The Sterilization of Hypodermic and Other Syringes by Boiling.

BY CHARLES A. POWERS, M. D., oF Denver, COLO.

However simple and efficient may be our present aseptic technic, there yet remain many minor details in which our methods fail to give entire satisfaction. We have hitherto been unable to sterilize injection syringes in which the piston and washers are made of leather. This difficulty is now, however, happily overcome by Hofmeister of Tübingen, who, in the Centralblatt f. Chirurgie, July 4, 1896, sets forth a method by which we may render these important instruments absolutely aseptic.

His procedure rests on the principle that leather may be boiled at will in plain water after previous hardening in a formalin solution. The plan is as follows:

1. Only such syringes may be sterilized as consist of glass, metal and leather. The metal parts must be united by solder or screws, rather than by cement.

2. The piston and washers are removed and freed from lubricating fat by ether.

3. They are then placed in a two to four per cent formalin solution for twenty-four to fortyeight hours.

4. After the formalin has been washed off, the syringe may be put together and is then ready for boiling.

5. All air should be removed by working the piston back and forth while under water; the syringe may then be boiled at will in plain water (thirty minutes should suffice).

I have thoroughly tested this procedure on a number of hypodermic, exploratory and aspiration syringes, and can verify Hofmeister's statements in every particular.

Apparently the only change which the leather undergoes is a darkening and a slight thickening. Previous to immersion in the formalin solution, it may be well rubbed with gauze, dipped in ether and after sterilization, it is to be again lubricated with sterilized oil. If the piston consists of two pieces of leather separated by an oil-space, I have found it well to insert the first of these in the glass barrel before boiling. A moderate swelling of the leather may necessitate trimming its edge with a sharp knife.

I have put an ordinary hypodermic syringe through this sterilization process four times, at intervals of two days, without apparent change in the leather. What its limitations are as regards repetition, time will determine. It may be that the leather will have to be removed from

so many sources of infection in these syringes (exploratory aspiration of pus, for instance), and absolute asepsis when making injections is so much to be desired, that I am certain that this simple procedure will find wide employment.-Medical News.

Case of Traumatic Tetanus Successfully Treated With Veratrum Viride and Gelsemium.

In a recent issue of the Medical News Dr. Fordyce Grinnell of Pasadena, Cal., reports the following interesting case:

Guy B., a boy, aged six, while playing in his yard, barefoot, cut the ball of his left foot on a piece of glass. The wound apparently healed. Some nine days after (April 14), he complained of stiff jaws and difficulty in swallowing. These symptoms increased until, on the night of the 16th, tetanic spasms began to manifest themselves. The cicatrix of the wound was cleaned and scraped. It seemed somewhat tender on pressure, but no foreign body was discovered. The site was scarified, however, and turpentine and oil applied, and four-grain doses of ammonium bromid were given every two hours.

As no perceptible improvement was noted, on the 17th Norwood's tincture of veratrum viride was given, at first one drop every hour, then two drops every hour. As this did not seem to prevent the return of the spasms from time to time, fluid extract of gelsemium was given, at first in drop doses every hour, in conjunction with the veratrum, then in two-drop doses, and finally in three-drop doses. The veratrum was also increased on the 20th to three drops every hour, so that the child was taking three drops each of the veratrum viride and the gelsemium every hour, and it seemed to require this amount to control the spasms. This dosage was continued for forty-eight hours. Only once during this time did it produce active vomiting, or sufficient nausea to require an opiate to control it. When this relaxed condition was obtained, the drops were decreased to two of each on the 22d, and on the 25th to one of each, which was continued until the 27th, when the interval was lengthened to two hours, and gradually thereafter discontinued.

The ammonium bromid was given in three to four grain doses every two hours during this entire period.

The remedies in diminished doses were continued to the 30th of April, when the boy could open his mouth without difficulty, had a good appetite, was playful, but more boisterous in his manner than usual, or, as his mother said, "more nervous."

The remarkable thing to me was the tolerance in one so young of such powerful reme

dies in such doses. It seemed to require these doses to control the conditions producing the tetanic spasms. The instructions were to decrease the amount and frequency of dose when distinct signs of nausea appeared or the signs of convulsions abated.

I had been led to think that veratum viride might prove a valuable remedy in traumatic tetanus, as it had done in puerperal and other convulsions, and that gelsemium, in its peculiar action in causing relaxation of the muscles of the jaw, might prove a valuable adjunct, and in this case these remedies did not disappoint.

(380) Suture of the Heart.

Cappelen (Norsk Magazin for Lægevidenskaben, March, 1896), reports the following case: A man, aged 24, had some hours before admission received a stab from a knife in the left side. He went home alone, and about an hour afterward was found lying in a pool of blood. He was brought to the hospital in a cab, and on admission was found to be unconscious; the pulse could not be felt, but pure, though weak, heart sounds could be heard to the right of the sternum, on a level with the fourth rib; the impulse could not be felt. In the fourth left intercostal space, in the middle axillary line, parallel with the rib, was punctured, non-bleeding wound I c.cm. long. After a camphor injection the patient began to breathe and the pulse could be felt. The left side of the chest did not move in respiration. Under chloroform narcosis a resection of the fourth rib was made after enlarging the wound. The pleural cavity was filled with partly liquid, partly coagulated blood, compressing the lung. After evacuating the blood, which was estimated to be about 1,400 c.cm., the lung dilated and was found not to be wounded. By resecting 5 cm. of the third rib a wound 1 cm. long could be seen on the pericardium, bleeding freely. The sac was filled with coagula, and on enlarging the opening a wound 2 cm. in length was seen on the left ventricle, causing the bleeding. The wound was sutured and an artery tied, after which the hemorrhage ceased. The needle was brought half way through during a contraction and then dropped, and when the heart dilated after a second contraction the point was grasped and the needle brought completely through. The suturing was made very difficult by the rythmic movements of the lung, which covered the whole operating field, and by the heart contractions, which, however, were perfectly regular and quiet all the time. The pericardial cavity was emptied of clots as far as practicable. The pulse after the operation was very quick and feeble, but improved after a

subcutaneous saline injection. The patient sank gradually, however, and died two and a half days after the operation. At the necropsy it was found that a large branch of the coronary artery had been wounded; the wound had begun to heal, but there was evidence of pericarditis, and various bacteria were found in the fibrous exudation. The knife had passed through the pleura in front of the lung without wounding it, and again through the pleura and pericardium into the heart.-British Medical Journal.

The Treatment of Fractures.

The subject of fractures (says Dr. Andrew J. McCosh, Medical News, July 11) has in recent years, in this country at least, been somewhat overshadowed by the advances in operative surgery. American surgeons have however, always manifested a keen interest in the repair of fractured limbs, and many of the most important methods for the treatment of this class of cases have been devised and perfected by them.

For the treatment of fractures of the lower extremities two new methods, or, rather, modifications of old methods, have been recently proposed in Europe and have already been employed to a considerable extent in the United States. Each of these possesses features of novelty and also of practical utility. Each is worthy of more extensive trial.

The first is the method of "massage and mobilization," which has been systematized and strongly advocated for the past six years by Lucas Champonière. He claims that this method is revolutionary and paradoxical, and one absolutely new and contrary to the theory and practice of surgeons. Such terms are, however, extreme, for the plan is not entirely novel, though it has never before been carried into execution in such a systematic and thorough manner as is advocated by this surgeon. According to this method, immobilization of the limb is avoided. Massage is begun at once the sooner the better-and employed

daily until the bones have united. The seances, as a rule, last fifteen to thirty minutes. At first the manipulations must be gentle, and pressure should not be made directly over the ends of the fragments. In the intervals the limb is supported merely by a flannel bandage evenly, but not tightly, applied by sandbags alone. Splints or other immobilizing apparatus are not employed. The claims advanced for this method are: Rapid disappearance of pain and swelling, prevention of and more rapid absorption of the cedema and infiltration of the soft parts and of the effusion in the joints, preservation of muscular nutrition, and the more rapid formation of a firm callus. As a consequence, the fracture is followed by but little stiffness of either muscles, ligaments, or

joints, and as soon as the bone is united the function of the limb is fully restored and the patient thus saved weeks or months of pain, stiffness and disability. In certain cases, however, the originator of this plan grants that his treatment cannot be carried out in all its details. When the mobility of the fragments is so great that there is danger of a permanent deformity, or when the ends are so sharp that manipulation is apt to produce repeated traumatisms of the soft parts, or where the vitality of the skin has been endangered on account of the severity of the injury, the use of massage should be postponed for a week or two and the limb may be even confined for a few days in splints. There can be no question but that in certain cases this plan of treatment possesses advantages over the recognized treatment by complete immobilization. For example, in fractures of the radius or of the fibula, the period of inability will probably be considerably shortened. It is not, however, a safe method to employ in every case of fractured leg. The risk of bony deformity is probably increased, and it is very doubtful if either the patient or surgeon will be satisfied with a crooked limb even at the expense of a shorter and an easier convalescence. In many cases this method must prove a dangerous one, and it therefore cannot be recommended for routine practice.

The other method is the so-called ambulatory plan of treatment for fractures of the lower extremity, but especially of the leg. The method is not entirely novel, for at different times it has been used by surgeons in this city, though perhaps not in the systematic manner in which it is now practiced in Holland, Germany, and in our own country. Plaster of paris has always been largely employed in this country, and has been especially popular in New York and Boston, in which cities, indeed, its use has been for many years almost universal in the treatment of fractures of the leg. The fracture box has happily disappeared, and in most of our city hospitals is not to be found in the surgical armamentarium. According to the ambulatory plan of treatment, the use of the plaster splint is carried to a still greater state of perfection. It is claimed that the patient can get out of bed a few days after the accident, and can walk at the end of the first week, with the assistance of one crutch or a cane. About twelve years ago, it became the custom of several surgeons in this city to encourage their patients to get out of bed as soon as possible, and often they would be able to walk on the injured limb at the end of a week or ten days. This plan, however, which only differed in a few details from the method now called the ambulatory, seemed to have fallen into disuse, in part, perhaps, due to the custom in our hospitals of handing over

the treatment of fractured legs to the hospital internes, many of whom have habitually enveloped the limbs in rolls of cotton underneath the plaster. The ambulatory treatment, as systematized at the present day, consists in the use of a plaster splint snugly applied, without the use of cotton on the leg, but with this addition: that on the sole of the foot, underneath the splint, is placed a pad of cotton about threequarters of an inch thick and slightly deeper at the heel. This splint grasps the leg firmly about the bony prominence, especially at the upper part of the leg and head of the tibia. The leg thus hangs suspended to a certain extent in the splint, the greater weight being borne on the bulging part of the leg below the knee, the sole of the foot being separated from the splint by the pad of cotton. The principle is the same as that taken advantage of in the use of an artificial limb, though, of course, the avoidance of pressure at the end of the limb is less perfectly accomplished. In a few cases this splint can be applied immediately before swelling has resulted. Generally, however, this is impossible, and it is then wise to delay its application for four or five days, so that it may not be rendered unserviceable by the shrinkage of the limb. The short period of confinement to bed and the preservation of muscular nutrition are the main advantages of this plan of treatment, and as a result the general condition of the patient remains good and his period of invalidism is much shortened. It is not, however, a method adapted for all cases. In a considerable number the pain is so great that the patients cannot walk; in others, the weight of the splint or timidity prevents locomotion. In some cases the shape of the upper part of the leg prevents proper support; in others, the obliquity of the fragments is such that there is considerable risk of overriding and ultimate shortening, and in still others, the laceration and contusion of the soft parts is too severe to warrant the early application of the splint. Experience seems to show that the ambulatory splint can be used with distinct advantage in from 30 to 40 per cent. of simple fracture of both bones of the leg and in nearly all cases of fracture of the fibula. The same principle may be occasionally employed with advantage in the treatment of fracture of the knee, though, of course, the apparatus must be of a different pattern.

One fact must not be forgotten in the trial of new methods-that is, that there is no class of cases, either in surgery or medicine, where the medical attendant is liable to meet unjust criticism or suits for malpractice as in cases of fractures where a perfect result has not been obtained. Caution, therefore, should be exercised in the employment of methods which have not received the general sanction of surgical authorities.

Miscellany.

The Hippocratic Oath.

Under the above title Dr. W. S. Brown of Stoneham, Mass., writes as follows of the Kitson-Playfair case in a recent issue of the Times and Register:

The recent trial in London, Kitson vs Playfair and wife, opens up a serious question for the medical profession to answer, namely, is a physician justified, under any circumstances, in revealing a secret confided to him? The defendant, Dr. William S. Playfair, is a professor of obstetrics in King's College, London, with a lucrative practice in fashionable circles; and the jury has awarded the plaintiff, Mrs. Kitson, damages amounting to $60,000, for betraying a professional secret. The circumstances are briefly these: Mrs. Kitson is an Australian lady, wife of Mr. Arthur Kitson, the husband's reputation for morality being rather below par. At all events, the lady has had four or five miscarriages, and has been under some doctor's care most of the time since her marriage. She came to England alone, towards the end of 1892. Latterly she was attended by Dr. Williams, who called Dr. Playfair in consultation. On February 23, 1894, she was placed under chloroform, and examined by both practitioners. Dr. Playfair, during the legal trial, testified that "he found the neck of the womb dilated to the size of a five-shilling piece." He found a spongy mass inside, which "he at first took to be an intra-uterine cancerous growth. The mass was not growing from the interior of the womb, and it was easily scooped out and removed.

On removing the mass, he specially examined it, and found it to be a small portion of fresh placental tissue, of a spongy consistence, and containing fresh blood in its interstices. He said to Dr. Williams, 'she must certainly have had a recent miscarriage.' The mass removed was not a blighted ovum." This last remark referred to a statement by Dr. Spencer, professor of midwifery in University College, London, who was "of opinion that the body removed in February, 1894, might have remained in the uterus since October, 1892. What witness was shown was a piece of a dried blighted ovum."

Dr. Playfair also testified that "the plaintiff had told him, prior to the operation, that she had not menstruated since December, or thereabouts, and that menstruation had always been regular." During the cross-examination he stated that "he had formed an opinion adverse to the honor of the lady on February 23, and still holds it."

I do not propose to discuss the legal aspect

of this case; but, there are two or three points which require to be taken into account in forming an opinion as to its medical bearings. The husband, Mr. Arthur Kitson, is a brother of Dr. Playfair's wife. The sum claimed as damages was only $25,000, and the jury gave a verdict for $60,000. On account of relationship, Dr. Playfair made no charges for his professional services.

I do not know whether Dr. Playfair ever took the Hippocratic oath or not. Oaths (except profane ones) are going out of fashion nowadays, and with good reason. They are a remnant of barbarism. For no honest man is more likely to tell the truth after swearing to do so than before; and dishonest men do not usually stick at trifles. Here is a ver-. batim copy of the Hippocratic Oath, taken from the Sydenham Society, edition of the works of Hippocrates:

"I swear by Apollo, the physician, and Esculapius, and Health, and All-Heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation-to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. will give no deadly medicine to any one if asked, nor suggest any such counsel; and, in like manner, I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under

I

the stone, but will leave this to be done by men who are practitioners of this work. Just whatever houses I enter I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, if freemen and slaves. Whatever, in connection with my professional practice,, or not in connection with it, I see or hear in the life of men which ought not to be spoken of abroad, I will not divulge as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all men, in all

times! But, should I trespass and violate this Oath, may the reverse be my lot!"

The Hippocratic Oath (minus its Pagan and local features) is no longer administered to medical graduates; but its essential principles are as worthy of observance to-day as they ever were. Is a physician justified, under any circumstances, in revealing a secret confided to him professionally? I reply, no, emphatically no! And there are at least two good reasons which seem to me to settle the question.

First, the uncertainty of histological and pathological evidence. Here we have two obstetricians, occupying chairs in celebrated London colleges-not tyros, but experienced, talented teachers-one of whom testifies that a spongy mass, removed from the uterus, is a piece of fresh placental tissue, and the other that it is a piece of a blighted ovum! Since the trial, a writer, in the British Medical Journal, says

"Chorionic villi are very prominent, prettylooking objects, when seen in microscopic sections, but it is not always that we can swear to them. Other structures may simulate them. Admixture with blood may partly destroy the villi, and greatly modify their appearance. The very nature of the placenta offers great difficulties for evidence of the kind required for legal evidence."

* * *

I admit that cases occur in which the proofs of conception are decisive; but it is surely our duty, in all doubtful cases, to give our patient the benefit of the doubt, and keep the suspicion to ourselves I think that a physician is not even justified in expressing his suspicions to a consultant He should first be absolutely sure. A woman's moral character should not be impugned on the doubtful evidence of microscopic sections. .

Second, the notorious uncertainties of the law itself. This very trial demonstrates the unreliability of legal opinions. The lawyers on both sides wriggled through a quagmire of doubt. In every case, a conscientious man must make up his own mind what his duty is, and be governed by that, regardless of legal consequences. It would be better to go to jail for "contempt of court," than go to Coventry for betraying a patient's secret. During this trial, the question was raised whether Dr. Playfair was not privileged to tell his wife, as a family secret. I hold that a secret ceases to be a secret at all when told to anybody; and the last person a physician should gossip to is his own wife.

The essence of the Hippocratic Oath is embodied in the French law, which makes "the betrayal of professional confidence a punish able offense." In the state of New York, the law says, "No person duly authorized to practice physic or surgery shall be allowed or

compelled to disclose any information which he may have acquired in attending any patient in his professional character." I am told that there is no special law in Massachusetts anent betrayal of professional secrets; but the injured party could prosecute under the common law.

In this comparatively enlightened period, physicians do not need an oath to induce them to keep professional secrets; most of them do so. If a medical practitioner is not prompted to remain silent from a sense of honor, he is likely to do so from a sense of pocket; for a man must be a fool who habitually lets out his patients' secrets.

As far as law is concerned, I do not see why we are not as much entitled to professional privilege as lawyers or Catholic priests. A lawyer is not compelled to divulge his client's confession; neither is a priest. I claim that our profession is as necessary to public welfare as either law or religion-in some respects more so—and that it should be our privilege, as it is our duty, to keep the essence of the Hippocratic Oath.

To Drive Away Flies.

Dr. H. S. Baketel of Derry, N. H., writes: "Many practitioners of medicine among the poorer classes are greatly annoyed by flies in the sick room. The annoyance to the patient is doubly great. Such, at least, was my experience not long since on New York's great east side. An excellent safeguard against these pests is the sweet-pea flower. The Lathrus maritimus, the purple variety, grows near the seacoast from New Jersey around to Oregon, and beside the coasts of the Great Lakes. The Lathyrus ochroleucus is found on the hillsides from New England to Minnesota, and even further West. It is distinguished by its small, yellowish-white flower. Either of these varieties can be grown in the sick room, and the sweet odor emanated seems very offensive to the ordinary house fly."

Silver in Surgery.

Although the ophthalmic surgeon has long recognized the efficacy of silver as an antiseptic, Professor Credé of Dresden has recently presented the further claims of this metal to the attention of the general surgeon. Lactate of silver is an excellent germicide, but its easy solubility (in fifteen parts of water) renders it rather dangerous as a dressing. The citrate, however, is only soluble in 3,800 parts of water, and is therefore quite safe. It is found that a dilution of silver of even 1-80,000 still retains appreciable antiseptic qualities, while a solution of sublimate weaker than 1-20,000 is worthless. A novel suggestion is the use of