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"•■ York 14509 USA ^S (716) 482 - 0300 - ■"'hone BB (^16) ZSe-59S9 -Fax SOMF. KURMlTv-W CLINICS, R. J. MAxroN, M.D.. L.R.C.P.&S. (EniNj. L.F.F-&S. ((iLASc.nw), roRT WILLIAM, UNT. Reprinted from tht New York Medical Journal INCORPURATIKr. THt Philadelphia Medical Journal and The Medical News. .'icptciulh-r -'A, ;friter apologizes for its brevity, offering in excuse the fact that his was primarily a pleasure trip, and attendance at clinics was only a side issue. These few facts are written with the hope that they may be of interest to some of my fellow practitioners. LONDON. In this immense city with its numerous fine hos-_ pitals, the ordinary tourist is handicapped by the fact that most of the surgical clinics are held in the afternoon, for most of us prefer to work in the morning and holiday after lunch. At Guy's I'os- pital one may usually count upon seeing work any afternoon. The great drawing card at this hospital to the visiting surgeon is that surgical superman, Sir W. Arbuthnot Lane, whose never failing cour- tesy and kindness cannot be forgotten by any one who has had the pleasure and privilege of seerag him at work. His short circuiting bowel operations and his bone work are his most interesting pro- cedures. He short circuits in cases showing the earmarks of intestinal stasis ; for instance, one case was that of a woman aged thirty-two years, consti- pated, nervous, and with marked staining of the skin. If the colon sags markedly, instead of doing the short circuiting operation, he removes the colon. In "hronic ulcer of the stomach, he also does one •Read before the Thunder Biy, Ont.. Medical Society. June ii. 1914. Copyright, 1914, by A. K. Elliott Publllhirc Company. fh35 Manion: Some Europtan Clinict. of these operations, following it by liquid paraffin treatment. Of the liquid paraffin treatment he speaks highly in gastric ulcer cases and in chronic constipation, makmg the statement to the writer that many cases of ulcer of the stomach may be cure<', temporarily at least, by rest and liquid paraffin. One woman operated upon in the presence of the writer, had first been operated upon by Mr. Lane eight years before for appendicitis, which operation relieved her for three years. Then, her symptoms returning, he did a short circuiting opera- tion with a side to side anastomosis betweefl ileum and sigmoid, giving her good health for another three years. Again she complained of pain in the abdomen. He opened the abdomen and found that at the ileosigmoid junction the ileum had kinked, causing obstruction. He relieved the kink and sewed the mesentery in such a way as to prevent a recurrence of the obstruction. He stated that now in all cases he does a side to side anastomosis, and always stitches the mesentery of the ileum in place to prevent sagging. His bone work needs no praise from me, but it is marvelous to watch him opien up fractures, replace fragments, plate them, and close up the wounds with great rapidity, at the same time appearing to be in no hurry, without once putting his gloved finger in the wound. To use his own words, he "always operates on fractures of all kinds, and at once, as there is no danger." This is no doubt true for him, but not for all of us. In one case of a T shaped fracture of the ptella, he made a straight incision, protected the edges with gauze, coapted the three fragments with his own forceps, put in two plates, fixinj; both lower fragments to the upper, and closed the wound with clips, the whole taking fifteen minutes, and nothing had been in the wound except his frequently sterilized instru- ments. The small amount of bleeding he ignored, for as a principle he tries to leave no catgut or other ligature material in the wound. It is beautiful work as he, does it. On being questioned as to the per- ManioK: Snmf Huroffaii CImiet. ccntage of plates later re-noved, he stated that he removed none. At oni. the clinics he demon- strated on the skin of ou. arms that his stomach and bowel clamps, whitn have concavo-convex blades, do no injury to the tissues. He takes great pleasure in arguing points with his visitors, making even the youngest feel perfectly at home, and one just naturally leaves his clinic beli-.ving that no more masterful surgeon or more charming man exists. He stated that he was looking forward with much pleasure to the Clinical Congress of Surgeons in July. In the same (Guy'O hospital are a number of other fine surgeons. The writer saw Mr. Dunn per- form a very able operation for removal of a car- cinomatous tongue through the neck, using intra- tracheal anesthesia. Another afternoon the clinic of Mr. Fagge was attended. One case was that of a woman which was diagnosed simply as "abdominal pain," but in which he removed an adherent ap- pendix and gallstones, and relieved a kink at the cecum. One interesting statement made by Mr. Fagge was that "while hematemesis is suggestive of gastric ulcer, it is no proof, for it may be found when the only lesion is appendicitis." Mr. Belling- ham Smith was, like the others mentioned, most kindly, and he is well worth witnessing at his gyne- cological operations, which he performs with ad- mirable deftnesj and rapidity. All of these men are aseptic in their technic, and visitors, who are al- lowed on the floor, wear gowr.j, caps, and masks, and wash their hands before entering the operating room. Drop method ether is used a good deal. Guy's buildings ar old looking, but tie operating department is new, clean, and aseptic. St. Thomas's Hospital is a fine colleclion of '. lild- ings ; the entrance is decorated with marble busts of past maiiters. Here the writer saw Mr. Marriage perform a mastoid operation, which was as interest- ing as this operation usually is to the general sur- geon. The anesthetic was chloroform and ether, Vom'iiii. Some European CVimVi. followed by nitrogen. An interesting case operated in by Mr. Battle was that of a man who had had dysentery in the tropics, and now complained of pain in the right chest accompanied by expectoration of fifteen or sixteen ounces a day of foul matter. The diagnosis was abscess of the lung. Intratracheal anesthesia was used and an incision was made in the axilla, removing two inches of rib. The abscess was found three inches from the surface of the lung, and a tube inserted. The technic at this hospital is ex- cellent, all the up to date accessories being em- ployed, and this is roughly trne of most of the European clinics. In this re^rd one might easily imagine oneself in an operatmg room in Chicago, New York, Toronto, or Fort William. A pofitable afternoon was spent at Middlesex Hospitjl, watching the work of Sir John Bland Sutton, whom the writer had the pleasure of seeing at Chelsea Hospital ten years ago. He did not, in 1914, appear any older or any less the surgeon than in 1904. Sir John was, as is the custom with all the London surgeons, late. If any of them ever come at the time called for the operations, the writer failed to discover it. Sir John quickly and beautifully re- moved a strangulated parovarian cyst. His closure of the abdomen was as follows : i. Through and through linen, not tied ; 2, interrupted linen in peritoneum, tied; 3, tied through and through sutures; 4, con- tinuous linen in skin. This made a veijr pretty closure. Another case at his clinic was that of a woman who had been sent into the hospital for the removal of a fibroid of the uterus, and whom he was to examine under ether. On examination no fibroid was found, but he said that it was a case of tumor of the bUdder. Hematuria prevented him using the cystoscope satisfactorily, so he dilated the urethra with graduated dilators and inserted his finger into the bladder, finding an egg sized polypus. He re- marked that some objected to this method of ex- amination, but "I have been doing it for five and twenty years -ithout injuring a patient." As he MdMion: Some liurofcan Clinics. had not the patient's consent for an operation on the bladder, he said that he would have to obtain it and then he would go in suprapubically. In his clinic no caps or masks were used bv himself or assistants, the "sisters" wearing caps. In all the London hos- pitals, iodine is largely used. An amusing thing m most of these hospitals is the small pot de chambrt shape cf the pus basins. DUBLIN. In the Irish metropolis two hospitals were visited, but unfortunately no operations were on at the time. The far famed Rotunda was gone over, in company with a courteous house surgeon, w'lo showed the massive building with its fine opcratmg room, delivery room, good laborat ries, and large, airy, clean wards. The hospital is > msectarian, and is in charge of Doctor Jellett, whc .cceeded Doctor Tweedy, whose writings are widely read. They have very little sepsis after labor, and *hei.- treat- ment is an intrauterine douche, perhaps only 0"e, followed by autogenous vaccines prepared in t' own laboratories. In front of the hospital is a pi;' erected in honor of F'arnell, that stout Home Ruicr, on the base of the pillar being the following quota- tion from one of his speeches which seems apropos during the Irish troubles of today : "No man has a right to fix the boundary of the march of a nation. No man has a right to say to his country, 'thus far shalt thou go and no further.' We have never at- tempted to fix the ne p'us ultra to the progress of Ireland's nationhood and we never shall." There are many good clinics in Paris, but they are not much attended by Americans or Canadians, except French Canadians whose knowledge of the French language is an open sesame to them. The Paris surgeon's native courtesy makes him welcome the visitor royally, but generally speaking, to get the best from the clinic one must know some Manioii: Some European Ctinici. French. During a fairly lengthy stay in Paris only two prominent clinics were visited, in addition to a morning spent at the Pasteur Institute. At the Hotel Dieu, that oldest of the hospitals of Paris, Doctor Potherat, chief of the service, a surgeon of the old school, welcomed the writer, regretting his inability to speak English. The writer's rather limited knowledge of French, by the way, was of much service, not only in France, but throughout Europe. The technic here was excellent, the sur- geon and assistants (wearing gown, cap, and ma^k, and all, except the surgeon, rubber gloves. The ab- dominal cases were prepared with alcohol and iodine. The operator worked quickly and showed rapid judgment in a diffiiMlt case of fistula after an abdominal abscess, using a rectus incision to open the abdomen. The wound was closed with continu- ous catgut and clips. One old fashioned instrument was used by this handsome old surgeon, in the form of a pointed hook which he thrust through the tissues, threaded, and withdrew, doing this as rapidly as another could use a needle. Despite the age of the Hotel Dieu, the operating rooms are quite modem. In the quadrangle are a number of monuments, among them one "to their dead com- rades, victims of their devotion during their in- ternships in medicine in the hospitals of Paris from 1802 to 1902." Doctor Doyen's clinic is one of the most popular in Paris. His private hospital is an immense and elaborate institution in the rue Piccini just off that most beautiful promenade, the avenue du Bois de Boulogne. No sign or mark on the building dis- tinguishes it from the many beautiful private man- sions in the neighborhood. That the institution is well known was evidenced by the unhesitating manner in which the chauffeur of a hailed taxicab landed the writer at Doctor Doyen's door, with that nerve racking, comer skidding rapidity known best to the Parisian chauffeur. Most of the others present were French, with a sprinkling of Austrians, Matiiou: Some European Clitiict. one of whom spoke highly of this clinic. The wait- ing rooms and studies are decorated with busts and paintings, and contain books. On one of the walls of the operating room is a large crucifix, no doubt to inspire faith and hope in the minds of the pa- tients, and perhaps for the same pious reasons which caused a great man like Pasteur to be religious in the highest sense. Doctor Doyen, who has the ap- pearance of a good natured, well to do, comfortable farmer, showed us perhaps a dozen cases of cancer in which he had operated in the past seven years, some of them quite recently, by excision followed by what he called electrocoagulation. They were good results, but some showed large defects in the area of the previous cancer. He seems very well satisfied with his own results. He operated in a number of cases by this method, one being exceed- ingly striking. It was that of a large carcmoma involving the right ear and surrounding tissue, mak- ing a swelling the size of a fist. He first exposed quickly the carotid, probably to be ready to tie it if necessary. Then he made an incision completely surrounding the tumor and the ear, removing both very rapidlv. In dissecting away some glands, he cut a piece' out of the side of a vein, immediately stitching the vein with fine silk. After tying the necessarv vessels, which were very few considering the magnitude of the operation, he curetted the sur- face, then used the electricity, thoroughly cooking the surface into a dry eschar, and finally covered the wound with a dry powder dressing. It was a beautiful and rapid piece of work in a hopeless look- ing case. After his operations, he demonstrated on a piece of raw beef the effects of varying currents of electricity with different electrodes, showing well his power to have whatever effect he wished, and convincing one of the value of electricity used prop- erly in these cases. The spectators wore gowns, and in addition there was a glass screen between the operation and the visitors. Doctor Doyen at times loses his temper with his assistants in true Latin Manion: Some European Ctinicj. fashion, but in this he cannot equal some Italian surgeons, who appear at times on the verge of physically maltreating their assistants. The Pasteur Institute in the rue Dutot is worthy of a visit. The whole neighborhood is named after Pasteur, and in addition m another section of the city is a monument in his honor. Paris is as- suredly one of the cities which honor their scientists. In front of the institute is the Gtatue of a boy fight- ing with a wolf, probably representing Uttle Meister or little Jupille, his first two patients for the pre- vention of hydrophobia. Inside the institute are the usual features of a research laboratory, rabbits, mice, guineapigs, and smells, but most important are the earnest workers ia their laboratories. They treat here fifteen or twenty patients daily for the pre- vention of hydrophobia, and as I came out a pair of anxious parents with a frightened child rushed in to participate in the gift that Pasteur gave to the world. All about, one recognizes the veneration in which the master was held. Near the entrance to his tomb, which is in the building, are two silver wreaths, one "from the Institut de Pasteur to its chief," and the other "to Pasteur from the students of France." The sarcophagus is exceedingly beauti- ful, and is in a crypt of marble and varicolored mosaic. The tomb was built by his children, and contains also the body of his loving and loved wife. Worked into the mosaic are the following: "Faith, Hope, Charity, Science"; and on the other side, "Blessed is he who carries in himself an ideal of beauty, and who obeys it, an ideal of art, an ideal of science, an ideal of patriotism, an ideal of the virtues of the Gospel." The institute is at present in charge of Doctor Metchnikoff and Doctor Roux. This beautifully picturesque Swiss city is the home of Dr. Theodor Kocher and his son. From the hotel or.e sends a card with a request to attend the operations, and the following day Doctor 1 Manioti- Some European Ctmict. Kocher has a message telephoned to let one know the hour and the place to attend. At the hospital the visiting surgeon is given every welcome. Both father and son speak English. The writer saw both operate at the Insel Spital. The details are ex- cellent, gowns, caps, masks, and gloves being em- ployed, the assistants wearing cotton gloves over the rubber ones. Most goitre operations are done under local anesthesia, novocaine one per cent, with adren- aline; the line of incision only is injected, yet no complaints come from the patients during the opera- tion. Many forceps are used, arresting all bleeding as the operation proceeds ; generally slow and care- ful work is done. To children and nervous patients ether is given with a modified Clover inhaler, which is also used in other operations. Both father and son operate in the same room at the same time, and a spectator can watch the two operations, if he does not wish to see too many details. Dr. Theodor Kocher is a small old man with a pleasant, smiling face, which gives a hearty welcome to the visitor. 1 4 In this romantic old city of the Caesars and the Popes, one very entertaining morning was spent at- tending the operations of i-iofessor Bastianelli at the Policlinico Umberto, a fine, large, two storied building, erected in 1893. Professor Bastianelli, who speaks English fluently, and whose kindness is unbounded, has a large service, doing many opera- tions three mornings a week — Tuesday, Thursday, and Saturday. Iodine preparation is used exten- sively in this clinic, as is also ether by the drop method, although occasionally chloroform is used. The operating table is that of Janetti, of Turin. It stands on a central pivot and can be put into any position. Professor Bastianelli spoke highly of some of the American surgeons, particularly of Murphy, whose joint work he lauded enthusias- tically. Among the cases operated in was one of ulcerating tu'jerculous glands in ttie neck. He dis- Manion: Some European Ctmies. sected them out, and sewed up the wound tightly, using catgut and silk. He stated that he rarely, pert^ps twice yearly, operated for tuberculous elands He does not use tuberculin, but injects about the affected glands iodine solution, one per cent with potassium iodide, two per cent. He says that "this is an excellent remedy, as it takes about two years to effect a cure, and in Italy with its warm sun and the Mediterranean, tuberculous elands get better m that time anyway." Another case was one of gangrene of the skin, caused by the previous surgeon thinking that he had a case of broken arm. and putting the arm in a plaster ot Paris bandage, the swelling causing an ischemic paralysis and sloughing of the skin at the elbovf. Then the arm was allowed to heal m a flexed i»si- tion Doctor Bastianelli had previously remedied this by a large flap from the belly wall, and he was now completing the separation of th^ skin. Ihe man could ateiost completely straighten the arm, giving a fine result. The professor showed us a number of other cases of skin grafting by the same method. FLORENCE. Two mornings were spent at the old Santa Maria Nuovo. The arcaded front of the building is dec- orated with many old frescoes, very artistically done, but one of them, namely, the Slaughter of the Innocents, 1 thought slightly inappropriate for the front of a hospital, and especially did 1. think this when, on entering this 2,000 bed hospital, 1 saw the good work done. The time was most pleas- antly spent with Professor Machiti, who spoke no English, but spoke French fluently. No one coula be more courteous than he. Among other opera- tions, he did three hernias by the Bassini method, which, he told the writer, he found the most satis- factory, under novocaine lumbar anesthesia. He uses this form of anesthesia entirely in operations below the nipple line, and has had no complications, •'jamais, jamaisf He never uses any other suture ManioH: Some European Clinics. material but silk, and in the three operations he tied only one vessel. For most bleeders he grasps the base of the vessel and fat virith an angioclast re- sembling a curved artery forceps, and twists the tip of this mass. He is careful to get a dry wound, and he has had only two per cent, of recurrences: In this clinic gowns, cap, and thick rubber gloves are used. The operator's hands are prepared with soap, sterile water, and ether, and the patient with six per cent, iodine. The gowns, caps, and gloves were not changed between operations. The operating room was old but good, but the amount of water that is thrown carelessly about in some of these operating rooms is appalling to an American or a Cana- dian. At times one almost fears having to swim to safety. Under spinal anesthesia the patients did not experience any discomfort, though his manipu- lations were no gentler than they would be under general anesthesia, but, he says, it occasionally causes temporary paralysis of the sphincter ani. The patients recover from its effects in one or two hours. Professor Machiti used no needle holder, even when working in fatty depths, and he did his work rapidly and accurately. In fact the needle holder is not much used in Europe outside of Vienna. VIENNA. In this great centre one can see many operations, but a large percentage of them are done by assistants or by the assistants of the assistant. In von Eisels- berg's clinic during four or five days' attendance, von Eiselsberg was seen only once. The technic is the same as that seen at Chicago, or Rochester, or New York. Goitre is usually done under local an- esthesia, using the patient's voice to protect the re- current nerve. The sitting up position for opera- tions on the head and neck is also much employed. Iodine is much in evidence in the preparation of patients, and the ether drop method is used. The warmth of patients during operations is apparentW not considered essential. The spectators are gowneu, Mjnion: Some European Clinics. and are expected to keep absolute silence. Michel's clips are used for the skin. The operations by the young surgeons are naturally slow, and diagnosis is not any more perfect than one might expect. In one case a child had portions of two ribs removed for an empyema which did not exist, or, at least, was not found. These young operators are neither better nor worse than other young surgeons. The right rectus incision is used in appendix cases. The writer did not have the good fortune to see any work in Hochnegg's clinic, and after only eight days spent in Vienna does not think that criti- cisms would be fair, but from the surgical work witnessed he dees not tHink that there is any neces- sity for a young surgeon \q leave the American con- tinent to see good surgery. The American Associa- tion of Vienna is of much use to the postgraduate student, particularly in case of a long stay. In talking with a number of the members who have spent some time in Vienna, they expressed the opin- ion that the surgerj- there is not at all extraordinary, in fact that in general work Vienna is much over- rated, only really excelling in pathology, eye and ear work, and in x ray teaching. The pathology should be pspecially good, as all fatal cases must be examined post mortem. The writer spent one morning in the post mortem room of the Kranken- haus, and saw five ai lopsies, and he understands that there are daily about ihis number. On leaving the hospital and regaining the Ringstrasse, one may spend a few elevating moments in the court of the immense University of Vienna. In this court are innumerable marble busts of past professors, among them those of Nothnagel, Billroth, Skoda, and Krafft-Ebing. As one saunters about the court and corridors and notes the groups of students, some hurrving to their work, others lounging about, care- less or anxious as may be, one is wafted back through the years that have gone to those happy, careless, never to be forgotten (and unfortunately, never to be recalled) student days. In Vienna, a Manion; Some European Clinics. knowledge of German is needed to get the best out of the work. At the Clinical Congress of Surgeons in Chicago, in November last, a number of us had the pleasure of meeting Professor Kronig of Freiburg, and for this reason, as well as for the fact that this little German city stands high clinically, it was a great privilege to spend a couple of days in this charming and beautiful spot. From the hotel the directions of the concierge were quite German : "Follow Bis- marckstrasse till you come to Rheinstrasse, and then go to number seven, to reach the hospital." Unfortunately, Professor Kronig was just leaving for his Easter holidays, but he welcomed his visitor as an old friend. His assistant. Doctor Haus- feldt, demonstrated some of their work to me, a great deal of which consists in thp treatment of cancer (in both male and female patients), with radium, mesothorium, and Rontgen rays ; they think the results very promising. They have employed the treatment for only two years, but are very hopeful for the future, although they make few positive statements. Frequently they operate first, then use their treatments. The hospital is the uni- versity clinic, and the buildings are quite up to date. Professor Kronig's private patients occupy a large wing of the building. The treatments are very costly, and Doctor Kronig jocularly remarked that at times it is necessary to watch the patients when they have in some part of their bodies a valuable tube of radium.