oughly as possible, but as a means of further diminishing the number of organisms introduced into the wound. Some of the hand bacteria may filter through the meshes, but the great majority are retained in the gloves. The author has investigated this question of permeability by a number of experiments. Having smeared his hands with a culture of the bacili of rabbit septicemia, he carried out a number of operations on rabbits, in one series with gloves and in another without them. The operation-a deep incision in the back along one side of the vertbral column, closed by sutures-was the same in all, and lasted exactly the same time, fifteen minutes; all the animals in both series died. An exactly similar set of operations was then performed, only the hands, after being infected, were mechanically washed for one minute, i. e., very incompletely disinfected; under these conditions the wearing of gloves made an important difference, for all the animals operated upon without gloves died, while nearly half of those in which gloves were worn recovered.

The importance of changing the gloves at intervals was shown by another series of experiments: If the gloves were used for a number (four) of operations, one after the other, they no longer protected the wound from infection; whereas, if they were changed after each operation, the number of organisms which passed the meshes became smaller and smaller. For the details of these and other experiments the reader is referred to the original paper, but the author presents a strong case for the efficacy of gloves in diminishing the risks of wound. infection so far as the hands of the operator and his assistants are concerned.

The next point investigated was the deposit of bacteria from the air of the theater upon the surface of

gloves. The author estimated the number of organisms deposited from the air of the theater by exposing large agar plates. The number varied with the disturbance of the atmosphere and with the presence and number of individuals in the theater, whether participants or spectators. While on the days between operations only three points of growth resulted after half an hour's exposure, the number rose during an operation to sixty or more. The number of points of growth was materially increased by merely walking about the theater, although clothed in an aseptic overall, or by waving a sterilized towel so as to circulate the air and its floating particles. The number was remarkably increased after the entrance of spectators into the theater. The effect of disturbing and separating dressings in which discharge had dried by evaporation was not only to disseminate organisms throughout the air of the theater, but it was found that they tend to cling in large numbers to the coat of the operator, rendering the latter a carrier of infectious material. Every one who is to enter the operating theater should put on an aseptic overall immediately before entering, and preparations for the operation should be made as far as possible in the anteroom, so as to disturb the atmosphere of the theater as little as possible. The operator and his assistants must persistently avoid any contact with septic material and must wear rubber gloves when obliged to operate or handle septic wounds or suppurating conditions, such as appendicitis. In aseptic work rubber gloves are not only a hindrance to manipu

lations but may be a source of danger, for if they are punctured or torn the accumulated perspiration and bacteria of the hand escape into the wound. Cotton gloves are worn in all aseptic procedures, especially in the handling of ligatures and sutures, and they should be changed at intervals during the course of the operation.

Surgeons who have not persistently tried operating in cotton gloves are apt to think they will interfere with their manipulations, whereas the contrary is the case; they give a better grasp of the instruments, and especially of the ligatures and sutures. Doubtless they impair the accuracy of touch, for example in exploring the abdomen with the fingers introduced through a sinall incision; but for this purpose the glove is removed, the fingers are washed in saline solution and are introduced into the belly; the necessary information having been obtained, the subsequent manipulations are performed with the gloved hands. In practice it is convenient to have several pairs of cotton gloves sterilized along with the gauze, towels and overalls in the metal drums in everyday use.-American Prac. and News.

Notices and Reviews.

"The Practical Medicine Series of Year Books," comprising ten volumes on the year's progress in medicine and surgery. Issued monthly, under the general editorial charge of Gustavus P. Herd, Professor of Laryngology and Rhinology, Chicago Post-Graduate Medical School.

"Volume IV. Gynecology," edited by E. C. Dudley, A. M., M. D., Professor of Gynecology, Northwestern University Medical School, etc., with the collaboration of William Healy, A. B., M. D. Chicago: The Year Book Publishers. 12mo. Pp., 200. Price, $1.25.

The aim of this volume is like that of the other volume

constituting this series, to present in an abstracted form the most important contributions to gynecology during the past year. The book being designed entirely for practitioners, the presentation of the practical phases of the various subjects is naturally a characteristic of the work. The contents are divided into six parts.

The first, under "General Principle," reviews the contribution to the sociologic aspects of the subject, with particular reference to occupation as related to the health of women, sterility and the treatment of insanity, and those to general diagnosis and treatment. In this section numerous descriptions of new instruments and operative procedures are presented.

Part II is devoted to infection and allied disorders, in which is presented a very satisfactory review of the pros and cons pertaining to these questions.

Parts III and IV are devoted to tumors and traumatism

respectively, while Part V comprises five chapters on uterine and other displacements, and Part VI presents the

contributions on disorders of menstruation.

It should be kept in mind that this is a year-book, a review of the most important contributions appearing during that time, and in no sense a text-book. In some instances the editor has added a few comments, which add greatly to the value, in that the reader has the benefit of his mature judgment upon the value of the contribution relative to that point. Dr. Dudley's scientific attainments. wide experience and skill as an operator well fit him not

only for the selection of what is good and wholesome for the general practitioner, but also as an authoritative critic upon the statements made.

Such a book is of inestimable value to every physician who wishes to keep posted upon the advances in this department of surgery, and while of most value to those who are not accessible to large libraries, the references being given will enable those more fortunately located in this respect to readily locate the original contribution if the abstract should not prove satisfactory, which must rarely occur. A. I. B.

Notes of Societies.

AMERICAN ACADEMY OF RAILWAY SURGEONS.

The ninth annual meeting of the American Academy of Railway Surgeons will be held at Kansas City, Mo., October 2 and 3, 1902, under the presidency of Dr. A. F. Jonas, Omaha, Neb., chief surgeon of the Union Pacific Railroad.

A symposium on "The Surgical Organization of the Railway Service" has been arranged for and subdivided as follows:

First. The advancement of the surgical service of our railway systems.

Second. Is the management of the surgical service, through a chief surgeon, an improvement over its management by an unprofessional official of the company? Third. The advantages and disadvantages of the volunteer relief system.

Fourth. The advantages and disadvantages of the hospital system.

Fifth. Suggestions for the best modern practical plan for the organization of the surgical service of our railway systems.

Also a symposium on "Fractures," divided as follows:
First. Dressings of fractures.

Second. Delayed and non-union of fractures.
Third. Compound fractures.

Fourth. Deformities, the result of fractures and how to prevent them.

In addition to the symposium a large number of papers have been promised on important, practical subjects. The preliminary program is as follows:

PRELIMINARY PROGRAM.

"A Paper on Some Persistent and Not Entirely Explained Symptoms, Following Injury." Dr. R. H. Cowan, Assistant Chief Surgeon Norfolk & Western Railroad, Radford, Va.

"The Diet in the Treatment of Surgical Cases." Dr. A. B. Brumbaugh, Surgeon Pennsylvania Railroad, Huntingdon, Pa.

The Progressive Character of Surgery, and Its Connection with Hygiene." Dr. G. P. Conn, Chief Surgeon Boston & Maine Railroad, Concord, N. H.

"What Is the Value of An Injury?" Dr. J. F. Pritchard, District Surgeon C. &. N. W. R. R., Manitowoc, Wis.

"Penetrating Gunshot Wound of the Skull-Loss of Gray Matter-Function of Speech Lost and ParalysisTrephining and Elevation of Depressed Fragment-Recovery of Speech and of Paralysis." Dr. L. Sexton, District Surgeon Illinois Central Railroad, New Orleans, La. "Primary, or First-Aid, Dressings of Fractures." Dr. W. Ruml, Surgeon C. & N. W. R. R., Cedar Rapids, Ia. "Deformities, the Result of Fractures, and How to Prevent Them." Dr. John E. Owens, Chief Surgeon C. & N. W. and Illinois Central railroads, Chicago, Ill. "Compound Fractures." Dr. A. L. Wright, District Surgeon C. & N. W. R. R., Carroll, Ia.

"Delayed and Non-Union of Bones." Dr. James H. Dunn, Surgeon Great Northern Railroad, Minneapolis, Minn.

"Is the Management of the Surgical Service Through a Chief Surgeon an Improvement Over Its Management by an Unprofessional Employe of the Company?" Dr. S. L. McCurdy, Surgeon Pennsylvania Railroad, Pittsburg, Pa.

"Responsibility of Railway Companies in Tuberculosis from Trauma." Dr. J. D. Griffith, Consulting Surgeon K. C. & F. S. & M. R. R., Kansas City, Mo.

BELGIAN SOCIETY OF SURGERY.

The annual congress usually held in Brussels in June will this year meet on the 8th, 9th and 10th of September. The deliberations this year will be devoted exclusively to the three following questions:

1. The treatment of appendicitis. Lecturers: MM. A. Broca, Paris; A. Gallet, Brussels; C. Roux, Lausanne and Sonnenburg, Berlin.

2. The treatment of fractured limbs. Lecturers: MM. Tuffier, Paris. A. Depage, Brussels; Rottschild, Frankfort, and Th.

3. Asepsis of the hands, of the operated area, of the suture and ligature material. Lecturer: M. Walravens, Brussels.

The presence at our congress of so many foreign surgeons has induced our society to lay the foundations of an International Society of Surgery, in accordance with a proposition of our president. Ch. Willems, M. D., Chairman; H. Verneuil, M. D., Honorary Secretary.

Correspondence.

Burlington, Ia., August 14, 1902.

To the Editor:-In your July issue in the report of the discussion of a paper on "Infected Fingers," read at St. Louis, I am made to say: "The treatment Dr. Fairchild has outlined is responsible to a great extent for many fingers which go to the bad," etc. This is not correct. What I said, or intended to say, was that the neglect of early operation on these infected fingers was responsible for many of them going to the bad. Dr. Fairchild's treatment, especially his advice to put such patients to bed, seems so eminently practical and correct that I do not wish to appear as criticizing the same.

Railway Miscellany.

RICHARD H. AISHTON.

Mr. Richard H. Aishton, who has just been appointed assistant general manager of the Chicago & Northwestern, is making a rapid climb up the ladder of success. He is but forty-two years of age, having been born on June 2, 1860. He received his education in the public schools at Evanston, Ill., and entered the service of the Chicago & Northwestern in 1878 as axman with an engineering corps. He remained in the engineering department until June 1, 1895, serving consecutively as rodman, levelman, assistant engineer, superintendent of bridges and buildings and division engineer. He

R. H. AISHTON.

was then for nearly two years assistant superintendent, and on April 1, 1897, was made division superintendent. From the latter position he was promoted to the general superintendency on November 1, 1899.

The report that the Pennsylvania intends to erect ex perimental plants for water purification at Fort Wayne and Altoona is pronounced by Dr. Charles B. Dudley, chemist, to be premature and not in accordance with the facts. No decision has been reached relative to such work at the places named or at any other place. The Pennsylvania, in common with other roads, has merely come to an appreciation of the necessity of improving the quality of its water supply, but the method of procedure is not yet determined upon.

The Mississippi railroad commission has declined to authorize the state attorney-general to attack the alleged merger of the Southern and the Mobile & Ohio Railroad companies. The commission declares that if the merger is contrary to the laws of Mississippi the attorney-general has the power to bring suit against the roads on his own volition. This indicates that the state authorities do not share the absurd prejudice of some of the politicians against the absorption of a poor road into a strong system, with the result of better service, more equivalent rates, the State having ample power to prevent any abuses.

RAILWAY NOTES AND NEWS.

President Hill, who always has a basis of facts for his estimates, predicts that the earnings of the Northern Securities Company for the current year will be $150,000,000. This means an increase of $36,800,000 in the earnings of the three companies, which, for less than a year have united in the great merger, their receipts for 1901 being as follows: Great Northern, $30,564,000; Northern Pacific, $32,561,000; Burlington, $50,052,000; total, $113,177,000. The grain traffic of the vast wheat country which these roads serve promises to exceed all records, while immigration and the development of trade and industries have largely increased the earnings of the nearly 20,000 miles in the new system.

Automobile accidents, due to reckless running, have become so alarmingly frequent that the new conveyance will soon have to be abated, as a public nuisance, unless speeding can be absolutely and every where prohibited. It does not matter much if now and then a hair-brained fellow, who converts a residence street into a railway, with a wild locomotive rushing over it at top speed, gets his neck broken, but the danger and damage which result to the public, to whom the highways belong and who build and maintain them, are serious matters. City and village ordinances limiting the speed of automobiles to 8 or even 12 miles an hour are contemptuously evaded by the drivers of machines that can run 40 or 60 miles an hour, and the possibility of occasional arrest, at the cost of a $5 fine, will never prevent speeding up to the limit at every opportunity. The only way to stop this dangerous sport is to stop the construction of motor carriages capable of making a speed of more than, say, 12 miles an hour. This might be done either by prohibitory enactments against the manufacturers, or by refusal of municipalities to license machines which can be made to run above the prescribed maximum. If automaniacs want to build roads to be devoted solely to their sport, with ample protection of crossings, the construction of high-speed machines for use exclusively on such courses might be permitted. But this would need to be under condition that the detection of such a "devil-wagon" upon any other road or street would mean its confiscation and, in extreme cases, the electrocution of the murderous driver.

The

There can be no hope of permanent peace between employers and employed until the wage-earners show the same scrupulous regard for their agreements which they expect of the wage-payers. The action of the car shop employes of the Union Pacific at Omaha in suddenly quitting work on Monday last, a few weeks after they had made a contract with the company for a period of 12 months is disheartening to the real friends of labor, as it seems to indicate that agreements with wage-earners, either as individuals or in an organization, are practically worthless unless supported by pecuniary guarantees-in other words, unless individuals give bonds for the faithful performance of their part of the contract, and labor organizations are incorporated and capitalized so as to be financially responsible. Union Pacific and its shopmen agreed to test the effect for a year of the piecework plan, on the basis of a wage which should not be less than the workman's time would amount to, at the regular scale, with a premium for extra work. Now, the men have broken faith without notice and without even submitting their complaints, and, it is said, are endeavoring to induce all carmen on the system to be equally unfair. In this case unionism does not appear to be responsible, at least directly, as the majority of the car shop men were not members of any union. Immediately after abandoning their work, however, the strikers proceeded to form a union, electing a full set of officers, including a treasurer, without providing any funds for the treasury, and then began to look up a national organization with which they could affiliate. As none of the railway men's unions can afford to stand for contract-breaking, it is not likely that the new society will really be welcomed by any.

VOL. IX.

SECONDARY HEMORRHAGE.*

BY A. L. WRIGHT, M. D., OF CARROL, IOWA.

Hemorrhage occurring one or more days after the completion of an operation, in sufficient quantity to precipitate the patient near the danger line, just as the surgeon begins to rest secure in the thought that his patient is safe, and that he has contributed in no small degree toward the recovery of that patient from a serious malady, or possibly have tided him over an impending pitfall, is one of the most alarming complications the surgeon can encounter and demands prompt and speedy action in order to avert a threatening fatal issue. I cannot think of a more startling summons to the surgeon than a call to a patient who has recently passed through the trying ordeal of a surgical operation with the announcement that the patient is bleeding.

Secondary hemorrhage is not very common, but occurs sufficiently often to give rise to the most serious apprehension on the part of the surgeon regarding the safety and welfare of his patient, and not infrequently brings the patient so near the "dead" line that life seems to hang by a mere thread.

It is not my intention to take up and consider hemorrhage occurring and due to the puerperal state. While no doubt we might consider this subject with profit, it more properly belongs to the province of the obstetric rather than the general surgeon. Neither is it my intention to discuss those hemorrhages due to blood changes, that altar its chemic and structural composition so as to contribute in no small degree to the hemorrhagic dyscrasia and prevent its coagulability, such as we find in hemophilia and where a patient has suffered for a long time from cholelithiasis obstructing the common duct. Surgeons are always alarmed when operating upon cases of this kind. The prolonged bile toxemia produces such chemic changes in the blood that the patient not infrequently bleeds to death from a constant and profuse oozing from the surface of the mucous membrane lining the gall bladder; packing these cases avails little or nothing; they continue to ooze till life is extinct.

I shall at this time consider such forms of secondary hemorrhage as the railroad surgeon is liable to encounter, due to the division of an artery or a vein. The vessel has been, as the surgeon supposed, carefully secured, but, owing to some inherent cause, or extrinsic influence, the occluded vessel again becomes patulous and threatens the life of the patient.

* Read before the fifteenth annual meeting I. A. R. S., St. Louis, April 30May 2, 1902.

No 4

Secondary hemorrhage during the past decade has become comparatively rare, and will seldom occur, provided the operation wound is kept aseptic. Before clean surgery was so vigorously enforced alarming hemorrhage occurSince the reintroduction of the application of the ligature ring some days after an operation was not uncommon. to a severed vessel for hemostatic purposes in amputations by Ambrose Paré in the sixteenth century, down to within the memory of many of those present, secondary hemorrhage was not infrequent, owing to the dislodgment of the occluding thrombus in the effort to pull out the ligature that had been tied and the end left hanging from an angle of the wound, serving a twofold purpose, that of primarily enabling the surgeon to withdraw it when the vessel had been sufficiently secured to warrant the removal of the same, and, secondly, a more important function, that of drainage; the latter function, however, was unintentional. I vividly remember one case that came under my care during this period. A brakeman had fallen under the wheels and sustained such crushing injuries that an amputation of the leg was necessary through the middle third. The leg did well until the time arrived. when I thought the ligatures ought to be removed.

As a matter of fact, from some unexplainable cause, there had been no infection, I had primary union throughout except along the track of my ligatures; this was unfortunate for the brakeman, as my ligatures around the vessels had become encysted and the distal end of the arteries had not necrosed as they usually did under such conditions, making the removal of the ligatures a simple matter. Very firm traction was necessary to bring away the ligature and in doing so the thrombus in the end of the vessel was loosened and soon after my departure the visa-tergo pushed it out. Very soon the dressings and bed were saturated with blood, the restlessness of the patient alarmed the attendant and I was summoned, the stump reopened and the bleeding vessel again secured.

While primary union of a wound was the exception rather than the rule in the days of "laudable" pus, it was cured and a ligature left dangling from the wound with a unfortunate for the patient when the vessel had been seinvolved the distal end of the partly strangulated vessel, view to its removal. Infection was the rule and promptly causing it to slough and making the withdrawal of the ligature an easy matter.

Senn has taught us that in order to secure the best approximation of the vessels it is only necessary that the intima be brought together and that firm traction should not be made. When the knot is firmly tied the intima and a portion of the media are ruptured, the adventitia is all

that remains and this becomes a dense tendinous cord around the constricted end. The constriction will produce strangulation of the tissues and thus subject your patient to an additional danger, besides that of secondary hemorrhage, that of opening up an avenue of infection. The vessel, if one of large caliber, should be secured with two ligatures about one inch apart and carefully tied, care being taken not to rupture any of its coats, the object is the prevention of secondary hemorrhage. Ballance and Edmunds claim that the end of the vessel, when tied in this way, does not separate at once, but remains an obliterated cord, care being taken not to constrict the tissues so as to produce pressure necrosis. Tension should be put upon the ligature sufficient to approximate the intima. only, and no more. Too firm tension on a suture or ligature no doubt favors infection, whereas, if the tissues are not strangulated their vitality is not interfered with.

The idea formerly prevailed that a severed vessel was prevented from bleeding by the thrombus that formed in its interior, and became organized. This is now generally abandoned, the clot is primarily protective. It is generally absorbed and is replaced by granulation tissue. If the wound remains aseptic and the trauma to the blood vessel is not too great, the ligature soon becomes covered with granulation tissue, the granulations insinuate themselves into the interior of the vessel and thus close the ligated end. On the other hand, if the wound becomes infected, or there has been a large amount of trauma inflicted, there is then a large amount of inflammatory material thrown out as a protecting callus to the wounded vessel. If infection follows operative intervention the thrombus that forms the temporary plug may become involved and give way, alarming hemorrhage resulting.

The source of alarming secondary hemorrhage is from an artery as a rule, although I have seen a most alarming and profuse hemorrhage come from a branch of the middle hemorrhoidal vein following the removal of some hemorrhoidal tumors. The flow of blood was quite readily controlled by pressure. A number of cases of secondary hemorrhage have been reported to me as due to the slipping of the ligature. This can occur very readily, even where the utmost care has been exercised in the tying of the ligature, if the tissues are much swollen and the precaution is not taken to squeeze out the swollen tissues with a pair of pressure forceps. Take as an illustration the swollen and engorged broad ligament as often encountered in pelvic inflammation, if the precaution is not taken to crush the tissues sufficient to force out the inflammatory exudate at the site of ligation, or by passing a needle armed with the ligature through the tissues we may not infrequently be summoned to look after a patient who is bleeding.

Eliminating infection as an etiologic factor, also the dislodgment of the occluding clot by mechanical means, before the clot has been replaced by organized tissue, I am of the opinion that secondary hemorrhage is exceedingly rare, except there is an abnormal or diseased condition of the blood vessels themselves. An endarteritis is no doubt the most frequent pathologic condition of the vessels that contributes to the cause of secondary hemorthage. An arterio-sclerosis no doubt renders the subject liable to secondary hemorrhage. The vessels are less

elastic, the several coats are more easily torn while ligating than those with normal tissues. A most alarming hemorrhage occurred in a patient upon whom I had made a Kraske operation for malignant disease of the rectum. The patient, a man sixty-five years of age, was beginning to show sclerotic changes in his blood vessels. On the fourth day after the operation, when I was beginning to feel quite secure, the man was taken with a most violent hemorrhage. It was impossible to secure the bleeding vessel with forceps or a needle armed with catgut. The operation wound was finally packed with gauze, which soon controlled the difficulty and tided us over till danger was passed.

A dangerous and alarming hemorrhage may come from a vessel that has received a lateral puncture and the opening be temporarily closed by the thrombus that forms between the coats and in the tissues surrounding the vessels, or the wound in the vessel may be closed by the instrument producing the trauma, as in the case of a brakeman who received a wound in the leg from the explosion of a torpedo that had been placed on the rail. The tin covering imbedded itself in the anterior tibial artery. The wound of entrance was very small and little was thought of it at the time. A few days later the man had a very profuse hemorrhage take place from the small wound of entrance. Enlarging the opening down to the artery revealed the true state of affairs, a small piece of the tin envelope of the torpedo had punctured the anterior tibial and remained fast, completely occluding the opening in the vessel for several days, or until nature's efforts at repair, or muscular action, loosened the occluding piece of tin and hemorrhage resulted; the artery was ligated.

Syphilis no doubt contributes its quota to the list of those who suffer from secondary hemorrhage by reason of the effect it has on the blood vessels, and possibly on the chemic composition of the blood itself, lessening its plasticity and decreasing the coagulability of the same. It is quite generally conceded that the subacute inflammatory condition of the lining of the arteries in endarteritis is of specific origin. When this pathologic condition is suspected, although unable to prove the same, the patient should be placed on a most rigid anti-syphilitic treatment in order to avoid other and more serious complications.

An operation wound should be kept in a most thoroughly aseptic condition, so as to lessen the liability to secondary hemorrhage, if for no other purpose. The most rigid rules must be enforced while dressing the same. Many a wound has been kept perfectly clean until the first dressing, but, owing to carelessness on the part of the surgeon or some of the attendants, infection has occurred and serious trouble followed.

I have dwelt at considerable length and referred to the subject of infection frequently in this paper, believing that it is responsible for a vast number of cases of secondary hemorrhage. If the operation wound is kept clean there will be comparatively few cases of this kind following operations. All wounds should be dressed carefully and the most scrupulous care exercised in cleaning the same. Drainage should be ample, so that if the wound is not entirely free from foreign matter there will be little opportunity for pus to burrow, and destroy contiguous

structures.