nerves, lessens swelling, limits the amount of exostosis and organized exudate, and therefore avoids the risk of the callus, involving the nerve trunks or interfering with muscle action.

7. We have about concluded that the term "ununited fractures" is a myth, and will gradually fade away before the increasing knowledge of this condition.

8. Non-union is almost invariably due to the interposition of the soft tissues or imperfect apposition of the fragments.

9. The results obtained by the operative treatment of fractures will do much to relegate Buck's extension, and similar forms of treatment of fractures to the realms of past, unsurgical, methods of dealing with this form of

emergency surgery.

10. Sprains are often associated with fracture or a dislocation of the bone and cartilage

and therefore should also be examined with the x-ray.

II. The early operative treatment of bad sprains lessens the accumulation of fluid in or about the joint by establishing drainage.

12. Drainage lessens pain and prevents the organization of the exudate and therefore avoids the interference with muscle and nerve action.

13. The removal of the exudate allows of a greater degree of immobilization by a cast or splint, and makes a normal relationship of joint ligaments more possible.

14. During the operation, ligaments and other torn tissue can be sutured to their normal points of anchorage.

15. Statistics prove that the removal of the exudate from injured joints, shortens the convalescent period, produces a firmer joint, and results in a greater proportion of cures.

ST. BARNABAS HOSPITAL

MINNEAPOLIS

A GUMMA IN THE ABDOMINAL WALL

IN THE SERVICE OF DR. C. H. HUNTER Mr. S, aged 23, single; occupation, pressfeeder.

Six weeks before admittance to the hospital the patient noticed a swelling in the lower left quadrant of the abdomen. With this mass there was no general disturbance and but little pain or tenderness. His general health was fair. The swelling gradually increased in size, until upon admittance to the hospital a hard, firm mass, irregularly rounded and about four inches in diameter, was found. It involved the abdominal wall midway between the umbilicus and the left iliac spine. The borders of the tumor or swelling were not clearly defined, but extended out gradually into the tissues of the abdominal wall. Only slight tenderness was felt on pressure. The temperature at this time varied from normal to 99.6°. No history of syphilis could be obtained, and no indication of specific disease was disclosed upon examination.

FIRST OPERATION.-Jan. 27, 1905. An incision slightly internal to a point midway between the umbilicus and the left iliac spine was made through the skin and muscle to the subperitoneal tissue. The cut tissues were hard and infiltrated,

and from the bottom of the wound a very small quantity of pus exuded. The cavity was packed with iodoform gauze.

Following the operation there was but a slight discharge. The indurated area failed to soften. and increased in size, extending down towards Poupart's ligament.

February 6th. The leucocyte count was 14,300. Massage and hot flaxseed poultice were tried, but with no improvement.

February 17th. Examination of pus from the wound proved it to be sterile.

February 19th. Leucocyte count was 18,000. Patient's temperature at this time varied between normal and 101°, but with no definite septic cause. Owing to the increase in induration and in the leucocyte count it was thought that the drainage was insufficient, and a second operation was decided upon.

SECOND OPERATION.-The second operation was performed February 22d. An incision parallel to the first, and about two inches external to it, was made. Beneath the skin and involving the fascia a typical gumma was found. It. was surrounded by dense infiltration with a degenerative center slightly yellowish in color and of a custard consistency. The muscles and subperitoneal tissue were also infiltrated with dense connective tissue with areas of degeneration. All loose softened tissue was curetted out, iodoform sprinkled in, and the cavity was then packed with iodoform gauze.

As soon as the patient recovered from the immediate effects of the operation he was placed on specific treatment; at first mercury and potassium iodid internally, followed by inunctions. Rapid improvement followed; the swelling and hardness softened and disappeared. Now, at the end of four weeks, the tissues of the left abdominal wall are as soft and flaccid as those of the right.

CITY HOSPITAL

MINNEAPOLIS

A SUCCESSFUL CASE OF HIP-JOINT AMPUTATION FOR SARCOMA OF THE FEMUR

IN THE SERVICE OF DR. J. CLARK STEWART

Katie B, aged 14, came into my service at the City Hospital with an immense sarcoma of the left femur, as shown in the illustration. She has had this tumor for at least eighteen months, and it has grown quite rapidly during this time, until at present she is unable to walk or even turn herself in bed, and has suffered a great deal of pain in the leg.

Examination shows an under-sized and poorly

nourished child with an immense tumor of the left thigh, which apparently does not encroach upon the pelvis, there being a couple of inches of free space at the upper end of the thigh. Careful examination shows no other growths in any part of the body, and no intrapelvic growth. Her red-blood count is about three and a half million, and hemoglobin 45%; urine, normal; pulse, about 110, and of poor quality.

On November 11th I did a Wyeth's amputation at the hip-joint, and was disappointed to find that there was sarcomatous infiltration of the muscles above the line of section, even involving the short muscles of the hip. The flaps had to be peeled off the tumor, and the femoral artery had to be dissected free from a tumor mass before ligation. The amputation was completed, however, without much loss of blood, and the bulk of the sarcomatous tissue was cut away, and the flaps were suiured together, being ample to

cover.

The child stood the operation well, though at one time her pulse failed, and she was given a hypodermoclysis while upon the table. She reacted well after the operation, had no per tible shock, and the next morning showed a temperature of 99°, and pulse 104,-better than before operation. She made a rapid recovery with complete healing of the stump, but soon after this secondary tumor appeared at the angle of the lower jaw, which seemed undoubtedly to be sarcomatous. In view of this, and the great uncertainty of recurrence locally, she was given injections of the mixed toxins of erysipelas and prodigiosus, from which she obtained very marked reactions, it being noted that when the toxins were injected into the tumor, reactions were very much more marked than when injected into an indifferent point. Under this treatment the stump opened up, and there was a profuse discharge of broken-down sarcoma; the tumor on the jaw became smaller, and her general health improved. Injections were given twice weekly and the dose was increased up to 13 minims, after which she obtained so severe a reaction that its further use was deemed immediately dangerous. For this reason and because the microscope showed that the original tumor was a small, round-celled sarcoma, a form eminently malignant and one not giving good results from the Coley treatment, the injections were discontinued. Since that time the tumor on the jaw has grown rapidly, and there is evidence of retroperitoneal tumor in the left groin.

The child probably has very few months to live, but her condition has been immensely improved, and she has been relieved of very great suffering by the amputation, which is therefore justified as a palliative means of treatment in this case.

CASTS IN URINE

In an article upon the clinical significance of tube casts in urine, Thomas C. Craig (Brooklyn Medical Journal, January, 1905) thus gives his opinion concerning the significance of casts: "One is often asked the question, Are tube. casts always indicative of kidney disease? I can only give you my own individual opinion on this point by saying that it depends on the character of the cast found, and its permanency in the urine.

"Formerly we were taught that the simple finding of an innocent looking hyaline cast was an infallible sign of Bright's disease; but we know at present that this is not so, unless accompanied by other confirmatory symptoms. Hyaline casts are frequently found in the urine of healthy persons, but their presence can generally be explained by error in diet, drink, or exercise. Under these conditions they soon disappear. Then, again, we know that hyaline casts are found in the majority of cases of persons over fifty years of age who lead a strenuous life; and quite frequently in the urine of persons much younger who pursue an occupation demanding extreme muscular and mental fatigue. Then, again, we must not forget that hyaline casts are extremely common in senile degenerations, of the kidneys in persons over sixty years of age. Yet in many of the abovementioned cases there is no trace of albumin present, and no sign of disease evident, and the person lives on to advanced age."

FLICKER'S MODIFICATION OF WIDAL REACTION

One of the chief objections which has been raised to the Widal reaction as a practical help in diagnostic medicine, is the necessity of growing from day to day a living culture of the typhoid bacillus. This requires a bacteriological laboratory and considerable bacteriological knowledge. A modification of the living culture method has been devised by Ficker, which, if reliable, promises to make the test more available for clinical work.

Ficker's preparation is practically a suspension of the dead typhoid bacilli. It is a slightly cloudy fluid, which will keep for a long time if placed in a dark, cool place. The procedure for making the test is as follows:

Blood serum is obtained from the patient, and diluted ten times with sterile saline solution. Ficker collects the blood in a special test-tube by incision and cupping. By means of graduated pipettes .2 and .I ccm. of the blood serum dilution is placed in the two glasses No. 1 and No. 2, the former containing .8 and the latter .9 ccm. of the dead culture mixture. A third glass tube contains the so-called "diagnosticum" without the blood serum. The contents of the tubes are then thoroughly mixed, and the tubes. are set aside for from 10 to 14 hours, but not longer than 24 hours. If the reaction is positive the fluid in glasses 1 and 2 becomes clear, and the dead typhoid bacilli are agglutinated in the center and bottom of the glass. Ficker's method has been tested by the work of Gramann Meyer, Radzikowski, Ehrson, Blum, and others. report the test as satisfactory, and advise its use by clinicians for practical reasons.

MALARIA AND INFECTIVE ENDOCARDITIS

All

Infective endocarditis occasionally presents some one of the clinical types of malarial fever. Coleman (Am. J. Med. Sci., March, 1905), in discussing the diagnosis of infective endocarditis simulating malarial fever thus sums up the evidence which a blood examination will furnish:

"In infective endocarditis there is generally, though not always, leucocytosis; in malaria leukopenia is the rule except during the paroxysms. In infective endocarditis the polynuclear leucocytes are increased; in malaria there is relative

lymphocytosis. Pigmented leucocytes are found in nearly all severe and protracted or fatal cases of malaria. The red cells and hemoglobin show much the same changes in both conditions, namely, rapid marked oligocythemia, hemoglobin reduction, and degenerative changes in the cells. The recovery of the infective agent from the blood is often possible, and always conclusive, provided no other nidus than the heart valves can be found."

DEATH OF DR. W. P. SPRING

Dr. W. P. Spring, an old friend and contributor to THE LANCET, died at St. Barnabas Hospital Wednesday, March 22, 1905.

Dr. Spring graduated from Harvard Medical College in 1879, and began practice in Minneapolis soon afterward. For many years his office and residence were on the East Side, where he had a good business.

Dr. Spring had many friends all over the city. His gentle manner and the inspiration and confidence he brought to the bedside were his characteristics. He was a man of good judgment and a safe adviser.

During the past few years his work has been limited to x-ray work and electrotherapeutics. He made a careful study of his subject, and was enthusiastic, but not overzealous. His integrity would not permit him to make promises to his patients that he could not fulfill. His attitude toward the results of the x-ray treatment was in line with the best and conservative

men.

He was at one time prominent in county politics, and occupied the offices of county physician and coroner of Hennepin County. He was the examining physician for the Soo line for several years.

He was a member of the American Electrotherapeutic and X-ray societies, and a member of the Minnesota State Medical Association and the Hennepin County Medical Society.

Dr. Spring was one of the quiet, gentlemanly practitioners of medicine, a man to be remembered, and one that will be missed in Minneapolis.

LEGISLATIVE CURIOSITIES.

The meeting of a legislature is like the deliberation of a jury-no one knows what the ultimate cutcome of either will be.

The state legislature of Nebraska in order to make a record for economy has cut off all appropriations for the State Board of Charities and the prison visitors. The state will be unable to do any charity work for the next two years. Evidently the sick, poor, and imprisoned had no. lobbyist to look after their interests. No one with a "pull" took any interest in the unfortu

nates.

A heroic band of legislators can easily screw up their courage to lop off appropriations for necessities when no advocate is at hand to remind the lawmakers of the needs of the dependents. To redeem themselves in some one's eyes this same legislative body passed a bill, which only lacks the Governor's signature to make it a law, requiring all Christian Science healers who heal for pay to take a four years' course in medicine, and pass the examination required of regular physicians. The Governor may not sign the bill, and if he does, the healers will get remuneration for their work in some way. If this bill is the outcome of a controversy between the medical profession and the representatives, the former are to be congratulated. Minnesota physicians long ago gave up trying to urge legislation of this kind, for each attempt was a fail

Our legislators are made out of different material; they believe in letting in any sort of healing device. Two years ago the osteopaths were legally recognized, and this year the latest defective medical freak, the chiropractics, were received with open arms. No opposition was encountered from the physicians. The larger the number of fads the better the prospects for an early death.

The medical profession suffer no loss from these new methods of treatment; the effect is upon the people. When some one has had enough he will rise and smite the offender through the courts of law. In time the people

will become educated to the fact that the physicians who practice medicine are friends, and not. commercialists, and when one of the faddists commits a blunder that costs a life or two it is possible that the public will appreciate the source and cause of the error. On the other hand, noimmediate results need be expected, as it takes years to convince some people that the faddist is only a fad, and that certain forms of insects live only a brief period, and then disappear from view.

Legislators are bound to protect the public, but it seems rather strange that the voice of advice from the medical man is always listened to with suspicion, while the baby appeal of the last new cure-all is received in innocent and all-abiding confidence. Such is the faith in all forms of quackery and patent medicines.

The legislature has decided to kill the pure food bill. The members evidently prefer to tempt their tissues with all kinds of preservatives and adulterants, presumably to study the effects of both a sufficient time before providing good foods for the rest of the state, which is a further evidence of blind faith, corporation influence, and poor judgment.

HOSPITAL LEAGUE

A "League of Mercy" organized in London a few years ago for the benefit of the sick poor and the hospitals has proven so successful that a work on similar lines has been organized in New York. For a few months past the same plan has been carefully considered in Minneapolis, and was to have been brought before the Hennepin County Medical Society at its March meeting, but the illness of the promoter prevented it.

Each hospital in the city, public or private, is to have a representative on a board to comprise a committee to raise an endowment fund to be distributed among the hospitals. The principal object is to create a system to stimulate and educate the public to give annually a sum of money for the benefit of the hospitals and the care of the needy. Under the present state of affairs the hospitals usually face a deficit at the end of the year, and thus make, it difficult for any hospital to do the charity work that is necessary for the good of the sick poor.

A central committee with a paid business manager to inaugurate a system and make it broad and far-reaching is the second aim of the organization. A committee of this kind would be able to study the hospital problem and persistently educate the public in right giving. Such an organization would do away with the haphazard methods usually employed. It would also take the place of large social functions ostensibly given to raise money for a single institution. It would also give an opportunity to those who are able to give but little money to help by suggesting means to others or permitting the man of moderate means to raise a certain sum from his fellows. Doubtless various methods will suggest themselves. Much can be done through the churches and organizations of all kinds all over the city. A certain sum can be set aside for the hospital fund, and, together with that raised from private sources, the amount should be large. A distribution among the hospitals would remove the deficits, relieve embarrassing situations, and provide for the care of a large number of deserving cases. The New York plan will be watched with interest, and if an interest can be aroused among the well-known generously inclined Minneapolitans the organization can be easily promoted.

The work of the chairman of such a committee will be engrossing until the organization is perfected. After the plan is explained and the people educated to giving, the system would run smoothly with a constant influx of money.

MISSOURI DECISION AGAINST OSTEO

PATHS

The Journal of the A. M. A. for March 18th publishes the full text of the supreme court ruling in a suit for damages for treating hip disease as partial dislocation. The suit was the outcome of a case that was treated at Kirksville by the president of the A. T. Still Infirmary, the home of osteopathy.

The patient, a child of seven, was afflicted with a slight stiffness of the right hip, but it was not sufficient to make her lame or to cause her pain or to materially interfere with locomotion. She received preparatory treatment to relax the muscles and tendons, then the "partial dislocation" was forcibly reduced, and became