stairs and to attend to household duties with no discharge from any source and no pain nor discomfort of any kind.

Two other laparotomies which I did shortly after this, one for ovarian cyst and the other for ovarian abscess, were in the same ward at the same time, and both made quick and uneventful recoveries, with no erysipelas developing.

The case is interesting to me for several reasons: First, the large size of the tumor. Of course, there have been larger ones. I remember seeing my old professor, Dr. Goodell, of Philadelphia, remove a cyst weighing 120 pounds from a woman who weighed but eighty pounds. She died, however. Then, in scooping out the cyst contents they escaped freely into the abdominal cavity, and in doing the toilet of the abdomen, in our enforced haste, I knew that we did

not remove all the jelly from the coils of intestine, yet no bad results came from its retention.

A cystic appendix made an unusual complication. Then when a septic diarrhoea, general sepsis, periuterine abscess and erysipelas all followed in rapid succession, and were all present at once to depress and exhaust the patient, and when, in spite of them all, she stubbornly refused to die, insisted upon being bright and cheerful and feeling well, and with the aid of supporting treatment and generous hypodermics of strychnia, finally made a triumphant recovery, this should teach us never to despair of a laparotomy case while pluck and breath remain in the body.

In respect of the choice of operation, there are three main conditions for which these operations are required, namely, artificial anus from any cause, gangrenous hernia, and malignant disease of intestine.

The enterotome appears to have fallen into disuse in the treatment of artificial anus, and the extra-peritoneal operation is only applicable to certain cases; the intra-peritoneal operation must, therefore, be used for the majority. This can be performed either by an end-to-end junction or by implantation, or by lateral openings after inverting and closing the open ends. The last we consider to be the easiest and safest proceeding, especially if the surgeon has not much experience in intestinal surgery, and of the methods. of effecting it, Halsted's operation is preferable to Senn's. For end-to-end anastomosis (which is the ideal operation) Maunsell's operation is preferable to all those in which recourse is had to mechanical aids, whether of decalcified bone or of metal.

Department of Railway Surgery.

GEO. CHAFFEE, M.D., Editor.

226 47TH ST., BROOKLYN, N. Y.

OFFICIAL ORGAN

N. Y. STATE ASSOCIATION OF RAILWAY SURGEONS. ERIE RAILWAY SURGEONS' ASSOCIATION. FLORIDA STATE ASSOCIATION RAILWAY SURGEONS. PLANT SYSTEM RAILWAY SURGICAL ASSOC'N. THE ASSOC'N OF SURGEONS OF THE SOUTHERN RAILWAY CO.

EDITORIAL.

RAILWAY HOSPITALS.

The readers of the INTERNATIONAL JOURNAL OF SURGERY are familiar with this subject. It has been written up by a number of writers holding responsible positions; but in our opinion there has never been anything written which has carried more weight in favor of the railway hospital, than a voluntary contribution on this topic in The Railroad Trainmen's Journal for October, by Mr. J. H. Reno, an employee of the M. K. & T. R. R. Following Mr. Reno's contribution we give an extract, on the same subject, from an address by Mr. M. E. Ingalls, President of the Big Four and C. & O., delivered before the railroad branch of the Y. M. C. A., at Clifton Forge, Va. Coming from so high an authority as President Ingalls, his words are also worthy of the highest consideration.

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MR. RENO'S CONTRIBUTION:

Nearly three months ago I was taken down with typhoid fever-that awful disease; but I am now able to get around. I have been in the hospital all the time, except ten or twelve days, but I feel thankvery ful toward Drs. Yancey, McNeil and Dunlop for their kind treatment, and also to the sisters, who have been faithful as nurses and carefully watched over us dur

ing our sickness. I am a believer in the hospital system for a good many reasons. The employees of the M. K. & T. R. R. keep up the hospital by paying the small sum of fifty cents per month. There are, of course, some times where one is just as well off at home; but this only applies to men who have families, and only to them. But as to the man who is not married, the hospital is, undoubtedly, the place for him. I can, practically, say this to be so, for I have had the trial and find, in my case, that the expense has been nothing. We.have experienced doctors and nurses at a moment's notice. If anything comes up that they are wanted, they are very quickly notified. Patients are not allowed to eat anything that will not agree with the kind of medicine they are taking, and that one particular thing the doctors watch closely. Since I have been here, and as long as I had fever, two eggs, soft-boiled, a cup of milk and a cup of beef

tea, was my diet for a long time, and so it is with every one. We used to get so hungry that we would beg for something to eat, but we were refused, and I am very thankful for being refused, as my judgment was not as good as the doctor's. The hospital system is one of the best things that can be established on a system of railroads, and I would like to see more hospitals established throughout the country; even if it does not do some individual good, some one else will be benefitted thereby, and fifty cents a month is not very much. The hospital department was established on the M. K. & T. system several years ago, and the Western country is now pretty well supplied. This system (or rather this hospital) treated in the year of 1893, 850 patients; 1894, 705 patients; 1895, 1,525 patients, and up to September 1, 1896, 1,250 have been treated. At this rate of increase over 1895 about 1,800 patients will be treated in the hospital at Sedalia. It might be a pertinent inquiry to make at this juncture regarding the future growth of the hospitals upon the railways of the United States. The past history of these institutions plainly shows the manifold benefits to the employer and employees. There has been a continuous growth in the number of hospitals upon the railways, and those established are flourishing and well patronized. We can, therefore, predict that the future will see a marked increase in the growth of these departments, for the reason that they are in more perfect unison with the spirit of independence of the country than any other form of relief yet devised. They do not interfere with the liberty of the employee or labor organizations, but enable the employee to exercise his ability and capacity to protect himself in ways which are most agreeable and beneficial, and to exercise his own will in the formulation of his protective plans of insurance. Investigation shows that the Order of Railway Conductors, Brotherhood of Railroad Trainmen, Brotherhood of Locomotive Engineers, Brotherhood of Locomotive Firemen, have insurance at a cheaper rate per thousand dollars, than commercial insurance companies or relief associations. Thus, as an illustration: the Order of Railway Conductors' insurance feature only costs $14 per $1,000. This includes death and permanent disability. The Brotherhood of Locomotive Engineers charges about $16.05 per $1,000, and so with the Firemen and Trainmen. Under the hospital department arrangements, the employee has the right of litigation. In addition thereto his own protective plans of insurance. Hence, with the favorable condition thus evolved, and from frequent conversations with employees, we are convinced that the hospital department is the favorite plan amongst them. This being the case, we are honestly convinced that time will plainly show that the hospital plan will be the one which, by its merit and

PRESIDENT INGALLS SAYS:

"The Management of this company are not willing to stop and rest with what they have done, They expect to go forward and establish hospitals along the line, with a large central building here for that purpose, and we hope that the same organization will assist in its development. We hope to see yet upon the road a system of pensions and annuities; and above all, we would like to see a savings bank feature established, so that every employee, each month, could deposit some portion of his earnings, however small, in a safe and convenient bank. There is nothing that makes men so rich and so careful as daily, weekly and monthly savings."

In 1879 he was appointed Inspector of the National Board of Health, and served for four summers in that capacity.

In 1880, he established the National Quarantine Station at Saprelo, Ga., and had charge of the same until the close of the season of '82. In 1889 he was appointed Chief Surgeon of the Central Railway of Georgia, which position he still holds.

He has devoted himself to making the organization of the surgical staff as complete as possible, and maintains the surgical department at a high standard.

Besides being a member of local and State societies, Dr. Elliott is a member of the National Association of Railway Surgeons, of the American Academy of Railway Surgeons, and an honorary member of the New York State Association of Railway Surgeons.

Dr. Elliott is a typical Southern gentleman, with a personality both pleasing and interesting.

Dr. R. Harvey Reed, of Columbus, was born in the proverbial "log cabin," near the village of Dalton, Wayne County, Ohio, in 1851. His primary education was obtained in an old-fashioned country school house. He next attended the high school at Dalton, and subsequently Mt. Union College, at Alliance.

Owing to his limited means, the doctor was obliged to earn the money necessary to obtain his education. Dr. Reed began the study of medicine at Alliance, attended the medical department of the University of

Pennsylvania, and graduated in the Centennial class of the university with honors.

He entered private practice at West Salem, where he remained until 1880. In that year he moved to Mansfield where he was appointed surgeon of the Baltimore & Ohio Railroad; first in the capacity of local surgeon, and in 1884 consulting surgeon, which position he still retains. He was also appointed surgeon of the Pennsylvania railroad, physician to the Childrens' Home, and health officer during his residence in Mansfield. He is at present Chief Surgeon of the Columbus, Sandusky and Hocking Railroad, and surgeon of the Toledo and Ohio Central Railroad.

He was a charter member in the organization of the Ohio Medical University at Columbus, and was elected to the chair of Principles and Practice of Surgery and Clinical Surgery in the same, in 1891. He is surgeon of the Protestant and University Hospitals and editor of the Columbus Medical Journal. He was one of the organizers of the National Association of Railway Surgeons, which he served in the capacity of treasurer for seven years, and is now editor of the American Academy of Railway Surgeons. He is a member of the American Medical Association, the Ohio State Medical Society, the Columbus Academy of Medicine, and numerous other scientific bodies.

WHAT IS SHOOK AND HOW SHALL WE TREAT IT?*

BY R. H. COWAN, M. D.,

Surgeon N. & W. R.R., Radford, Va.

Such widely divergent views are held by different surgeons as to the nature of that condition known as shock-the mode of its production and the deviation from the normal standard of health-that I feel no hesitancy in asking the question: "What is shock ?" And while I do not presume to solve the problem, which far abler men have, it seems to me, signally failed to elucidate, I would like, in a brief review of certain theories, to make some suggestions as to the etiology and pathology of shock, based on its symptoms and the action of those remedial measures which have seemed to prove most efficient.

In attempting to review what has been written on the subject, one can but think that shock is either produced in widely variant ways from as widely different causes, or else that very different conditions are regarded by surgeons as shock.

Paralysis and irritation of vaso-motor nerves have both been adduced as prime factors in its production. Dr. Estes holds acute anæmia the cardinal feature

*Read before the Fifth Annual Meeting of the New York State Association of Railway Surgeons, held at Academy of Medicine, New York City, Nov. 12, 1895.

in shock, the condition being due to psychic impression. Another surgeon finds an analogy between the phenomena observed here and in inflammation, viz.: contraction of capillaries and arterioles, followed by dilatation, stagnation of currents, etc. As regards the condition of the heart, one writer maintains it is in a state of almost tetanic rigidity, and consequently capable of very imperfect contraction, which explains the rapid pulse and lowered blood pressure. Another holds the organ, itself anæmic, in its endeavor to maintain the circulation is excited to undue effort; the reduction, in bulk, of the blood supply, explaining also the lowered pressure.

After all, these explanations are, perhaps, not so irreconcilable. For instance, the resemblance between this condition and that of inflammation (or rather the earlier stages of the latter) is, indeed, striking; and might even be traced further. The reaction which follows shock and which may proceed to surgical fever, seems to occupy a relation to it very much like that of active inflammation to congestion.

Dr. Geiger, of St. Joseph, Mo., says: "If we find, so far as I am able to discern, the same condition in a localized area, we describe it as inflammation. Why may there not, then, be a first stage of vaso-motor irritation, followed, as in inflammation, by vascular dilatation ?"

In shock, a systemic disturbance characterized by general vascular relaxation in its second and third stages, stagnation is naturally marked in the abdominal circulation. The feebly supported vessels, readily yielding, become the receptacles for the bulk of the circulating fluid; in consequence of which we have a condition of anæmia from hemorrhage into the veins as decided as though the blood were withdrawn from the body. Should the injury be complicated by external bleeding, this condition is simply aggravated.

Shock is nowhere, perhaps, more common than in those severe, crushing injuries received under the wheels on our railways. In abdominal surgery, it is often responsible for an untoward result. Dr. Manley mentions the intolerance of the anterior and lateral walls of the thorax to incised or punctured wounds: "Locality and extent of injury, as well as the nature of the destructive agent, probably bear a definite relation to shock. On the other hand, a trivial wound or minor operation, as the opening of a small abscess, or scarification for vaccination, may cause profound shock. Introduction of the urethral sound has been followed by collapse, or even death. Two recent cases in my own practice may be mentioned. The first, a young man of fine physique, in whom decided shock followed the (painless) introduction of the urethral sound. The second, a woman of delicate constitution, from whom I removed a large ovarian cyst.

In this case, owing to the adhesions and short pedicle, I made an unusually long incision. There was absolutely no shock, and recovery was rapid and uneventful."

So, then, we find severe shock may result from injuries in various locations: From wounds involving slight structural lesions, and from those causing complete and extensive tissue destruction; from those attended with excessive hemorrhage, and from those where blood loss is, practically, nil; from painful and comparatively, painless injuries; from operations done under anesthesia, and from wounds received while the recipient of injury was in full possession of his faculties, and clearly realized what was about to happen.

The above facts seem to me important in enabling us to get at the etiology of shock. If we are to ascribe its causation either to irritation or to paralysis of nerves as a direct result of injury to the structures, should it not naturally follow that the severity of the shock would be in direct proportion to the area of injury, or to its location? I am by no means sure, however, the facts would bear us out in this theory. Again, if we accept a psychical causation for shock, why should it be so frequent in operations done under anesthesia? These questions, it is true, are easily asked. The answer is more difficult but none the less important. I remember reading sometime since, an article in which the writer claimed that shock, due to railway injury, was invariably more severe in those cases in which the injured person was fully cognizant of the approaching danger, as in the case of a switchman, whose foot, inextricably caught in the face of an approaching train, must fully realize his terrible situation some seconds before the receipt of injury. I regret that I have failed to note such cases. If the statement be borne out by statistics, it would go far to establish the psychic theory.

Before we can decide the exact modus operandi of the production of shock, it seems to me we must decide exactly in what way fright affects the heart and circulation. Doubtless by an impression received by the brain, and transmitted by the nerves. But is the immediate effect on the heart tonic or paralyzing? Are the peripheral vessels differently affected from the more deeply-seated circulation? We must also inquire how injuries affect the circulation. Again, through the nervous system. But how? That a psychic and a physical element may, singly or conjointly, be factors in the production of shock, I think true; that loss of blood from ruptured vessels may be a potent factor, I think equally certain. With regard to what I suppose is properly the pathology of this condition, Dr. Estes' assertion seems indisputable; viz.: that "shock is a condition of anæmia." I

have long thought this, and have been governed in my treatment accordingly. The anæmia, of course, not being necessarily due to extra vascular outpouring, but from slowness of the venous return and consequent insufficient supply to the heart, that organ, both from impairment of its muscular tone and deficiency of blood, is unable to supply the arteries, and we have acute anæmia. That a patient under shock is in an anæmic condition, is evident. The blanched and chilled condition of the surface, the weak, rapid, almost imperceptible pulse, the dulled mental faculties, all point to interference with circulation, to anæmia-the anæmia being rather an effect than an etiological factor in the production of shock. Is not that condition of great physical depression which is almost or quite concomitant with injury the first indication of shock? Indeed, during this stage blood loss is not usually marked; there is stagnation of the current and, usually, only venous leaking. In some cases the impression made on the nerve-centres may be overwhelming, death quickly ensuing. In others, the first impression may not be so great, but the heart, from impairment of the ganglia governing its action, is not equal to the performance of its function as a force pump; there is stagnation, insufficient blood supply to stimulate the already weakened nerve centres, the one condition acting and reacting on the other until there is an entire suspension of function and death. If the vessels be emptied as from a wound of the femoral artery, fatal syncope will occur; the blood is, we know, an essential stimulus to the centres presiding over respiration as well as cardiac action, and it matters not whether the blood be poured out from a large vessel, or stagnation occurs from insufficient heart action, the result is the same. Naturally, if with shock there be considerable extraneous hemorrhage, the condition is aggravated.

Savory describes shock as a "temporary exhaustion of nerve force-the result of the violent, sudden and excessive expenditure of it."

Dr. Estes calls attention to the anæmia as the important feature of shock.

If these statements are intended as definitions of what may, I suppose, be called the pathological condition, both are, I think, correct, the exhaustion of nerve force and the hemorrhage standing in the relation of cause and effect, and the latter still further reacting on the former; but before either, I believe there is a period, almost instantaneous, perhaps, of over tension or over-stimulation of nerves. How else can we explain rupture of the heart, except by a sudden and powerful over-stimulation and consequent contraction of its involuntary muscle fibres?

"The grief that does not speak, whispers the overwrought heart and bids it break."

How is this whisper borne to the heart by the nerves?

Rupture of the heart is of comparatively rare occurrence, but is it not simply the result of overwhelming shock? However, if it be claimed that shock is of nervous origin, it may be asked: "Will not blood loss, pure and simple, produce the same or a very similar condition?" In answer, I would suggest that an injury sufficient to produce excessive hemorrhage, even though the wound be limited to so small an area as simply to sever a large artery, might seriously affect the ganglionic centers, and that, furthermore, the lack of stimulus to the brain and nerve centers, occasioned by the hemorrhage, would produce that very paralytic condition of heart and vessels which occurs in shock; and as a matter of fact, this seems to be exactly what occurs in cases of hemorrhage where the heart's action becomes so enfeebled that blood loss is almost arrested simply from inactivity of the force pump.

That shock is of nervous origin, whether due to direct injury to peripheral nerves, deep-seated ganglia, brain, or spinal cord, or to psychic impression (I believe it may be received through any or all of these media), would seem to me apparent, not only from its effect on the circulation, but from the fact that the function of every organ seems more or less impaired. This is notably true of the stomach, eyes, voluntary and involuntary muscles. The effect on the circulation is, however, most serious. When the life current stagnates, oxygenation is imperfect and the body loses its natural warmth; carbon dioxide is retained and acts as a further depressant. There is, probably, a fall in the amount of hemoglobin, though this is denied by some in shock, though admitted in hemorrhage.

The treatment of shock, adjusted to what I believe a proper interpretation of its symptoms, should consist in an effort to stimulate and tone up the depressed nervous centers, and restore the circulation and thereby relieve the anæmia of heart and brain; and in my own experience nothing has proved as efficacious as the application of heat, and far better than hot bottles to the extremities, is, I think, a hot water bag laid over the heart; and better than either, the hot operating table described by Dr. W. O. Perkins in the September number of the INTERNATIONAL Journal OF SURGERY.

Theoretically, the intra-venous injection of a large quantity of hot, salt water would seem an ideal treatment, not only as furnishing a circulating medium, but the heat acting in the most direct manner as a stimulant to the cardiac and vascular muscles. I say theoretically, this method recommends itself; its practical worth having now been demonstrated by Dawbarn and Wyeth, I see no reason why, hence forward,