depended on the engineer for vision, and the engineer upon the fireman for color.

Another case in point. An engineer and firemen were sent for examination, and it was found that the fireman was color blind, while the engineer had only two-sevenths vision. This I knew prior to the examination because I had examined him about six or eight years previous to the time he was sent up for examination. After the examination was completed and the report sent to the superintendent of the division, and the engineer receiving notice that he would not be employed, it was learned that he depended upon the fireman for color sense, and the fireman on him for vision.

In regard to engineers and firemen making mistakes at your office and not on the road. If you change the surroundings, put them on different roads, they cannot locate the switches. They will make the same error, or else approach the switches with undue caution. so as to be able to stop in case of emergency, and it is a notable fact that this plan is tried among engineers who are old in the service. On approaching the station it was noticed how extremely careful they were in entering the station to see that everything was correct, and also in approaching switchlights.

Regarding the use of the electric light, referred to by Dr. Hoy, it is much easier at the

CLINICAL REPORTS.

Kansas City Hospital, Missouri Pacific Railway Hospital Department.

OSTEOMYELITIS.

A. B. W., an agent for the Missouri Pacific Railway, aged 24, and maimed, entered the hospital December 9, 1895, with an osteomyelitis, which was the result of an injury received eleven years ago. The right tibia was very much enlarged anteriorly, and a sinus extended into the medullary canal to the depth of three inches. The anterior surface of the shaft of the tibia corresponded to the swollen portion some three inches in extent. The medullary canal was thoroughly curretted and all necrotic and inflammatory tissue removed. The operation was performed by Dr. Hamel. Good recovery.

COMPLICATIONS FOLLOWING AMPUTATION.

W. B. M., single, clerk, Missouri Pacific railway, aged 31, was run over while attempting to get on a moving train July 20, 1895. The left leg was crushed at the junction of lower and middle thirds. It was amputated five inches below the knee, cutting through apparently healthy tissue. The flaps and muscles sloughed after twenty-four hours, followed by cellulitis of the entire leg and thigh, complicated by a sapræmic condition. Secondary

and Chicago & West Michigan Road lanterns are swung in front of the applicant to decide what color is presented to him. The intensity of the flame is always the same, and this makes quite a difference. If there is no defect in vision there is no mistake in selecting the color. If the applicant is visually defective it is simply guesswork.

An Unusual Termination to a Malpractice Suit.

Dr. W. O. Henry of Omaha has had a somewhat novel experience with the courts. He sued a patient for the amount of his bill and was in turn sued by the man for malpractice, damages being set at $8,000. Not only was the Doctor victorious in disproving malpractice, but he convinced the plaintiff and his attorney of the justice of his cause, and the former went out and borrowed $345 with which to pay what he owed for medical services, to save which he had instituted the malpractice suit.

the bone sawed through the tubercle of the tibia. The stump healed kindly and union was complete in three weeks. Several weeks afterward a very large and painful neuroma was developed in the stump, and this, with the head of the fibula, which was left after the secondary amputation, were removed. The patient is well. These operations were performed by Dr. G. F. Hamel.

AN ISCHIATIC BURSITIS.

T. McH., engineer Missouri Pacific Railway, entered the hospital last March, presumably with an ischio-rectal abscess. It was opened, but did not do well. The trouble began with a swelling to the inner side of the right tuber-ischii. The original trouble was undoubtedly an ischiatic bursitis of several months' standing before he entered the hospital, which afterward suppurated. This was complicated by a severe diarrhoea, which lasted

several weeks. Examinations revealed sinuses extending in all directions, passing around the tuber ischii down between the flexor muscles of the thigh to within three inches of the knee joint, upward following the course of the sciatic nerve and then upward and inward along the outer side of the ilium as far as the sacro-iliac articulation. The patient was put under the influence of chloroform anæsthesia and all the sinuses were laid open, extending from the lower opening in the thigh to the inner side of the tuber-ischii and upward and outward for two inches, then upward and inward on the dorsum of the ilium to the sacro-iliac articula

tion.

Further examination revealed necrosis of the tuberosity of the ischium, and a piece of necrosed bone as large as the first joint of the thumb was removed from the inner side of the tuberosity. In laying the sinus open a part of the gluteus maximus and biceps muscles were cut through, when another sinus was found extending up under the gluteus maxiums muscle to the outer side of the tuberosity of the ischium. The wound was thoroughly curretted and packed with gauze. The operation was performed by Dr. Geo. F. Hamel and the patient recovered completely.

FRACTURE OF THE NINTH AND TENTH DORSAL VERTEBRÆ.

F. S., married, aged 26, coal heaver for the Missouri Pacific Railway, was injured at Sedalia by falling from a coal chute. He was admitted to the Kansas City hospital July 24, 1896, with complete paralysis of sensation and motion from twelfth rib down. There was an absence of all reflexes except the cremasteric. An examination revealed fracture of the ninth and tenth dorsal vertebræ. In the absence of Dr. King, consulting surgeons Smiley, Fulton and Thompson were called in and confirmed the diagnosis. The patient was put under the influence of chloroform and an incision made over the spine, extending from the ninth to the twelfth dorsal vertebræ. The muscles were cut away. Further examination revealed comminuted fractures of the spine and laminæ of the ninth and tenth dorsal vertebræ, with dislocation forward of the ninth vertebra. The ninth and tenth ribs were fractured and the parietal pleura was ruptured. There was complete disorganization of the cord from pressure. On July 29 patient had a chill, followed by a tem

H. O. B., aged 36, single, painter for the Missouri Pacific Railway, fell from a ladder, sustaining a Colles' fracture of the left radius and concussion of the spinal cord, followed by paraplegia, and further complicated by multiple neuritis and cystitis from using the catheter. A vesical calculus formed. Perineal cystotomy was performed and a calculus as large as a filbert removed. A doubt still remains whether this stone was previously formed in the bladder or whether it could have formed within a month. Dr. Hamel operated. The patient recovered.

RECURRENT OMENTAL HERNIA.

John L., married, aged 34, locomotive engineer. Diagnosis: Recurrent right, oblique omental hernia. The patient was operated upon about one and a half years ago, when a McBurney's operation was made. The hernia. recurred within a year after the operation. He was again operated upon December 28, 1895. It was intended that a Bassini's operation should be made, but after making an incision it was found impossible to do so on account of the abnormal condition of the parts and extensive adhesions of the sac and entire contents. About eight ounces of omentum was removed, as it was impossible to return it on account of adhesions. The operation was performed by Dr. Hamel and was followed by recovery.

AMPUTATION-OPEN FLAP METHOD.

A. B. A., switchman for the Missouri Pacific Railway, had his left leg crushed at the junction of the middle and lower thirds. The leg was amputated four inches below the knee on September 21, 1895, and the stump was treated by the open method, on account of the unhealthy appearance of flaps and muscular tissue; about one inch of both flaps and the muscular tissue on the fibular side of the stump, sloughed. After the necrosed tissue came away, the remaining portion of the fibula was removed and the flaps sewed together. Re

covery followed with a good stump. Dr. Hamel operated.

FRACTURE OF THE SKULL THROUGH THE ORBIT— ENUCLEATION OF THE EYE.

Wm. M., section laborer for the Missouri Pacific Railway, was injured by falling on a pick, the sharp point passing through the orbit up into the brain. He entered the hospital July 4, 1895. On examination nothing could be seen but a slight wound of the left lower eye-lid and ocular conjunctiva; this was followed the next day by hemorrhage into upper lid with oozing of blood. The patient being unconscious, no history could be obtained and the diagnosis of fracture of the supra-orbital plate was made. The patient was placed under the influence of chloroform and on examination a probe was found to pass between ocular conjunctiva and the eye-ball up into the brain. It was decided to remove the eye-ball in order to get free drainage. The contents of the orbit was then removed by Dr. J. H. Thompson, after which Dr. King made a further examination and found that the inner half of the supra-orbital plate was fractured and pushed up into the brain for fully an inch. The bones were then removed, bringing away a portion of cerebral substance. A drainage tube was inserted in the brain and the orbit packed with gauze. The wound was redressed upon the third day, at which time another small piece of bone was removed. The discharge was persistent and quite free for some eight or ten days. The patient's mind gradually cleared up and he was discharged four months after the injury, seemingly well and in good mental condition.

A CASE OF SECONDARY HEMORRHAGE.

I. B., a brakeman for the Missouri Pacific Railway, aged 32, was admitted to the hospital February 22, 1895. His left leg was crushed up to the knee joint. An amputation of the thigh was performed at the junction of the lower and middle thirds.

The patient did well until eight days later, when secondary hemorrhage occured: the flaps were opened up but no particular point could be discovered from which the hemorrhage came. The arteries ligated showed that they were intact. Blood seemingly oozed from bone and muscle. Each muscle was ligated separately with a circular ligature passed around the entire mass. The flaps were

closed without drainage, and pressure made with a gauze compress. This stopped the hemorrhage, but suppuration followed and the parts healed by granulation. Dr. Rule amputated.

Traumatic Rupture of the Biceps Muscle of the
Arm, With Open Fracture of the In-
ternal Condyle of the
Humerus.

At a recent meeting of the Philadelphia Academy of Surgery, Dr. John B. Roberts presented a man, twenty-eight years of age, who was admitted to the Methodist Hospital on December 11, 1895, with a longitudinal wound six inches long in the middle line of the front of the left arm just above the bend of the elbow. The limb had been injured by being caught between the bumpers of two railroad cars. The ragged end of a torn muscle, evidently the biceps, was seen through the wound, and the bicipital fascia was laid bare. Careful examination showed that the internal condyle of the humerus had been split off by an oblique line of fracture running into the joint. It was evident that the injury had torn nearly the whole thickness of the biceps muscle, and that the muscular fibers so torn had retracted into the upper part of the arm. The incision was extended upward for six inches to uncover the retracted fibers. The small portion of muscle untorn, which was about as thick as a little finger, was found to be the central portion of the biceps. The main mass of the muscle was drawn downward and sutured to its tendon with catgut. These sutures were applied very much as in the ordinary method of teno-suture. A counter opening was made on the back of the arm and a drainage-tube inserted because of the probable septic character of the wound, though sterilization was attempted. The wound was then sutured and the limb placed with the elbow flexed and the hand supinated so as to relax the biceps.

The next day it was necessary to remove some of the stitches because of the swelling due to sepsis. A plaster of Paris splint was applied to the back and internal surface of the arm in such a way as to keep the hand and arm in the position just described.

The patient has done well, the wound at the present time, January 17, being a superficial ulcer, and the patient having considerable action at the elbow-joint.-Annals of Surgery.

A Philadelphia paper once announced the arrival of the Siamese twins in that city in the following manner: One of the Siamese twins arrived here on Monday last, accompanied by his brother."

Under the title of "Some Surgical Sins of Omission," Dr. Charles B. Nancrede, professor of surgery in the University of Michigan, than whom there is no more careful and painstaking surgeon, has written a most excellent paper, which was read before a recent meeting of the Detroit Medical and Library Association, and published in the Physician and Surgeon for August, 1896.

His paper was inspired by the thought that interest in head injuries, especially so far as the general practitioner is concerned, seems to have died out, and he quotes Nussbaum, who says truly that the fate of a wounded man is in the hands of the surgeon who first examines him. It is the family doctor who is naturally first consulted about injuries to the head and other parts of the body, as well as about diseases of the eye, womb or liver, and what a wise and good man he should be! He should be wise enough to recognize all known. ailments, and true enough to himself, his profession and his patient to decline the care of cases which he is not prepared by training and experience to manage with skill; for no one man can be skilled in internal medicine,

surgery, obstetria, gynecology, ophthalmology, and the other specialties of modern medicine. The general practitioner, however, is almost daily called upon for advice in regard to some case requiring the care of one skilled in some special field, and if it be a case of injury he must at least be able to apply a temporary dressing in accordance with the dictates of modern surgical art, even if the injured part be an eye. That due care is not always observed in the ordinary handling of scalp wounds and more serious injuries of the head, even by those professing to be surgeons, is the reason for the excellent paper from which we shall quote. Dr. Nancrede says:

tween.

"The first evil practice to which I desire to call your attention is the natural sequence of the fundamental error that a scalp wound is a trivial affair, demanding neither special care nor skill in its treatment, because the scalp is such a vascular structure that open traumatisms will nearly always heal by the first intention, or by a rapid granulating process. This, like all half truths, sometimes proves more disastrous than the most serious error. Dangerous consequences from ordinary scalp injuries are doubtless the exception, but they are needless exceptions in nearly every instance, and when human life is at stake are not to be tolerated. If all believe firmly as I do, that every scalp wound, however trivial, is one menacing life, the exceptional--that is, dangerous-cases, will be few and far beWhence comes the danger? From infection. But why should infection be so dangerous in structures from which their vascularity should be best able to cope with germs? Because of the vascular relations existing between the most superficial vessels and the intracranial circulation. Did time permit, I could demonstrate the very numerous routes of direct and indirect vascular communication between the scalp and the vessels of the brain. Suffice it to say that the vessels of the scalp, surrounded with their perivascular lymph sheaths, communicate with those of the aponeurosis of the occipitofrontalis muscle, the latter's with osseous ves sels, and the diploic in turn with the great venous sinuses of the cranium. Hence, in those cases which are in reality at the outset nothing more than simple scalp wounds, a cellulitis, septic puelo-phlebitis, osteo-myelitis, infective meningitis, or even pyemia may, and too often does, result from unfortunate environment or unskillful treatment of a scalp wound. I have seen death from pyemia follow a mere abrasion produced by a blow with the bare fist on the forehead, and tetanus from an insignificant head wound. But what war

rant exists that the smallest scalp wound is nothing more? Let me give a few illustrations of simple scalp wounds, as they were termed by those who first treated them."

He then recites the case of a youth who came complaining of a sore on the left side of his head, which had existed for over two months, the result of a blow which had not caused unconsciousness or other brain symptoms, and which had been treated as a "simple scalp wound.” A penknife blade was found in the "sore" which had penetrated the brain substance for over an inch and had caused an abscess from which the boy subsequently died. He describes another case as follows:

"Again, a boy having been knocked down by a snowball thrown by a man, received a small wound in the frontal region. He came under the charge of one of the out-surgeons to the same hospital. Until serious intracranial mischief became manifest no suspicion of the real nature of the injury was entertained. One of my colleagues explored the wound, as should have been done at first, discovering a small pebble imbedded in the bone, a compound fracture, infection, etc. The case terminated fatally in a few days by diffuse intracranial suppuration and brain abscess."

These cases abundantly illustrate the fact that no wound or injury about the head is so trivial as to be treated without care and thoroughness, and, as Dr. Nancrede says:

"The best way to illustrate the 'sins of omission' committed in such cases as we have been considering will be to contrast the proper course with that too commonly pursued.

"After thorough sterilization of the hands and instruments a compress wet with some efficient germicidal solution should be placed over, or lightly packed into, the wound. Next the scalp should be shaved and disinfected for at least one inch around the wound, preferably much farther. Agents calculated to remove all oily materials should be employed to enable the germicidal solutions to act. Renewed disinfection of the hands must precede the disinfection of the wound itself, which should now, for the first time, be explored. Should the slightest doubt exist as to the presence of a fracture, the wound must be sufficiently enlarged to determine this and secure disinfection. Passing by, for the present, omissions of important measures in the treatment of fractures, let me contrast the two methods commonly employed during an examination of a scalp wound. The attendant takes off gloves, which have been used for

months perhaps, while attending all sorts of contagious diseases, as erysipelas. Oftentimes, without washing the hands, or after a perfunctory attempt, without cleaning the nails, removal of the hair around the wound or sterilization, the wound is explored and infected, if it has not already become so, when, finding a fracture exists, the physician if surgically inclined proceeds to attempt such disinfection as will give him least trouble, or salve his conscience, after which he operates. If not willing to operate, after infecting the wound and thus doing all the damage he can, he sends for a surgeon or has the patient conveyed to a hospital. I have said "the practitioner uses such measures of disinfection as will give him the least trouble or will salve his conscience," because a man proceeding as I have described, either does not believe in asepsis at all, or is not honest enough to do what he knows is his imperative duty."

It takes a little more time to be thorough and in our work, it requires more care thoughtfulness always to be clean, but a little. more time may save a life and a little more care may save a limb, and we have no right to do less than our best for every case for which we become responsible. The man who is habitually clean about everything can most easily and surely sterilize his hands for an operation; he who is thoughtless about putting his fingers into pus and unclean places, without immediately sterilizing his hands, will see many suppurating wounds and some cases of septicemia in spite of corrosive sublimate and carbolic acid.

He believes in actively interfering in all cases of compound fracture of the skull, and

says:

"As an operation, properly conducted, should lessen the immediate risks to life rather than increase them, and as it is the sole prophylactic means at our disposal to lessen the chances of grave sequelæ, I contend that it is out duty to intervene. False notions relative to the pathology of compound fractures, together with certain statements which are still allowed to remain unchallenged in our standard surgical works, explain the antiquated practice too often still in vogue. Some of my own writings are obnoxious to the charge of incorrect pathology likely to give rise to errors in practice, but my practice was better than my pathology, and I have since endeavored in my various public utterances to correct any misapprehensions left. *** The modern and sole reason in many cases of compound fracture which induces the surgeon to operate is not intracranial hemorrhage, compres