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quickly follow. If the larger vessels are severed, death will follow if relief is not afforded promptly. Hemorrhage must be checked at all hazards by whatever plan the nature of the wound indicates. The severance of certain muscles and nerves may so displace the parts that breathing is impeded, and sometimes completely obstructed.
A serious complication may suddenly arise in these wounds by the entrance of air into a wounded vein, especially if it be one of the jugular or the subclavian. Death will quickly Death will quickly follow if not relieved. Emphysema may readily follow when the air passages are open below the glottis, especially if the wound through the integument does not correspond in situation to that made in the air passage. Suffocation may occur from a small amount of blood in the larynx.
When the nerves of the neck are injured partial or complete paralysis will follow in the muscles supplied by the particular nerve. If the pneumogastric and recurrent nerves on both sides are severed, there will be paralysis of the muscles which open the vocal cords, and death will usually follow from tachycardia or oedema of the lungs.
The treatment of wounds of the neck requires very prompt action, first in checking hemorrhage, which must be done, even if the wound has to be enlarged or a new one made in order to ligate the bleeding vessels. Clots and foreign bodies must be carefully removed from vessels and air passages; rigid antisepsis must be employed, and especial pains taken to get the proper anatomical relations in closing severed muscles, nerves and cartilage. An interesting case was reported, showing the various conditions in treating wounds of the neck successfully where the trachea had been severed.
This paper was discussed by Dr. H. L. Getz of Marshalltown, Iowa, who reported a similar case, that of a man who had cut his throat in attempting suicide. The trachea was partially severed, but the great vessels had escaped the knife. He operated by successive layers of sutures and succeeded in closing the immense wound and getting a complete recovery. His patient was fed through a tube for one month.
Dr. Rhett Goode of Mobile, Alabama, reported to the Association "A Case of OsteoSarcoma from Railway Injury," and presented specimens.
ABSTRACT OF PAPER BY DR. RHETT GOODE.
He said in substance: The patient was a fairly intelligent man of thirty years, with a clear history, who suffered dislocation of the left knee and fracture of the external condyle of
the femur. The dislocation was reduced and the patient sent to the Charcity Hospital in New Orleans, where he remained for one month, at the end of which time the knee was ankylosed, swollen and tender. The swelling became located more at the external condyle. This continued for two and one-half years, at which time the patient came to the notice of Dr. Goode. Upon examination he found crepitation upon pressing the external condyle, and that the osteo-periosteal tissue was enlarged, covering a softened mass. An exploratory incision was made and the contents of the capsule were found to be those of a giant celled sarcoma of bone. The limb was amputated at
SARCOMA OF FEMUR.
the lower third of the femur; recovery was rapid, and during the six months since the performance of the operation there have been no symptoms of return of the malignant growth.
In discussing the case Dr. Goode said: "The pathology of sarcoma is perhaps the best understood of anything relating to it; the etiology is debatable, the prognosis is problematical. The diagnostic symptoms are indistinct. Generally there is no pain unless an injury be under repair or a nerve involved or pressed upon. If preceded by an injury, there will be continuous tenderness, pain, perhaps throbbing. But for a long time the tumor will probably have been confounded with inflam
mation. The exploring needle offers the sure, safe and quick means of diagnosis, for by it may be found sarcoma cells, stroma, blood clots and serum, or it may be determined that inflammation is the correct diagnosis, in which case no harm will have been done.
"The rate of development will be found to depend upon the position and the rate of cell migration. Cartilage is the only tissue which offers any considerable obstacle to its progress. The cells wander in the line of least resistance and hence follow nerve sheaths, blood vessels, lymphspaces, and the medullary substances of bones, setting up new sarcomata wherever they may become fixed. This is why prognosis is so difficult and why diagnosis
F. W. SCHMIDT, M. D., RIVERDALE, ILL.
should be made as early as possible, for with early treatment there is far less liability to general systemic infection. Again the causes which produced the first tumor may produce a second, even though the surgeon has done his utmost to remove the source of infection.
"Sarcoma frequently follows trauma in predisposed subjects, possibly in the majority the history of injury has been given.' So states Dr. Matas of New Orleans. But while injury is a powerful predisposing condition it is not an essential cause.
"The latest theory is that the tumor is caused by embryonal tissue which proliferates without purpose or restraint. This tissue is primarily composed of embryonic cells, which have preserved their proliferating power from an early period in the life of the individual. These cells
are probably roused to action by the process of repair, and thence results the sarcoma. Experiment tends to confirm this theory, for when certain healthy adult tissues have been inoculated with embryonic cells, those cells have proliferated, as do those of the true sarcoma; but inoculation of true sarcoma cells has uniformally been a failure.
"Excision is the only treatment for sarcoma, and when it is of bone it is advisable to amputate as for a severe injury, though it is not necessary generally to cut off above its proximal cartilage. Resection of the arm, ribs, scapula or clavicle are allowable, but are not generally successful."
The discussion was opened by Dr. A. I. Bouffleur of Chicago, who said: The occurrence of sarcoma following fracture is of great importance to railway surgeons. Sarcomata, etc., do not extend to bones beyond the distal joint, but they do extend beyong the proximal joint, as is shown especially in sarcoma of the head of the humerus, which is so frequently followed by sarcoma of the scapula, that operators now insist on removal of all of the upper extremity except in those cases recognized very easily. The process of bone repair is so long, the changes being first retrogressive and later progressive, that the conditions are favorable for the development of a sarcoma. Sarcomata do not develop in scars of soft tissues, but they do occur in bone scars. Carcinoma, on the other hand, quite frequently develops in scars which are subjected to repeated or excessive friction. Injuries of the periosteum without fracture are occasionally followed by sarcoma.
Dr. Louis J. Mitchell of Chicago also discussed the paper and exhibited specimens of bone sarcoma. He said: I have not much to add to what has been said, but would like to speak about the traumatic aspects of sarcoma. Since the researches of Marjolin, we know that irritation and other forms of trauma are associated with sarcoma, and the researches since then place the traumatic etiology of sarcoma on an equally conclusive basis. Some authors refuse to admit any connection between trauma and tumor formation, but the evidence in favor of this view seems overwhelming. Nègle (General Pathology) gives 7-14 per cent of all tumors as due to trauma. Dr. Gross of Philadelphia found a traumatic history in 10 per cent of his tumors of the breast. His father, the lamented Prof. S. D.
Gross, in 144 cases of osteo-sarcoma found such a history in 43 per cent. As regards the lapse of time, Loewenthal (Arch. f. Klin. Chirurg.), gives a table of 800 tumors, both malign and benign (358 carcinomas and 316 sarcomas). In these the interval of time after the injury varied from a few days to 49 years. The trauma, first, may cause an increased growth of Cohnheim's embryonal remnants; second, change the nutrition of the wound tissues from normal to pathological processes (Loewenthal). The trauma may be fractures, contusions or long continued irritation. It would seem that Prof. Dennis' aphorism is true. Mechanical injuries, especially of bone, is associated with sarcoma, peripheral irritation is connected with carcinoma, and sinus or other irritation with epithelioma.
The last paper of the morning was, "The First Care of the Patient in Railway Traumatism," by Dr. A. L. Fulton, Kansas City, Mo.
ABSTRACT OF PAPER BY DR. FULTON.
Dr. Fulton first assumed in his paper that an accident occurs remote from the ordinary facilities for complete surgical dressing, and that the surgeon is forced to employ temporary means in the emergency. He names three elements of danger at the time of the injury, viz., shock, infection and transportation of the injured, the greatest of these being infection from microbal dirt on the skin, in the clothing and elsewhere. He referred to shock as dangerous and probably lasting from both a physical and psychical standpoint." Neurasthenia and hysteria mingled make a troublesome complication.
The immediate treatment of shock should be vigorous. Strychnine, nitro-glycerine and morphine are recommended for obvious reasons. They are to be given hypodermically. Whisky as a stimulant he condemns without modification. It is not a stimulant in a true sense, but on the contrary will depress, cause vomiting and will, in severe shock, have a tendency to strangle the patient. Given hypodermically it may produce troublesome ab
Fractures, contusions and wounds were next taken up by the essayist. Simple fractures are to be cared for by immobilization by means of any apparatus that is sufficiently light and strong to serve the temporary purpose, such as a gun with the butt in the axilla and the muzzle bound to the foot and bandaged to the body, also above and below thigh fracture. A broom or piece or fence board may be employed in the same way. For fractured leg an umbrella, walking-stick or the like may be
shock as described at our meetings. He would advise that we instruct the employes in first aid. He would not condemn the tourniquet.
Dr. Lane of Kansas said he believed our first duty was to be honest to ourselves and everybody else, especially in the treatment of shock. He advised physiological rest rather than stimulation. He also favored absolute quiet and isolation in the treatment of these
Dr. W. R. Hamilton, Pittsburg, Pa., ad
ANDREW L. FULTON, M. D., KANSAS CITY, MO.
vocated the publication of instructions to employes by every railroad on "What to do till the doctor comes." He has written such a pamphlet, which has proved of value on his road. He did not believe in the application of the tourniquet, but would rather use compress and bandage.
Dr. Warren, Sioux City, Iowa, believes the first concern should be, "How much is the patient bleeding?" He therefore advocates immediate attention to hemorrhage, absolute rest, warmth and injection of sterile saline solution.
Dr. P. J. Dougherty of Junction City, Kan., believes that whisky in small doses is a stimu
lant and would use it in preference to strychnia. He condemned turpentine.
Dr. S. S. Thorne of Toledo said that all we need in the treatment of shock is heat and rest. Dr. Hatch of Quincy, Ill., thinks that an emergency box should be placed in every available place where railway accidents are liable to happen. He has placed several on his road at an expense of less than $2.00 each, and they have been a great saving in money as well as from a humanitarian point of view.
Dr. Fulton, in closing, said that digitalis had no place in the treatment of shock. Soap and water will not kill microbes in and upon the skin, but turpentine will.
The meeting then adjourned until 9 a. m. to-day.
The Professional Anæsthetizer.
The Medical Record says editorially,
"So far as we are informed in the matter, there exists in this great city no physician who makes a specialty of administering anæsthetics. There would seem, however, to exist a demand in this direction. Surgeons are constantly at a loss to find at short notice men of experience in ether and chloroform administration, no less than in other forms of general and local anesthesia, upon whom they can call for assistance in their important operations. The post at the head of the operating table is an honorable one, and at times everything depends upon how ably it is filled. If the surgeon is constantly distracted in his work by solicitude and perhaps alarm for the safety of his patient in the hands of one whom he does not know as a careful giver of the gas, he may be prevented from putting forth his best efforts for the patient from the cutting side of the operation. Large surgical hospitals might at times with advantage avail themselves of the services of such a professional anesthetizer. Not infrequently, as all operators are aware, the life of the patient, no less than the success of the operation, is jeopardized by the careless or ignorant manner in which this important part of the procedure is carried out by a novicus just out of the medical school. In almost all institutions it is the junior on the staff, who is going through the process of gaining knowl
edge and skill rather than applying that previously acquired to whom this important duty. is given over.
Every surgeon is aware of the great difference in men as ether givers, and the sense of relief he feels when a good man manipulates the inhaler. Then, too, we might speak of the great saving of time, to say nothing of the saving of ether. Much more ether is usually employed by the novice than is at all necessary, and all will admit that, other things being equal, the less the patient consumes the better it is for all concerned.
The probable explanation for the fact that
F. W. THOMAS, M.D., MARION, OHIO.
this important field remains uncultivated-we almost said worked-is to be sought in the unwillingness of young men to enter upon a career which would seem at first glance to offer so little for the future, whatever the emoluments of the present might be. This objection is, however, more imaginary than real, and the opportunities offered for advancement would surely be greater than in many occupations in which young physicians engage during the waiting years, such as insurance examination, inspection for health boards, newspaper work, or society reporting. Who will be the first to engage in this new specialty?
FROM THE REGISTER.
The number of registrations with the treasurer thus far has been eminently satisfactory. Dr. Lewis has been kept busy all the time receipting for dues, and the following is the list of those who had paid their dues for the ensuing year up to last evening at the time of going to press:
Dr. A. B Anderson, Loc. Surg., C. R. I. & P. Ry., Pawnee City, Neb.
Dr. D. F. Anderson Loc. Surg., St. J. & G. I. Rd., Edgar, Neb.
Dr. L. L. Ames, Loc. Surg., K. C. F. S. & M. Rd.,
Dr. E. Armstrong, Loc. Surg., Mo. Pac.
Dr. C. B. Allen, Loc. Surg., Ia. Cent. Ry., Morning
Dr. D. B. Adams, Loc. Surg., Burlington Line, 43 3rd St., Cameron, Mo.
Dr. W. H. Alley, Loc. Surg., St. L. I. M. & S. Ry., Forrest City, Ark.
Dr. M. E. Alderson, Loc. Surg., L. & N. Rd., Cor. College and Winter Sts., Russelville, Ky. Dr. W. J. Alexander, Loc. Surg., M. K. & T. Ry., Marthasville, Mo.
Dr. Frank Anthony, Local, C. & N. W. Ry., Sterling, Ill.
Dr. J. F. Archer, Loc. Surg., Ill. Cent., Shelby, Miss.
Dr. Saml. Bell, Loc. Surg., C. & N. W. Ry., 359 Bridge St., Beloit, Wis.
Dr. W. H. Burgesser, Loc. Surg., K. C. F. S. & M. Rd., Deepwater, Mo.
Dr. A. A. Bondurant Dist. Surg., St. L. S. W. Ry., Cairo, Ill.
Dr. John P. Burke, Loc. Surg., Mo. Pac. Ry., cor. Smith and Oaks Sts., California, Mo.
Dr. T. N. Blakey, Loc. Surg., L. & N. Rd., 18th
and Main Sts., Hopkinsville, Ky.
Dr. F. H. Boucher, Asst. Loc. Surg., Ia. Cent. Ry., Marshalltown, Ia.
Dr. W M. Bruce, Loc. Surg., Vandalia Line, Casey, Ill.
Dr. T. H. Brannan, Loc. Surg., C. L. & W. Rd., Canal Dover, O.
Dr. George A. Boyle, Loc. Surg., M. K. & T. Ry.. Louisburg, Kan.
Dr. A. M. Beers, Loc. Surg., C. & M. Rd., Newcomerstown, O.
Dr. T. C. Boulware, Loc. Surg., Mo. Pac. Ry., Butler, Mo.
Dr. C. W. P. Brock, Chf. Surg., C. & O. Ry., 206
Dr. Geo. H. Brown, Dist. Surg., M. K. & T. Ry.,
Dr. Albert I. Bouffleur, Surg., C. M. & St. P. Ry.,
Dr. Reuben Barney, Surg., C. M. & St. P. Ry., Chillicothe, Mo.
Dr. J. H. P. Baker, Loc. Surg., Wabash Ry., Salisbury, Mo.
Dr. P. M. Burke, Loc. Surg., Ill. Cent. Ry., La Salle, Ill.
Dr. E. H. Bayley, Loc. Surg., C. M. & St. P. Ry., Lake City, Minn.
Dr. D. C. Brockman, Loc. Surg., Iowa Central Ry., Ottumwa, Iowa.
Dr. Edwin R. Bennet, Loc. Surg., C. & N. W. Ry., 448 Seminary St., Chicago, Ill.