The local surgeon, by his present test, eliminates those applicants with myopia and decided astigmatism, also those who have perceptible loss of vision due to pathological lesions. He should also eliminate the hyperopes of medium and high degree. It certainly seems to me. worth while for the employe to know it if he is afflicted with a condition which may at any time cost him his position. It is also of importance to the employer to know if he is educating a man whom he will be forced to discharge at the time of his greatest usefulness.

PATHOLOGICAL CONDITIONS DEPENDENT ON FRACTURES INVOLVING THE FRONTAL SINUSES.

BY RUSSEL S. FOWLER, M. D.

Fractures involving the frontal sinuses are usually the result of direct violence. They are divided into those involving the anterior wall of the sinus alone and those involving the posterior wall either alone or furthermore complicated by fracture of the anterior wall.

All fractures involving the frontal sinuses are open fractures—that is, they are liable to direct infection, for it is impossible to cause a fracture of the bony walls without involving the mucous membrane lining the sinuses. The loss in continuity of the mucous membrane is accompanied by more or less hemorrhage into the sinuses, which may be sufficient to produce the condition known as hematoma of the sinus. Subcutaneous emphysema readily occurs and may extend over a large portion of the body. With or without this condition of emphysema there is hypermia of the mucous membrane, and an acute catarrah inflammation may result. This may be termed the first stage in the pathology of the sinus. Should the frontal duct be patent, the effusion escapes with the usual mucous secretions of the cavity. Should the duct be closed either by being directly involved in the fracture or by swelling of the mucous membrane, the result of the traumatism, the condition becomes a more serious one. The mucous membrane becomes more generally hyperemic and swollen and may finally become enormously thickened so as to fill the greater part of the cavity. The secretion from the mucous membrane, which has been increased during the hyperemic stage, gradually becomes less as the sinus becomes dilated. Unless outlet is afforded for the accumulated secretions, either by operation or by the intra-sinus pressure being sufficient to force at least a portion of the accumulated secretion through the duct into the nose, diatation proceeds. The bones may become very much thinned. The eye is forced downward and outward from the bulging of the sinus at the inner angle of the orbit. In extreme cases there may follow a hernia of the mucous membrane of the sinus through the opening between the orbit and the tear duct into the nose. This herniated condition of the mucous membrane may be of sufficient size to fill the nasal cavity. As the distension thus progresses, the secretion becomes thick and fetid.

This condition is known as mucocele and constitutes the second stage of sinusitis. Should, in such a case, the anterior wall alone be fractured, the secretion

may force its way through the line of fracture and form a tumor under the overlying skin.

More serious still is the third stage. Here infection is. added to one or the other of the stages already described. If infection is added to the first stage the mucous membrane becomes the seat of a destructive septic inflammation, the underlying bone may become involved and bonenecrosis result. Should drainage through the normal channel be sufficient, which is rarely so, no distention of the sinus will result. But usually, as is also the casewhen a mucocele becomes infected, there follows a collection of infected fluid within the sinus. This is known as: empyema. The mucous membrane is first attacked by the septic process, later the bone. The thin septum dividing the two sinuses is attacked by the septic process and crumbles away so that there results one large cavity lined by bone bared in part of its periosteum and mucous. membrane covering, with here and there areas of softening and necrosis.

Such mucous membrane as survives the septic process is red and somewhat thickened. In places it is thin and atrophic. Its surface is rough and granular. Here and. there may be noted fungus granulations. The quantity of septic fluid, mucus, necrosed bone, and septic mucous membrane may be enormous, considering the normal size of the sinuses. Needless to say, the rapidity of the destructive changes depends in a great measure upon the kind of infection. Staphylococcus infection is severeowing to the confined nature of the sinuses, but not so rapid or destructive as streptococcus infection. The gross appearances are similar to mucocele and depend in great measure upon whether or not there is an intermittent escape of retained septic material through the normal channels.

Should relief not be afforded, the septic process extends from the bone to the soft parts, and in case of fracture of the anterior wall, rapidly forms a phlegmon. Here the spread is more rapid. The skin becomes involved and sinuses are formed through which the pent-up secretions find an avenue of escape. Such sinuses usually form in the area known as the "root of the nose," or in the roof and inner angle of the orbit. The posterior wall of the sinus may be perforated in a similar manner, and the fluid effect a rapid entrance into the cranial cavity, should a fracture of the posterior wall be present, there to set up a septic meningitis or cerebritis.

There remains but one other class of fractures which may involve the frontal sinuses, open fractures in the true sense of the word. As there is free drainage through the wound for all secretions, no distension of the sinus is possible. The swelling of the mucous membrane reaches enormous proportion and may fill the entire cavity.. Granulations spring up on its surface and rapidly become large and profuse. The secretions consist of thick and viscid mucus mingled with the secretion from the granulations.

Pathology of the Healing Process.-Following operations which give adequate drainage and in the case of open fracture the healing process is slow and takes place by granulation, the discharge gradually lessening and the sinus cavity becoming more and more encroached upon by granulation tissue until complete healing is effected. Brooklyn Med. Jour.

THE

Railway Surgeon

A Nonthly Journal of Traumatic Surgery

changes occur? No, this never happens; there is no such thing as the immediate and complete union of two ends. of a divided nerve. It may take place to a very slight extent, but this is of theoretic rather than practical importance. After a nerve has been divided, if sutured within an hour, even if divided at time of operation and sutured

MONADNOCK BLOCK, CHICAGO, ILL.

According to an author in the Medical News, the surgeons on the Trans-Siberian line, "located about every twenty-five decimal leagues apart (I decimal league is equal to 64 statute miles), are generally uniformed army surgeons, who have been drafted from Russia, on increased pay, across Siberia, and mostly combine the offices of physician and surgeon. The pay is about 150 rubles (say $80) per month, and you can do more with $40 in America than the equivalent of $80 in Siberia."

In two lectures on nerve injuries* delivered at St. Bartholomew's Hospital, London, Mr. Anthony A. Bowlby pointed out that the effects of an injury to a nerve are out of all proportion to its size, and though only a very small punctured wound may have been inflicted, yet the consequence may be that the hand or a great part of it may be practically paralyzed and useless.

He asks what happens, supposing, as soon as a nerve is divided, the two ends are sutured together. Do they ever grow together immediately, so no degenerative

*London Lancet, July 19 and 26, 1902.

degeneration in the peripheral end. This may be somewhat diminished, but the changes in the muscles still take place. If the nerve has been sutured after division as carefully as possible and has healed under aseptic precautions, which returns first motion or sensation, the latter undoubtedly, it returns and may become comparatively complete months before there is the slightest evidence of the restoration of motor power. The muscles, if wasted, undoubtedly take time to be restored.

Primary suture is best carried out as soon as possible after division of a nerve. In most cases Mr. Bowlby thinks it is best in suturing a nerve to pass one suture consisting of some absorbable material right through the nerve above and below. He thinks also the best material is tendon, usually quite fine, such as a kangaroo tendon. Silk remains as a foreign body and causes the formation of fibrous tissue and consequently hardness and tenderness in the sutured nerve. A tendon suture lasts a long time, is strong, yet ultimately completely removed. many cases only one suture is needed, and produces enough coaptation. In some others one or two fine sutures may be put through the sheath, but as a rule these are not necessary. After suture the parts should be put at rest on a suitable splint, and warmth, light use of the part, massage and galvanism used, all of these latter tending to keep the tissues supplied by the nerve in a more healthy condition. The chief cause of failure of primary union is sepsis.

In

As regards secondary suture, Mr. Bowlby points out that the easiest place to find the nerve is above and below the scar, not at the scar itself. The bulb on the upper end should not be cut off, as it is tough and resistant and holds a suture exceedingly well. If there is much trouble in getting the ends together, much can be done by flexing the limb. Here again the chief cause of failure is sepsis, but another potent cause is the length of time, for there may be many changes in the motor fibers and the muscles and possibly in the spinal cord.

We must not expect too complete restoration of muscular power or sensation, especially in the nerves of the hand. The author advises that secondary suture be undertaken in every case of a punctured wound where a nerve appears to have been completely divided, or so nearly so that it is probably materially injured. Up to two years' interval between the injury and the secondary suture in a young patient we may reasonably expect a good restoration of sensation and muscular power. After four years, however, no one has recorded a case of complete restoration of motor power, though there are cases of restored sensation.

Never forget that all abscesses of the abdominal wall should be opened freely and at once. Never hesitate or delay to open and drain an abscess in the loin, due to rupture or injury to the kidney.-Fenwick.

Translations.

THE TREATMENT OF FRACTURES BY IMMEDIATE BONY SUTURE.

[Translated for The Railway Surgeon.]

At a discussion on this subject held at the recent German Surgical Congress, Völker of Heidelberg said he had used sutures of silver wire in six cases of complicated fracture of the extremities, four of the leg and two of the forearm. All were cured without complications. This intervention is absolutely benign when we have to deal with a bone located superficially, like the tibia and the bones of the forearm, but it is different with the deep bones, like the humerus and the femur, as well as cases of inter-articular fracture. As to the rapidity of consolidation, bony suture has no advantages over non-operative treatment. It even seems as if callus formation is especially slow when the bones are sutured. As regards the ultimate result, the author obtained perfect coaptation of the fragments in four cases; in the other two, owing to secondary displacement, he was obliged to apply plaster casts.

Lane of London uses bone suture, not only in complicated fractures, but also in subcutaneous fractures whenever coaptation cannot be obtained by ordinary means. He uses either silver wire or steel screws. The strictest asepsis is necessary in order to prevent these objects being expelled as foreign bodies.

König of Altona believes there is no marked correction between the ultimate formations of a fractured limb and the "restitutio ad integrum" of the bone, for we constantly see more or less vicious union with perfect recovery of function. Hence bone suture does not seem to find its principal indication in fractures of the diaphysis, but above all in epiphyseal fractures, where the shortness of one fragment deprives us of the necessary means to obtain good coaptation. In these cases he has used immediate bone suture for over a year past, which lessens the amount of callus and allows rapid resumption of movements. Under these conditions it is preferable to operate early in cases where clinical examination and radiography shows the impossibility of accurate coaptation by ordinary means. Early intervention is, in fact, easy to carry out, and notably shortens the length of the

treatment.

Trendelenburg of Leipzig insists on the utility of operation in intra-capsular fracture of the neck of the femur. He uses a screw pressed through the great trochanter and pushed on into the femoral head. He advises making a longitudinal incision in front of the trochanter in order to be sure by introducing the finger that the screw reaches well into the head.

Pfeilschneider of Berlin thinks silver wire is not strong enough, and he uses steel screws instead, but these latter are always expelled like foreign bodies.

Körte of Berlin also advises the use of bone suture whenever the usual means do not suffice. He has used it in twenty cases, especially those about the elbow.

Henle of Breslau said his experience led him to believe that suture caused very late union in diaphyseal

fractures, while it hastened it in those of the epiphyses. He thinks that, as a general rule, non-operative measures, especially permanent extension, are sufficient.

Lauenstein of Harburg has used Hansemann's method in several cases. This consists in the application of a long metal plate, uniting the two fragments, and fixed to them by many screws. He obtained good results, but the fracture must be made compound, and the foreign bodies removed afterward; besides, it sometimes leads to the formation of sequestra.

Schede of Bonn, like Trendelenburg, has tried treating intra-capsular fracture of the neck of the femur by the aid of a ferrule passing over the neck and extending on to the head, preferably of ivory. He believes this treatment can be used not only in old fractures, but in recent ones also.

Schlange of Hanover said we must not extend the indications for operative treatment of fractures too far. There are, however, some cases, notably the fracture of the tibia at the junction of the middle and lower third, where bony suture is the only sure means of coaptation.

Bier of Griefswald, like Pfeilschneider, has noticed that metal screws are generally expelled. In the rare cases in which he thinks operative treatment of fractures indicated, he uses a simple metal awl instead of a screw; this remains in the wound until consolidation occurs, and is easily extracted. He makes use largely of massage when there is but little displacement or the fracture is intra-articular.

Bardenheuer of Cologne believes that bone suture can be avoided in most cases if thorough use has been made of permanent extension. He cites, as a notable example, the fracture of the tibia alluded to by Schlange; in this variety good coaptation can be obtained by combining permanent extension, following the axis of the fractured bone with transverse tractions acting in an opposite direction, one on the upper fragment, the other on the lower. The only inconvenient feature is the necessity of rigid surveillance, and rather frequent changing of the extension, so as to adapt the force to the extent of displacement. Moreover, while he has treated a large number of fractures, he has not had recourse to operative treatment for some years, nor has he ever seen the formation of a pseudarthrosis.

Kocher of Berne thinks it necessary to distinguish between fractures of the apophyses, the epiphyses and the diaphyses. For the latter non-operative treatment often accomplishes the desired result. It is different with fractures of the apophyses, among which may be mentioned those of the olecranon, epitrochlea and patella.

In these, non-operative treatment never brings about recovery from an anatomic standpoint, and recourse must be had either to immediate bone suture, the only procedure producing true recovery, or else, from the beginning, resort to mobilization and massage. As to fractures of the epiphyses, there are some cases where all non-operative measures are impotent, and where even massage and mobilization do not guarantee perfect recovery of function. Thus in intra-articular fracture of the humeral condyle, principally in the child, as well as in some fractures of the upper end of the bone, operative treatment alone is susceptible of furnishing a satisfactory result.-(La Revue Medicale, 1902, p. 55.)

At the suggestion of the Austrian section of the Red Cross Society, a bicycle has been built, and is now on trial in the Austrian army, which can be easily and promptly transformed into an ambulance for carrying wounded persons or the victims of an accident. This bicycle can be changed into a sort of stretcher on wheels, so that a wounded person can be carried on it by one unaided, instead of requiring two bearers, like the ordinary stretcher. When there is an accident the cyclist pedals to the scene. Then begins the transformation of the cycle, which has forks so arranged that the wheels can be mounted on the same horizontal axle, instead of in the ordinary tandem position. The handles are then mounted and the canvas cover adjusted. This is thickened at one end to serve as a pillow. Finally, the legs are adjusted and the footboard that is connected with their upper extremities.

The total weight of the machine, including all its equipment, is 24 kilograms (53 pounds); it costs about 220 francs ($44). Our ambulance material is thus increased by a useful device. We have had for some time a quadricycle for the transportation of the wounded, which is operated by two riders. The speed of transportation is thus increased, but the system is faulty in requiring two cyclists, which in many cases might prove an inconvenience. The Literary Digest, abstract from "La Science Illustree."

AMBULANCE CARS IN GERMANY.

In order to insure immediate aid to persons injured in wrecks, the state railway administration of Prussia has decided to maintain ambulance cars at seventy-seven principal stations throughout the country. The cars will con

tain full hospital equipment, including operating tables,

beds and everything necessary to render first aid to the wounded. Each car will be in charge of a medical officer, and all the railway employes will be trained in the performance of first-aid duties.

None of the cars will require more than an hour and a half to reach a hospital, thus enabling quick transportation of victims who require serious attention. Within the last year there has been an unusual number of railway fatalities in Germany, due to inaccessibility of medical facilities.

FIRST-AID ON THE C. & N. W.

Train employes of the Northwestern road are to receive instruction in medicine and surgery, so that they shall be able to set a broken leg and bind up the wounds of the injured.

W. A. Gardner, general manager of the company, now has the plan under consideration, and, together with Dr. John E. Owens, chief surgeon, is arranging the details. The purpose of the project is to make every train crew on

the Northwestern system competent to give first-aid to the wounded and injured in wrecks.

It is proposed to establish a school of instruction, where train crews can be taught rudimentary surgery, become familiar with many of the remedies used for the purpose of temporary relief and learn what materials are used and how to use them. In this connection every passenger and freight train will carry a medicine chest well stocked with all the materials which the physicians and surgeons think essential for the purposes. Decision has not entirely been made as to the contents of the medicine boxes, but they will have, among other materials, a supply of splints, cotton, bandages, various lotions, salves and restoratives. The employes who will receive instruction as to the best manner of using the supplies are engineers, firemen, conductors and brakemen.

NORFOLK & WESTERN RAILWAY COMPANY.

1. RULES REGARDING THE EMPLOYMENT OF SURGEONS.

First. In all cases of injury to passengers or employes requiring surgical aid, the nearest regularly appointed surgeon of the company must be called without delay and the case put in his exclusive charge.

Second. In case of sudden emergency, where a passenger or employe has been so injured as to require immediate medical or surgical assistance, and the attendance of the company's surgeon cannot be had at once, then proper surgical aid should be procured to attend until his arrival; but there must be no delay in sending for the company's surgeon, notwithstanding the called surgeon is in attendance. In case of a serious accident, where a number of persons are injured, the company's surgeon in each direction must be called.

Third. The company's surgeon, upon being summoned, must immediately attend, and upon his arrival he shall at once take exclusive charge of the case and entirely relieve the called surgeon from further care or attendance, so far as the company is concerned.

Fourth. The company's surgeon shall, upon relieving the called surgeon, obtain from him, if possible, a statement in writing (on the company's blank, or otherwise), showing the condition of the patient at the time he was called, the result of his examination and the treatment given, and for his services and making said report the called surgeon shall be paid reasonable compensation.

Fifth. Upon the arrival of the company's surgeon and his taking charge of the patient, the called surgeon, if one has been called, shall be distinctly notified by the company's surgeon that the company will no longer be responsible for his attendance or services, and that they are no longer required, unless his assistance should be further needed by the company's surgeon.

Sixth. Except in cases of injury to passengers and employes where delay might be attended with serious results, the company will not be responsible for the employment or services of other surgeons than those herein named, and no obligation of any kind must be assumed for the company beyond the services required while awaiting the arrival of the company's regular surgeon, the fees of the called surgeon for making his written report, and his further services, if needed by the company's surgeon.

Seventh. Employes will be expected, whenever able, to visit the company's surgeon's office for treatment.

Eighth. Should the patient prefer the services of a surgeon other than the one provided by the company, it must be distinctly understood by the patient and such surgeon that the company will not be responsible for the services rendered.

Ninth. No injured person shall be quartered in a hotel, boarding or private house at the expense of the company, except upon instructions from the chief surgeon or other officer of the company.

Tenth. The company's surgeons will be furnished bandages and other ordinary appliances for dressing wounds, upon making requisition for same on the chief. surgeon. When a considerable number are injured and unusual quantities of appliances are required, authority to purchase must be obtained from the division superintendent.

II. EMPLOYES WILL OBSERVE THE FOLLOWING MEDICAL DIRECTIONS IN CASES OF ACCIDENTS.

A. In accidents to persons, the ranking employe of the road present will take command and direct proceedings for the relief of the injured.

B. When there is danger from fire, remove all persons promptly from the train, looking first to those who may be helpless from injury or jammed in the wreck.

C. Take hold of the injured gently but firmly and withcut fear. Lay the injured one down on cushions, blankets, clothing or straw, where he will have perfect ventilation and not be in a draught or strong current of air. Loosen the clothes about the neck and body to permit easy breathing, and place the injured part in the position. most comfortable to the sufferer. Do not permit strangers to approach and talk to or ask the injured one questions. Place him, if possible, in charge of one or two friends and keep him warm with proper covering.

D. As soon as practicable, summon the nearest surgeon of the company and notify the superintendent by telegraph. State the number of persons injured and the nature and extent of the injuries, as clearly as time will allow, in order that the surgeon may come with what is needed.

E. Bleeding. If the bleeding is from the limbs, keep them bent and the bleeding points elevated as much as practicable.

F. In case of broken bones, place the injured part in the most natural position, or, if this cannot be done, then in the position most comfortable to the patient. Having done this, seek to steady the limb either by splints of wood or by a pillow folded around the limb and tied in the desired position. In case of broken ribs, relief will be afforded by a wide bandage around the chest drawn as tightly as can be borne. When a broken bone is suspected do not move the limb about to find out if this is so.

G. In cases of burns or scalds, cover the part with a paste made of baking soda and water.

H. When there is much weakness from an injury, whisky may be given in small quantities, say from one to two tablespoonfuls, to be repeated at short intervals, if necessary. Large quantities must not be given, and no whisky must be given if the head is injured. In all cases.

of weakness from shock or loss of blood keep the patient

warm.

I. Cold water, ice, tea, coffee, milk or soup may be freely allowed to all injured ones who wish them.

J. In moving an injured person, place a board, door, shutter or mattress, with one end at the patient's head, and lift or slide him gently on it. If the patient can sit up, he may be carried in a chair or upon the locked hands of two persons, around whose necks he throws his arms. to steady himself.

K. When forwarding a patient who has been seen by a surgeon, obtain from the surgeon a written statement as to his opinion of the nature and extent of the injuries, and attach this statement, along with the name of the injured one (if it can be obtained), securely to his clothing.

L. When the injured person is able to be moved, take or send him to the nearest surgeon of the company in the direction in which the first train is moving. It can then be decided whether the patient will be treated there or taken to some other point.

M. When the injured person is not able to be moved, place him in charge of the station agent, section master or some official of the road, and summon the surgeon of the company most easily obtained.

N. In urgent cases, if no surgeon of the company can be promptly had, summon the nearest physician to take charge of the case until the company's surgeon arrives.

O. In a general emergency, summon the surgeons of the company in both directions and wire the superintendent if more surgeons are needed.

Life is a railway; the years are stations; death the destination; physicians the engineers.-Montreal M. Jour.

Simple contusions of the abdomen are comparatively rare, for the wall usually gives way before the blow, and so escapes much bruising; in fact, when a bad contusion of the abdominal wall is met with, the probability is that there is also injury to the abdominal contents, and this constitutes the great importance of these cases.-Cheyne and Burghard.

Excessive and even fatal hemorrhage may follow wounds of the omentum or the mesentery without any injury to the intestinal wall. The extent varies from a simple tear, which does little more than rupture one vessel, to an extensive laceration of the omentum or detachment of the mesentery, either from the spine or the bowel; in the latter case very serious secondary intestinal phenomena may result from the injury to the blood supply of the bowel.-Cheyne and Burghard.

Tillmanns says that the rare backward dislocations of the humerus are best reduced in the following manner: The arm is raised to a right angle or the horizontal, extended, rotated and then adducted, while at the same time the head is forced into the glenoid cavity by direct pressure from behind. If this is not successful, reduction is sometimes accomplished very easily by strong abduction of the arm with subsequent rotation inward, or by elevation of the arm and pressure of the head into the cavity.— Ex.