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onds only. It was done by the antero-posterior flap method; the femoral artery was controlled by finger pressure; only three or four vessels required a ligature; lint dipped in water was placed between the flaps, and the stump was folded in a towel and all signs of blood cleared away.
In a few minutes the patient woke up completely and could answer these questions: 'Did he feel able to undergo the pain of the operation?' 'Yes, he would submit as best he could.' 'Did he not know that the limb was off? Then he remonstrated against trifling with his feelings at such a moment; but, when the towel was removed from the uplifted stump so that he could see it, he burst into tears and fell back on his pillow.
"The scene at this moment was most impressive, for the success of the whole proceeding was as complete as could be witnessed at the present time. The great surgeon was almost as much affected as the patient; he saw at a glance what a blessing was in store for the human race, and what a boon for the surgeon, and he could scarcely command himself sufficiently to address even a few words to the spectators.
"The next case did not go off so smoothly. The patient was a rough fellow with an ingrowing toe-nail. He became boisterous and violent under the inhalation; he thrust the assistants on one side, jumped off the table, and, so far as I remember, escaped from the theater. He must, however, have been restrained or brought back and rendered insensible, seeing that the necessary operation was done without pain.
"Liston for that day could think of nothing but this wonderful discovery. He wrote this short note to Dr. Boot: '5 Clifford street, December 21, 1846. Dear Sir:-I tried the ether inhalation to-day in a case of amputation of the thigh, and in another requiring evulsion of both sides of the great toe-nail, and with the most perfect and satisfactory results. It is a very great matter to be able thus to destroy sensibility to such an extent without apparently any bad result. It is a fine thing for operating surgeons, and I thank you most sincerely for the early information you were so kind as to give me of it. Yours faithfully, Rob. Liston.' He also wrote a characteristic letter to his old friend and former assistant, Professor Miller of Edinburgh. I think the letter found its way into a Scotch newspaper, but I can only remember that it began and ended with a quotation from St. Paul, 'Rejoice, and again I say rejoice.'
"That evening I dined with Mr. Liston (I was acting as his private assistant at the time). Two ladies were present, and after the cloth was removed nothing would content him short of my exhibiting the effects of ether by inhala
tion. When about half under its full effect I could just hear the elder lady say, 'Liston, for God's sake stop; you will be the death of that poor young man.' He did stop, but I felt the effect of his strong grip of the lobe of the ear for a day or two."
The Doctor's Mistakes.
The following excellent editorial appeared in a recent issue of the New York Medical Record:
While it is unnecessary to deny that all human judgment is fallible, it is eminently judicious on the part of such as are called upon to venture opinions on probabilities to lessen as much as possible the chances of proving a rule. In the case of the doctor, the difficulty in fitting a prognosis to an ultimate fact is oftentimes insurmountable. The law of chances, with its multiplicity of controlling circumstances, is always against positive and unqualified assertions. The patient himself, with his hereditary proclivities, his individual environment, and his inherent vital power, is always an uncertain factor in a calculation of results. Even taking all such conditions into account, the best of men err. No one can be so sure that he is right that he has never had reason to regret that he has been too direct and too positive in the expression of an opinion. Our patients are never charitable in condoning this fault, but always hold it against the man who commits it. The more he attempts to explain, the worse off he is. The results of an autopsy are past all arguments for reconciling prognostications with facts. If the patient lives when otherwise he should die, he never loses his lucky privilege of talking back. His family and friends forget the joy of his recovery, often in spite of fate, in the satisfaction of getting even with the physician who gave up his patient so prematurely. The sympathies are always on the side of the man who wins, and, while no one regrets his reason for felicitation, the absence of one less witness against us might under other circumstances he borne by us with becoming resignation. The lesson is learned too late, that of saying and promising too much, and in thus doing more than our real duty to our patients. When we cannot control the causes of disaster, it is worse than folly to predict results. If we mistake a seventy-year clock for a twenty-year one, the pendulum in the former generally swings on until it runs down in its own regular way. It is the vital pendulum, after all, that must be studied, and until it actually stops it is never safe to say what is or what will be.
In all our relations with our patients, it is the safer and better rule to be more than cautious in our temptations to think aloud in their presence. A discrete general guards his line of
possible retreat with as much care as that of attack, concluding that while it is quite bad enough to be defeated, it is still worse to be hopelessly bagged by the enemy. The older practitioner need not be told that the practice of his art is constantly beset by startling surprises. Patients not only get well who should die, but many die without ostensible scientific reasons. To reconcile these constantly recurring experiences makes him an ever-ready trimmer to circumstances and an adept diplomatist with shifting fortune. While apparently knowing everything, he finds it eminently fitting his actual position to know little and say less. The loophole of expediency is as essential to him as are his advice and prescription to his patient. He learns to be astonished at nothing and always on the lookout for the unexpected. A sudden death is always explained with greater plausibility by the man who never declares his positive prognosis than by the one who has previously committed himself to its impossibility. So also with a doubtful diagnosis. It is always wiser to wait and see the eruption than on general reasoning to promise its appearance, to be sure that pus is present before risking a dry tap. The qualifying "if" comes in everywhere and every time. If the patient does not die, he may live; if pus is not present, the signs are simply misleading; if the case is not one of measles, the clinical history is wrong, and the patient has not been exposed; if it is not diphtheria, the bacteriological examination is at fault; if the wound does not heal, the sutures were not thoroughly aseptic. When nothing is promised, nothing is pected. We must balance one condition by the other, and the more evenly we do this the less often will the physician be charged with what he cannot reasonably help. A guarded mouth never needs to explain why the foot dropped in.
The Legal Value of Dying Declarations.
In the Boston Medical and Surgical Journal for November 26 Dr. Daniel March Jr. of Winchester, Mass., remarks that dying declarations, as defined by the American and English cyclopædias, are statements of homicide made by the victim under the solemn belief of impending death. The effect of such belief is regarded as equivalent to the sancity of an oath. Declarations so made are substitutes for sworn testimony, and they must be such narrative statements as a witness might give on the stand if living.
The importance to the physician or medical examiner of a knowledge of the subject of dying declarations, he says, was impressed upon. his mind by a case of death from criminal abortion which occurred in his district about a year and a half ago. In this case the accused was brought to trial and convicted. During the
trial dying statements of two different persons were offered in evidence. In one case this evidence, if admitted, would have been favorable to the accused; in the other, to the prosecution.
Dr. March thinks it is important for the physician in attendance upon a woman likely to die from the results of a criminal abortion to have clearly in mind his legal position and responsibilities. He quotes as follows a few of the acknowledged principles which have a bearing upon such cases: Dying declarations are accepted in law without being sworn to. It is naturally presumed that all statements made at such a solemn crisis must be sincere, believed at heart to be true by the dying person, even if subsequently shown not to be so.
The attending physician under such circumstances having expressed the opinion that the patient is dying and in sound mind, a magistrate should be summoned to take down the statements that the dying person may wish to make. Should it not be possible to obtain the services of a magistrate, then the attending physician can take down the dying declarations. The physician should, however, limit himself to writing down the exact words of the dying person, without offering any interpretation whatever. The statements should be read over to the dying person, and, if possible, her signature obtained.
The declarations must be made, not simply in articulo mortis, but under the sense of impending death, without expectation or hope of recovery. They are admissible even though others may not have thought the person would die.
The declarations may be signs or other appropriate modes of communication. It is not necessary that the examination of the dying person should be made after the manner of interrogating a witness in the case, although any departure from that mode may affect the value and credibility of the declarations. It is no objection to their admissibility that they were made in answer to leading questions, or were obtained by pressing and urgent solicitation, but the declarations must be made under a sense of impending dissolution. It does not matter that death failed to ensue until a considerable time after such declarations were made.
Declarations of a deceased person are admissible only in reference to those subjects to which she would have been competent to testify if sworn in the case. They must. therefore, in general, speak to facts only and not to mere matter of opinion, and they must be confined to what is relevant to the issue.
The circumstances under which the declarations were made are to be shown to the judge, and it is his province and not that of the jury to determine whether they are admissible.
If the deposition of the deceased has been taken under any of the statutes on that subject, and is inadmissible as such for want of compliance with some of the legal formalities, it seems that it may still be treated as a dying declaration if made in extremis.-N. Y. Medical Journal. Researches Concerning the Action of Chloroform.
Reynier continues to advocate chloroform, which he thinks is much more easily used than ether. Patients react very differently from its effect, but a pre-anaesthetic examination of each patient will enable one to judge in advance what is likely to occur during chloroformization.
In a normal case the cerebral cells are first affected, then the medullary cells, and finally the bulbar. According to the more or less great resisting power of these various cells, fatal accidents may mark the early stages of anææsthetization. In alcoholics, whose cerebral cells are in a continual state of hyperæsthesia, delirium is observed, which may reach the stage of delirium tremens. In hysterical subjects all varieties of hysterical attacks may occur, even paralysis and syncope. The same is the case in epileptics. In morphinomaniacs only slightly intoxicated, chloroformization is easily and rapidly accomplished; in others, on the contrary, it is more dangerous. In ataxic subjects the period of medullary excitement nearly always gives rise to reflexes which may arrest the respiration and heart-movements.
These accidents, which mark the beginning of chloroformization, may also occur at the end; therefore, patients should never be left until completely awakened.-Universal Medical Journal.
Billroth's Advice to a Young Man Intending to Study Medicine.
A correspondent of the Boston Medical and Surgical Journal has published a letter addressed by Billroth to an intimate friend, from which we extract the following: "You tell me of the tribulations of the landed proprietor, his subjection to wind, weather, fire and the like; well, I have no intention of discouraging you or Robert, but the doctor does not lie altogether on a bed of roses. Competition grows. constantly more fierce; in the beginning things generally come hard. As a student one has the pleasure of obtaining something of a glimpse into the workings of nature, as well as the diseases which assail humanity. The state of entire satisfaction which ensues on the passing the examinations is gradually undermined. by the discovery that our knowledge is but fragmentary; that in those cases where we would most gladly render assistance we often fail of doing so; often, too, are we harrassed by doubts as to the proper course to pursue.
less one is willing to pass through the world in a state of chronic perturbation, one must rest content with doing his duty to the best of his knowledge and belief. A man's greatest blessings are then met with in the shape of a placid and loving wife and undisturbed domestic happiness. Hardly, however, have you reached your home prepared to enjoy these pleasures, when there comes a knock on the door, and duty calls you out again into the cold and stormy night. Few are the joys of the physician. Here and there true loyalty on the part of his patients, emphasized occasionally, although perhaps seldom, by a material token, infrequent gratitude for the most absolute devotion to duty, nay, even for personal sacrifice; joy over a completed cure; the consciousness of having done one's utmost-these are ordinarily the highest satisfactions the physician can attain. You think, perchance, that I paint the picture in too gloomy colors; but when twenty years have gone by and these lines fall into Robert's hand, he will perhaps say that I was right. If once he has a true vocation for medicine, he need not take this into much account. You wish me to write you plainly and in detail. Do not fear lest I continue in this strain; the worst has been said, and, after all, the state of things here is not much worse than one finds in other walks of life. What special quality must one possess in order to be a good physician? My colleague here, Nothnagel, whose work on diseases of the nervous system will at some later day be appreciated by Robert, when inaugurated professor of the house clinic here, said, among other things in his address, 'Only a good man can be a good physician,' and I, too, share this opinion; it is the supreme regulator of the inner, as well as of the outer effect of the physician's actions. To the phrase 'good man' I would like to add the words 'well brought up,' that is, in a family the existence of which is permeated by a spirit of charity toward all mankind. This condition is fulfilled in the case of your Robert. He must be actuated by an uncontrollable impulse to help other unhappy creatures, at first implanted in him at his birth and well developed, while cultivated feeling and the experience of life have later led him through reflection to the conviction that, however eagerly the man of moral training may chase after happiness, he will ultimately find true happiness to lie in making others happy to the extent of his ability. In this direction alone dare he cultivate egotism, I mean make himself happy, and as much so as possible. In so far as this orginates in his moral training, it willbea never-failing source of self-purification, a means of strengthening the sense of duty, a reinforcement of his own moral nature. Should misfortune overwhelm him, he will find that, in assisting others who are even more unfortunate than himself, he has gained comfort as well as
the strength requisite for pressing on in the race. To enable the physician to spend himself freely, he must have accumulated a rich fund of knowledge. And in possessing such a treasure the physician enjoys the special privilege of seeing it increase directly in proportion to the lavishness with which it is spent. Activity in the practice of medicine leads to increase in experience, development of judgment, impels us to supply the deficiencies in our knowledge, enables us to follow the progress of the art of medicine, which itself results from the progress of science. A physician who gives himself up to critical, unprejudiced observation sees his own stock of experience and knowledge increase in the very dispensing of it for the relief of others-always provided that he is a good man, with a strong sense of duty, has a sound understanding and takes delight in work and in his calling."-Medical Record. Legal Responsibilities of the Operating Surgeon.
A recent suit for damages against a surgeon in London for exceeding the wishes of a patient regarding the extent of an operation has just been decided for the defendant. The case was one of double oöphorectomy, against the express wishes of the patient that but one ovary should be removed. During the progress of the operation it became evident to the surgeon that the removal of the remaining offending organ was necessary for a radical
The patient, in consequence of this act, was compelled to break a marriage engagement which had been pending. The testimony in the trial bore upon some very important questions of professional responsibility in this and similar cases. While the course to be pursued must be governed by individual circumstances, the general reasons for specific action are admittedly controlled by well-understood general principles. The result of the case in hand carries with it a lesson of danger in lawsuits, which every surgeon should thoughtfully consider. It is legally held in this country and in other civilized communities that the consent of the patient, when such can be obtained, is always necessary in dividing the responsibility of any operative treatment. In the case of a child or of an insensible patient in imminent peril, the nearest relatives or friends are competent to decide for or against surgical interference. When such precautions are not or cannot be taken on the part of the operator, he assumes the sole responsibility of the result. No surgeon cares to do this when he can avoid it, and as a consequence he protects himself against the possibility of subsequent misunderstanding accordingly. A refusal to take proper advice under given circumstances is the affair of the patient and that of no one else. Hence, in the eyes of the law the patient has the right to decide
his own chances; in other words, is privileged to take his life in his own hands, in spite of the judgment of the person who is summoned to his aid.
In the actual course of an operation the case is entirely different, and the discussion of the duties of the operator opens up a wide field for the exercise of his judgment in assuming unlooked-for risks, in meeting unsuspected conditions of emergency, or pressing matters of expediency. It is just here that a line can be drawn between what may be actually necessary to avert immediate death or subsequent disability and the surgeon's ideal of a complete operation. Especially is this true when the loss of an important organ is to be considered, and when the patient has forbidden. its removal under any circumstances. No good operator would care to undertake the treatment of any case with such an embarrassing handicap; but when he does, he must, save in very exceptional instances, religiously abide by the conditions.
In the present case, the testimony showed that the operator, when asked to promise that but one ovary should be removed, replied that he would use his best judgment in complying with the request. The tacit consent to such a proposition was legally implied by the patient voluntarily placing herself upon the operating table, although she positively declared that she had given no direct assent to the proposal of the surgeon. Although it was not claimed that the removal of the second Ovary was necessary to save the life of the patient at the time, but that it was for the sake of an ultimate cure, the jury, fortunately for the defendant, took the lenient side and most liberally indorsed what on general principles might be considered a laudable motive. Strictly speaking, however, there was a dangerous possibility for an entirely opposite. view. That such chances should not be taken again is the real moral to this particular tale. One of the experts for the plaintiff expressed his belief that the second ovary was not sufficient diseased to require removal, but he evidently merits the pity of every practical gynecologist.
While this case may be looked upon as a leading one in protecting the surgeon in doubtful emergencies, the pros and cons cannot be weighed too carefully to prevent a disastrous reversal of the present ruling. If it necessary that one more word should be said on this point, it is better in cases of doubt, when such can be safely done, to perform an exploratory operation and obtain consent for more radical measures afterward, than to be called to account for what the patient may term to be disobedience to his or her commands; but safest and best of all is never to undertake any operation whatever without the freest possible liberty for the use of personal
judgment on any and every contingency.Medical Record.
Differential Diagnosis of Abscess of the Brain.
In the Fortschrit d. Medecin, November 15, 1896, Oppenheim emphasizes the difficulty of differential diagnosis in traumatic brain abscesses, which may be confounded with traumatic meningitis, apoplexy, encephalitis, tumor, epilepsy, traumatic neuroses, etc. Cases cited prove how easily a one-sided traumatic apoplexy, or a hemorrhagic non-purulent encephalitis may, from symptoms alone, be taken for abscess. Oppenheim mentions a striking
case in a boy, in which a wound on the forehead was followed by slow pulse, optic neuritis, rigidity of the neck, etc. A diagnosis of frontal abscess was made, but puncture gave no pus. On the following day the pulse was 144, there was fever and unconsciousness, and rapid death. The autopsy showed a well-developed tubercular meningitis. The boy was ill before the accident. The traumatism merely gave an impulse to the development of the disease.
Suppurative meningitis occurring with an abscess is likely to be overlooked. An abscess of the brain is marked by normal or subnormal temperatures; fever is by no means a necessary symptom. If an attack begins with a rise of temperature, it is probably not due to an abscess of the brain-certainly not to an uncomplicated one. A slow pulse is, perhaps, the most reliable single symptom.
It is also well to remember that patients suf-. fering from ear troubles often become hysterical, and that a hasty diagnosis of hysteria, even if the typical symptoms are present, may falsely be made in cerebral abscess of otitic origin.
Czerny (Centralblatt für Chirurgie, No. 31, 1896), in an abstract of a paper read before the German Surgical Society, states that he was induced to use the buttons by the results of recent experiments made by Marwedel on animals. These researches prove that the button effects a very even union of the intestinal walls without pseudo-membranous adhesions, and that the opening shows no tendency to subsequent contraction. Of thirteen cases in which the author has used the button, three were fatal. In one of these fatal cases death was the result of pressure gangrene and perforation, in consequence of the application of too large a button. In the other two cases the button was used under the most unfavorable conditions of enterectomy for extensive gangrene of strangulated hernia.
The button, Czerny found, was usually discharged in the stools, in the course of the second or third week.
In a case of successful gastro-enterostomy,
the button had not been passed up to the date of the patient's discharge, twenty-four days after the operation.
It is pointed out that the use of the Murphy button, like that of every other method of intestinal approximation, requires practice, although its mode of application can be more readily learned than that of a good double suture, which, in Czerny's opinion, is still the best method of closing wounds in the intestines.
The chief objection to Murphy's method is the sojourn of a heavy metallic substance in the intestinal canal; until this has been dis
charged naturally by the bowel the surgeon
must remain anxious as to the welfare of his patient.
It is concluded that Murphy's button, though not the final solution of the problem of intestinal suture, marks an important advance in this direction, and, therefore, demands careful study.
The Early Morning Hour he Best for Operations.
The hour for capital operations is by no means an unimportant consideration. A writer in Gaillard's Medical Journal says that in following the course of operative cases and various operators for a number of years in the hospitals of a large city it seemed that the early morning hour had a great many claims entitling it to serious consideration. A good night's rest, attained artificially if necessary, an empty stomach, the patient all ready for anææthesia upon awakening, the fear and dread of what is coming being crowded into the fewest possible moments, the whole day with active attendants constantly moving about and alive to every demand of the patient, the ability to run in and see for one's self how the case is doing during the first twelve to eighteen hours without encroaching upon the practitioner's allotted time for sleep, are a few of the points which seem to recommend an early hour. On the other hand, it cannot be denied that it may be a source of greater task upon the surgeon's powers, especially if he be concerned and anxious, as conscientious men always must be, in regard to capital operations, and if this anxiety interferes with the operator's sleep. Even with this disadvantage he believes the operator capable of doing better work before he has become tired and annoyed by the various demands upon him during the early hours of the day. It would be impossible to compare the results, because of no data with which to make the comparison, but he believed that the men who have operated extensively in the early morning hours have never returned to afternoon operation as a matter of choice.-Medical and Surgical Reporter.