Societies.

LOUISVILLE SURGICAL SOCIETY.

Stated Meeting, June 9, 1890, D. W. Yandell, M. D., President, in the chair.

Dr. A. M. Vance showed two legs removed because of injury. The first was from a child. It was gangrenous before removal. The second was from an adult. The limb had sustained a compound comminuted fracture. The doctor wired the broken tibia after removing a keystone piece. The fibula was not broken. Sloughing began and pus escaped freely from the wound. On the middle of the eighth day grumous blood occupied the cellular planes. The soleus had ruptured. Amputation was done at a point four inches below the knee.

DISCUSSION.

Dr. Roberts saw No. 2 after two or three days. Temperature 101°. The wound showed no sign of decomposition. It was covered with iodoform. Sensation was perfect. On the sixth day the temperature was 100° A.M., 101° P.M. Still not offensive. Saw no pus. He gave the opinion that there was good hope of saving the limb. There was, however, some risk of abscess. He thought it would be six months before the patient would be able to use the limb. He had strongly recommended the attempt to save the limb, but the patient preferred amputation to tedious convalescence. After wiring the position was good. His good results lately in very serious cases led him to urge conservatism. Though the specimen under examination shows great contusion of the calf, the condition does not lead him to modify the opinion as above stated.

Dr. A. M. Cartledge said he should consider this a border line ease. He believed the patient would have gotten well under antiseptic treatment; but the question of a useful limb would have been very doubtful, while a tedious convalescence through a hot summer was one of the conditions of conservatism. While conservatism should be the rule in extra-vascular injuries, he believed that, taking the case for all in all, amputation was the best thing to do. He had advised like treatment in similar cases.

Dr. Vance said that on the appearance of the

large amount of slough he thought that conservatism in the case would result at best in an uncomely and practically useless limb. Later, however, the limb presented such conditions. as in his opinion made amputation necessary as a life-saving measure. In any case, a good stump with an artificial limb is to be preferred to a deformed, useless leg.

Dr. A. M. Cartledge read a report of a case, "Penetrating Knife Wound of the Abdomen." (See p. 12.)

DISCUSSION.

Dr. Vance said that he was on record in the

opinion that all penetrating knife or gunshot wounds of the abdomen should be thoroughly explored. He thinks that in the case under discussion no one could say that the gut was not wounded. The knife might have made the gut septic as it did the cut in the abdominal wall.

Dr. Roberts agrees with Dr. Vance in his general proposition. In this case he would have tied the protruding omentum at once and cut it off.

Dr. W. L. Rodman said that he was opposed to laparotomy simply for the purpose of exploration in the absence of symptoms indicating a wound in the gut or an important vessel. Recently he had seen two cases of stab wound of the abdomen. In one the omentum was protruding and covered with dirt. He used Senn's gas test, and, obtaining negative results, enlarged the wound, tied and cut off the omentum, returned it, and got a perfect result. In a hundred cases of stab or shot wounds of the abdomen a good number will be found in which laparotomy is not necessary. Senn's test, with the state of the temperature and pulse, will enable the surgeon in most instances to arrive at a correct opinion.

Dr. D. W. Yandell thought the question still sub judice. It can not be settled until we are in possession of more abundant statistics. There are those who hold that all cut and shot wounds of the abdomen are fit cases for laparotomy. There are those who say, wait for symptoms. Individual cases are delusive, but we should make a distinction between stab and shot wounds. In this part of the world shot wounds are more likely to injure important organs than knife wounds, because the latter are usually

made by jack- or pen-knives which have short blades. In southern countries, where the long dirk is a common weapon, dangerous wounds are made. Here a slash or long cut is usually made. There the wound is a deep stab. Senn's test being tried, there must be found many cut wounds of the abdomen in which laparotomy is not necessary. I would say: First try Senn's test; if negative, wait. But in shot wounds, despite Senn's test being negative, vessels are often wounded and other damage done which may necessitate an immediate laparotomy. If I were myself shot in the abdomen, I would call for a laparotomy without delay. There is a disposition now to call a halt in indiscriminate laparotomy. Not every man at the cross roads can do it well.

Dr. Vance wished to put on record a case of gunshot wound seen secondarily. The patient. was a countryman, shot through the belly; the wound of entrance was at the upper border of the ileum, to the left of the spine. A probe passed in the direction of the wound of exit, which was just below the umbilicus. The probe entered to a distance of four inches. Patient had been shot six weeks before. was emaciated, but walking about. The ball probably did not enter the abdomen.

He

age. The doctor resected the seventh rib on the right side, and permitted a large quantity of pus to flow out. The patient made a rapid recovery. In four weeks from the day of operation he was driving a street car. There was no subsequent sinking of the chest.

Dr. W. L. Rodman had seen five cases of empyema, upon three of which he had operated. The oldest patient was a man of fiftyfive years; the youngest a child of seven years. Four of the five had the effusion on the left side. Of this number there was but one fatal case; in this the effusion was circumscribed and broke into the lung. In all these cases the pleural cavity was washed out with chloride of zinc after the following formula: Zinc chloride (officinal solution.), 10 gtts.; water, a teacupful. This when increased to fifteen or twenty drops causes some pain. In the opinion of the speaker it is the best antiseptic for this situa

tion.

Dr. Cartledge had seen six cases. In four of which resection of the rib was done. Two were treated by aspiration; of these one died. In one only was the disease found on the right side. The patient was an old woman. The disease was chronic. There was marked contraction of the chest, and the ribs overlapped. The eighth rib was resected and the cavity evacuated and cleansed. The patient got well. The second was in the person of a strumous boy. It was a case of pleurisy followed by empyema. There were sinuses filled with pus. The patient had hectic, and was much emaciated. He seemed nearly dead at the time of the operation. The speaker re-ected a rib and removed the pus. Recovery was complete. In another the pus was encysted and the cavity communicated with the lung. The patient expectorated fetid pus. There was septic infection. The speaker operated by resection. The patient died. Another case was seen to-day

The patient

is a woman. She had, on the 29th of last July, an attack of pleurisy followed by an ischio-rectal abscess of large size. Later there was great distension of the chest on the left side; aspiration at the seventh intercostal space brought away plenty of matter. The speaker cut down on the seventh rib and resected it at once. A gallon of pus escaped.

A tube was inserted. The case made slow progress. The tube was removed and the wound healed; but at intervals it would break open, and there would be a discharge of sero-pus. The patient complained of pain in the left shoulder blade. The lung had not expanded; the chest was still flat. The speaker reopened the wound, took out two inches of the rib, carried two fingers into the cavity, and broke down a number of adventitious bands. This procedure gave rise to some hemorrhage, but it enabled the surgeon to get rid of considerable foul pus and to thoroughly wash out the pleural cavity. A flexible silver tube was introduced. The cavity was scraped out, not washed

out.

Double resection, breaking up adhesions, and getting rid of isolated pus cavities did the work. The lung expanded. The patient made a complete recovery. The speaker does not favor the washing out of the cavity. It is possible that a primary washing may do good, but the daily washing is pernicious. A tube may be inserted for complete drainage, but it is advisable to guard the cavity against the entrance of air as much as may be possible. The German opinion on this subject is well founded.

Dr. Yandell said an interesting feature in the report is that all cases of pulmonary fistula died, and no other. He thinks that with reference to aspiration we are in the transition stage. He has seen a great number of cases. There have been many changes in practice since Bowditch wrote his famous paper on this topic. The speaker mentioned two cases only: One, an army officer who was struck by a minie ball in the chest during the war. He was left for dead on the field, but was picked up next morning. Hemorrhage was then very great. Suppuration set in with enormous flow of pus. This was in 1864. I saw him in 1866. He was a shadow. He had a harassing cough. There were present all symptoms of copious suppuration and a very offensive odor-four openings had closed. There was one opening at the left of the sternum, and one a little way beyond. By closing one with the finger the patient could expel pus a distance of four feet. Four of the ribs were matted together below the heart. I removed portions of three, making an opening large enough to introduce the hand.

I touched the

heart. I swept out the bottom of the cavity and brought out chips of lead, a bit of serge, and several strips of his overcoat. Recovery was perfect. The man is living to-day. I made this large opening because of experience in a case in 1850. A doctor was thrown from a horse, injuring the fifth and sixth ribs. This was followed by pleurisy, empyema, abscess, and fistula. Two ribs were matted together. I removed a small portion and trusted to washing out the cavity. I lost sight of the case. The patient died. At the autopsy there was found nearly a tablespoonful of exfoliated bone at the base of the cavity. I determined then that thereafter I would make an opening large enough to cleanse and drain freely, and to trephine whenever the ribs were matted together so that the wound could not close. If the opening is low enough down and large enough, it is not necessary to irrigate. Warren Stone insisted in such cases that the opening should be so large that every thing could run out. Where drainage is incomplete irrigation is necessary. I do not think we can keep out air, nor that it is necessary when the cavity has once developed pus. All old plans to prevent its entrance failed. Some would filter the air through cotton. I think well of the chloride of zinc. It is not possible to render the cavity aseptic. Prevent ingress of germs as far as you can; but to do so effectually in these cases is an impossibility. Whenever I have had large openings and adequate drainage the cases have done uninterruptedly well.

E. R. PALMER, M. D.,

Secretary.

RICHMOND ACADEMY OF MEDICINE AND SURGERY.

Stated Meetings June 10 and 24, 1890, W. W. Parker, M. D., President, in the chair.

Dr. J. N. Upshur reported a peculiar case of indigestion in a lady of fifty-four years, very much "run down" from mental and physical overwork.

The peculiar feature was a severe pain, spasmodic in character, occurring periodically about every ten days. Its seat was about the pylorus and downward and to right along the edge of the ribs.

When the doctor first saw her she had three of these attacks at intervals of about twelve hours. The first he relieved in a few hours with morphia and atropia hypodermically, the two last with grain doses of nitro-glycerine, administering it twice for the second and once for the third attack. No eructation of gas and water followed the last of the three, as had been the case always before. The general treatment given was a light nutritious diet, attention to bowels, and a tonic of phosphate of iron, quinine, and strychnine. She had no recurrence of the pain. Nitro-glycerine had been suggested to the doctor's mind by the fact that the pain in its acuteness resembled the spasm of angina pectoris. He had much confidence in nitro-glycerine for the relief of the edema, dyspnea, and cardiac distress of Bright's disease; had tried it with much success for the temporary relief of aggravated sciatica. Though slower in action, its effects were more permanent than nitrite of amyl.

A Sequela of La Grippe. June 24th. Dr. W. W. Parker reported the case of a robust young man afflicted with influenza a short time ago, this being accompanied by an inflammation and considerable swelling of the muscles. of the neck; and this, in turn, followed by a frightful eruption of vesicular character over the whole body, very much like chicken pox. It was particularly marked upon the hips and inner side of the thighs, where it resembled confluent smallpox. It continued ten days or two weeks, leaving extremities first and gradually. There was fever, very slight constitutional disturbance of any kind, and but little itching.

A Singular Experience with Scarlet Fever and Measles. Dr. Wm. B. Grey reported, in reference to two children affected with scarlatina (aged respectively two and four years), that just about the commencement of desquamation the older one developed the eruption of measles. In four or five days the younger did the same. Furthermore, said the doctor, about this time. the father, an old man, took scarlet fever.

Hematoma Auris. Dr. Charles M. Shields reported a case of hematoma auris occurring in a lawyer of about sixty years of age, and perfectly sound in mind (the trouble very rarely appearing except in the insane).

About a month before the appearance of the growth the man had suddenly lost consciousness one day, and in falling had bruised the side of his face corresponding to the trouble. The doctor enlarged an opening found upon anterior wall of canal about one half inch from external orifice, The cavity into which it led would hold about five or six drams. The discharge was very offensive. Prescribed a wash of peroxide of hydrogen. From one Saturday night until the following evening the patient had five or six hemorrhages, losing in all about twenty or thirty ounces of blood. The only resource for perfect control of the flow was packing the cavity with cotton saturated in Monsel's solution. The doctor thought the man would recover, but with considerable scar.

Dr. M. D. Hoge reported the case of a man who, since an attack of la grippe, had fallen into a stat eof melancholia almost amounting to insanity. He suffered excessively from nervousness and an intense pain in the head, the latter being treated successfully with morphia, cocaine, and bromide of potassium. He still complained of great pain in his head, until one night he pounded himself over the head with a poker until he had peeled off a large piece of scalp, and produced enormous hemorrhage. He then felt better. Some time after the doctor found a sequestrum of bone (a portion of the external table) in the wound, which he removed, and the part began to heal beautifully. The man was very much depressed all along, and believed himself going crazy. He complained of hearing voices. The doctor reasoned him out of that state and pronounced him now on the road to recovery.

Dr. W. W. Parker thought the hearing of voices a pretty sure sign of insanity.

J. W. HENSON, M. D.,

Secretary.

THE Bishop of Dutch Guiana was in Baltimore, June 22d, and said that leprosy exists to an alarming extent in Surinam. Three of the Redemptorist Fathers have been attacked by the disease, and one of them is dying of it. Rev. Charles Currier, of Boston, who has also been among the lepers, accompanies Bishop Wulfingh.

Reviews and Bibliography.

The Student's Surgery: A Multum in Parvo. By FREDERICK JAMES, Gant., F. R. C. S., Senior Surgeon to the Royal Free Hospital. 817 pp. Price, $3.75. Philadelphia: Lea Brothers & Co. 1890.

We much doubt whether the quickest way to gain a full understanding of a subject is to study it in epitome. The increased tax imposed upon the imagination more than offsets the time expended in reading fuller and more graphic explanations, and the cost of larger works. Those, however, who like condensed work, and who have easy-working imaginations to come to their aid, can not fail to be pleased with the Student's Surgery. It is a model of condensed, pointed statement; so much so that a search for surplus words must be well-nigh a fruitless one. As it deals largely with established facts and settled principles, there is left but little room for criticism or controversy. Yet even among established procedures we wonder if there are not some that will bear reinvestigation. In this age of antiseptics must we, for instance, still burn "deep and thoroughly" every case of chancroid, and even before the time of avowed antiseptics the more extensive chancroids were not Burnt, and we dare say the less extensive did not need to be burned. With half a dozen dressings a day of laudanum, tannin, and claret wine, a chancroid is healed in our experience, as quickly as any other sore of the same extent, and all the more quickly for not being cauterized. True, the smoking aquafortis gives. the patient a higher notion of our prowess, and in the existing state of his feelings the punishment hardly responds to his self-reproach, but with all that we are willing to answer to the charge of all the heresy involved in the assertion that if only one case had been burned there had been burned one case too many. The work is from imported printed sheets, and there is a pleasant absence of any American riding on a saddle-blanket behind the English author to fame. There can be no doubt that many works relating to practices in foreign countries are in some essentials different from our own, and really need emendations

to adapt them to the customs of our people; but by all means, when American physicians want to appear as authors of books, let them write them. The typography and binding of the work are exceptionally attractive, and on the whole it will compare favorably with any work of the period before the profession. D. T. S.

Correspondence.

PARIS LETTER.

[FROM OUR SPECIAL CORRESPONDENT.]

In his thesis for the doctorate on the treatment of chronic adenitis and cold abscesses by injections of naphthol, etc., Lasserre points out the following inconveniences due to the treatment by etherized iodoform:

(1) Violent pain due to the sudden distension which follows the injection. This distension has sometimes produced extensive sphacelus of the skin, or it produces a compression of the neighboring organs. (2) The cure is slow, as a great interval is necessary between two successive injections, and as at least three or four injections should be practiced. (3) The danger of ether, which has often produced prolonged sleep, difficult to subdue; moreover, iodoform, in an anfractuous wound, offers dangers of iodoformic poisoning. Naphthol is inoffensive, very antiseptic, but little soluble. It is not soluble in water, and alcohol of 1 per cent, except in the proportion of 33 centigrams, 1 gram in the liter of water to which is added 50 grams of alcohol. To practice injections of naphthol, one must employ the strong solution of which Dr. Bouchard has given the following formula: Naphthol B., 5 grams, alcohol at 90° 33 grams, warm distilled water q. 8. for 100 centigrams; to be filtered warm. At the moment of practicing the injection the bottle must be immersed in boiling water. At the same time the syringe should be plunged in a hot antiseptic solution. These precautions are necessary to prevent the precipitation of the naphthol, which would block up the needle or the canula of the trocar. The pus should first be evacuated, and then the injection with the antiseptic solution should be practiced slowly.