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him. The old impacted fracture was now complete and as near a transverse one as I ever saw. Outside of bruises this was the only injury. Fearing non-union I put the fracture up in plaster. We hung him up on a tripod, commenced the plaster just above the knee, carrying it up the thigh to the body, then in spica style around the body, leaving the left leg free. After a week's time I instructed him to get on his crutches, hoping thus to create local inflammation enough to cause union. In two months' time he was going almost everywhere again. I cut the cast off during the twelfth week and happily found good union with a still larger callus. The right knee stayed at right angles until he fell down again, about a year after he was first injured. He was sure he had broken it over again, but when he found he could completely bend his knee, he knew what he had done. Two years after the injury he was walking with a cane with hardly a limp.
Whenever it is possible I attend my own cases till discharged. I attend to every minutiæ and visit them as often as necessary. The difference in bills it is hard to make the non-professional understand. If an amputation is done and everything goes as it should, the patient is out on crutches in three weeks or so, and the bill of two or three hundred dollars is thought to be all right; but the patient with a crushed leg which the surgeon has saved by months of hard labor and ingenuity, and which is far superior to any artificial one, protests the bill for several hundred dollars. It makes one feel as though he had not done much of a good thing after all.
In Case I observe that continual immersion in hot water resolved the inflammation. I say continual. I get the patient in an easy posture and keep the limb completely immersed in water as hot as the patient can stand, for hours at a time.
Case II was rather unique. Over one-half of the forearm was completely skinned.
In Case III the knee-cap was severed quite smoothly a little outside the center. The periosteum of both tibia and femur was cut through. When the knee was sharply flexed the ends of both tibia and femur were completely outside the wound.
I am firmly impressed that had I omitted. the drainage tube primary union would have
taken place and saved the patient long, long weeks of suffering, and me weeks of hard work and worry. But when I see him now walking with hardly a limp, and doing all the work he did before the injury, I certainly have no regrets.
Case IV shows nature's great reserve in reparative work, particularly in the fracture through the trochanters, where there already existed a large provisional callus, there was, for all this, a good union. Nature, after all, with a little help, is a great surgeon.
I have always maintained that it is the surgeon's duty to attend to the after treatment of his cases personally. I have almost always done so and my results are good-pardon the egotism. I am not afraid to compare results with anyone. In my opinion these good results are greatly due to the personal attention I give my patients in the after treat
1001 Harrison street.
HOW THE RAILWAY SURGEON SHOULD AID THE FAMILY PHYSICIAN.
BY EVAN O'NEIL KANE, M. D., KANE, PA.
The railway surgeon should not merely be prepared to render his services as a company surgeon to the railway that employs him, but he should realize the necessity for being always ready to aid his less surgically inclined medical brethren. There is plenty of surgical work of every description to occupy him if he chooses to show the profession in his vicinity his willingness and ability to help. Yet there. are comparatively few local railway surgeons who recognize the duty they owe to the rest of the profession in this respect. It is to be regretted that so few skilful operators reside outside of the large cities. Also that those who do are encumbered with a busy general practice. This renders it impossible for them to attend promptly the summons of physicians in their locality. Consequently in many an emergency the patient dies for want of the proper operative treatment, or becomes a chronic invalid, or is crippled.
In reply to the demand for better and more easily procured surgical aid, the answer made. is that all patients requiring such treatment should at once be dispatched to a hospital; that
it is useless to operate upon them at their homes and that chances of recovery are always so much better in a hospital than in private practice, that no other method should ever be pursued. This is obviously absurd. Such a course may be well enough for the poor and ignorant, perhaps, or for the homeless and helpless pauper. But who that has a home of his own, a loving family and devoted friends, is willing to break all ties and be transported to some distant institution, far from all he holds most dear. Especially is this true if he contemplates, as who does not, the possibility of his not surviving the operation.
The city and hospital surgeons, too, do not seem to consider the position held by the family physician in such a case. They entirely ignore the part played by him in conducting his patient's case to a favorable termination, counting for nothing his intimate knowledge of the sufferer's indiosyncrasies and family history. Last, but by no means least, they forget to view the family physician's position from a pecuniary standpoint. No one cares to lose sight of a lucrative patient and have fees which really belong at home paid to some specialist in a distant city. And too often the patient, if he returns, comes back prepared to sneer at his old medical adviser, believing that he knows nothing, and determined that henceforth neither he nor his family will allow their cases to be "botched" at home, but will in the future "doctor in the city." The family physician, too, no matter how much time and anxiety he may have expended prior to the departure of his patient to the hospital, must expect the payment of his fees for such services to be postponed indefinitely, that the bill for hospital care and the surgeon's services may be paid promptly.
It is to be hoped that the need for good surgeons who are ready and willing to promptly when called by their medical brethren will ere long be sufficiently appreciated by our railway surgeons to make them desirious to fill this want. Many of our local railway surgeons are as capable and as intrepid as is any one of our city specialists of hospital fame, and were they willing to give special attention to operating for their medical brethren promptly and for reasonable fees they not only would confer upon them a great benefit, but would soon find themselves amply repaid for the
trouble and the little additional outlay in instruments and surgical outfit. The fact of their having free transportation, too, upon the roads with which they are connected would not only enable them to operate with less expense to the patient, but also should the family physician request it, make the first dressing and explain thoroughly to him the future conduct of the case, with only an expenditure of time.
Their training and experience with serious emergency work fits them peculiarly for this very sort of operative surgery. For not a few of them have more than once been obliged to put their courage and ingenuity to the highest test. With them it is not an infrequent occurrence to have to fill at one time the position of surgeon, assistant and nurse, yea, even chloroformist, spiritual adviser and police as well. And yet despite every adverse circumstance and surrounding, their skill and ability is proved by the success that crowns their efforts. With such a training and so varied a surgical experience as is thus obtained by the country or railway surgeon it is strange his services are not more highly appreciated.
With a portable operating table, such as that of Dr. Buchanan, an emergency operating case like that of Dr. Bevan, and with plenty of sterilized normal salt solution and a welllighted and tolerably clean room in which to operate, there is no reason why the average railway surgeon should not obtain as brilliant results as the better equipped hospital surgeon.
My position in connection with hospita! work for many years forbids my depreciating the superior value of hospital care for injured and operated cases, yet I cannot deny in justice. to the general practitioner, that many a life is jeopardized and the chances of recovery lessened by the fatigue, fear and anxiety incident upon removal from home, friends and family physician to the hospital. I see, also, no reason why, all things else being equal, provided a good nurse is obtained, a case cannot be as well cared for subsequently at home as in a hospital and certainly both patient and family will be far happier and the family physician better paid.
Dr. O. A. Hopkins of Lynchburg, O., has been appointed assistant chief surgeon of the Pittsburg & Western Railway, with headquarters at Pittsburg, the appointment to take effect November 20.
THE FUTURE OF RAILWAY SURGERY.*
BY CLARK BEll, Esq., of NEW YORK, PRESIDENT MEDICO-LEGAL CONGRESS
OF NEW YORK.
Whatever may be said or thought of the claim that medicine was not an exact science, by its enemies, its devotees or its friends, no one can, in the light of the wonderful progress made in modern surgery in the single generation since the American civil war, deny or question even the scientific precision now attained by its great leaders and exponents in the practice of surgery.
The steps by which the science of surgery has advanced in our day and generation have been as grand and stately as they have been effective, and as valuable to mankind as they have been wonderful, yes, almost marvelous in results.
In 1861 a gunshot wound of the abdomen was regarded as almost necessarily fatal. Today as illumined and illustrated by Surgeon J. N. Hall and other masters of this branch of surgery, and explanation for the reasons of his failure would be rightfully and lawfully demanded of the surgeon who lost such a
In my boyhood the ablest and most successful surgeon in Western New York, where I then resided, told me that in abdominal surgery, especially in woman, he frankly stated to his patients before operation that the risk of life or death was almost even in cases of ovariotomy.
See that great army of suffering women of the past, who, with a courage higher than that of the soldier who faces death in battle, because without its stimulating excitement, have faced and met death under the knife of the surgeon, due to the ignorance of what is now universally known in the practice of that art.
We lament the ignorance and superstition which swelled the vast army beyond the Styx; of widows burned on the funeral pyres of their dead husbands; but is that concourse, vast as it may seem, greater than the mothers and daughters of our forefathers, who thus perished for the want of that light in surgery
*Read by title at the Ninth Annual Meeting of the National Association of Railway Surgeons at St. Louis, Mo., May, 1896.
whose rays are to-day as effulgent as the sun? I remember Sir Lawson Tait announcing in the British Medical Journal, not a great many years ago, that brilliant record of six hundred cases of abdominal surgery in women without the loss of a single life, and to-day the properly equipped and skilful surgeon who lost such a case by his own fault could be made to respond in damages if sued for malpractice, as all now agree he should be made responsible.
Electricity has thrown upon surgery a brilliant, a marvelous, a penetrating and a wonderful light, of incomparable value and incalculable worth. With its magic lantern it has revealed much of the human body to the eye of the surgeon hitherto veiled, dark and inaccessible, while the new Roentgen ray, or its recently discovered properties, opens the outer door of a vestibule to a yet unexplored gallery of human knowledge in surgical science, as amazing in its results, even thus far reached, as it is counter to the hitherto accepted views of man. We are facing some marvelously strange facts just now in physics, when we find a light that passes through solids and metals at will, but which with great difficulty penetrates glass, through which the light of the sun passes readily, and we are considering whether we shall recast our definitions of the word "opaque" as applied to matter, and are searching for that unknown, mysterious, yet silent force, that, stronger than gravity, and overpowering, yet in spite of it makes the shoot of grain grow and stand erect, and advance upward like the tree, which under the nurturing hand of nature produces, when undisturbed by extraneous influences, some of the most beautiful and graceful objects in the created universe.
All the sciences act as handmaidens to surgery and pour into her lap the wealth of their discoveries.
Chemistry, which stands as a base and corner-stone for the whole structure of the physical sciences, the prolific mother of the wealth of the whole world, stands to surgery not unlike the angel who rolled away the stone from the sepulcher two thousand years ago, opening the door through which the light comes forth to glorify, illumine, and by which we see that before hidden and unknown.
It is doubtful if there is anything that re
ally exists which can properly be called new. Whatever is, always was, and must be old, and from the beginning.
Chemistry knows all. To her nothing is She simply now and then withdraws the veil which obscures the imperfect human vision, and reveals to her favorites, little by little, that which she may have before blazoned at noonday, in the pre-historic times, to her favored priests, who then kept alive the sacred fires upon the altars within her temples.
She has her favorites, and she lifts a corner of the curtain to such superb students as Edison, Tesla and Roentgen, from which come glances and flashes of a light incomparable and brighter than the noonday sun, to teach us how limited is the sum of present knowledge of the great truths of nature, and how little the wisest man does really know of what may be some day attainable and general human knowledge.
Truths are truths, entirely independent of human appreciation or perception, and the limitations of human knowledge do not offset, change or even modify them.
The knowledge of a few of the mysteries. of electricity furnished to mankind by the wizard Edison were truths before, and would have been truths had Edison died in his boyhood; and the quality of the cathode ray was neither changed nor modified by the genius. of Roentgen in his recent discovery.
The microscope, the spectroscope, the marvels of photography; the ripe labors of the bacteriologist; the whole field of advance in antiseptic surgery; the wonderful inventive genius of man in the construction and adapta tion of instruments and appliances for surgical work; electricity as a force in the delicate mechanics of surgery, and notably of the saw, with its almost incredible velocity, so admirable in delicate operations upon bone and cartilage, and of producing at will, and in exact locations, intense heat, not to enumerate many aids now at the ready surgeon's hands, place the surgeon of to-day on an immeasurable height above even the surgeon of 1861.
The railway surgeon then enters a field quite new in the domain of surgery in the past, but he is armed cap a pie and he has a great future.
The first railway was built after the close of the first quarter of our century.
a slow growth at first, but has become now, upon the American continent especially, the foremost factor in development and in the advancing march of civilization.
In surgery it has a field wholly its own. It represents and protects an enormous class, whom it treats in cases of accident, and whom it has to regard as well in preventing against accident, and in avoiding so far as possible by precautionary measures:
1. The employes of the railways.
2. The great public who travel upon them. The mission of railway surgery in the immediate future should be:
I. To arrive at the highest stage of excellence in ability to treat the injured.
2. To establish the hospital as a fixed system in railway service, the better to execute the first great duty, and to give to the most exposed class, the employe, the very highest and best surgical service combined with the greatest economy to both railway and sufferer, be he employe or passenger.
3. Prevention of injury upon railways so far as possible.
4. Improved sanitary measures in the interest of the general public in the transportation of passengers to prevent infection or the spread of contagious diseases.
Suture in Veins and Arteries.
Dr. Sabanyeff of Odessa reports two cases of this kind. In the first the suture was applied to the femoral vein wounded during incision of the inguinal glands; in the second to the femoral artery. In the latter case the patient died from the original disease, and Dr. Padalka found by microscopical examination that the healing of the wounded artery took place from without inward. Dr. Heidenhans (Centralblatt für Chirurgie) cites two previously recorded cases, one involving the com mon femoral and the other the common iliac. He reports an instance in his own experience, in which in removing cancerous glands from the armpit an incision was made in the main artery. The bleeding was arrested by digital compression and the edges of the arterial wound were brought together by a continuous suture of catgut. Bleeding was thus completely arrested. The lumen of the vessel was not apparently diminished. The sutures held in spite of strong arterial pulsation. The patient made a good recovery. The axillary artery could be felt pulsating along the whole extent of the armpit.-Medical Record.
The extremity terminals of our body are of special interest to the railway surgeon, first because they are the parts with which he has most frequently to deal; secondly, the injuries thereto are usually of the contused and lacerated variety; thirdly, the wounds are always primarily infected, and lastly, there is practically always a monetary element connected with the case and consequently with its result. While these points are in no sense new, we desire to call attention to the increasing conservatism which our present methods and means of treatment of wounds unquestionably justifies.
At a recent surgical convention the subject of hand injuries were generally discussed, and some of the results reported were quite remarkable. Conservatism was the unanimous verdict. There can be no doubt but that the very free blood supply of the hand, like that of the face, better fortifies these tissues against the invasion of pathogenic micro-organisms than other parts of the body. And it is also unfortunately a fact that in no part of the body
are the effects of suppuration more disastrous than in the hands. While we are favored, then, by nature as to the probability of sepsis, our patients are especially endangered by the character of their occupation and by our failure to secure asepsis. As to our duty to the unfortunate whose future is to a certain extent in our care, there would seem to be no doubt, regardless of the pecuniary considerations of the case. It resolves itself into the simple question of right and wrong. It is right to preserve, and wrong to destroy, that which can be saved, and if there is any question as to the viability of the tissues of these parts, the cause of humanity demands that the injured party be given the benefit of that doubt. This general proposition should be qualified by a certain element of expediency, and that is providing the parts can be rendered useful. A stiff finger or one devoid of its flexor tendons is a menace to both the hand and life of the average railway employe, and therefore it is as positively wrong to save a useless finger as it is to unnecessarily sacrifice parts of a doubtful one. The determining element of the viability of an injured tissue is the circulation, and while nature is the great restorer, uncleanliness is its greatest antagonist. The teachings of the day are cleanliness at the cost of any amount of time and regardless of the discomfort to the patient. With absolute cleanliness secured at the first dressing practically all of the danger disappears. In parts so readily accessible as the hands and feet, thorough cleansing and absolute disinfection would seem to be easily obtainable, and yet we are reluctantly convinced that the large majority of wounds of these members are allowed to suppurate even in these, the closing days of the nineteenth century. Our books and journals are full of new powders and solutions for the easy securance of asepsis, but the circumstances under which nine-tenths, if not more, of the injuries are treated, render short routes impracticable. It matters not whether we use chemical antiseptics or not, as long as we secure asepsis, but usually some potent germicide, in addition to mechanical measures, will make our disinfection more certain. By maintaining asepsis there is absolutely no danger in attempts at conservatism, even with necrosis of large areas of tissues.
In railway employes the question of