-CONSERVATIVE TREATMENT OF FOOT INJURIES.*

BY MARK MILLIKIN, M. D., HAMILTON, OHIO.

An Irishman, bragging about his horse to a prospective purchaser, said: "See what a fine fut he has fur standin'."

Were one to judge from the frequency of foot accidents in my vicinity, one might infer that the victims had some of the attributes of the Irishman's horse. At least some trespassers have had difficulty in getting out of the way. A large proportion of severe injuries under my care have been those of the foot.

About a year ago a young fellow stealing a ride on a night train attempted to get off at Hamilton, just before the train stopped. In some way he slipped, and his left foot got under the wheels. It was split between the third and fourth toes half way up the foot. The bones were crushed and tissues torn apart. There were two cuts on the ankle, two or three inches long, and one over the instep running up, over and around ankle, about eight inches in length. There was a cut through the heel causing it to hang loose. Owing to my absence at the time, Dr. Tilton took charge of the case. The fourth and fifth toes, with their metatarsal bones, were removed and the outside integument was used for a flap. The other rents. were closed, requiring in all about fifty stitches. The patient was left with three toes. Dr. Tilton put the patient under my care next day. It was evident from the number of transverse cuts over the back of the foot that the blood supply to some of these flaps was partly or entirely cut off, and that sloughing would follow. The only question was, how much? In a few days large pieces of some flaps turned black and were lifted up and cut off. Underneath were healthy granulation.

Now comes an important part of treatment. Heretofore we have probably attempted to disinfect, by means of irrigation and antiseptic powders, but when the granulations are exposed we should not attempt to hurry cicatrization. The plentiful dusting of aristol, boric acid, etc., on the surface and gauze over all, I believe, hurries healing. But here is a flap of skin and connective tissue to be replaced, which may have been a quarter or a half inch thick. Our aim should be to encourage the formation of new tissue. I have seen chronic ulcers do well (after having had a variety of pastes and powders) under a simple application of codliver oil. It would appear that this easily-digested fat acts as a food to the unhealthy granulations, and that they are therefore stimulated. If

the raw, granulating surface of a healthy wound is kept

well greased with vaseline, oil, lanoline or a mixture of two or more of these substances, I believe the making of new tissue is promoted. Certain it is that growth is not lessened by such treatment. When the gauze to be applied is plentifully smeared with greasy material there is no sticking, and consequent bleeding on renewing it. This itself is a gain. Moreover, it is easy to incorporate in your application some one of the essential oils whose odor is pleasant, and whose antiseptic powers are too often forgotten.

This patient now has an ulcer on the outer side of the

*Read before the first annual meeting C., H. & D. Surgeons, Dayton. Ohio, May 6, 1932.

foot in dense scar tissue. It is about one-eighth inch deep and three-quarters inch in diameter. The outer toe stands up so that a hole must be cut in the shoe for its comfort; the other toes are normal. The man is hard at work every day in a foundry and walks without limping.

Another patient, a boy 15 years old, while stealing a short ride between freight cars, was dislodged from his position by the train coming to a sudden stop. His right foot was caught between the couplings, and the dorsal surface, with the exception of a little strip over the first metatarsal bone, was bared of skin, exposing tendons and nerves. This flap was attached along the metatarsophalangeal joints and the cut over the dorsum of the foot was over the tarso-metatarsal joints. It was brought back in position by catgut sutures. As was expected, extensive sloughing of the flap occurred. But the surprising thing was to find that the blood supply to the four outer toes was so impaired that they also turned black, and in a few days I was able to twist them off. One naturally would expect that enough blood would come through the sole of the foot to nourish them. About this time a peculiar accident occurred. The dressings, which were necessarily very loose, became one day so disarranged that a fly gained access to the sloughing mass. She did her part well, for one day I was surprised to find a peculiar movement to one of the flaps. You may imagine why. Her offspring were washed out by a stream of bichloride and no harm seemed to result. Apropos of this a recent writer in the Philadelphia Medical Journal narrates a similar experience, and says: "After all, I guess maggots do good. They are not fond of live flesh; decayed matter is a hobby which they all love to ride." However, I would not advise the propagation of flies in gangrenous tissue as a conservative measure.

Granulations filled up the lost tissue in a most satisfactory way. The two terminal bones of the second toe were twisted off because of gangrene, leaving the first phalanx exposed. It was my belief that this would later have to be removed, but even it was well covered by the new tisAt present this boy's foot is well, except for an ulcer about the size of a cent in the middle of the original bared spot. If he would take care of the foot by keeping off of it as much as possible, probably it would heal. But he is a restless youth, sometimes working in a foundry, and always on the move.

sue.

Another patient one night tried to crawl under a freight about under the cars the train started. He was rescued train. He was very drunk at the time, and while bungling by a passerby, but not before his left foot was damaged.

The metatarsal bones, with the exception of the outer one, were fractured, and the first metatarsal was denuded of flesh. The toes were intact. There was a cut on the plantar surface between the second and third toes. The first metatarsal and part of the internal cuneiform bone were removed, as was the big toe. Even then the dorsal and plantar flaps did not cover the gap by from one to one and a half inches. If you tried to set one metatarsal bone, its fellows were apt to become further dislocated. The condition of this part of the foot might be described. by the word "squashy." After vainly trying to line up all the bones I let them alone. To put on a splint below and above tight enough to squeeze the bones into place seemed

to me to be a good way to further diminish the blood supply, of which at that time but little could be known. Though the inner side of the foot presented a raw surface after approximating the dorsal and plantar flaps by catgut stitches, it was left as it was, trusting to granulations. There was little sloughing, but a good deal of discharge from within. How the bones united only the Xrays can tell. However, there was a good arch to the foot, probably caused somewhat by new bone. The tendons to the toes were evidently involved in all this new tissue, for their motion was nil. His bibulous tendencies got him into trouble and caused his dismissal from the hospital before all was healed. At that time he was putting some weight on the foot.

The question arises, what will happen to these patients twenty or thirty years hence? They are young now, the nutrition of their scars will never be better. Suppose they develop varicose veins, will the scar tissue break down and form large ulcers? They may wish that they had had a foot amputation long before. It is the dictum of a celebrated surgeon to treat the foot as one bone. I confess to have been governed by this teaching in the treatment of these injuries. Save all possible; make all possible by encouraging granulations.

The treatment of large or small areas of granulations, where tissue has been lost, is, I believe, best done by some fatty substance, as a base. Such a dressing does not stick. There is, therefore, no bleeding or pain on its removal. It does not form scabs, which constrict the superficial capillaries. After all, it is not such a departure froin Nature as might seem, for is not the surface of a granulating wound covered with a little fat from the disintegration of dead cells?

SURGERY OF THE HEART.*

BY B. MERRILL RICKETTS, PH. B., M. D., CINCINNATI, OHIO.

Injuries and surgery of the heart have, until recently, been classed as anomalies. This one fact shows how little confidence there has been in successfully dealing with the heart surgically. At one time simple needle puncture of the heart was thought to always result in instant death. Experimental physiology and surgery shows what can be done and how to do it. It is the basis upon which the heart surgery, especially, has been placed.

Twenty-five dogs were used in the experimentations. Penetrating and non-penetrating wounds of the heart were made and closed with sutures of different material. Interrupted silk sutures were found to be the best. No

wounds of the auricles is much greatter than those of the ventricles.

Knotting of the sutures should be firmly secured, otherwise they may become untied by the constant action of the heart. The sutures should pass through the bottom of the wound when non-penetrating and through the endocardium when penetrating. If not in the latter, the wound may become enlarged from within. Sutures should not be made tight enough to cut the heart tissue.

The mortality is less in wounds of the right than those of the left auricle and ventricle. Bleeding is more severe in wounds from sharp instruments than when due to bullets.

Conclusions: 1. Injuries and diseases of the heart have resisted surgery longer than almost any of the tissues or organs of the human body.

2. They however, no longer offer such resistance but find themselves subject to attack by the same surgical principles as other parts of the body.

3. Experimental surgery teaches one to reason from animal to man.

4. Aneurism, foreign bodies, ossification, together with abscess, syphilis and gangrene, possess features which will have a great bearing upon, and will greatly influence the future surgical work of the heart.

5. The application of surgical principles in certain. cases of aneurism of the heart will, no doubt, be accomplished by suture electrolysis, or the injection of gelatin. or something of a similar character.

6. The removal of a certain class of foreign bodies whether they have formed within or have entered from without, should, and no doubt will be accomplished.

7. That a cardiac abscess should be incised and drained, there can be no doubt.

8. Tumors of a pedunculated character on the external surface of the heart can and should be removed. 9. Pedunculated tumors within the cardiac chambers can also be successfully removed.

10. Parasitic cysts (animal or vegetable) when upon the external surface of the heart or in its wall should be incised and drained.

II.

conditions were desired.

The pericardium may be entirely removed without death resulting. Either one of the coronary arteries may be litigated at its base without producing death. In a certain class of cases it is best to suture the pericardium to the chest wall that drainage may be perfect.

It is ideal to suture during systole but one will be satisfied to secure perfect suturing in systole or diastole.

Even though the auricular wall is thinner than the ventricular it may be sutured with equal success. Owing to this difference in thickness the per cent of penetrating

* Abstract of paper read before Surgical Section, American Medical Association, Saratoga, N. Y., June 10-13, 1902.

14. Suturing or any other surgical procedure should not be discontinued because the heart should cease to pulsate. The work can and should be completed within a much shorter time in a quiescent heart.

15. All means should be resorted to, while the suturing of the myocardium is being completed, to re-establish the heart's action.

16. Drainage of the pericardial sac is necessary in many cases of injury of the heart.

17. Exploratory incision of the pericardial cavity and its contents has been shown by both experimental research and operations upon the living human body to be exceedingly rational, valuable and justifiable.

16. Exploration of the heart itself by puncturing it with a needle or knife to locate a foreign body or to detect pathologic conditions within the myocardium or its chambers, will at no far distant day be found useful, necessary and recognized as an accepted surgical procedure. 19. Why should these conclusions be fallacious when it has already been shown that nine of the twenty-seven cases of heart wounds treated by suture have recovered?

ADDRESS UPON THE SUBJECT OF HOSPITALS.*

BY CARL F. HOLTON, GENERAL CLAIM AGENT, BOSTON &

MAINE RAILROAD.

It is characteristic of our time that we accept our insti

tutions without thought of the necessity that originated or the years that have perfected them. Yet all the adjuncts that are inseparable from our advanced civilization-all the gigantic systems and marvelous inventionshad their beginnings in some need of man.

In the present instance the relief of suffering humanity is a necessity no more imperative to-day than it was in the beginning of time. Therefore, in our modern hospital, we have the evolution of an establishment founded hundreds of years before the Christian era. From the writings of Socrates we learn that physicians were appointed by the government to attend upon the patients at the dispensaries about the fifth century before Christ, and it was a position much sought. These physicians in their turn appointed slave doctors to attend to the poor while they themselves attended to the rich. Among the Romans it was the custom to set aside for guests apartments, which they called "hospitalia," and it was from this our word hospital is derived. Several hospitals were established for the use of sick pilgrims near Bethleliem. Hospitals were spoken of in the council of Nice (A. D. 325) 3 institutions well known and deserving support and encouragement. The Hospital Dieu, perhaps the oldest hospital in Europe now in use, was founded about A. D. 600 by St. Landry, bishop of Paris, for all deserving and sick persons of whatever sex, age or condition. The first hospital built in England was erected at Canterbury by Archbishop Lanfranc in 1070, and in 1208 the Hospital of the Holy Ghost and St. George's Hospital were established in Berlin. The earliest account of physicians and surgeons being connected with a hospital among the Templars was under John de Lastic, who in 1437 defined the duties of aforesaid physicians and surgeons. In 1456 the Grand Hospital of Milan was opened. This remarkable building is still in use as a hospital and usually contains more than 2,000 patients. During the first of the sixteenth century another cause

began to influence the establishment of hospitals, namely,

the necessity of providing for the care of the large number of sick and wounded incident to war. The Italians were the first to produce writers on military surgery, about the beginning of the thirteenth century, but we find no account of a military hospital being erected until 1575, where, at the siege of Metz, through the influence of Ambrose Paré, the first famous military surgeon, one was built.

The first mention made of a hospital in this country was

At the thirteenth annual meeting of the National Association of Railway Claim Agents at Milwau.ee, Wis., May 28, 1902.

at a meeting of the Association of Friends at Philadelphia, held September 25, 1709, when it was voted that "Thomas Griffith is ordered to pay Edward Shippen to the value of 8 pounds sterling, when there is stock in his hands, towards defraying the charges of negotiating matters in England in relation to the school charter, and one that is endeavored to be obtained for a hospital." Apparently this effort was not a success, although so large a sum was appropriated. In 1751 Dr. Thomas Bond of Philadelphia went to Benjamin Franklin and asked his assistance and coöperation in the project of a development of a hospital "for the reception and care of poor sick persons, whether inhabitants of the province or strangers." Dr. Bond tried to get this through himself, but everyone whom he approached on the subject

asked for Franklin's opinion, and when told he had not been talked to they decided to think it over and did nothing more. Franklin took hold of it, and an act was passed at that session at the House of Representatives of the Colony of Pennsylvania, "An act to encourage the establishing of a hospital for the relief of the sick poor of this province and for the reception and care of lunatics." This was approved by the governor, May 11, 1751, and a charter was granted by George II. February 6, 1752, an advertisement was inserted in the Gatients. This was the Pennsylvania Hospital, which has zette, stating that the hospital was ready to receive pasince been separated into the Pennsylvania Hospital and the Pennsylvania Hospital for the Insane. The next established was the New York Hospital in 1771; the third, Christ Church Hospital in Philadelphia in 1772, and, fourth, the Massachusetts General Hospital in Boston in 1811. Since their establishment in this country they have steadily spread from city to city and state to state, until now in the United States there are upwards of hospitals and 10 corporation hospitals, making a total of 789 public hospitals, 219 private hospitals, 31 railroad

1,049 institutions, containing, at an estimate, 80,000 beds, or accommodation for one out of every thousand of the total population of the United States.

But the question which especially interests this association is the value of hospitals along its lines for the care of injured passengers and employes. Whether railroad. companies should maintain hospitals, over which they have absolute control, or should patronize public institutions, is a matter for debate, and as my experience has been largely with public hospitals, I will take up that question first. It would seem that location and conditions should largely govern the advisability of railroad overland routes run through a country where there are companies utilizing public hospitals. Many of the great pitals available. Under such circumstances it seems that few cities, and where there are practically no public hos

the only feasible course to pursue is for the companies to establish hospitals of their own; but in the thickly-settled

portion of New England and the Middle States, where cities are separated by a short distance only, and where in nearly every city there is established from one to five. public hospitals, equipped with all the modern appliances and conveniences, there seems to be no necessity for such

a measure.

It is true that there are disadvantages as well as advantages to be met with in public hospitals. The railroad

companies cannot dictate who or who shall not visit their inmates, but all well-organized hospitals realize that it is not for their interest or for the good of the patient to allow that class generally known as "legal scavengers" admittance. On the other hand, one of the great advantages obtained is that the patient receives the benefit of the very best medical knowledge in the land. It is considered a great honor among physicians and surgeons to be appointed on the staff of these hospitals, and as the position is much sought after, only the best receive the appointments, as a rule. Another advantage to be gained is that a perfect record is kept of the patients' condition from the time they enter until they are discharged or leave at their own request, and as a rule, if the physicians are called into court to testify, they are unbiased, as they are in no way connected with, or under obligations to, the railroad.

In this connection let me say that in advocating the use of public hospitals I do not mean that railroad companies should take advantage of these institutions because they are free and send their injured there as charity patients. None of these hospitals are self-supporting, but are supported by endowments and contributions, either from state or municipal authority, and railroad companies should make a liberal annual donation or arrange to pay a stated sum per week. This course would assure certain privileges which otherwise would not be granted. And, if occasion requires, you can say to the injured employe: "We have provided you with the best of medical skill and the best of hospital accommodations, for which the company pays liberally." The variety of opinions obtained by authorities in consultation often result in the saving of a limb, or restoration of some part, that would have been sacrified if left to the hasty decision of one person. The value of this to the company is readily understood.

I recall a case which occurred on one of the Western roads while I was connected with the company. An employe's arm was badly crushed at the elbow and the local surgeon decided upon immediate amputation. The man objected to having the operation performed until further advice had been procured. He was therefore sent at once to the hospital at Albuquerque. The chief surgeon examined the arm and decided it might be saved. His opinion proved correct, as he succeeded in restoring the arm to an almost normal condition.

To revert to conditions nearer home, we find that the Boston & Maine Railroad at the present time is operating about 2,300 miles of main track; counting second, third and fourth tracks and sidings, their total trackage is a little over 4,000 miles, and they operate in five states and the province of Quebec. It has about 25,000 employes, and of that number about 3,000 are injured annually. The majority of these injuries are slight and do not require hospital treatment.

through which we run, three hospitals with 321 beds; in Maine, in the territory through which we run, two hospitals with 164 beds; in the province of Quebec, in the territory through which we run, three hospitals with 200 beds, making a total of 58 hospitals with 4,042 beds, or on an average of a hospital to every forty miles of track. This, of course, would hardly be a fair estimate, as the majority of the accidents occur at our large yards at such points as Boston, Lowell, Lawrence, Nashua, Manchester, Worcester, Springfield and Portland. At all these large centers the hospitals have an ambulance service, and within fifteen or twenty minutes after the accident has occurred the injured party is at the hospital, and there is hardly a point on our system that an injured party cannot be conveyed to a hospital on regular trains within two or three hours. It is an erroneous idea that the duty of the claim agent ceases with the delivery of the patient at the hospital. He should visit the patient often, ascertain if anything is required, and if within reason procure it. Also, it is his duty to visit hospitals and establish friendly relations with officials and attendants. If the company is making an annual donation, or paying a certain amount weekly to see that bills are passed promptly. Incidentally a ticket to some summer resort, given to the matron, or even to some of the nurses, is money well invested and in the long run will show returns. I hold this matter of cultivating a friendly connection with hospitals to be of the utmost importance. No reputable hospital would tolerate an attempt to unduly influence their attitude, and such a procedure is outside the domain of legitimate transactions; but harmonious. relations are to be earnestly desired, in so far as they can be conducted on a basis of satisfactory business relations and mutual good will.

The effect of a favorable influence on a weakened patient should not be underestimated. Oftentimes the entire settlement of the case depends on the attitude of the persons in contact with the injured one. Our duty to the patient is equally urgent. Mistakes occur, although I believe less frequently in these well-regulated hospitals than in any other institution of equal magnitude. But if a patient in whom you are interested complains of his treatment, it is the duty of the claim agent to look into the matter, and if there is any good ground for complaint bring it to the attention of the officials of the hospital and try to have it rectified. Many of these complaints are made through a misunderstanding of the effort which is being made by the surgeons to save some limb or portion thereof.

I recall a case which occurred at one of our hospitals in Massachusetts. An employe had his hand badly crushed and was sent to the hospital. After he had been there a week or ten days I received a letter from him, stating that he was being mistreated and was going to leave; that at the beginning they had not performed an operation which they now claimed it was necessary to perform. I immediately responded to the letter and made an investigation of the case. My investigation revealed these facts: Upon his admission to the hospital the surgeon discovered that the hand was badly crushed, and the necessity of amputating one finger was beyond all question. But they saw a possibility of saving the index finger, and so dressed the hand and waited developments.

After ten days it was found that circulation could not be restored, and there was then no other course to pursue but amputation. It was for this cause that the patient made the complaint, while in reality it was the best recommendation the hospital could have; it would have been an easy matter to have amputated the finger at the time, but in order to try and save it they waited until there was absolutely no hope. After it was explained to the patient he saw it in the proper light and said that of course he would have been glad to have waited months if the finger could have been saved.

In all the cases which we send to hospitals there is not I per cent of bad results to be directly laid to any neglect or fault on the part of the surgeons or hospital attendants. We have a few of what is known as "ligamentous unions" of the bone, and a few in which the bone refuses to unite. These, however, are rare, and in the latter the surgeons have been unable to explain why, under certain conditions, the bones will not unite, when apparently the patient is in a healthy physical condition.

Under our present system we seem to be deriving the best results possible, so far as concerns the treatment of hospital cases, but a phase of the matter is yet to be considered. I refer to the class whose injuries are not of a character that require them to be admitted as inmates of a hospital. All of these large hospitals are taxed beyond their capacity by what is known as out-patients, and it is a fact that patients are obliged to wait hours for their turn, and owing to the great number to be treated it is possible that some cases are slighted. This raises the question as to the advisability of railroads establishing dispensaries at their large terminals or junction points, where accidents are frequent, for the treatment of minor injuries, these to be under the charge of the chief surgeon. While the Boston & Maine has no chief surgeon whose jurisdiction extends over the entire system, yet I am convinced that a man possessing the right qualifications for that position would be of great benefit to the company. It cannot be expected that claim agents can be as well qualified to pass upon medical bills, or even to select doctors for consultation, as a man who has chosen it as his profession. While I am not of the opinion that a medical organization is necessary on our New England roads, or that we would derive as good results as we do under our present system, I am convinced that a well-chosen man for the position of medical adviser would be of great benefit and assistance to the claim department.

There are, of course, many considerations involved which time will not allow me to consider. We recognize the repair shop of to-day an important adjunct of a railroad. A broken link in a chain, or a bent piston-rod is not cast aside, but receives the attention necessary to restore it again as a useful member. How much more should the injured body of an employe become the care of the corporation upon which he is dependent! What infinite care should be taken to surround the sufferer with all the many attentions and skilful devotions necessaryi to secure speedy recovery that infallibly tend to produce harmony and loyalty between employer and employe, which are essential to the success of all industrials to-day. Upon us as railroad claim agents devolves this important duty. See to it that the duty is well performed.

BORO-CHLORETONE, THE NEW SURGICAL DRESSING.

BY WALTER P. ELLIS, M. D.

A preparation that possesses all the good, with none of the bad or disagreeable properties of iodoform, has been a desideratum for "quite a while." In fact, from 'the time that drugs began to be generally used by surgeons as a local application to wounds, both accidental and surgical, there has been a demand for some drug that possessed its antiseptic, anesthetic and healing powers without its undesirable qualities, such as the possibility of poisonous action when used for too long a time, or over too large an extent of surface, and its intensely disagreeable odor, which manifests itself at all times and under all conditions. No other odor, less obnoxious, is able to overcome it, and the fact of the almost universal use of iodoform in venereal diseases has caused the laity to associate the peculiar penetrating smell with those diseases. That alone is quite sufficient to render its use in many innocent cases, where it is otherwise strongly indicated and its therapeutic effects desirable, entirely out of the question.

The local anesthetic quality of the new hypnotic, chloretone, united to the antiseptic and healing properties of boric acid, as is found in the new drug recently introduced to the profession under the name of "boro-chloretone," forms an ideal preparation for the purposes for which iodoform has been so extensively employed. The writer has had it under observation and in almost constant use since it was first brought to his notice some months ago. Its use has been productive of such satisfactory results that he feels constrained to give others the benefit of his experience. In two cases, especially, the outcome was gratifying to such a superlative degree as to merit special report.

Case 2. R. E. H., aged 76, proprietor of a large sawmill, in which many small circular saws are used, met with an accident in which the little finger of the left hand was sawed off at the metacarpo-phalangeal joint, the same joint of the third finger sawed completely out, leaving the finger hanging only by the skin on the palmar surface, and the middle finger torn and mutilated on the extensor side for almost its entire length. The wound. was cleansed, the ragged ends of tissue removed; the third finger was stitched in place, and the wound of the middle finger brought together in the best possible manner. The whole was then covered pretty thoroughly with borochloretone and bandaged. The dressing was changed on the third day, and daily thereafter. It did remarkably well from the first, in spite of the patient's advanced age, and in three weeks from the date of the injury the healing was complete, there having been but little pain at any time, and no suppuration to speak of. There were three fairly good fingers saved on a hand which looked at the time as if all, save the index, were irretrievably damaged. The rapid healing, freedom from suppuration and pain, were undoubtedly due to the boro-chloretone, which was dusted freely over the parts at each dressing.

In conclusion, I will say that my experience, covering many cases similar to those reported, has convinced me that boro-chloretone is the ideal dry dressing.-American Prac. and News.