3. Almost all neurological diseases lead to deformities and these should be guarded against. The orthopedic treatments will not only save many disabilities, primary or secondary, but also hasten a cure, if such is possible, and check the disease.

4. The principles of braces or plaster employed in anterior poliomyelitis can in general be used in hemiplegia, polyneuritis, peripheral nerve injuries, Erb's palsy and the myopathies.

5. Braces, massage and exercises should be used where there is even only a slight hope of improvement, as those cases are very rare in neurology when these methods are harmful. These, however, must be used intelligently. They should be used very cautiously in hysterical and functional cases. 6. Birth palsies, peripheral nerve injuries and hemiplegia should receive early orthopedic treatments and the bad deformities will not occur.

7. In the myopathies, the application of braces will prevent the occurrence of these distressing deformities and prevent the stretching of some muscles, which is a great factor in the deficient function. It also prevents overuse of the weakened

muscles.

8. Re-education of muscular action is the most useful part in proper treatments of the neuro-muscular diseases.

I wish to express my sincerest thanks to Dr. Wachsmann, the Medical Director of Montefiore Home and Hospital for permission to make free use of the material at the Home, and to Drs. Taylor, Byrne and Elliott for co-operation in carrying out some of the observations made in connection with this work.

529 Courtland Avenue.

BIBLIOGRAPHY.

1. Abrahamson, Isidor.-The treatment of the Muscular Atrophies and Dystrophies in White and Jelliffe's System, Vol. II, pp. 99-139,

2. Barker, F.-Monographic Medicine, Vol. IV, 183-284.

pp.

3. Beevor, C. E.-The Croonian Lectures on Muscular Movements and Their Representation in the Central Nervous System. (London, 1904; Adlord & Son, 112, p. 80.) 4. Bowen, W. P. and McKenzie, R. Tait.-Applied Anatomy and Kinesiology: Lea & Febiger, 1917.

5. Blahd, M. E. and Stern, Walter C.-Cerebral Spastic Paralysis: J. A. M. A., Nov. 2, 1918, Vol. 71, pp. 14701474.

6. Bucholz, C. H.-Therapeutic Exercises and Massage Lea and Febiger, 1917.

7. Bucholz, C. H.-On the Exercise Treatment of Paralysis: American Journal of Orthopedic Surgery, Vol. IX, 1911-1912, pp. 633-663.

8. Bradford, C. H. and Lovett, R. W.-Orthopedic Surgery: Wm Wood & Co., 1911.

9. Byrne, Taylor and Boorstein.-Restoration of Motor Function in a Resected Nerve Treated by End-to-End Anastomosis with Considerable Loss of Nerve Tissue: Medical Record, January 5, 1918.

10. Camp, Carl D.-Paralysis Agitans and Multiple Sclerosis in White and Jeliffe, Vol. II, pp. 651-672.

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11. Clarke, Taylor, A. S., and Prout.-A Study on Brachial Birth Palsy: American Journal of Medical Science, October, 1905.

12. Elliott, G. R., and Boorstein, S. W.-Orthopedic Treatments in the Hemiplegics of Long Standing: J. A. M. A., Jan. 1, 1916, Vol. 67, pp. 31-32.

13. Ewing, William G.-Orthopedic Treatments of Nerve Lesions-American Journal of Orthopedic Surgery, Vol. XVI, 1918, p 346.

14. Franz, S. I., Schultz, M. E. and Wilson, W. A.The possibility of Recovery of Motor Function in Long Standing Hemiplegia. J. A. M. A., Dec. 18, 1915, p. 2150. 15. Frenkel-Tabetic Ataxia.-Blackiston.

16. Jones, Robert.-Notes on Military Orthopedics: 1917.

17. Longworthy, Mitchell.-General Principles of Splinting for Paralysis from Nerve Injuries; Special Application of those Principles in Median and Ulnar Paralysis: Am. Journal of Orthopedic Surgery, Vol. XVI, Nov., 1918. 18. Lovett, R. W.-Treatment of Infantile Paralysis: 1916.

19. McKenzie, Wm. Colin.-The Action of Muscles: P. B. Hocher, 1918.

20. Maloney, W. J. M. A.-The Co-ordination of Movement: Journal Neurological and Mental Diseases, N. Y., 1914, XLI, pp. 273-285.

21. Maloney, W. J. M. A.-Locomotor Ataxia: Appleton, 1917.

22. Mayer, Leo.-Orthopedic Treatment of Gun Shot Injuries: W. B. Saunders Co., 1918.

23. Oden, R.-Systematic Therapeutic Exercises in the Management of the Paralysis in Hemiplegia: J. A. M. A., Vol. 70, No. 12, March 23, 1918.

24. Oppenheim, H. (Bruce Translation).-Textbook of Nervous Diseases: 1911.

25. Ruhräh and Mayer.-Treatment of Anterior Poliomyelitis W. B. Saunders Co., 1917.

26. Shenen. James.-Treatment of Injuries of Peripheral Nerves, in White & Jelliffe's System, Vol. II, pp. 54-99. 27. Stookey, Byron.-Mechanism of Peripheral Nerve Injuries. Surg., Gyn. and Obst., Nov., 1918.

28. Sherrington, C. S.-Decerebrate Rigidity and Reflex Co-ordination of Movements: Jour. Physiology, London, 1897-98, XXII, pp. 319-332.

29. Spiller, W. G. Diseases of the Motor Tracts: Modern Medicine, Osler & McRae, 2nd ed., Phila., 1915.

30. Sherrington, C. S.-Reciprocal Innervation: Jour. Intern. Cong. Med., 1913, London, 1914, Section II, pt. 2. 31. Sever, James Warren.-Obstetric Paralysis: Amer. Jour. of Dis. of Children, Dec. 1916, Vol. XII,. pp. 541-578. 32. Starr, Clarence L.-The Role of Orthopedic Surgery in Modern Warfare: Am. Jour. of Ortho. Surg., Vol. XVI, 1918, p. 415.

33. Stiles, Harold J.-Operative Treatment of Nerve Injuries: Am. Jour. of Ortho. Surg., June, 1918.

34. Sayre, Reginald H.-Further Experiences with the Treatment of Volkmann's Ischemic Paralysis: Am. Jour. of Ortho. Surg., Vol. IX, 1911-1912, pp. 557-562. 35. Tilney, Frederick.-The Treatment of Cerebral Hemorrhage, Embolism and Thrombosis in White & Jelliffe, Vol. II, pp. 433-475.

36. Taylor, A. S.-Results from the Surgical Treatment of Brachial Birth Palsy: J. A. M. A., 1907., p. 96. 37. Thomas, J. J. Obstetric Paralysis with Especial Reference to Treatment: Boston Med. & Surg. Jour., April 2, 1914, CLXX, No. 14.

38. Thomas, T. Turner.-A Common Mechanism for Most Injuries of the Shoulder Region: J. A. M. A., Sept. 19, 1914, Vol. LXII, pp. 1018-1024.

39. Thomas, T. Turner.-The Relation of Posterior Subluxation of the Shoulder Joint to Obstetrical Palsy of the Upper Extremity: Annals of Surgery, Feb., 1914.

40. Taylor, A. S.-Volkmann's Ischemic Paralysis and Contracture: Annals of Surgery, Jan., 1917.

41. Vulpiuo, Oscar.-The Treatment of Infantile Paralysis: Translated by Todd, A. H., 1912.

42. Whitman, R.-Orthopedic Surgery, 4th Ed.: Lea & Febiger, 1910.

JOURNAL OF SURGERY.

American Journal of Surgery

PUBLISHED BY THE

SURGERY PUBLISHING CO.

J. MacDONALD, Jr., M. D., President and Treasurer

15 East 26th St., New York, U. S. A. to whom all communications intended for the Editor, original articles, books for review, exchanges, business letters and subscriptions should be addressed.

SUBSCRIPTION PRICE, TWO DOLLARS. FOREIGN, TWELVE SHILLINGS.

Original Articles and Clinical Reports are solicited for publication with the understanding that they are contributed exclusively for this journal.

It is of advantage to submit typewritten manuscript; it avoids

errors.

CHANGE OF ADDRESS. Subscribers changing their address should immediately notify us of their present and past locations. We cannot hold ourselves responsible for non-receipt of the Journal in such cases unless we are thus notified.

ILLUSTRATIONS. Half-tones, line etchings and other illustrations will be furnished by the publishers when photographs or drawings are supplied by the author.

SPECIAL NOTICE TO SUBSCRIBERS

The "American Journal of Surgery" is never sent to any subscriber except upon a definite written order. Present and prospective readers please note this.

WALTER M. BRICKNER, M.D., F.A.C.S., Editor

NEW YORK, JULY, 1919

SALUTATORY.

With this issue of the JOURNAL the editor resumes his duties after a lapse of eighteen months occasioned by military service. This break, though a long one, was the first in the service he

has endeavored to give to the readers of the AMERICAN JOURNAL OF SURGERY since its initial appearance in April, 1905. In the continuance of

that service he hopes to bring to bear whatever broadened outlook a first hand experience with the activities and emotions of war and with war sur

gery-at the front and in a large base hospitalhas given to so much of the art and the science of surgery, as he may have learned in the years of his civilian practice.

The editor wishes to express his grateful appreciation of the loyal services of the various members of the JOURNAL staff in carrying on its work in his. absence. Especially he and our readers are under obligation to Dr. Ira S. Wile who, in addition to the conduct of his own department, "Surgical Sociology," so well filled the post of editor-in-chief. Dr. Wile is not a surgeon but he is an experienced medical journalist, and a medical sociologist of national repute; and he has been in touch with surgical literature and with the activities of the JOURNAL through the unique department therein which he established nearly ten years ago. That

valued feature of the JOURNAL-the accomplishments of which Dr. Wile modestly summarized in the last issue-will continue under his guidance. While he is quite able and willing to supply all the material needed to fill as much space as we can usually spare for "Surgical Sociology," we have no desire to make that department exclusively edi torial. Its columns are open for contributions and discussions, which, indeed, it is part of its purpose to encourage.

The engagement of so large a percentage of the profession in the military service has caused, in the last two years, a great shrinkage in the number of articles contributed to medical journals. With the return of these men and women-to civilian practice and the lessening of the burden that fell, in their absence, upon the others, contributions will presumably soon regain ante-bellum proportions, and we have no doubt that the AMERICAN JOURNAL OF SURGERY will be favored again as abundantly as before. The editor has heretofore rejected a large percentage of the articles submitted as falling below the standard he has adopted for his readers and, in their interest, he hopes to continue this beneficent practice. The JOURNAL aims to be a "magazine of practical surgery in all its branches" but it seeks also to be representative of the best in the progress of clinical surgery and surgical therapy.

War conditions have hampered much the department of abstracts, not only in respect of foreign

journals but also, in no small measure, of American publications. These difficulties will gradually

disappear with the return of peace. In addition we

are putting in operation a plan that will, we believe, greatly improve this department, so that it will furnish each month a résumé of recent surgical articles of importance or of clinical interest gleaned from the various medical journals of this and other countries.

ties of the JOURNAL the editor bespeaks a continuIn resuming the literary cares and responsibiliance of the indulgence with which its readers have for so many years borne with him.-W. M. B.

the following clinical deductions, suggested chiefly by our own experience: The manifestations of wound diphtheria are neither constant nor characteristic; a grayish or whitish membrane is not always present; any discoloration or membrane, an otherwise unexplainable necrosis, even only an unusual odor, appearing in a wound, should arouse a suspicion of the possibility of infection by b. diphtheria; the patient may be overwhelmed by accumulating toxins before the changes in a previously normal-appearing wound are accounted for or, sometimes, even before these changes attract serious attention. In one of our cases the yellow membrane disappeared, the entire wound becoming gangrenous and distinctly green, the gangrene extending as a black area in the adjacent skin. These observations were in children. It was interesting to note that in adults wound diphtheria may also present variations from the membrane type. In a base hospital, at a time when there were sporadic cases of nasal and pharyngeal diphtheria, we noted the occasional development on previously clean, granulating wounds of soldiers, of characteristic diphtheric membranes. In addition to these, however, there were two cases of what we believe were true infections by Klebs-Loeffler bacilli, in which no membrane whatever appeared. Previously clean, actively granulating wounds, ceased to contract; the granulations "melted away," exposing the underlying muscles, which, in one case, showed here and there minute green areas of necrosis; the temperature was elevated for a few days; a narrow zone of redness and swelling appeared in the surrounding skin; then the inflammatory reaction subsided and the wound slowly contracted, without granulating, the organisms persisting in the wound -despite all antiseptic treatment-until it was completely cicatrized!

While in children the infection of a wound by diphtheria is often quickly fatal, the soldiers whom we have seen with the same wound infection were at no time alarmingly sick, even though the membrane was over a large, granulating thigh stump.

At the base hospital where these cases were seen a considerable number of wounds was found to contain organisms morphologically and culturally identical with the Klebs-Loeffler bacillus. Some of these wounds were examined for diphtheria because they presented suspicious changes of one kind or another; some merely because they were ward. "contacts." Not a few of the wounds in which the organism was found showed no variation from the appearance of normal granulations; some exhibited a translucent colorless or grayish film; in

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some the granulations had changed somewhat in color or size and the healing process had become sluggish. Toxin tests from the bacilli in one of these wounds proved negative; and we are prepared to believe that in most of these cases the bacteria found were only diphtheroids.

Reporting "An Outbreak of Diphtheric Wound Infection among Returning Soldiers" (Journal of the Am. Med. Assn., September 8, 1917) Fitzgerald and Robertson, of the Canadian Army Medical Corps, record that between May 20th and June 7th, 1917, among sixty-seven men with suppurating wounds, from which cultures were made, "thirtytwo were found to be suffering from b. diphtheria infection"!

Adami and co-workers in a study of "Diphtheria and Diphtheroid Bacilli in Open Wounds," (Canadian Medical Association Journal, September, 1918) express the opinion that most of the cases recorded by Fitzgerald and Robertson were instances, not of diphtheria, but of wound contamination by diphtheroids. They demonstrated that diphtheroids have not only the same morphologic but may also exhibit the same cultural peculiarities as the Klebs-Loeffler bacillus; and that the only decisive differentiation is by test of toxin production.

Recently Hartsell and Morris, of the U. S. Army Medical Corps, made "A Report of Sixty Cases of Wound Diphtheria" in a base hospital (Journal of the Am. Med. Assn., May 10, 1919). These were findings in routine wound cultures! The authors state that in no case was there any systemic symptom; twelve per cent. showed a gray membrane; "about one-half showed only a faint grayish discoloration of the granulating surfaces which under ordinary conditions would have passed unnoticed; about 6 per cent. looked absolutely healthy." As in the Canadian report, only one culture was tested for virulence. It proved toxic, as it did in the single instance from the series of Fitzgerald and Robertson; but both sets of authors failed to state whether the test was made from the culture of a wound clinically diphtheric or from one of the wounds examined as a routine.

The conclusion seems inescapable that most of the cases recorded by Hartsell and Morris were also instances, not of wound diphtheria, but of infection by diphtheroids.

While these two reports have the merit of drawing attention to diphtheric wound infection, it is to be regretted that they put on record a much higher incidence of such infections in war wounds than has actually existed. It is unfortunate, too, that

JOURNAL OF SURGERY.

they so confuse the clinical notion of wound diphtheria for, as we have pointed out, this does occur quite atypically. These publications may lead, on the one hand, to the unnecessary isolation of some cases and, on the other hand, to the more serious mistake of dismissing as a "diphtheroid infection" a case of true wound diphtheria without a characteristic membrane.

The diphtheroids are regarded as non-pathogenic. Some of them, however, appear to interfere with normal wound healing. Further observations may even demonstrate that certain varieties are patho genic.-W. M. B.

Surgical Sociology

Ira S. Wile, M.D., Department Editor.

BLINDNESS.

The advances made in the protection of workers from accidents tending to injure eyesight were emphasized during the period of speeding up attendant upon war. In fact, the entire movement for the conservation of vision has progressed very rapidly during the past five years. Fortunately, war itself has been responsible for only a small number of men lacking in both eyes, and the number deprived of one visual organ was not large among the Americans. A certain meed of pity is extended to those who have suffered damage to vision in the demonstration of their patriotism, but their loss is no more depressing to them or more damaging to society than similar conditions existent among the countless other persons robbed of eyesight through accident or disease.

Fortunately, the attitude towards the blind has undergone many alterations. The blind man is not to be regarded as an object of pity, merely deserving a pittance or a charitable contribution. He is to be recognized as a man capable of fulfilling his destiny, despite a handicap. He is to be given an opportunity to develop his normal self-respect and to retain his individuality, supported by the consciousness of independence achieved through effort. The rehabilitation of the blind is a matter of the utmost importance, and merits greater emulation in connection with the every-day living of those unfortunate enough to suffer from complete visual disability.

Accidents and injuries, together with sympathetic ophthalmia, constitute the single greatest cause of blindness, being responsible for more than one-eighth of the entire amount in the United States. If one adds to this the blindness arising

from poisons, foreign substances in the eye, exposure to heat, and from eye strain in industry, the percentage is raised so that one may state that a little over one-sixth of all blindness is occasioned by external injury or from causes other than dis

ease.

In a most excellent volume, "The Blind," (The Macmillan Co., 1919), Harry Best, Ph. D., has summed up the general knowledge pertaining to blindness. He presents not merely statements of their general condition, but excellent discussions of blindness and its prevention, the provision for education for the blind, children and adult. He describes, at length, the material provision that is being made for those afflicted with blindness and details the various types of organizations interested in their welfare.

The single chapter devoted to blindness and accidents merits a reading by ophthalmologists and surgeons, as well as by those interested in the social welfare of men. Here one grasps the significance of industrial hazards that are involved in work with abrasive wheels, clipping, cutting, or driving metal, hewing or carving of minerals, cutting wood, sand blasting, the handling of explosives and the dangers from the bursting of boilers or gauges or the breaking of belts. The dangers of powerful glares and intense heat, the likelihood of injury by hot or noxious chemical substances, particularly those used in connection with work with chemical and explosive industries are made patent.

"By reverting to the general table giving the several causes of blindness according to the census returns, we learn that nearly one-fifth (18.3 per cent) of all blindness from accidents and injuries is due to explosives, including those in mines and quarries, those in construction and similar work, and those from bursting shells in military actions; nearly one-eighth (11.8 per cent), to firearms; nearly one-tenth (8.9 per cent), to flying objects (not occurring in explosions); 5.9 per cent, to falls; 5.7 per cent, to cutting and piercing instruments; 4.1 per cent, to burns; 2.2 per cent, to animals; 2.2 per cent, to blows to the head; 2.0 per cent, to explosions not referred to above; 1.6 per cent, to explosions of a nature not indicated; 1.3 per cent, to unfortunate results of operations; 0.8 per cent, in mines and quarries; 0.4 per cent, to machines; and 34.8 per cent, to miscellaneous causes. Of blindness resulting from foreign substances in the eye, about half is due to acids and other substances of chemically destructive nature, and half to dust and other particles. Of that resulting from poisoning, 22.3 per cent is to be ascribed to wood al

cohol; 18.5 per cent, to tobacco; 17.6 per cent, to chronic lead poisoning; 11.1 per cent, to alcohol other than wood alcohol; 8.3 per cent, to chronic occupational poisoning other than from lead; and 22.3 per cent, to other forms of poisoning." In the way of prevention it is important to realize that types of accidents vary somewhat in their most frequent occurrence with the period of life. “Injuries from cutting and piercing instruments are most common in the early years of childhood, being the leading single cause among accidents from the first to the ninth year, after which time they decrease more or less rapidly. Injuries from falls also happen most often in this period. Injuries from firearms are of greatest frequency in the late years of youth, being the foremost cause from the tenth to the nineteenth year, after which there is a gradual decrease. Injuries from explosives show the largest proportions in youth and early and middle adult life, or during its most active working period, representing from the twentieth to the fifty-fourth year the chief cause of blindness from accidents. Injuries from flying objects and from burns, though fairly constant through life, reach their highest mark towards middle life, those from the former being also the leading cause after the fifty-fifth year. Blindness from exposure to heat, from foreign substances in the eye, and from poisoning are, like injuries from explosives, of greatest occurrence during the working period of life. Blindness from strained eyes increases with advancing years.'

These few figures are most suggestive of the lines along which attention must be directed in order to aid in the work of conserving vision. Basic figures are always requisite for framing programs. Legislation can be effective only when soundly founded upon facts. The gleaning of statistical material from all sources in the country is an essential prerequisite for visualizing the sources of accidents to the eyes. The establishment of divisions for receiving reports of accidents of all kinds, and of tabulating results is most necessary in order properly to devise laws and ordinances for the protection of the young and the old, in civil or industrial life.

While blindness is receiving more attention than ever before and while the community conscience is being fortified to accept blindness at a different valuation than heretofore, there is an imperative necessity for establishing every safeguard for the elimination of those unnecessary accidents which rob individuals of their highest potentials and tend to destroy the full social value of human beings.

If the prevention of blindness can strike the same sympathetic cord in the community that is struck by the sight of the afflicted, the conservation movement would receive a new impetus, and the need for organizations for the conservation of vision. would be greatly decreased.

"MODERN MEDICINE."

The developments of modern medicine are to be recorded in a journal to which, in new form, we give cordial welcome. Modern Medicine, in most attractive garb, steps into the field of medical literature, pointing out new horizons in health to be explored and expanded. Its aim is to discuss "the application of medicine and allied sciences to industrial efficiency and national health." Appearing monthly, it is to reflect the progress in medicine and health and present to the medical profession a résumé of the numerous problems in health administration and industrial and social health.

The basic thought underlying Modern Medicine is that in a world of ideas, the right to be well is by no means as important as the idea that people must be well, insofar as the science of medicine can make it possible. The new conceptions of medicine and surgery are swept along on a current of. social progress, and those who would be consecrated by baptism need but to go toward the

stream.

The initial number (May, 1919) is most promising, and, as an earnest of intention, it creates hopes and expectations, the realization of which will enrich medical knowledge. We bid our contemporary warmest greetings, and shall look to it for a spirit of cooperation that must shape the destiny of medicine in giving voice to the underlying principles of health conservation.-I. S. W.

Book Reviews

Surgical Treatment. A Practical Treatise on the Therapy of Surgical Diseases for the Use of Practitioners and Students of Surgery. JAMES PETER WARBASSE, M.D., Fellow of the American College of Surgeons, American Medical Association, American Academy of Medicine, New York Academy of Medicine; Surgeon to the Wyckoff Heights Hospital, Brooklyn, New York; Formerly Attending Surgeon to the Methodist Episcopal Hospital, Brooklyn, New York. In three octavo volumes with 2,400 illustrations and a separate index volume. Volume III, 861 pages; 864 illustrations. Philadelphia and London: W. B. SAUNDERS COMPANY, 1919.

In the review of volumes I and II (May issue) we called attention to the general character and unique features of this large, comprehensive, thoroughly interesting and altogether attractive work.

Volume III continues the surgery of the abdomen (appendix and bile tract), and deals with that of hernia,