PRACTICAL VOL. XXV. A MONTHLY JOURNAL OF MEDICINE, NEW PREPARATIONS, ETC. R. H. ANDREWS, M. D., Editor, 2321 Park Avenue, Philadelphia, Pa. TERMS. PHILADELPHIA, JULY, 1903. SUBSCRIPTION, $1.00 PER YEAR, in advance, including postage to any part of the United States, Mexico and Canada. Postage to any foreign country in the Universal Postal Union, including Newfoundland, 25 cents a year additional. SUBSCRIBERS failing to receive the Summary should notify us within the month and the omission will be supplied. When a change of address is ordered, both the new and the old addresses must be given. Subscriptions may begin with any number. HOW TO REMIT.-Payment may be made by Postal Money-Order, Bank Check or Draft, or Express Money-Order. When none of these can be procured, send the money in a Registered Letter. All postmasters are required to register letters whenever requested to do so. RECEIPTS.-The receipt of all money is immedi- Address THE MEDICAL SUMMARY, This journal has an extensive and constantly inereasing circulation, is substantially established, and therefore presents to business houses desiring to reach the rank and file of the medical profession throughout the land, a most valuable advertising medium. Entered at Phila. Post Office as second-class matter. THE PROPHYLAXIS OF CHOLERA INFANTUM. ment. No. 5 Cholera infantum is not so common as many practitioners believe; many who talk glibly of numerous cases of cholera infantum have never seen a genuine case. The laity are too ready with the term in describing any case of summer diarrhea, but the physician should discourage such reckless nomenclature and inspire a proper respect for the dreaded term. Instead of lessening his reputation as a skillful physician in "cholera infantum," such a course will enhance his reputation as an honest practitioner and a cautious diagnostician, and will belittle the bombastic declarations of those who seek to make mountains out of mole-hills. Every case of gastro-intestinal trouble in an infant demands prompt and energetic treatment, for a simple diarrhea may become a cholera infantum within a few hours, if neglected; when, under proper treatment, it would have subsided without serious consequences. Even before a diarrhea is ushered in, so soon as symptoms of gastro-intestinal indigestion become evident, nurse and mother should be on their guard, and endeavor to correct the faulty hygiene before irreparable damage is done to the delicate organism. It is the duty of every physician to impress this upon every nurse and mother within his clientele; if After studying every new suggestion,and clinically testing every new drug commended in this complaint, the experienced physician is forced to confront the fact that in view of the extremely high mortality under all methods of treatment, it is the part of wisdom to confess that prophylaxis is of vastly more moment than treat- the physician did his whole duty, cholera infantum would be almost unheard of except among the poverty stricken and the grossly ignorant. BOTTLES.-The nursing bottle and nipple (no intelligent physician will longer tolerate the use of the old fashioned long tube nursing bottle) should be thoroughly scrubbed, inside and out, with a brush and hot water and soap immediately after the babe has finished nursing, and then be rinsed in pure water and immersed in a solution of baking soda till again needed, when they are rinsed 1 pure water and filled for use. FOOD.-Once a suitable food has been selected, an amount sufficient for twentyfour hours should be pasteurized and placed on ice ready for use as needed. It is well to have enough bottles for twentyfour hours and to pasteurize the food in the bottles and cork with sterile cotton until it is time to attach the nipple for feeding, so that all handling of the pasteurized bottle and food is obviated. DIAPERS.-Every diaper should be removed as soon as soiled, and should be removed from the apartments and placed under water to await complete cleansing. If the stool is removed from the diaper immediately by scraping it off with a dull knife or stick, the cloth is much easier washed clean, and is in every way safer. The practice common with some of only washing the diaper when soiled by a stool, or of drying it when wet with urine and again using it, is to be condemned in unmistakable terms. When the mother or nurse washes the soiled diapers, she must cleanse the hands carefully before handling the bottle or food. FEEDING. The infant should be fed a proper amount at regular stated intervals, and the remainder of the food should be immediately emptied out and the bottle cleansed. No "left over" food should be again utilized. BATHING.-The infant should have a full bath at least once daily, preferably about the middle of the day when the temperature of the room is likely to be equitable. BOWELS.-Proper bowel action should be maintained, neither constipation nor diarrhea being neglected. Laxatives, cathartics, variations in food in older infants, and enemas make up the corrective mea sures. CLOTHING. Good judgment should be exercised here, as elsewhere. Most babies are kept too warm. It is not necessary to smother them in flannels in the hottest summer months. One flannel article should never be dispensed with, however; i. e.,the flannel binder. It is not necessary that the binder be either heavy weight or too tightly applied. It does good by keeping the surface of the abdomen at an equable temperature and by guarding it from sudden changes in temperature. As soon as a baby is able to kick in hot weather, it should be laid on its back on the floor out of draughts, and allowed to exercise the legs so as to give the abdominal muscles opportunity for develop ment. WARNING SYMPTOMS.-Immediately on the earliest symptoms of the mildest gastro-enteric disturbance, the food should be suspended, and a cathartic dose of castor oil given, and the infant fed only on the white of egg well beaten and stirred in water (the white of one egg is equivalent in food value to three ounces of breast milk.) After twenty-four hours, even if the premonitory symptoms had advanced as far as vomiting, a cautious resumption of the customary food may be attempted. Such treatment will almost universally avert more serious trouble. Hard and undigested curds are always a danger signal, and denote that alteration in the character of the food is imperatively demanded. 131 Original Communications. enlightened and an exacting public, which Brief and practical articles, short and pithy reports of interesting cases in practice, new methods and new remedies as applicable in the treatment of diseases, are solicited from the profession for this department. Articles intended for the Summary must be contributed to it exclusively. The editor is not responsible for the views of contributors. Write only on one side of the paper. AMPUTATION AFTER TRAUMATISMS. BY THOS. H. MANLEY, M. D., PH. D. EVERYONE imbued with a humane spirit can only regard a major amputation as a most calamitous affair, because the severance of a limb from the body presents many of the tragic aspects of an execution, for it means the destruction of a large section of a man's frame, a member which he depends on to support or carry his body, or one that enables him to maintain an existence. No wonder that one who has lost a limb, no matter what his calling in life, is looked on with pity and compassion; for he is no longer a whole man, and however we may succeed in supplying an artificial substitute, he is forever conscious of his loss, and is at great disadvantage in the battle of life for an existence. Hence we all hail, with a profound sense of gratitude, the triumphs of surgical science, in the management of grave traumatisms of the extremities, the achievements of those conservative methods by which many maimed and shattered limbs are now spared, which in only the recent past were promptly sacrificed. The subject of amputations following traumatisms should be studied, apart from those rendered necessarv for pathological conditions, for several important reasons; one of which is, because of the enormous advances made in the direction of conservatism, in the preservation, the regeneration and transplantation of tissues, and hence our responsibilities are now greater than ever, when we deliberately proceed to detach a limb from the body. We are dealing with an intelligent, an demands that all the resources of our art are exhausted before we resort to an amputation of a limb or any appendage of it. On the consideration of Osteoplastic procedures after severe crushes it was noted that nearly any description of a preserved limb, whether short, stiff or deflected, is far more serviceable than any description of a substitute. Amputations after traumatisms are attended with a larger mortality than pathological conditions. Erdman's statistics have plainly demonstrated this.-Annals of Surgery, Sept., 1895. In a grave disorganization calling for a complete severance of a member, the whole body suffers great shock. There has been invariably a considerable loss of blood, and the injured, realizing the terrible character of his misfortune, suffers from the most distressing melancholy. When through systemic conditions, or extraneous influences suppuration or widespread sloughing set in, with systemic toxemia, the mortality is large; this is notably so in military surgery and in general hospitals where the sanitary surroundings are inadequate. In traumatic amputations, the patient subjected to the effects a double shock, the primary, at the time such violence was sustained as to fatally mangle the limb, and the secondary when its severance from the body became necessary. ON FLAPS AND STUMPS. The ingenuity of surgeons has been taxed to the utmost in the way of devising such flaps as will best protect the nude ends of the bone and at the same time secure them against the effects of friction or pressure, hence we have the bisected flap,. the circular, the oval, the muscular, the cutaneous, the osseous, the periosteal and others. But, unfortunately, there is no flap, however formed, which will always. guarantee against sloughing or retraction or against that common sequela the "painful stump." In the mechanical disorganization of any part of a limb, we will do well to generally discard the employment of any specially formed flap, and act in the principle of THE CUTANEOUS, NERVE AND OSSEOUS TIS- It has been my experience, that some of the best clothed stumps have remained the most sensitive, and that many which were partly invested by scar tissue, were the most tolerant to pressure but the most comfortable. This has been specially conspicuous in amputations through any part of the leg. At the time when we employed strong chemical solutions, especially those of corrosive sublimate in irrigating the severed parts, and when primary union of the flaps was expected, a painful endositis of the stump frequently demanded a consecutive resection of it, however well it might be covered in by the integument. No one at the time of a primary amputation can determine with accuracy the degree of vitality in the flap. If one could, we would have no sloughing; nor can we estimate with certainty the extent of muscular retraction, and hence, in this respect our most careful calculations may fail and we are chagrined as the healing advances to observe that the ends of the bones will be inadequately covered. The elastic constriction of an Esmarsch bandage, while economizing the loss of blood, inflicts fresh violence on the circulatory apparatus of a limb mangled, if not employed with caution and as briefly as possible. Since this valuable hæmostatic agent came into use, secondary hemorrhages after amputation and consecutive sloughing of the flaps are. more common. At the middle of the long shafts, distant from the numerous articular and recurrent arterial branches of a joint, peripheral asphyxia of the flaps is most prone to occur after an amputation. Bulbous enlargement of the large nerve trunks after division, is a troublesome sequela after an amputation. This proliferation and projection of the neural elements after division, in some instances advances to a remarkable degree. In a case recently coming under my care, the proximal end of the divided median nerve took the form of a tumor, and at first was believed to be a bursa mucosum. Six months before, I saw the case, through an accident, the man sustained a deep seated laceration of the wrist on the flexor aspect. Sensory paralysis of the parts supplied the median nerve following. On dissection of the parts the tumor like was found to be a large bulbous growth from the proximal end of the median nerve. End to end approximation of mass the divided healthy ends was readily effected with a very satisfactory result. This case illustrates a pathological state, precisely the same as occurs in the divided nerve-trunks after various amputations. A general atrophy of all the anatomical elements sets in, but the nerve goes on proliferating and becoming engaged in the contracting scar tissue, or forcibly compressed against the unyielding end of the stump, becomes the source of perverted, sensition or acute pain. Various means have been suggested to obviate this condition at the time of amputation, such as making a long section of the nerve, removing a cuneiform section of the medulla and separately enclosing the sheath with fine suture. From the testimony of our latest writers on amputation, it does not appear that any of these tentative measures have succeeded in preventing the troublesome complication. The condition of the osseous parts after an amputation through a large shaft, may be such as to leave a highly irritable or painful stump when an artificial limb is adjusted. It is noteworthy that when a partial section of a bone-shaft is made, as in a McEwen osteotomy or when a sliver of a healthy bone is removed from its long axis, reparative processes are rapid and so complete that the individual is never conscious of the traumatism when the parts are healed. A complete transverse section of a shaft, however, inflicts great violence to the histological architecture; the entire periosteal envelope is severed, the vascular supply, through the finer vessels at the line of severance, is cut off, a limited area is for a time isolated from its normal nutrition; the medullary membrane and substance are forcibly torn through, and all the parts which minister to the vitality and protection of the osseous parts have been violently sundered. When the reparative processes of the economy are undisturbed by pathological changes, after cleavage of a shaft, we find that the sawn end of the bone tends to fill in by a process of hyperplasia of the connective tissue elements; this later becomes infiltrated by osseous substance,contributed by the osteo-blastic layer of the medullary and periosteal membranes. The end of the bone assumes a rounded or conical outline and is finally invested by a layer of compact bone substance. The end of the bone may be adherent or non-adherent to the soft parts of the stump; when not enveloped freely by the flap, it is often adherent to the scar. The divided bone is the chief source of trouble after amputation in continuity. When protracted pressure on the osseous end, by muscular contraction may provoke pain; again inadequacy of cutaneous covering and exposure leads to endostitis or exfoliation. In growing children, the conical or "sugar-loaf stump" is a frequent cause of repeated resection. It cannot be said that any stump, not protected by transplanted bone, is capable of supporting the weight of the body without harmful pressure to it. This is so well known to manufacturers of artificial legs that they are so constructed now that the weight is sustained by osseous projections some distance above the surface of the stump. But, even then, in order to firmly encase the remaining part of the limb, the circulation is impeded, the nutrition of the stump impaired, and the skin is often so drawn on as to re-open the scar, or induce a painful ulceration of it. Therefore with a full knowledge of a tendency of painful irritation or intolerable suffering from any stump which must support weight or bear the adjustment of an artificial limb, we can appreciate the importance in all diseases or disorganizations of the foot of sparing no effort to preserve any part of this member as a support to the exclusion of every kind of artificial support. 115 W. 49th St., New York. A VALUABLE DIGESTANT. BY W. R. D. BLACKWOOD, M. D. HE history of medicine is honeycombed with fads and frauds. In all departments this is true beyond any possibility of denial, and in none is it more so than in therapeutics. For ten years I kept a book in which was entered the name, character, dose, price, and comparative value of the new drugs brought out by enterprising manufacturers, and then in desperation I quit, for the book was growing too full, and the attempt to remember about these wonderful cure-alls was liable to bring on congestion of the brain in my friends to whom I lent the thing for their information or for their confusion-and the latter was the general effect, as they told me. Some time ago I looked over the mass with a view to see where we stood in this list of wonders, and the result was that out of above eight thousand preparations, about twenty are still looked on with favor (more or less, according to the ability of the investigator,) and the balance have been forgotten by all but their promoters. If this appears incredible to my readers who have not tried the experiment which I did, let them simply tabulate the ads. in our magazines, both medical and literary, and they will get some idea about the multiplicity of new malady-crushers in a very short time. It has been the same in other directions; look at the blue-glass dodge which kept the factories running to supply the demand for this cold end of the spectrum, and think of the thousands of panes (nay, pains!) which adorned our windows for about a year or so, and think of the lots of nice girls who lost their chance for a steady beau who might have evoluted into a tangible helpmeet thereafter, because he got scared at her lividity in the rays of the prevalent fad which was to bring health and all the rest to the dwellers in that particular residence. Have we forgotten the list of great men who advocated the pumping in of sulphuretted. hydrogen into the unfortunate rectums of all who had phthisis or who were supposed |