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consumed by the old method, is quite sufficient comment.
At the present time there is but one other hospital in New England which has an operating-room exclusively for abdominal surgery, which can compare, in completeness of equipment, to this. It is the only hospital in New England to which persons in affluent circumstances can come, and secure the much greater safety in passing through the critical ordeal of an abdominal operation which this perfectly.organized department affords. Curiously enough, the other hospital referred to, admits only charity cases, thus debarring the well-to-do from securing that which their means should enable them to get.
The doors of the Hospital and the benefits of this department are open also to the poor, who receive exactly the same care and attention, as far as the operation is concerned, and all necessary isolation and nursing during convalescence.
RULES FOR THE USE OF THE LAPAROTOMY ROOM. First. No furniture, instruments, apparatus, utensils, operating-frocks or dressings are to be removed from, or transferred to, this room from other parts of the Hospital.
Second. This room is to be used exclusively for Non-suppurative Abdominal cases, and Brain Surgery, but not including compound fractures of the skull.
No case of cancer, of any description, or suppurative cases, or cases in which suppuration is suspected, shall be operated upon in this room.
The room shall be used for no other purpose than as above stated, and shall be kept locked when not in use.
Third. The Internes, when occupying the room in preparation for, or during an operation, must wear white cotton suits which have not been in use in other parts of the Hospital.
Fourth. After an operation : (a). The instruments and apparatus must be cleansed without delay, by the senior Surgical Interne, or under his supervision.
(6). The room, utensils and tables must be promptly cleansed, and all soiled linen and débris removed by the Nurse in charge (see sect. VII.), or under her supervision.
Fifth. Physicians or students, not to exceed twelve in number at one time, may be admitted by special invitation only of the Operating Surgeon.
Physicians in attendance upon septic cases, and students attending exercises in the dissecting-room, are not to witness operations in this room.
Visitors may be admitted for the inspection of the room only when accompanied by the Superintendent, or some member of the Surgical Staff, and when the room is not otherwise in use.
Sixth. The temperature of the room is to be kept approximately at 80°, F., during an operation.
In cold weather the steam heat is to be turned on the night before the date appointed for the operation.
Two hours previous to an operation, the steam stop-cock is to be opened, and the atmosphere filled with steam vapor, and the same allowed to settle.
The floor, previous to every operation, shall be sprinkled with sterilized water.
All instruments, silk and silver wire, to be used in an operation, shall be wrapped in gauze and sterilized by dry heat for a half-hour at a temperature of 100°, C.
Gauze dressings shall be sterilized by steam heat for one halfhour preparatory to each operation.
Seventh. The Surgical Staff recommend: (a.) That the general care and supervision of the room be given to a responsible permanent nurse, who shall attend at all the operations.
(6). That each Surgeon provide two operating-suits, which shall be kept exclusively for his personal use in this room.
Preparation of Catgut and Silk-worm-gut. — First, thoroughly scrub, with a hand-brush, in soap and water, after which place for half an hour in ether, and then macerate in a 1:500 alcoholicsublimate solution for twenty-four hours; finally, transfer to a 1:1000 alcoholic-sublimate solution for permanent preservation. A half-hour before using, place in plain 95% alcohol.
Preparation of Silk. — (Iron-dyed silk to be used exclusively.) Scrub the silk in several changes of soap and water, until all excess of coloring material is removed, then wind on glass spools and preserve in a 1:10,000 alcoholic-sublimate solution. (See sect. vi.)
Preparation of Silver Wire. — Carefully cleanse, as mentioned for other sutures, cut into ten-inch lengths, place in a clean ignition-tube, plug the opening with absorbent cotton, and sterilize by keeping it at a temperature of 100°, C., for a halfhour.
Preparation of Sponges. — Thoroughly beat them to remove dirt and bits of shells, then macerate in six changes of water for at least twelve hours, squeezing them dry at each change. Next, place in a saturated aqueous solution of potassium permanganate for twenty-four hours, renewing it once during the time; then rinse very thoroughly in clear water. Transfer them to the bleaching-solution, which is a 1:100 aqueous solution of sodium hyposulphite, to which a little hydro-chloric acid should be added, (a half drachm to the quart). As soon as decolorized, remove at once and wash thoroughly in several changes of water. Carefully pick out all bits of foreign matter, such as shells, and trim off any loose bits of sponge. Keep them in a 1:1000 aqueous sublimate solution until required for use. All soiled sponges are to be discarded and removed from the room.
A CASE OF COMPOUND FRACTURE,
BY W. K. BOUTON, M.D., MELBOURNE, AUSTRALIA. That the world is small and experiences similar is exemplified by a case which happened here in Melbourne under my care, and which I have decided to report after reading the February number of the GAZETTE, in which a case of “compound fracture of the tibia and fibula " is reported by Dr. Rand, of Monson. I do not offer the case for comparison, nor that I may tell a “bigger one,” but simply to show that at times cures will occur in spite of all rules, and without the consent of the surgeon.
In 1891, March 18, J. S., a man, aged 29; height, six feet; weight, about 170 pounds; was engaged in a contract of removing a bank of earth. A two-wheeled dray was loaded with nearly two tons, and the horse, a large, powerful brute, started off in a wrong direction, whereat J. S. ran forward to turn him, and before he could save himself his feet had slipped forward in front of the wheel, which passed over the legs at the lower third. The ground being soft, the left leg being underneath came off with but serious bruising and a wound, which required only two stitches. With this we have nothing more to do. But the right leg was decidedly a serious matter. Both bones were badly broken, and the tibia laid bare nearly its entire length, a wound twelve inches long, with tissues sadly mangled. To be candid, of several surgeons who saw the case, not one of us but thought it waste of time to defer amputation. But the patient was determined to have a trial made to save it. Consequently a dressing of sponges was used, side-splints applied, then the whole put in a box-splint with adjustable flaps, and a beginning made. Within three days the crushed and injured tissues were actively gangrenous. On the sixth a line of demarcation began to form, and in eight days there was a sloughing surface commencing just below the knee, at a point running diagonally backward on both sides, seeming to follow the outer margin of the soleus muscle, until it reached the lower third of the leg, when it dipped backward, passing directly round, leaving the whole anterior portion denuded of skin, and a space at the back three inches in length; thus a full half of the leg was laid bare, and the muscles exposed. The tibia for half its length was to be seen, even the periosteum being torn away. Dressings with sponges were continued, renewed every six hours. As soon as
the line of demarcation formed, the gangrenous slough commenced to clear off, and granulation began to fill in the open part. The patient's strength was fair, and the same applications were carried out for five weeks and three days. Thus, on the 25th of April all but two inches of bone was covered by granulation. Everything seemed progressing but the one essential point, There had been no attempt at union of the bones; on the contrary, out of each broken end of the tibia, which overlapped, had grown granulated excrescences. Under the circumstances, I determined to try what a little mechanical operating might do. So, under an anästhetic, a good half-inch of bone was sawn off each exposed end, holes drilled front to back and side to side, two pieces of steel wire passed through the separate holes and twisted, and, in order to make it still stronger, the drill was passed between the wires diagonally from the upper segment into the lower, and left there. The side-splints, heavily padded at either end, were applied. This left the centre of the leg with a space between the splints, so that the granulated surfaces could be readily dressed. The whole put up in the box-splint. On the 6th of May, eleven days after the suturing, the bone was covered and the drill removed. On the 17th the wires had become so loose that, through an incision of the newly-made tissue, they were drawn out, bringing with them a piece of bone one and a half inches long by one inch wide. From this time there was little trouble. The surface went on filling in, skin formed over the denuded part, and on July 7th, or one day short of sixteen weeks, it had all covered. There was a fistulous opening at inner seat of bony union, which discharged slightly. The entire limb was now encased in a plaster-splint, and the patient allowed to go about on crutches. A trap was cut at point of fistula and dressed with dry lint. After some weeks the discharge ceased. In four months the plaster was removed, and he was allowed to use the leg. At present writing, thirteen months after the injury, he can walk five miles at a stretch, without the aid even of a stick. The boot of the injured side has been raised only a quarter of an inch to make it equal with the other.
Query. — Extension was never applied — Where does the extra length come from? He suffers no pain now, except in cold, wet weather, and but for his limp no one could tell that he had been injured. Notwithstanding his prolonged vacation he declares he would not exchange his leg for any number of wooden ones. It is some years now since I have used extension in fracture of the leg, and yet, of numerous cases treated, good, bad, and indifferent, in no single instance has there been shortening, except in the case just reported. If splints are not to hand, any piece of board will answer, cut in length from knee to heel,
and three to four inches wide, with a right-angle extension reaching to the height of great toe; one applied to each side of leg. Care must be used in padding not to allow the splint to press on the bone at the knee or ankle, and to have the great toe on a line with the inner margin of patella.
While writing the above another case has come to mind, peculiar in the fact that, happening in the unsettled back country, or "bush," and no doctors to hand, it was expected to get well without treatment; but after three weeks, as it got worse, the man was brought to Melbourne, and, falling into my hands, I found fracture of both bones. No attempt at union, but sidesplints applied, like an ordinary case, and, though rather protracted, it did not hesitate to do itself credit.
A JEWISH CIRCUMCISION.
BY J. HOLBROOK SHAW. I recently attended a Jewish circumcision, and as the details of the ceremony may be interesting to the readers of the GAZETTE, I will give them. The armamentarim consisted of: First, a glass of water, containing two pieces of cloth; second, a glass of vinegar and water, containing a sponge; third, a wine-glass of carbolic acid (five per cent.); fourth, a bottle of tincture of arnica ; fifth, two strips of bandage of cotton flannel, one inch wide and eight or ten inches long; sixth, a knife, resembling a table knife in shape, with ivory or bone handle, very bright, twoedged, and apparently very sharp; seventh, a silver instrument for holding the prepuce perfectly flat.
The ceremony was supposed to take place at 9 A. M. The Rabbi arrived at 9:30, and at 10 an oldish man, whom they called the principal, and a younger man (his son, I thought) came. huge pillow was placed on the bureau, and the young man, who was rather corpulent, sat down on it, much to my astonishment, as I had supposed that the baby went on that.
I was thus far sitting without my hat on, but was now requested to put it on, which I did, the more willingly as the room was rather cold.
The baby was brought in on a pillow and placed in the arms of the fat young man, head towards him, feet away, thighs flexed, one in each of his hands. Just before this arrangement was completed the Rabbi engaged in a lengthy and quite unintelligible chant, and the oldish man took a position on the infant's right, armed with a cup of sugar and water and a sugar-teat, which teat he applied at the critical moment with an assiduity which did him credit, and contributed much toward making the operation a success.