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cultures obtained by the planting of the silk into nutrient media were due to the formation of a stiff layer upon the outer surface of the bacterial mass, so that the cocci upon the interior of this mass remained at a distance from the action of the alcohol and were therefore not destroyed.
The practical outcome of the whole matter is, that alcohol must be regarded as a strongly sterilizing material in cleansing the hands when we have to deal with the ordinary bacteria of the operating room. It should be applied thoroughly with a stiff brush for several minutes after washing with soap. A bichloride or carbolic-acid solution should then be used, as usual.-Medicine.
A Case of Traumatic Ophthalmoplegia.
Dr. David Webster of New York reports the following rather unique case in the Medical News of February 29, 1896:
On the 17th of November, 1895, Edward F. McC., aged 6, while walking with a slate-pencil in his hand, stumbled and fell on a board sidewalk. He was picked up in a semi-unconscious state and taken home. Dr. Edward L. Bull was called to see him soon after the accident, and found ptosis, with total ophthalmoplegia of the right eye. There was a punctured wound beneath the right orbital edge, at about the junction of its middle and inner thirds. Besides this wound of the upper part of the eyelid, which was still bleeding, there was a slight bruise or mark on the brow, as though it had struck upon the pencil lengthwise. Dr. Bull examined the parts carefully, but could find no foreign body. On testing the vision of that eye the boy counted fingers and recognized a watch, but it is now doubtful if he saw the fingers with the injured eye, and the loss of sight may have been immediate. It is certain he had no perception of light in the eye a few days later. He looked pale and felt sick, and vomited from time to time for fortyeight hours after the accident. He then recovered his usual health and went about his play as usual, and has been well, so far as his general health is concerned, ever since. Dr. Bull sent him to me a few days after the accident. I found total blindness of the right eye, with absolute ophthalmoplegia and ptosis. The third, fourth, sixth and optic nerves were totally paralyzed. Ophthalmoscopic examination showed nothing abnormal in the media or in the fundus. It was thought there was slight exophtalmus at first, but I was not sure there was any when I saw him. He has had no pain in or about the eye at any time since the injury and there have been no indications for treatment.
When I saw him on January 8, 1896, there had developed a slight paleness of the right
optic disk. He had also recovered the power to raise his right upper lid a very little; otherwise, the status remained unchanged. There is now not only well-marked atrophy of the optic disk, but a neuro-paralytic keratitis has developed itself. The eyeball is slightly red and the cornea is hazy and anæsthetic.
The problem in this case is as to the nature of the injury. It seems to me most probable that the slate-pencil entered the orbit, injured the lenticular ganglion and fractured the walls of the orbit at or near its apex. The pencil may still be partly in the orbit and partly in the cranial cavity. I presume the same symptoms could have been brought about by fracture of the orbital walls from the force of the blow of the brow upon the board sidewalk, and possibly even by shock or concussion; but the punctured wound seems to indicate that a portion of the slate-pencil is embedded somewhere in the orbital tissues so deeply as not to be felt with the finger.
The nature of their profession exercises so great an influence on that longevity that only twenty-four out of every hundred attain their seventieth year; so that those who study the art of prolonging the lives of others, are most liable to die early, probably on account of the physical evils to which they are constantly exposed.-Davies.
That city is in a bad case whose physician has the gout.-Hebrew.
PRACTICE FOR SALE:-I offer for sale my practice in the county seat of one of the best counties in Iowa. Have been here for twelve years; am surgeon of the leading road entering the town; am medical examiner for six life insurance companies, etc. I simply require that my successor buy my office fixtures, mostly new-worth $700. Purchaser must be reliable physician with few years' practice. Address "Z. V.," care RAILWAY SURGEON, Chicago.
Desiring to remove to the Pacific Coast. I offer my well-established practice of over 20 years to any physician who will purchase my real estate, situated in one of the most beautiful and thriving towns in Southern Michigan, and surrounded by a very rich farming country. The town is intersected by two important railroads, for one of which the subscriber is surgeon. The real estate consists of a fine brick house of eight rooms and two fine offices besides, attached to, and a part of, the residence. A fine well of the purest water. two cisterns, waterworks, etc. Fine garden filled with choice fruit in bearing, peaches, pears and apricots and small fruits, raspberries, Fine barn and other outbuildings, comparacurrants, etc.
tively new and in the very best condition, all offered with the practice and goodwill at a very low figure for cash. Address "MACK, Surgeon," care RAILWAY SURGEON, Monadnock Block Chicago, Ill.
By reason of failing health, physician wishes to dispose of real estate and practice. Practice amounts to nearly $4,000 per Address WM. D. B. year. No charges except for real estate. AINEY, Montrose, Pa.
Desiring to remove to a warmer climate, owing to poor health. I offer my well-established practice of 11 years to any physician who will purchase my real estate; situated in one of the most thriving towns in the Platte Valley, in Central Nebraska, on main line of Union Pacific R. R., on which road I am the assistant surgeon.
The real estate consists of 2 lots "on corner," on which there is a fine artistic "modern" frame house. 8 rooms; stable 20x30, wind mill, tower and 30-barrel tank: nice blue grass lawn. trees and fine garden (all new); and all offered with my $5,000 practice and good will, at a very low figure. A part cash, balAddress ance on time. A very thickly populated country. 'BOVINE," care RAILWAY SURGEON, Monadnock Block, Chicago, Ill
Health vs. Money....
EXTRACTS AND ABSTRACTS:
Contraction of the Flexors of the Hand Cured by Shortening the Bones of the Fore
Treatment of Ankylosis of the Hip.. Death Under Chloroform..... Report of Two Fatal Cases of Hæmaturia. 113 Chloroform Narcosis and Albuminuria... 114 Case of Sternal Dislocation of Second and Third Costal Cartilages and of Clavicle, with Fracture of the Fourth and Fifth Cartilages....
Seventh Vice-President... E. W. LEE, Omaha, Neb.
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.
THE SYMPTOMS, THE DIAGNOSIS
BY JOHN B. DEAVER, M. D., PHILADELPHIA.
Mr. President and Gentlemen, Members of the National Association of Railway Surgeons:-The honor conferred by your distinguished president, Dr. Murphy, in selecting me to deliver the address on surgery before this association is highly appreciated. I fear, however, that I am not able to do full justice to the occasion. The railroads of the United States have assumed such magnificent proportions that to-day they far surpass those of any other land, both as to business and equipment. They represent more capital and employ more men than any other class of industries in this very progressive land of ours, and we, as Americans, must feel a just pride in the accomplishment of such success. Your organization, therefore, represents the medical side of America's greatest industry, and you may be proud of the influence and opportunities for good which are afforded you. The success of your organization, like that of the railroads with which you are associated, is largely due to the completeness and the practical workings of your system.
Our profession is peculiar in its relation to mankind. In olden times the doctor was the priest, and to-day we have not finished our duty to a patient when we have administered the proper remedies for the ailment for which we have been consulted. We must constantly strive to discover other methods to overcome the effects of disease. We give our time, our
*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May, 1896.
labor and make personal sacrifices not for financial returns alone, but because we have a high ideal of duty for which we are glad to make our sacrifices and accept as a reward the knowledge that our work has been well done and that man's life on earth has been made easier, his sufferings less because we have lived. What higher ideal can a man have than the sacrifice of self to the good of others. The happiest man is not he who goes to bed at night and says, I have made so many dollars to-day, but it is he who can say, some one is better off and happier to-day because I live. And this, gentlemen, is the glorious opportunity which presents itself to us, and is the reason our noble profession stands in a peculiar position to the rest of mankind.
The rush of progress is so great and the practical side of human character is so largely developed in these the closing years of the nineteenth century that I thought it wise to address you upon a technical subject. In selecting the subject, I have endeavored to present one which is embraced in your line of work, viz., a review of the symptoms, diagnosis and indications for treatment of acute intra-abdominal injuries without external evidence of violence.
The general and the railroad surgeon have many interests in common. Railroad gery being embraced in general surgery, it is impossible to draw lines of distinction. This is a fitting opportunity for me to raise my voice. in protest against specialism in surgery. I have always maintained that the general surgeon whose opportunities have enabled him. to deal with the various intra-abdominal affections, be they the result of disease or traumatism, occurring in the male or the female, is the more capable from his training than is the specialist, strictly speaking.
The diagnosis and the indications for treatment in the majority of cases of railroad injuries are comparatively simple, and seldom occasion much doubt as to the proper course to be pursued. The cases of severe railroad injury, which constitute an exception to this statement, are those in which there are both profound shock and extensive laceration of the soft tissues with free hemorrhage. I do not agree with those whose practice it is to amputate under these circumstances, with the belief that the presence of the mangled member is a
factor in prolonging the shock, and that, therefore, it is necessary to remove it before reaction can be established. I do not believe it to be good surgery to amputate at this time. Amputation during shock will never establish reaction, and bleeding can always be controlled by ligature, an Esmarch tube, or by a tourniquet. In intra-abdominal lesions I would only operate during shock where I believed free bleeding was going on. Opening the abdominal cavity for the purpose of controlling bleeding in the presence of shock, cannot be compared, from the degree of severity, with the removal of a limb during severe shock in the absence of uncontrollable hemorrhage. I emphasize this point, as I am sure it is a very important one. I consider that it is in the class of cases to which I am now referring that mature judgment is called for, and this is especially true of those accidents embraced in the title of this address, as there is no type of injury which calls for a more prompt diagnosis as to the probable result of the traumatic forces brought to bear and where immediate operative treatment is so urgently demanded.
The free bleeding which occurs when an abdominal viscus or vessel is torn or ruptured is a sufficient indication for radical measures, and when we realize that peritonitis follows invariably and will probably be purulent in a few hours, we cannot hesitate to state that early section is the proper measure to pursue. Contusions of the solar plexus and splanchnic nerves will give rise to symptoms which may be misleading, but which should not long puzzle the experienced diagnostician.
The arrangement of the bony and muscular anatomy of the abdomen peculiarly protects its contained viscera from the effects of trauma, but it is easy to comprehend how a slight accident may produce grave injury to its contents, when we consider the nature and the importance of the organs, their large vascular supply, their superficial location,.and the likelihood of fatal hemorrhage and shock following an injury to any of them. The forces which cause these injuries are percussive, concussive and crushing. The injuries produced by percussive force are rupture of the solid viscera, and of the hollow viscera when filled with solid, semisolid, or fluid matter. Concussive force causes rupture of the mesentery
or mesocolon or of the blood-vessels, and sudden violent displacement of the partially movable viscera. Crushing force may cause any of the above-mentioned conditions, and by direct compression cause pulpification of the solid viscera, or partial destruction of the walls of the hollow viscera, which sometimes results in pressure necrosis, and subsequent fecal or urinary fistula.
Every surgeon present has undoubtedly at some time in his experience, either in private or railroad practice, met with cases in the class covered by the title of this paper. These are cases in which the history and the general condition of the patient give the impression that there is a serious lesion within the abdomen, and yet upon examination we find total absence or only slight evidence of external injury. The tendency, I fear, with many is to treat these patients tentatively, only to be awakened at the autopsy to the fact that a rupture or a tear existed in the abdominal cavity, which by early radical operation might have been relieved. The mortality in these cases is appalling; reference to the literature of the subject will amply bear out this statement. The immediate effects of an injury, severe enough to cause a serious lesion of an abdominal viscus, are sometimes so slight, however, as to be misleading. Very often a patient will walk to a conveyance or to a hospital, complaining only of slight pain. In varying periods of time following the injury more decided symptoms develop, namely, signs of hemorrhage, if the solid organs be involved, early peritonitis if the hollow viscera be ruptured or torn sufficiently to allow their contents to escape.
In discussing the lesions of the abdominal viscera, I will speak of them in the order of their frequency. As it is impossible to group the symptoms so as to designate the particular organ or organs injured, the symptoms indicative of injury of each will be detailed. In cases of severe intra-abdominal injury there are a few symptoms which are common to all, and in the majority of instances warrant immediate operative interference. The most prominent of these is pain which is accompanied by shock, the degree of the latter depending upon the extent of the injury, the amount of blood lost and the temperament of the individual. Temperament and nationality have a strong bearing in the production of shock. Persons
of a highly nervous temperament suffer more from shock than do phlegmatic individuals. For example, Americans are far more liable to suffer a severe degree of shock following injuries or operations than are Germans. The pain in these injuries is peculiar and difficult to describe, but is readily recognized by one who has seen many of these cases, and by the patient himself. It is not like that of the ordinary intra-abdominal affections, but is described by the patient as if something had given way or ruptured, and is usually accompanied by a consciousness of impending death. There is present, also, tenderness, which will be more or less localized unless the ensuing peritonitis be general. In the early stages of the injury, when the shock is most profound, the pain may not be so pronounced, and if large doses of opium are administered it may be masked throughout the entire course of the trouble. When vomiting is associated with intense and agonizing pain, and when tympanites is also present, the indications clearly point to either intestinal or vesical rupture. On the other hand, if there is collapse with evidences of rapid exsanguination, this would point to hemorrhage from rupture of one of the larger vessels or from rupture of the liver or spleen. The vomited matter rarely contains blood unless the injury be one of the stomach or the duodenum, yet, if the injury to either of these organs be such as to establish a communication with the peritoneal cavity, vomiting may be absent, or, if present, may show no evidence of blood.
There is often seen a characteristic rigidity of the abdominal walls, which is due to intraabdominal irritation. I have seen it so pronounced as to call to mind the checker-board appearance of the normal abdominal wall as represented in sketches by artists of former times. This characteristic rigidity will, of itself, in my judgment, warrant, in the bulk of instances, opening of the abdominal cavity. This condition of the belly walls, in my experience, has been invariably associated with some form of serious intra-abdominal lesion. Associated with the peculiar rigidity is the severe abdominal pain, increased by the slightest movement or pressure. The rigidity under the foregoing conditions is quite as characteristic of a severe lesion as is rigidity of the lower right quadrant of the abdominal
walls in acute appendicitis when associated with the two remaining cardinal symptoms of this affection, namely, pain and tenderness.
Restlessness, consequent upon traumatism, while always indicative of a severe type of injury, is especially well marked in the class of injuries under discussion.
In dealing with injuries of the abdomen in the female, pregnancy, extra-uterine pregnancy, ovarian tumors, pyosalpinx, etc., must be borne in mind.
Rupture of any of the solid viscera of the abdomen is usually followed by fatal hemorrhage.
The abdominal organ most commonly injured is the liver. This can be readily understood when one recalls the size of the organ, its location and its friable nature. Further, from its great blood supply it also can be understood why a rent of any size involving this organ will be immediately followed by serious bleeding. In connection with rupture of the liver the gall-bladder is also liable to be torn from the relation it holds to the liver.
The symptoms of rupture of the liver are usually great lividity of the skin, marked embarrassment of respiration, distention of the abdomen which is not altogether tympanitic, itchiness of the skin, and, if the patient survives the immediate effects of the injury, jaundice.
Rupture of the gall-bladder or biliary ducts may occur as the result of blows upon the abdomen, especially if the gall-bladder be filled with gall-stones. The commonest seat of rupture of the biliary organs is the cystic duct.
Peritonitis follows rupture of the gall-bladder or ducts. If the tear be small and the leakage slow, the escaping bile may become encysted and the peritonitis remain localized. If rapid, there will be general peritonitis and death. If there be no rapid extravasation, there will be collapse, vomiting and dyspnea and abdominal pain. If the bile escapes into the general peritoneal cavity, there will be prompt general acute peritonitis, with intense jaundice and clay-colored stools. When the gall-bladder has been ruptured death almost invariably follows.
Mr. Battle' reports a case of rupture of the bile duct in a boy 6 years of age, who was run over by a cab, in which there was but slight
Lancet, London, 1894.
Autopsy. Liver and gall-bladder were intact, but about half an inch beyond the junction of the cystic and hepatic ducts the common duct was found to be torn completely through. No other injury was found.
The treatment of laceration of the liver and of the gall-bladder, the hepatic, the cystic or the common duct resolves itself into prompt surgical interference. The custom among surgeons to treat such injuries by operation after all other means have failed has been universally followed by a fatal result; therefore, if the injury to the viscus is of such a character as to partially or completely destroy its functional activity and the resulting hemorrhage almost sure to cause a fatal issue, it would be far better, even under such circumstances, to give the patient the benefit of a section and. possible treatment by operation.
If a tear of the liver be superficial, by early operative interference we are enabled to remove the blood and bile which have escaped into the peritoneal cavity, to surround the rent with strips of gauze with a twofold object: I. To prevent a second invasion of the peritoneal cavity by blood or bile. 2. To invite adhesions between the liver and parietal perito
The hemorrhage can be controlled by searing the torn surfaces with the actual or thermal cautery or packing with gauze strips.
When the tear in the liver is of such a character as to permit of suture, the latter, which should include the capsule, should be used. If there is doubt as to the thorough control of the hemorrhage by the sutures, the wound should be treated by the open method, gauze strips being placed between the liver and the parietal peritoneum to the outer side of the line of suture.
When the gall-bladder, the hepatic, cystic or common duct has been torn alone or in connection with injury to the liver, it may be necessary to establish a biliary fistula; however, the attempt, if possible, to suture the bladder or duct should be made.
Rupture of the spleen is less common than