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thin sheets of metallic silver spread upon linen cloth as a protective dressing in surgery. It is claimed that even in the occurrence of suppuration, the action of the products of the bacteria produces a lactate of silver, which prevents their further development.-Medical News.

The Employment of Asbestos for Dressings.

The Union médicale for July 18 contains an abstract of a review of a report made by Mr. Volintzeff to the Surgical Society of Moscow, which was published in the Gazette des hôpitaux. The results of the author's investigations are summed up as follows: The density of this product is much greater than that of cotton or of tarlatan; it is less porous than either of them and less hygroscopic. The escape of vapors takes place more slowly under a dressing of asbestos than under all others. It is not as good a conductor of heat as cotton is, but on this point, says the writer, the results of the investigations are not yet perfectly satisfactory. Asbestos absorbs the albuminoid solutions better than absorbent cotton or tarlatan does. In regard to the clinical observations, says the writer, M. Volintzeff thinks they are yet too small in number to enable him to give a definitive judgment. The product is not expensive, because it may be used several times.

The Right to Practice in England on an American Diploma.

An English court has recently decided that an American physician with a genuine diploma from a recognized medical school is at liberty to practice medicine in Great Britain, but must not assume any titles implying that he is a registered British practitioner. The case was that of an American who appended to his name the letters, "M. D., U. S. A.," and the court held that there was no attempt to claim qualifications other than those implied. The Medical Defense Union, which undertook the prosecution, was condemned to pay costs amounting to to about £800.-The Medical Record.

Iodide of Starch in Surgery.

Majewski (Wiener med. Presse, 1896, No. 19: Centralblatt für Chirurgie, August 1, 1896) recommends iodide of starch as an excellent application in suppurating and neglected wounds, phlegmons, panaritia and venereal sores. A mixture of one part of tincture of iodine and two parts of starch, he says, exceeds iodoform in antiseptic action and in controlling suppuration. It is exceedingly hygroscopic, almost odorless, and very agreeable.

Notices and Reviews.

The Stomach; Its Disorders and How to Cure Them. By J. H. Kellogg, M. D. Battle Creek, Mich., 1896. It perplexes one to know just how to take this book, whether as a book intended primarily for physicians or for patients. If for the former it is in most respects a failure. The crude cuts, the crude and half-complete description of physiological processes, the condensed quiz-compend style used in relating the symptoms of disease, make it of no value to a physician who has studied physiology, anatomy and the rudiments of practical medicine. Some of the hints as to treatment and the more accurate diagnosis of digestive failures of the stomach, are not without value to the practitioner. Nor is the book much more. of a success if it is intended for the patient as a "home physician." In the preface the reader is evidently regarded as a layman: "The individual who wishes to make use of this work as a means to his own recovery, must first of all carefully read the entire work. He should then seek, either with or without the aid of a physician, to arrive at a correct diagnosis of his case. If possible, the services of a skilled physician should be employed, a test meal taken and the methods of examination described on pages 134, 320 and 352, utilized. * * * The nature of the disorder being determined, it will be easy, by the aid of the table of contents or the index, to turn to the section which deals with this form of digestive disturbance; and then having become familiar with the causes of the trouble, and the means of preventing its aggravation, such rational methods of treatment as will be efficient, and it is believed, successful in a majority of cases, may be carried out at home." We predict that if the average dyspeptic reads these pages he will be sure that he has in turn, ulcer of the stomach, cancer, all the forms of dyspepsia, five, we believe, are described, dilated stomach, etc., etc., and that the only sure way of saving his life is to rush to the Battle Creek Sanitarium and have Doctor Kellogg put in charge of his case.

Many of the directions, e. g., the diet lists, the use of baths, the simpler massage movements, will be valuable in the home treatment of patients. Some, e. g., many of the mechanical Swedish movements, and the low tension sinusoidal current, will be extremely perplex

ing, to say the least. He will have some difficulty, too, in understanding what is meant by the elaborate methods of examining the stomach contents, "coefficients of digestive work," the classification of functional disorders of the stomach (p. 144), etc.

Some of the cuts are good, particularly those showing massage and Swedish movements. Others are wretched, e. g., the ones on pages 50 and 30. The plate opposite page 128 intended to initiate the layman into the mysteries of bacteriology, shows twenty-eight kinds of micro-organisms. If the plate is taken from someone else it should have been so stated, for as it is, we have to make Dr. Kellogg responsible for giving us representations-and not very good ones at that of "micrococci arranged in groups of four, found in the sputa of consumptive patients," the "bacteria termo," "bacterial termo" and "bacterium aceti," the "bacillus of malaria, found in the blood in cases of malarial fever:"

On the whole, the book will, we believe, add to Dr. Kellogg's reputation with the laity. But it will add little or nothing to the respect in which he is entitled to be held by the great body of practitioners because of his unusual natural ability, the good scientific work he has done, his wonderful versatility, his far-reaching and whole-souled charity.

J. B. H.

A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D. Philadelphia, Penn.: W. B. Saunders, 1896.

This is one of Saunders' New Aid Series, and is a credit to both author and publisher. Upon the whole, it is one of the best manuals of obstetrics we have seen and should prove of value to students and practitioners alike. Instead of the usual arrangement into chapters, the work is divided into two parts, Part I being devoted exclusively to physiologic obstetrics, and Part II to pathologic obstetrics. To the former is given 200 pages, while the bulk of the work, about 500 pages, is devoted to pathologic obstetrics. In each part the subjects are systematically arranged, and "reference is made easy by a system of paragraphing, italicizing and numbering." The author has introduced into the text quite a number of tables for differential diagnosis, which add considerable value to the book. The illustra

tions and diagrams, of which there are a large number, are in the main very good. We notice a number of excellent cuts, showing the various positions and presentation, which are reproductions, reduced in size, of original drawings used in Doederlein's manual, published in 1893, and for which no credit is given. We cordially recommend Dr. Dorland's manual as one that is up to date, and that would prove of value to students as a guide to the study of obstetrics, and to the busy practitioner as a reliable work of refer

ence.

Neuronymy.

At the last meeting of the American Neurological Society, Dr. Bert G. Wilder presented the report of the Committee on Neuronymy. Among the recommendations of the committee were:

1. That the adjectives dorsal and ventral be employed in place of posterior and anterior as commonly used in human anatomy, and in place of upper and lower as sometimes used in comparative anatomy.

2. That the cornua of the spinal cord and the spinal nerve roots be designated as dorsal and ventral rather than as posterior and anterior.

3. That the costiferous vertebræ be called thoracic rather than dorsal.

4. That the hippocampus minor be called calcar; the hippocampus major, hippocampus; the pons Varolii, pons; the insula Reilii, insula; pia mater and dura mater, respectively, pia and dura.

5. That, other things being equal, mononyms (single-word terms) be preferred to polyonyms (terms consisting of two or more words).

A Remedy for Black-Eye.

There is nothing to compare with the tincture of strong infusion of capsicum annuum mixed with an equal bulk of mucilage or gum arabic, and with the addition of a few drops of glycerine. This should be painted all over the bruised surface with a camel's hair pencil and allowed to dry on, a second or third coating being applied as soon as the first is dry. If this is done as soon as the injury is inflicted, this treatment will invariably prevent blackening of the bruised tissue. The same remedy has no equal in rheumatic sore or stiff neck.Medical Progress.

The honorary degree of Doctor of Medicine has been conferred upon Bismark by the University of Zena.

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No. 11.

CAPITAL OPERATIONS WITHOUT ANESTHESIA AND THE USE OF LARGE SALINE INFUSIONS IN ACUTE ANÆMIA.*

BY J. J. BUCHANAN, M. D., PITTSBURG, PA.

Mr. President and Gentlemen:-The question whether a given patient, suffering from loss of blood and nervous shock caused by the crush of an extremity, can endure the further traumatism of a capital amputation and live, is one which every surgeon whom I address must frequently meet; and on the wisdom of his decision may hang the fate of his patient. The question of prompt or delayed amputation in crushing injuries of the extremities has been debated by all surgeons, but I am sure that every one of you, whatever ground he may take in discussion, treats every case he meets on its own merits. If the shock and loss of blood are slight he operates at once; if they are profound, his patient pulseless, bedewed with cold perspiration, vomiting, with sphincters relaxed, he always delays. In the intermediary cases, however, where the loss of blood has been great, the pulse feeble and the delay of a few hours produces no evident change in the patient's condition, notwithstanding the vigorous use of heart stimulants and external heat, he regards the case as one calling for the utmost discrimination. Sad perience has taught him that in these cases the briefest anesthesia and the quickest amputation are often followed by profound collapse and death; on the other hand, he has learned that delay also has its evils, but little less pronounced.

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About four years ago I read a paper before the Association of the Surgeons to the Pennsylvania Company, advocating a thorough dis

*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., April 30, 1896.

infection of the injured part and delay of operation till complete reaction had been established, a period of several days if necessary. Numerous trials of this method have convinced me that a limb so severely injured as to require amputation and exposed to infection by the vulnerating body, with perhaps large amounts of visible dirt, cinders, grease and other foreign bodies ground into its substance, with countless nooks and crannies open to infection and perhaps many already infected, the devitalized portion, soon to be gangrenous, still attached to the living parts-numerous trials I say of the disinfection of such limbs. have convinced me that with the means now at our disposal it cannot be done with any degree of certainty. I bring this subject of disinfection of mangled and infected limbs before you to learn your experience in this matter. In numerous cases in which I have endeavored to disinfect a hopelessly mangled limb and keep it aseptic for days till reaction should be thoroughly established and amputation safely done, I have employed every antiseptic precaution customary in capital operations including thorough scrubbing of the skin, copious douching of the lacerated and separated muscles and bones with sublimate solution, the removal of foreign bodies and visible impurities, the removal with scissors of all tag ends and partly separated tissues, including often. the limb below, which usually hangs merely by the skin and a few tendons or shreds of fascia, packing of every nook and cranny with iodoform gauze and the application of a moist dressing of sublimate gauze. In spite of the most minute and painstaking care, I have found that as a rule these crushed extremities do not retain the characteristics of an aseptic wound. Now, when I read in a "Systematic Treatise on Surgery"* that, under these circustances, decomposition can be prevented in nearly every case, I am led to inquire of you whether this is your experience. It certainly is not mine.

The destruction of the high hopes which I had entertained of being able to tide such patients in perfect safety over the period of shock and acute anæmia brought me again face to face with the dangers of delay. Do not understand me to say that this mode of treatment by disinfection and delay is not in many cases

*Moullin's Surgery, P. 151.

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the best that can be pursued, but that it by no means assures the safety of the patient and the aseptic condition of his limb.

On the other hand, the loss of two profoundly debilitated patients from shock, following primary amputation under ether anæsthesia, led me to consider the part that the etheri

I

zation might have taken in the fatal result. know that it is the prevailing opinion that ether is not a depressant, but I am convinced that the depression following operation is often due to a considerable extent, to the anesthetic. While seriously considering this phase of the matter, about two years ago, a man was admitted to my hospital service with a crushed leg, requiring amputation just below the knee. He had lost a great deal of blood and, notwithstanding free stimulation, his condition was such as to make me somewhat doubtful whether he would survive an amputation under ether. With his consent I made a formal amputation below the knee without any anæsthetic other than the whisky with which he had been plied. I was surprised at the very trifling pain which the amputation caused and the absence of any added depression or shock from the operation. The patient improved at once and recovered. Very soon afterward a similar case was admitted, requiring an amputation just below the shoulder-joint. In this case, also, an amputation without anæsthesia was made, with apparently little pain and little additional shock, and the patient recovered.

Three cases of craniotomy, with elevation of depressed portions of the skull, done on perfectly conscious patients, added to my confidence in this procedure.

One morning about ten months ago a man was admitted to my service with a limb crushed to the knee. About ten o'clock the previous night he had been run down by an engine, whose wheels had passed over the limb. The hemorrhage had been severe and, when admitted, he was almost in a state of collapse. At ten o'clock I saw him and introduced into his circulation, through a canula in the popliteal vein, two quarts of normal saline solution. The improvement was marked and immediate. His pulse became stronger and slower, his lips red and his general appearance more hopeful. His condition, however, was still not such as seemed to me to warrant amputation. In two or three hours his powers again declined, and

at I o'clock two quarts more of the saline solution was introduced into his circulation through the same vein. At four o'clock the same quantity was introduced in the same way. The pulse was now of such a quality that it seemed probable to me that a rapid thigh amputation, without anæsthesia, would give the man his best chance for recovery. He consented to the operation and I amputated at the lower third of the thigh without any anæsthetic except whisky, and with but little pain or further depression of the heart's action. The man recovered. I call attention to the fact that, in the space of six hours, six quarts of solution was introduced into his circulation with the most marked benefit. To many surgeons operation without anæsthesia will doubtless seem a step backward, but, in the light of my own experience, in the cases just outlined, as well as in others, I am sure that this procedure, coupled with the use of large saline intravenous injections, will save some lives that would otherwise be lost.

I crave your indulgence for wandering somewhat from the strict letter of the title of this paper and beg to add, as a summary of it, the following statements:

1. Patients with limbs so crushed as to require amputation, who are in good general condition, should be operated on at once.

2. Those who present evidences of severe shock and great loss of blood should be treated by external heat and stimulants, including the hypodermic use of whisky, digitalin, strychnia and nitro-glycerin and the rectal injection of whisky, strong coffee and hot water. The crushed limb should be disinfected as completely as possible and a six per thousand saline solution of not less than two quarts for an adult be allowed to flow into a vein, this infusion to be repeated, if necessary, at intervals of a few hours, according to the effect produced.

3. If by these efforts complete reaction should be established, anæsthesia and amputation should be proceeded with as in ordinary.

cases.

4. If, however, a moderate or doubtful reaction only should occur, the propriety of a rapid amputation without anæsthesia should be seriously considered, if the consent of the patient be gained.

5. The complete disinfection of crushed, lac

erated, dirty and infected limbs usually cannot be accomplished.

6. The sooner such limbs are removed, the better, provided the patient's life be not lost in the operation.

7. If, notwithstanding the vigorous treatment just mentioned, an amputation, either with or without anæsthesia, be fraught with great risk, it is far better to disinfect as thoroughly as possible, drain well, pack all open spaces and take the chance of infection, which, in most doubtful cases, is probably less than the risk of death from shock following operation.

DISCUSSION OF DR. BUCHANAN'S PAPER.

Dr. Evan O'Neil Kane, Pennsylvania: I heartily agree with the doctor, that the danger of shock is greater than the matter of anæsthetic in those cases where there has been considerable loss of blood. However, with ether instead of chloroform, we commonly find a small amount has the same effect. A small amount of ether will relieve pain. Pain, as well as loss of blood, play an important part in railroad injuries in the production of shock. Our grave mistake is made in leaving a limb badly mangled after injury in order to wait for the patient to rally from shock, because there are two important factors that keep up shock, one oozing from many small vessels, possibly the opening of a plug in a large vessel. When the worst of the shock has passed off the oozing will not be sufficient to do away with the good of saline solution. If we put a tourniquet on to prevent oozing, we subject the patient to much pain, also to the risk of mortification. The cinders ground into the limb must be removed, and it stands to reason that there must be more or less septic material in the cinders, and if we wait for the patient to rally in order to get out the cinders, we lose valuable time. and we ought to amputate at once, removing the cinders with the piece of limb.

Dr. W. H. Elliott.-It may increase the shock in these cases to give an anæsthetic, but I have never seen it do so. Of course, this is a matter in which the surgeon is obliged to use judgment. In cases of profound shock from the crushing of a limb, it takes a very small amount of the anesthetic to produce insensibility, so small, indeed, that I am loth to think that it adds to the shock. In the warm climate in which I live, after having used ether almost exclusively for fifteen years, I have for

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