ful to him, but if neglected the temperature would shoot up a degree or two.

During convalescence we used a strong solution of carbolic acid instead of peroxide hydrogen, as it appeared to be more stimulating. The exhaustive night sweats were controlled with atropine and acid sulphuric. With two exceptions his appetite was always good. One has been mentioned, viz., when he was posioned by iodoform, the other, strange to say, was from accidental poisoning with atropine. A two-ounce solution of atropine for the eye was on the table in the medicine room, together with a solution of quinine and sulphuric acid, which latter he was taking, but by mistake he was given a teaspoonful of the former, which contained about one-half grain of atropine. He was delirious for a few days, but by the free use of morphia hypodermically came out all right.

He was given whisky as medicine when needed. Morphine was also prescribed when necessary, and, as is usual in such long, painful cases, the habit was formed and took considerable firmness to discontinue it when no longer necessary. There are no deformities in the leg except the stiff knee. The anchylosis is complete at a slight angle, so that in walking he does not have to swing the foot out to step forward. When he is walking from you the lameness will not be noticed.

There are many lessons taught in this case. The first abscess was at the end of the tube; there was no rise in temperature to amount to much until pus formed. Had we amputated, as advised time and again, even before and after the formation of pus, he would have recovered without suppuration, getting well in three or four weeks without a leg and suffering very little comparatively; instead getting well with a leg and a stiff knee, in fifteen or sixteen weeks, with a great deal of suffering. Now he is able to do nearly the same kind of work he did before the injury. Had I amputated and he had recovered he could not have done his work with an artificial leg as easily as he now does with his own leg with the stiff knee.

Had I consulted my feelings-I won't say interest-I would probably have amputated. I must confess that I am human; so when one of these cases falls to my lot, where I can see several weeks of hard, aggravating work, I

often ask myself: "Why not take the shortest road and amputate?" Up to date I have never given way.

Case IV: W. R. C., aged 45; freight conductor. In doing the switching at a way station the caboose was struck by a wild car running at a high rate of speed, knocking it from the track, catching the conductor between its rear platform and the platform of the station. His right femur was fractured through the neck, and there was an impacted fracture just below the trochanter. The left femur was fractured just above the knee very obliquely. Three ribs were broken on the right side. There were several scalp wounds. and the right hand was badly lacerated. Both ankles were sprained, the right the worst. There were many other contusions and sore places that were trifling compared with what is described.

This accident occurred in midwinter, 250 miles from home. By his own request he was brought home. After a little delay the fracture bed of the railway company was obtained and in a very short time the fractures were adjusted and he was lying with several pounds pulling each foot, the foot of the bed elevated six inches, the body being the counter extending force.

He was accompanied home by Dr. Billingsly, the company surgeon at Belleville, Kan., who aided me in putting him together. That night he had a hard chill and I found him the next morning with temperature of 101 degrees. I called in Dr. Thompson, who lived a few doors away, and requested him to look after his lungs. The second morning the temperature was 102 degrees plus, and he was expectorating blood quite freely. However, only one lung, the right, was involved. From this he recovered quite rapidly, everything considered. I endeavored to use as little retaining apparatus as possible to keep the legs in place. On either side of them I placed long, slim sandbags, and as the muscles relaxed I lightened the weights, endeavoring to keep the balance as near as possible. The cough irritated and caused a great amount of pain in the region of the broken ribs, but with careful bandaging the ribs were held in place and the muscles of respiration paralyzed. Mr. C. is of a nervous temperament, and as the pneumonia dis

appeared his wants and suggestions were very numerous. I had let up on the weights during the pneumonia, till the left, the oblique fracture, had slipped. It had eight pounds then but it required twelve to hold it. Eight held the right.

Toward the last of the third week, as he was convalescing from the pneumonia, his extremities became quite oedematous and there was quite an amount of albumen in his urine. Under a course of salines healthy conditions were soon established. The dressings of the legs had become somewhat deranged, making it necessary to renew them. In doing this we used all caution possible and took advantage of the circumstance to stimulate circulation by massage; then carefully and evenly bandaged the foot and ankle before applying the adhesive plaster for extension. At this time also that old curse of such cases, the bed sore, began to show up. With stimulating lotions for a few days, followed by a large square of adhesive plaster, it was entirely interrupted. He was also given a course of iron and digitalis, with a good, generous diet, It was very difficult to keep him still. He would get the bandages loosened in spite of me, and but for the well arranged fracture bed I do not know how I should have come out.

The eighth week I ventured to move the joints passively when I was re-dressing. The right knee was very stiff; the left one I dared hardly stir, the fracture being so near the joint. Apparently union was advancing in all the fractures. It was more noticeable at the trochanters. The provisional callus was easily felt. I had let up on the weights, the right six pounds, the left eight. I was greatly troubled with the cedema. In spite of heart tonics and saline diuretics the urine carried albumen more or less. Finally I bandaged each leg from the toes to the body and let the foot of bed down two inches, and used massage vigorously whenever the dressing was removed, as well as putting the joints through their normal motions. This carries us to the twelfth week.

Buck's method of treating fractures cannot be too highly commended. The principle of making the body the counter extending force, thus doing away with the old perineal band, was a great relief, for it was almost impossible to prevent perineal abscesses.

The sandbags for side supports were another great improvement over the long Desault splint, saying nothing about the comfort to the patient. We learned long ago by actual experience that the simpler an apparatus was and fill all the indications, the better it was. With a good fracture bed and Buck's position, a patient has more liberty without disturbing the dressings than any other I know of.

The twelfth week I let the bed down and removed all dressings. There was bony union in all the fractures. The callus at the impacted fracture was the largest. The joints were all quite stiff. The right knee I could bend but a few degrees without causing great pain; the left, to nearly a right angle. In the right femur-the neck—I was never sure whether the fracture was in or outside the capsular ligament. From all appearances there was bony union, hence this leads me to infer that it was outside. The provisional callus at the trochanters was very large. The oblique fracture of the left slipped a little in spite of me and bowed out somewhat. The ankles were quite stiff. I sat him up with his feet in a vessel of hot brine and with a large, soft sponge gave his legs a good rubbing, following with a thorough kneading, then re-applying the straps for extension, bandaged as before, putting on extension every night for several days. Every morning he was let down and every joint put through its normal motion as far as possible. All joints yielded readily except the right knee. The oedema disappeared slowly. I molded a felt splint to the left leg and on the fifteenth week discontinued extension. He could sit up an hour at a time without much distress and began to put some weight on his feet, but it was slow work for him. The sixteenth week the fracture bed was deserted. The right knee was gotten to a right angle; oedema was also going, but we were obliged to continue the bandages. With care he could bear some weight on his feet. By the last of July he was going all around on his crutches. Everything was going our way except the right knee that stuck at right angles. He would not consent to forcible

measures.

The first of August he was going down from the elevated depot to Union avenue, when he stumbled and went down promiscuously. He was gathered up and sent home, where I met

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

ment.

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 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 come 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 hospital 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.

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 day 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

case.

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