. Von Bergmann' removed the adenoma of the liver and checked the bleeding by drawing the wound together with silk sutures and tying them over strips of iodoform gauze placed along the wound. The sutures were left in place some days, and finally carefully removed. Korte had a case in which a gunshot wound of the liver was cured by iodoform-gauze tamponnade of the wound. Other writers cited are divided in their preference between the thermo-cautery and the tamponnade with iodoform gauze.
Dr. Schlatter adds to these cases five more of his own. A summary of these is as follows:
(1) Stab-wound of the liver; prolapse of the colon and omentum; profuse hemorrhage from the liver; wound about one inch wide and so deep that the finger-tip failed to reach the bottom; two deep sutures of heavy catgut and two capsular sutures of fine silk; recovery.
(2) Gunshot (revolver) wound of the liver; severe hemorrhage; three deep sutures of heavy catgut checked the bleeding and a good recovery was made.
(3) Gunshot wound of the liver by Flobert projectile. The track of the bullet involved the stomach, the jejunum, the pancreas, and the left kidney. Patient seventeen years old and liver tissue was friable. Six deep silk sutures stopped hemorrhage; death after eight hours.
(4) Rupture of the liver and right kidney two days before operation; extreme anæmia; laparotomy; suture of liver; hemorrhage stopped; saline infusion; death.
(5) Almost complete sagittal rupture of the left lobe of liver. Profuse exudate of bile into
1 Centralblatt für Chirurgie, 1887, p. 88.
2 Centralblatt für Chirurgie, 1891, p. 82.
3Deutsche medicinische Wochenschrift, 1892, No. 2.
4 Centralblatt für Chirurgie, 1893, No. 30.
5 Sammlung klinische Vorträge, No. 40.
peritoneal cavity; laparotomy and suture of the liver fourteen days after the injury; death.
In only one of these cases (3) was there a tendency for the sutures to cut through the tissues. In this case silk instead of catgut was used, and the tissues were more friable than in the other patients, who were all adults. The results, so far as the checking of the hemorrhage from the wounded liver was concerned, must be regarded as satisfactory. The combination of deep catgut sutures of large size with fine silk superficial sutures of the capsule is recommended, and will be used by the writer in the future. In view of the success attending the first of these cases the objection of Burkhardt to the use of sutures in any other than superficial wounds does not appear to be valid.
The fact that it is possible to completely close the abdonimal cavity after the use of sutures in wounds of the liver adds materially to the clinical value of the procedure.
That large bleeding vessels in the parenchyma of the liver may be ligated directly has been shown by Clementi's' experiments upon animals, and by Smits' and Von Bergmann's operations.
Where the wound is a large one, as after the removal of a tumor, the combination of sutures, mattress sutures, and tamponnade may be necessary; but as a rule the tampon should be used only in cases where sutures have failed to check the hemorrhage. Of the three methods the thermo-cautery is of least value. It will check only moderate parenchymatous hemorrhage, is of no value in extensive wounds, and is apt to be followed by secondary hemorrhage.
Another important question remains to be considered in this connection. However summarily the surgeon may act in gunshot or stabwounds of the liver, there remains a class of cases in which the diagnosis is often very difficult, and the proper course to pursue is uncertain. These are the cases of subcutaneous rupture. Of course, if, after a severe injury to the abdomen, in the region of the liver, there gradually develop the symptoms of internal hemorrhage, if the pulse becomes more rapid and small, if the patient grows more and more anæmic, if the area of liver dullness on percussion is increased, if pain, referred to the scapular region, develops, or icterus begins to appear, the diagnosis is easy. Unfortunately for physicians, cases where the symptoms are so well marked are very rare. Such violence as is caused by the kick of a horse does not by any means always result in an internal lesion. Fatal cases have been reported of this character where the autopsy revealed an acute peritonitis and no other internal injury. On the other hand, slight accidents may give severe
1 Centralblatt für Chirurgie, 1892, p. 84. 2 Op. cit.
results; for example, the mere fall upon the ice.' The cause of rupture of the liver may be an indirect one, as is shown strikingly in a case reported by Rezek,' where the victim fell a short distance, striking upon the feet; death was shown to have been caused a rupture of the liver and of the great vessels at its base. Aside from the size of the organ, the slight elasticity of its tissue, its method of attachment, and its weight are important factors in the occurrence of rupture.
The symptoms of internal hemorrhage may also easily be confounded with those of shock arising from slight contusions of the abdomen. Changes in the heart or in the brain will give a similar clinical picture to the one produced by bleeding; thready or absent pulse, deathly pallor, superficial and irregular breathing, and marked mental depression with restlessness. A differential diagnosis in such cases may be impossible, and time only will show the actual condition.
To diagnostic uncertainty must be added the other considerations, which add to the surgeon's perplexity. Certain cases of ruptured liver have gone on to a spontaneous recovery, without surgical intervention. Even if an operation be performed, the occurrence of liver-cell emboli may set at naught the best efforts, and the more severe and extensive the laceration the more apt is such a misfortune to Occur. In view of these facts would it not be better for the surgeon to sit idly by and allow the patient to await his fate?
To this important question most operators will answer, "No," and maintain that it is the duty of the surgeon in such cases to adopt the course that offers the greatest number of chances of success to the patient. If an operation be performed and a slight injury found, there is, of course, a very slight possibility that spontaneous recovery could have taken place. On the other hand, if the liver is found almost pulpefied by the severity of the trauma the patient would die in any case. Between these two extremes lie a great number of cases of varying severity. The decision must be given in favor of an exploratory laparotomy. If occasionally such an operation is performed with no discoverable necessity, the surgeon can, at the present time, easily justify the procedure as being on the side of safety; how much more severe will be the censure if he has failed to realize the gravity of the case, and has either operated too late or not at all.
The time of operation is to be determined by the fact that the sooner it is performed the more apt it is to be successful. For the surgeon the only question of doubt is regarding a possible unnecessary operation. With the practising physician the decision is much easier. If there is the slightest indication that
1 Meyer, p. 165, Case 86. 2 Edler, p. 346.
there may be a rupture of the liver, the decision of a surgeon should be at once obtained in order that no valuable time may be lost. The diagnosis will often be cleared up in the meantime, and an operation may be performed with the least possible delay.
The only remaining question to be considered is the one, What portion of the abdominal wall offers the best site for the operative incision? The upper portion of the liver, hemmed in as it is by the costal framework and by the diaphragm, is in a bad position for surgical access. The left lobe and the irregular and concave under surface is, on the contrary, most accessible. By moderate traction the anterior portion of the convexity can usually be brought within reach, and in a similar manner even the almost inaccessible posterior parts can occasionally be operated upon. In one case reported above (Case 4), Schlatter was thus able to suture the lobus spigelii. Division of any of the ligaments of the liver, with the possible exception of the suspensory ligament, which is of little or no hinderance to an operation, is scarcely to be contemplated. The use of tension will therefore be of but little as ance in moving the organ to any given site of operation.
In penetrating wounds the existing wound can be enlarged and converted as far as possible into the incisions about to be described. If site of injury is in the left lobe, or is undetermined, a median incision should be made; in wounds of the right lobe a curved incision along the lower border of the costal cartilages and to the right of the rectus muscle is to be preferred. In some cases these may be combined, thus forming an angular incision. Since by far the greater number of wounds of the liver are located on the ventral or lateral aspects of the vicus, these two plans of attack will nearly always suffice. Wounds situated posteriorly, the lumbar incision is hardly to be recommended on account of the thickness of the muscular walls, and the fact should be borne in mind that, as reported by Lannelongue, the thoracic wall can be resected along the anterior portions of the eighth, ninth, tenth and eleventh costal cartilages, for the pleura does not extend down to this part of the chest wall. The method of Lannelongue consists in an incision parallel with the thoracic border, and two centimeters above the same, beginning three centimeters from the border of the sternum, and ending at the junction of the tenth rib with costal cartilage. The retraction of the divided muscles exposes the costal cartilages to be resected, they are carefully freed from their attachments and cut through with cartilage scissors. Then, if the ends of the ribs are retracted and pressed apart, nearly the entire extent of the convexity of the liver can be made accessible.
It seems probable that if these practical sug
gestions of Dr. Schlatter are adopted as a basis of treatment, not merely by surgeons, but by the practising physician as well, the prognosis in injuries of the liver will in the future be much more favorable.-H. P. de Forest.
The Replacement of a Depressed Fracture of the Malar Bone.
At a recent meeting of the Practitioners' Society of New York Dr. R. F. Weir made the following report:
Fracture of the malar bone is not a common injury, and the depression of the broken bone into the antrum is yet more infrequent. From this complication marked deformity ensues from the flattening of the cheek and from the bony irregularity along the outer part of the inferior margin of the orbit. Disturbance is likewise produced in mastication and other movements of the lower jaw from the compression of the temporal muscle by the zygomal end of the fracture. Its recognition is easy, but the reposition of the displaced bone is usually difficult. The following cases illustrate a method that satisfactorily overcame the deformity, replaced the bone in its normal position, and restored the function of the temporal muscle. The measure adopted in the two instances to be presently detailed consisted in making a small opening with a gouge into the antrum within the mouth, just above the canine teeth, so that through this a No. 12 or 14 (English) sound could be introduced and by this means the depressed fragment forced upward and outward into its proper position. This procedure sufficed in each instance to a very satisfactory degree. The cases in detail are as follows:
Case I: Patrick McC-, aged 21 years, entered the New York Hospital, October 22, 1890, having been struck six days previously in the face with a heavy mallet, which felled him to the ground and left him for a time unconscious. When admitted to the hospital he was in good general condition, with his right eye nearly closed by an ecchymotic swelling, which invaded also the cheek. A depression existed not only in the region of the malar eminence, but also along the outer part of the inferior margin of the orbit and at the anterior extremity of zygoma. A sharp projection of bone could be felt just beneath the skin where the fracture terminated in the orbit. He was treated by local applications but suffered from the pain in the upper jaw, with, however, but little in mastication. He came under my observation about three weeks after the injury. The deformity from the difference in the two sides of the face was very pronounced and disagreeable.
Under ether, November 16, an incision was made through the mucous membrane, just above and to the outside of the right upper canine tooth and the antrum opened by a small