foot had been immobilized. Much to my gratification, there had apparently been no inflammatory action whatever, as the function of the tendon was as perfect as in the sound foot, with no evidence of any formation of adhesions. The treatment advocated for these fractures varies according to the location of the injury. In cases where the fracture is subastragaloid the use of splints will usually be unnecessary. The leg should be placed in a comfortable position and cold lotions applied until swelling has subsided, after which an immovable dressing should be applied and the patient allowed to get about on crutches (Agnew). the fracture. The second case was that of a man, aged 38, with Colle's fracture, treated in a similar way and completely cured, with free movement and no deformity, on the fifteenth day. The third case was that of a man, aged 40, who fractured his tibia and patella. The tibial fracture was treated in the usual way; the patellar fracture was unrecognized at the time, and after seventy days' treatment, when the patient was first seen by the author, although the tibial fracture was healed, the patient's limb was useless, as the patellar fragments were distant 2 centimeters, and only worked by weak fibrous union. Massage was practiced, and after fifteen days the patient could walk with crutches, the oedema disappeared, and flexion of the knee (previously rigid) could be obtained. At the end of a month the patient could walk well with a simple stick; in two months he could walk upstairs, so that no one would suspect any injury to the limb.-British Medical Journal. tion. For fractures of the posterior portion of the bone (immediately below the insertion of the tendon), the application of a side or anterior splint with the foot over-extended or the use of Monro's modification of Thillaye's apparatus a device for securing this position, is sometimes used. When the injury is of this nature, I do not believe it possible if there Changes in the Spinal Cord Following Amputabe much muscular contraction to secure enough relaxation of the tendon by position alone to obtain sufficiently perfect coaptation of the fragments, and though there is danger of death of the fragment when tenotomy is practiced, the upper portion of the os calcis being largely dependent for its vascular supply upon the tendon, I believe the dangers of a useless foot are less when an open, oblique tenotomy is made and perfect coaptation of the fragments obtained followed by immediate suture of the tendon than when an attempt is made to keep the parts in position by the use of a splint or any apparatus which has as yet been devised. (22) Massage in the Treatment of Joint Fractures. Pello (Archiv. di Ortoped, An. 13, fasc. 3, 1896), draws attention to the value of early massage and passive movement in the case of intra-articular fractures. He believes that the usual method of treatment by prolonged fixation delays recovery, and only too often leads to ankylosis. He then reports three cases where massage was practiced at once, and where the only fixing apparatus was a starched bandage freely cut away so as to allow of the massage. The first case was that of a boy, aged 6, with intra-articular fracture of the trochlear process of the right humerus. Light massage was practiced at once, and gave much relief to the pain; the joint was put up in a starched bandage. The next day a good part of the bandage was cut off, and twenty minutes' massage practiced. On the fifth day slight passive movement of the joint was commenced. On the tenth day the bandage was discarded; at the end of a month the elbow was as free in its movements as before Dr. Alfred W. Campbell detailed the changes found in three cases, one an amputation below the knee and two amputations through the upper arm. For purposes of comparison sections of a spinal cord from a case in which the entire brachial plexus had been injured in early life were shown. In all cases marked changes in the spinal cord were found in those segments which receive the sensory nerves from the skin and give off the motor nerves to the muscles removed. These changes were hemiatrophy, with universal reduction in size of gray and white matter, without definite sclerosis of special tracts, and a numerical deficiency of the nerve cells in the cornua, but especially in the postero-lateral group of the anterior cornu, all on that side corresponding to the amputation. In the case where the leg had been amputated there was a reduction in the number of the nerve cells in Clarke's column, in the lower dorsal and upper lumbar segments. The peripheral nerves above the site of operation revealed marked atrophic alterations and a filling up of the intervening spaces between bundles by large quantities of fat. The ganglia on the posterior roots presented atrophy of some nerve cells. In the brachial plexus case the hemiatrophy was not so marked and the posterior cornua were symmetrical, a condition which might be due to the skin being left intact. Reference was made to Sherrington, Head, and Thorburn's work on "spinal localization," and the wonderful accuracy of the results of these observers as confirmed by these cases was commented upon.-Universal Medical Journal. Miscellany. Management of Cases Immediately Following Operations. Sir Thornley Stoper (British Medical Journal) writes as follows: "If I may reduce to formulæ the matters I have referred to, I would put them thus: (1) That the tendency to prolong operations must be carefully guarded against, as it is a grave cause of danger. (2) That in the treatment of shock and vomiting following operation we get no help from the stomach, and must rely on the rectum as its substitute. (3) That heat, alcohol and opiates are our best remedies; and that the latter are well borne, and must be intelligently used to their full effect. (4) That drugs of the class ordinarily used to check vomiting are of little or no use in the cases under consideration. (5) That ice does not relieve thirst, and does harm by introducing water into the stomach and so provoking vomiting."-The Medical Record The Management of Railway Hospitals. It may not be uninteresting to the readers of the Fortnightly to give a cursory idea of the management of hospital departments upon railways as at present constituted. At the head of the department presides its chief executive, known as the chief surgeon, medical director or general surgeon. The chief surgeon has complete control and directs the management and disposition of cases, causes reports to be made, has charge of all hospitals and appoints all surgeons, renders personal injury reports to claim and legal departments, and causes to be kept a current history of every case treated. The chief surgeon directs the expenditure of bills incurred in conducting the department, vouching all accounts, selects experts for the company in damage suits and adjusts all disputed points pertaining to the department. The general manager is the only officer of the road to whom the chief surgeon reports and they alone are authorized to incur expense. The chief executive of the hospital department is held responsible for the proper performance of all its work and general efficiency, and therefore seeks to improve his department in every detail and being thoroughly cognizant of all that pertains to his department becomes an important factor in railway management. Local surgeons are appointed at every town of any importance and at large division points, where many employes are engaged, two surgeons are stationed. Most roads average one local surgeon for every twenty-five miles represented. The railways employ more members of the medical profession than any other industry; some of our large systems have as many as 325 surgeons in their employ. Local surgeons are supplied with printed instructions, covering all accidents that might occur, and in the event of an accident no misunderstanding nor confusion arises. All superintendents, train masters, conductors, engineers, brakemen, agents, road masters, section foremen and others have essentially the same printed instructions how to proceed in case an accident occurs and where to find the nearest local surgeon. All time-cards in force contain these directions and in addition thereto is printed the names and locations of all company surgeons of that particular division upon which they operate. When an accident occurs upon some portion of the road the chief surgeon or assistant chief surgeon is immediately notified by wire by the local surgeon and also by the superintendent, conductor or agent, detailing where, how and when it occurred, and the extent of injuries; the local surgeon is then directed regarding the disposition of the case and the advisability of transporting the same. Stretchers are placed at stations where local surgeons are stationed, and upon all baggage and wrecking cars, hence cases can be shipped with celerity. Notification is sent when a case is to be shipped and hospital ambulances meet the train. Should a passenger train be wrecked not only all local surgeons in the immediate vicinity are called, but invariably relief surgeons and surgical supplies are sent from hospitals. Instructions are likewise printed for the guidance of employes in case of sickness. Everything is explicitly stated regarding proper certificates of admission, character of cases admitted and requests for medicines and treatment through the mails. Records of all personal injury cases are filed in the chief surgeon's office. Thus, upon the Missouri Pacific the chief surgeon has over 30,000 reports of personal injuries on record for reference. the hospital, a personal bedside history is taken daily by the attending surgeon. We have, therefore, not only a record of the injury, but a daily history from the time of the injury until settlement is made. These departments never lack patronage. The Missouri Pacific hospital department, including two hospitals and five emergency stations, treats nearly 30,000 employes annually, and it is computed that the various hospital departments of the United States treat from 165,000 to 185,000 annually. At A hospital department as at present constituted consists of the following medical officers: Chief surgeon, house surgeons, consulting surgeons and specialists, oculists, aurists, throat and lung specialists, dermatologist, neurologist, bacteriologist and pathologist and consulting electro-therapeutist. The rapidity of growth of these departments has been substantial, and their results of cases treated will bear the closest scrutiny.-The Medical Fortnightly. A Neat Spherical Gauze Sponge. In a recent number of the New York Medical Record, Dr. G. W. Perkins of Ogden, Utah, says: Since the general use of heat for sterilization, gauze has largely replaced marine sponges in surgical work. Flat pads made up of several layers of gauze, and spherical sponges made by enclosing masses of loose gauze or absorbent cotton in an envelope of gauze, are the forms in which it is usually employed. The flat pads are easily folded in such a way as to place all raw edges of the fabric in the inside of the pad, and a few long stitches serve to keep them there. The spherical sponges which I have seen described and figured have been made by simply tying the enveloping layer of gauze and cutting off the excess a short distance beyond the ligature, thus leaving this cut surface with threads of the gauze projecting. This seems to me undesirable, because some portions of these threads might become detached and be left in the wound or cavity in which the sponge had been used. In casting about for a way to obviate this disadvantage, I first made the sponge as above described, but went one step farther by carrying around the projecting stump a circular purse-string suture, and in tying this pushed the stump into the center of the sponge, thus burying it out of sight. This answered very well, but left a hard lump at one side of the sponge, which sometimes interfered with grasping it in a spongeholder. I next tried. the following maneuver, by which I succeeded in making as neat and satisfactory a sponge as one could wish for. Instead of ligating the pedicle of the envelope of gauze, I twisted it once or twice and grasped it with a small hæmostatic clamp; then cut away the excess close to the outer side of the clamp and placed my purse-string circular suture about half an inch distant from the stump, and as I tied it pushed the clamp holding the stump of the pedicle into the sponge, disengaging and withdrawing the clamp just before the suture was drawn tight. The result is a symmetrical, sub-spherical mass of loose gauze, without raw edges on its surface and without hard lumps in its substance, which has in my hands admirably answered its purpose. This is merely an adaptation of the Dawbarn method of inverting the unligated stump of the appendix into the cæcum, and I dare say has been used before by other surgeons; but as I have never seen it in print, I offer the suggestion for what it is worth. Notices and Reviews. Book Notices. Lea Brothers & Co. of Philadelphia announce a new edition of this well known text book, to be issued during the present month, and in which such changes have been made as are necessary to represent the advances in anatomical knowledge and anatomical teaching. The sections on the brain, spinal cord and viscera have been entirely rewritten, and new matter and new engravings added.-The Medical Age. BOOKS AND PAMPHLETS RECEIVED. "Wharton's Minor Surgery and Bandaging," by Henry R. Wharton, M. D. "The Newer Remedies," by Coblentz; D. O. Haynes & Co., publishers, New York. "Transportation of Injured Employes," by Frank H. Caldwell, M. D. Reprinted from the Journal of the American Medical Association, February 29, 1896. "Eye Symptoms in Nephritis, as Seen With the Ophthalmoscope," by William Cheatham. M. D. From the American Practitioner and News, August 22, 1896. "Report of Relief and Hospital Department of the Plant System." "A Contribution to our Knowledge of Albumosuria," by M. L. Harris, M. D. Reprinted from the Chicago Medical Recorder. "Abscess of the Lung, with Report of Seven Cases," by E. Fletcher Ingals, M. D. Reprinted from the Journal of the American Medical Association, August 22, 1896. "Hypertrophy of the Pharyngeal or Luschka's Tonsil," by E. Fletcher Ingals, M. D. Reprinted from the Journal of the American Medical Association, September 29, 1894. "Operations Performed in the Eye Department of the Medico-chirurgical Hospital," by L. Webster Fox, M. D. Reprint from the Ophthalmic Record. "Choice of Methods in Performing Hysterectomy," by Fernand Henrotin, M. D. From the American Journal of the Medical Sciences, October, 1895. "Anti-toxin; Some Practical Remarks in Regard to Its Use," by G. F. Washburne, M. D. Plato said very well: "Physicians were the only men that might lie at pleasure, since ow health depends upon the vanity and falsity of their promises.-Montaigne. Officers of the N. A. R. S., 1896-7. F. J. LUTZ, St. Louis, Mo. 239 239 239 First Vice-President... W. R. HAMILTON, Pittsburgh, Pa. Secretary. man: J.N.JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa. No. 10. A PLEA FOR DELAY IN THE AMPUTA- BY ALBERT I. BOUFFLEUR, M. D., SURGEON C. M. & ST. P. Ry. Co., ETC., CHICAGO. From the frequency with which some of the phases of the subject of amputations is presented to medical bodies, and especially from the fact that this association was favored so recently as at our last meeting with an exhaustive paper on this subject as a whole, by one of our most honored members, which was followed by a lengthy general discussion, it might seem proper that I should offer an apology for choosing any phase of the subject for consideration on this occasion. Such, however, is not the case. When, where and how to amputate form the most, important subjects which the railway surgeon has to consider, and therefore the discussion of these questions is always pertinent. In general surgery we naturally look upon mutilating procedures with justifiable humility, but in traumatic surgery, in which the operating force has frequently performed the amputation before the case reaches us, we can look upon the procedure with an equally justifiable degree of pride. The question as to primary or secondary amputation has been discussed at such great length and with such frequency, and withal so enthusiastically, that we should all be convinced one way or the other, unless all propositions are more or less defective. In all the discussions I have ever heard on this subject, the condition which has seemed to separate those of different opinion, as the great wall separates China from Siberia, is that known as shock. One surgeon will *Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May, 1896. advocate early, immediate amputation, regardless of the presence or the absence of shock, and even regardless of surrounding circumstances; while another will advocate postponement until reaction has been well established. It cannot well be that the experiences of individual surgeons have been so diametrically opposite concerning the same condition. When we take into account the fact that shock is but one of the elements of danger it is not surprising that our results should have differed in dealing with similar injuries. We rarely, if ever, even hear of the cause of the shock being taken into consideration, and yet we all know that shock from hemorrhage is a greater barrier to an immediate operation than shock of a purely nervous origin. As a matter of fact, the administration of an anesthetic, which is so dangerous a measure in shock from hemorrhage, may prove beneficial in purely nervous shock. Shock is not the only condition which should determine when we should amputate and if we attempt to formulate a rule relating only to shock, the exceptions will, I fear, be more frequently operative than the rule itself. In all the arguments, pro and con, there must be some truth, and in my humble opinion the truth is distributed all the way from one extreme to the other. A substance that may serve as food for one person may poison another, and likewise the immediate operation may save one patient, while an operation deferred several hours, or even days, may be the only hope of another. The patient in his entirety should be the object of our consideration and not merely the single manifestation-shock. While the proper relation of operative procedures to shock is of most vital importance, since it so directly affects the life of the individual, we must not lose sight of the fact that the individual's life may prove to be a burden to himself and his family without the assistance of one or more members which would be sacrificed by a premature operation; limbs which might perchance be restored to life and utility if placed under favorable circumstances. That limbs, and especially fingers, are, even in these days, frequently unnecessarily sacrificed, cannot be successfully refuted. One need not look far to find surgeons who are performing amputations on the same principles that were taught decades ago, when the effects of the ever-present suppuration made conservatism and attempts at restoration of function worse than useless-dangerous. The old argument that delay meant sepsis and that sepsis left death in its wake, should surely not be given much weight in these days of enlightenment. Antiseptics and drainage have eliminated all danger of serious results from the reasonable postponement of an amputation. The surgeon, who practices on the basis of modern bacteriological knowledge, does not fear the slight toxæmia which results in all cases when dead or dying tissue is left in contact with the living. There can be no doubt, it seems to me, that an amputation is only indicated in traumatic surgery when the soft parts are so crushed and disorganized that repair of the injury is absolutely impossible, or if it should take place the injured member would be useless. I believe the last condition is a most pertinent one, since it is quite as serious a mistake to err on the side of saving useless numbers, as it is to sacrifice one which might have been of some use. If we accept this proposition we are then brought face to face with the conditions of the particular case before us, which must, at least in so far as the local conditions are concerned, be considered as a rule unto itself. While it is true that in many cases we can decide at once as to the necessity for amputation, yet in |