company and not by the patient; fourthly, the company and not the injured person pays the bills, and, fifthly, the employer of the surgeon and the payer of the bills is the party expected to remunerate the patient for loss of time, effects of injury, etc. For these reasons the railway surgeon requires an inclination to do and the ability to do more than the ordinary surgeon. In addition, there are great moral and sanitary problems connected with the operations of railways which interested surgeons alone can handle. There is great good in local "company" associations, as the surgeons of the company learn to know each other and better and more satisfactory work is done for the company, and the injured. Likewise, there is great good in a national association of railway surgeons, which brings together the surgeons of all the roads, and from all parts of the nation to discuss the subjects of vital interest to all railway companies and railway surgeons in common.

The great bugaboo of railway accidents, Ericson's Disease or Railway Spine, was made the subject of special study by the National Association of Railway Surgeons a few years since, and the facts and reasoning there presented were of such an overwhelmingly, convincing character that John Ericson, the author of that famous monograph which has cost the railway companies of this country so many millions of dollars, was compelled to admit that spinal concussion per se was practically an impossibility. In this one act the National Association of Railway Surgeons did more for the advancement of surgery as it applies to railway injuries than the general medical associations have ever or would ever have accomplished. Their special interest in railway surgery or surgery following railway injuries led to the final result.

The problem involved in the care of railway employes has been solved by the Railway Hospital system. The hospital appointments are like those of any other hospital, but the system of care is peculiar, economical, and eminently satisfactory.

As railway surgeons are not concerned in politics there would seem to be no reason whatever for the existence of district or state organizations for the consideration of topics which had better be considered by the company or national organizations.

The greatest benefit of company national

railway organizations is derived by the companies, and they should and usually do manifest their appreciation by granting the same courtesies that they do to other employes. The National Association of Railway Surgeons was and is the largest body of surgeons in the world, and should, therefore, be able to do much for the advancement of general as well as railway surgery. In the past there has been great need for the exercise of the principles of common sense, a condition which has not always characterized the action of some of our members, and we are of the opinion that the problem of passes can be solved by the same application. Railway companies should not be asked to give members of the National Association of Railway Surgeons or local organizations something for nothing. Give them thought and time, and have the meetings characterized by good, solid, scientific worth, and railway managements will be glad to render all possible assist

We desire to call the attention of our readers to Dr. Thorne's article upon this interesting subject, which appears in other columns of this issue.

The subject is handled in a masterly manner, and aside from the condemnation of amputations in the foot and some of the principles propounded, we wish to commend the teachings therein presented.

The subject of amputations is a vital one; in fact, it is considered by many the most vital one in traumatic surgery. It is surely the most frequent one in railway practice and, therefore. the special importance to us. To know when to operate is a difficult question to decide, and having decided when and possibly where to amputate, the technical problem of how to amputate demands consideration.

The author has given us a brief account of when to amputate to obtain the most prothetic relief, but as there is a large percentage of the injured who are not able to procure the prothetic apparatus, it is indeed a question whether or not the tarsal amputations of the foot should have a place in our considerations. The great principle which should apply in all

amputations in both upper and lower extremi

ties, is to save all we can, providing it can be rendered useful. It is our belief that by the careful anatomic attachment of the severed opposing tendons, the amputations in the foot can be made useful to a marked degree, and that they are especially indicated for laboring

men.

The article contains a most favorable report of our first vice-president's modification of Szme's amputation, which we desire to indorse as being a great improvement on the original operation.

The various practical hints inserted will certainly be of value to those who have not given this subjet special thought and study.

EXPLORATORY INCISION IN THE TREATMENT OF CLOSED FRACTURES AND DISLOCATIONS.

Among the Extracts and Abstracts of the present issue we republish an article by Dr. John B. Roberts of Philadelphia upon the above topic, which recently appeared in the Medical News. The old practice is attacked in a vigorous and yet logical and most convincing manner. The conclusions presented are in general good and acceptable. The treatment is not advised in all simple fractures and dislocations, but in a small selected class. The author says: "My advocacy of cutting down upon closed fractures is limited to cases in which ignorance of the exact lesion, impossibility of reduction, imperfect immobilization, or failure to deal efficiently with complicating lesions, makes the incision the less of two evils." The same procedure is advised in dislocations, which do not readily yield to manipulation under anæsthesia.

The position taken by Dr. Roberts is certainly both conservative and progressive, and when it is possible to carry the treatment out under those absolutely aseptic conditions which he so strongly emphasizes, it should undoubtedly be the practice in the class of cases referred to. Unfortunately, those favorable conditions are not omnipresent, and then the dangers of sepsis will make the two propositions nearer equal-and, therefore, render difficult the choice of the appropriate treat

ment.

Extracts and Abstracts.

A Review of the Surgery of the Peritoneum.

Treves (British Medical Journal, October 31, 1896) says that within the last few years the tendency of many surgeons has been toward the development of an elaborate technique to attain the so-called "strict antiseptic precaution," and the object gained, although of no practical value, has sacrificed much which should have been applied to the actual safety of the patient.

The surgical ritualists appeal to the infallible tests of the bacteriological laboratory, and bring forth, as conclusive evidence, an array of cultivations and inoculated tubes. Most English surgeons, on the other hand, are content to appeal to the test of the patient, and to bring forth records of results.

The work in the operating theater comes up for criticism a week or more after it is done. An operator in fishing boots, nurses with their hands and arms wrapped up in special towels, and a hose playing about the floor of the theater, may form an impressive sight, but to what degree does it bear upon the interest of the patient?

There is the amplest evidence that these extravagant and almost grotesque preparations for the operation are unnecessary; for that evidence demonstrates that such formulæ give in no one class of operations a better result than do the simpler methods with which we are familiar.

At present the actual handling of knives and forceps is overwhelmed by the dexterous disposal of the basin and the soap dish.

The technique, as carried out by the author, is as follows: The operating room is clean and free from dust, and there is nothing peculiar in the construction. The table is of wood. It is not bacteriologically clean, but it is handy to the surgeon and comfortable for the patient, two points worthy of some consideration. Some time before the patient enters the operating room the skin of the abdomen is shaved, well washed with soap and water and then with ether, and is finally covered with a thick compress soaked in a 1:20 carbolic solution, which is kept in position at least five hours before the operation. The surgeon is clean, but does not parade his cleanliness. The mackintoshes and blankets which envelop the patient are, in a domestic sense, clean. The towels which cover the

body in the vicinity of the operation area are

taken direct from the sterilizer.

The instruments are sterilized by boiling and kept in trays with 1:20 carbolic solution,

and before using this solution is diluted by boiled water.

The only sponges the author uses, made of Gangee tissue, are allowed to soak for twentyfour hours in 1:20 carbolic solution.

The author takes as a test of this technique the operation for appendicitis, which he has performed 150 times with but one death.

The character of the dressing used after the operation is of little or no moment. The wound is dried and well dusted with iodoform. The iodoform is retained in place by a pad of wool and a binder.

The fact that iodoform is swarming with microbes may disturb the bacterially-minded surgeon, but it disturbs neither the wound nor the patient.

Peritonitis and the Treatment of Peritonitis. --The evidence is practically complete which demonstrates that all forms of peritonitis are septic and due to infecting micro-organisms. The peritonitis ascribed to the pneumococcus has not yet emerged from the confusion of a bacteriologic squabble. Idiopathic peritonitis, which was at one time regarded as a definite and common disorder, has now, indeed, ceased to exist.

The constitutional symptoms of peritonitis are, in the main, those of septicemia, and it is from blood poisoning and not from inflammatory disturbances that the subject of peritonitis dies. When peritonitis is developed away from what is termed the small intestine area, it is apt to be localized. The surgical treatment of this form has not been most successful. On the other hand, peritonitis in the small intestine area is rapidly diffused, and is as rapidly attended with septicemic symptoms. In this form the operative results have not been so brilliant, and it is evident that the treatment of this terrible complication must still incline toward that desirable prevention which is better than cure.

Excellent have been the results obtained in tuberculous peritonitis of almost all grades. The examination of some 300 recorded cases, treated by abdominal section, shows that a prospect of cure may be expected in over 60 per cent of the instances.

The highest percentage of cures has been attained when the abdomen has been neither flushed out nor drained, but when the exudation has been merely evacuated and the parietal wound closed. With regard to the general management of the peritoneum in operative cases great care should be taken to avoid injuring the membrane, and it is much better to allow a few ounces of a harmless effusion to remain than to remove it by reckless flushing and sponging.

Perityphlitis.-The author denies the existence of the so-called appendicular colic. It is assumed by those who have been captivated

by this term that fæcal particles or foreign substances enter the appendix and cause intense muscular contraction of the organ. In opposition to this assumption it may be pointed out in the first place that fæcal particles are remarkably well tolerated in the appendix. In the next place the intensity of the colic must depend upon the power of the irritated muscle, and the supply of sensory nerves to the, disturbed part. It so happens that the muscular structure of the appendix is of the feeblest character. Moreover, the actual nerve supply of the organ is relatively poor.

It is needless to say that the great majority of examples of perityphlitis depend upon trouble in the appendix; but the author is convinced that now and then the peritonitis is started by mischief in the cecum itself, the appendix being sound.

In spite of all argument the etiology of perityphlitis is very simple. A catarrh leading to ulceration would appear to be the commonest factor, and it is this condition which precedes the stricture of the appendix. The author assumes that the origin of the appendix calculus is exactly identical with that of the rhinolith.

Foreign bodies, seeds and fruit stones play practically no part in the etiology of perityphli

tis.

As regards the question of the surgical treatment, Treves says it is seldom necessary to operate before the fifth day. He condemns the practice of immediate operation, as there is no sound basis for this procedure in either the pathology or the clinical prospects of the affection. It is true that some intense attacks end in death in forty-eight hours; these terrible phases of the malady are exceedingly rare on the one hand, and are not difficult to recognize on the other.

When an abscess is evident or suspected, the locality of the incision must be determined by the area of dullness and of the resistance. The incision should be free; the abscess cavity is gently examined as to its position and extent. The diverticula can be cautiously opened up with the finger. No elaborate search should be made for the appendix. Such search means risk to the frail abscess wall. Should the diseased appendix actually present itself, it can be ligated and taken away.

The high mortality accredited to this operation depends upon the blind resolve to excise the appendix at all hazards. The operation is concerned with the evacuation of an abscess, and those cases do best in which the least is done. As for drainage nothing acts better than iodoform gauze.

The treatment of the diseased appendix involves no new surgical principles and calls for no labored invention. The treatment of the abscess is based upon those great general prin

Complete reduction, exact restitution of contour, and perfect retention, are the conditions of full success in the treatment of fractures. Deformity, impairment of articular movement, non-union and neuralgic pain are remote results of failure to obtain these desirable conditions. Since aseptic surgery has made possible the prevention of infective inflammations in most open fractures, it is quite probable that better reduction, coaptation and retention result in open than in closed fractures of the same grade and character of bony lesion.

The recent application of skiagraphy to surgical diagnosis has proved that fractures seemingly well reduced and properly dressed with splints may be the seat of considerable deviation from the normal skeletal relations. At the Polyclinic Hospital recently. for example, a fracture of the middle of the radius, supposed to be well reduced and dressed, was shown, by the use of the Röntgen ray, while the splints were in position, to have its fragments overlapping to the extent of about half an inch. In another case a painful swelling at the seat of a former injury to the fibula was discovered to be due to unrecognized non-union at that point. The rigidity of the tibia prevented the lack of union of the smaller bone geing detected, but skiagraphy showed it plainly.

Nearly twelve years ago I advocated conversion of closed fractures of the cranium into open fractures by incision of the scalp, when ever uncertainty as to the character of the cranial lesion was prejudicial to intelligent treatment.' As part of my argument I said that no surgeon would hesitate to convert a closed recent fracture of the thigh or leg into an open one if it were impossible to replace fragments which were threatening life. I admitted that closed wounds are less serious than open ones, but asserted that with modern surgical methods, open wounds are preferable to closed wounds having inherent dangers that cannot be recognized without opening them. Further consideration and experience convinced me that this method should be extended to fractures in the limbs, even when life was not threatened, if obscurity of lesion or diffi

* Prepared for the second Pan American Medical Congress November, 1896.

culty in reduction jeopardized function. Accordingly, a few years later, I gave it as my opinion that recent fractures of the lower end of the humerus might with propriety be subjected to exploratory aseptic incision, if satisfactory coaptation was not obtainable under anæsthesia; and that such action, though it involved opening the elbow joint, was as legitimate in properly selected cases as the recognized exploratory incision made in obscure abdominal conditions.

My belief in the propriety and value of exposure of the fragments in a certain limited number of closed fractures has been strengthened as years have passed. The method, which I do not claim as novel, has, however, not been sufficiently impressed upon the profession to cause its adoption by surgeons in general. Allis of Philadelphia has advocated it in rebellious fractures of the upper third of the shaft of the femur, in order to apply steel screws for retentive purposes. In England, Lane has employed it in oblique fractures of the tibia and fibula near the ankle, for the same reason. McBurney and others have resorted to it in fracture of the upper end of the humerus complicated with dislocation. Dennis and Ricard also approve of it in cases where there is difficulty in obtaining correct apposition of fractures. Other writers may have mentioned the subject, and cases may have been occasionally reported, but, except in fractures of the cranium and patella, I think that most surgeons are more apt to be satisfied with imperfect results than to advise immediate exposure of the fragments before the patient comes out of the anesthesia induced for the purpose of examining and reducing the fracture.

This attitude of the profession in general has been evident in societies at which I have incidentally mentioned my views;" and is due to conservatism bred by the fear of open fractures felt by all in the pre-antiseptic period of surgery. The method has suggested itself to many practical surgeons, but it needs to be ever before our minds as a legitimate procedure.

My advocacy of cutting down upon closed fractures is limited to cases in which ignorance of the exact lesion, impossibility of reduction, imperfect immobilization, or failure to deal efficiently with complicating lesions makes the incision the less of two evils. An aseptic incision is almost devoid of risk, even if it opens a joint; but that slight risk should not be added to the patient's burdens unless the probability of deformity, of interference with joint movements or other functions, of pain, of paralysis, or of non-union justify it. Here, as in all departments of surgery, it is the surgeon's duty to exercise care and good judgment in selecting the method of treatment. To illustrate my meaning I cite fracture of the patella, which I have never treated by incision and suture of the

bone, because I have thus far always been able to satisfactorily bring the fragments together by hooks, subcutaneous suture, or splint. In one or two instances I have almost decided to lay open the overlying tissues in order to obtain approximation by direct appliances, but I have finally not been obliged to do so. The open operation I believe to be legitimate, and probably needful in a very few selected cases, but I am opposed to it as a routine treatment.

It is self-evident that the wound exposing a fracture must be aseptic, and that the operator who adopts incision must be familiar with the steps to be pursued at the inception of infective inflammation. A man who will hesitate to reopen the wound or drain the joint, at the moment septic premonitions show themselves, should associate a more energetic surgeon with himself in such operative treatment of fractures. The risk of incising muscles and opening joints, if done in an aseptic manner by an operator familiar with truly aseptic and antiseptic surgery, is unquestionably very slight. Primary union without disturbance of joint-function will be almost universal.

If it once be admitted that the seat of a fracture can be exposed by incision, with little or no risk to life, there are many advantages that will at once suggest themselves:

1. The exact lines of separation can be seen, and the significance of lines of comminution in relation to subsequent reconstruction can be fully appreciated.

2. Coaptation need no longer be guessed at by the sensations imparted to the examiner's fingers, separated as they are from the bone by varying thicknesses of muscle, fat and skin; nor need it be dependent upon the possibility of having conveniences for taking a skiagraph.

3. The fragments can be accurately fitted together, torn periosteum replaced, and muscular and fascial bands, nerves and muscles disentangled from undesirable positions between the pieces of broken bone. This prevents deformity by permitting restoration of normal contour of the limb, and lessens the occurrence of non-union, neuralgia, atrophy and ankylosis.

4. When the osseous, muscular, and vascular relations have been restored, they can be perfectly maintained by the application of sutures, pegs, nails, screws or ferrules to the bone, and sutures or ligatures to the muscles, nerves and vessels.

5. The pain, due to extravasation of blood, rapid inflammatory exudation or traumatic synovitis, is relieved by the removal of the clots and leaking out of exudation and synovial fluid. The interstitial pressure caused by extravasated blood and exudate has often heretofore caused surgeons to split the skin and deep fascia by long incisions, in very bad fractures, in order to avert threatened gangrene. A similar relief of tension in less urgent cases will

undoubtedly lessen pain and suffering, though such operative treatment would ordinarily not be adopted. The incisions employed to uncover the fractures are therefore indirectly of value as relievers of pain.

6. Pain is also lessened, in the few cases requiring direct retentive apparatus, because the sutures, nails, or screws prevent motion be tween the fragments better than external splints. Muscular spasm or incautious movement has therefore little opportunity to cause suffering.

7. Fat embolism is probably less likely to occur in fractures liable to its occurrence, if early escape for the fatty debris is permitted by incision.

8. Ankylosis from faulty position of fragments, irregular formation of callus due to stripped up periosteum, and gluing down of tendons, will seldom occur after the fracture has been disclosed to the scrutiny of a competent surgeon.

9. Repair of the broken bone and functional restitution of the surrounding tissues occur more rapidly than when coaptation is imperfect, or when damaged, muscular and other structures are left to the unaided efforts of nature. Impairment of digital movements after fractures is probably often due to coincident rupture or laceration of muscles, which might have been repaired by suturing with catgut, if the surgeon had known of the existence of the complication. The aseptic wound affords him this opportunity; and afterward usually heals so rapidly that it is of no disadvantage to the patient's period of convalescence. This early restoration of wage-earning capacity is of great value to many patients.

10. It not infrequently happens that a closed fracture seems to have been well set, and to have left little deviation from the normal; and yet the patient has lost some of his availability as a machine. This is most likely to occur in the lower limb, which, during locomotion, carries the entire weight of the man. A slight change in the axis of a bone or in the plane of an articulating surface may perhaps throw the weight upon the hip, knee or ankle in an abnormal way and induce a considerable and ever-increasing disability. This contingency is usually avoidable after the accurate inspection of the injured bone permitted by uncovering the fracture by incisions.

In vicious union of fractures due to absence of treatment, or to injudicous treatment, I believe that it is sometimes much better to expose the seat of deformity and divide the deformed bone with an osteotome than to refracture subcutaneously by an osteoclast or the surgeon's hands. Many cases can indubitably be well treated by refracture without incision or by subcutaneous osteotomy; but if there be a reasonable doubt as to one of these methods