active motion is begun. I am convinced of that, and that the patient will regain a more useful limb and regain the use of the limb more promptly.

Dr. William H. Donaldson (Fairfield): I am very glad to hear Dr. Bacon join the respectable minority, and I want to join with him. I am a firm believer in the use of a plaster cast, but I have seen too much injury done by the indiscriminate use of plaster. I believe that the mistake the old-time surgeon makes today, is in too much immobilization of fractured joints. We all of us within the last few years have been running up against a class of practitioners of a new school, who have taken to themselves the name of bone doctors (they are also called osteopathists), and we have known of a great many cases where good has been done by them, and their secret is not immobilization. I believe we make a mistake in putting up a fractured bone, either near the joint or away from the joint, and keeping it in a quiet position for five or six weeks. We make a great mistake in that we do not take the fracture dressings off frequently, and if we do not use motion, we ought to use massage. That is what we have neglected in the past, and which we are coming to recognize as very important treatment, near the joint or away from the joint. We should bathe frequently the injured limbs, keep them in good condition by general manipulation and massage, which will keep the ligaments, muscles, and skin in a healthy state, and keep all the parts in a healthy condition, by improving the circulation, and get better results. The surgeon who neglects bathing or massage is doing his patient harm and running a risk.

Dr. Ernest H. Arnold (New Haven): I think the statement in itself of Dr. Cook perhaps cannot be assailed in a general way. But I think in a special way, that is in special cases, his statement may not altogether hold. I think it is wrong to ever obey the one doctrine, especially in medicine, and especially in practice. Now I can imagine a great number of cases where you have to vary very much from the general statement put down here. I think in putting up his joints that Dr. Cook has seemed to put the cart before the horse. I think that if there is one fragment only, that is, if the fracture is only in one part of the joint, and that fragment has been properly replaced, and forms union, I think his statement is good and true. But if you have two fragments, one over the condyle of the humerus, and one perhaps over the radius or the ulnar, suppose those are not properly replaced (and they are not always properly replaced as you well know). If you let your passive movement go for five or six weeks and do not institute passive movement until you have firm union, then you may never discover that you have an anchylosis there, a bony anchylosis, not a fibrous one. The passive movement might have informed you of the misplacement of those small fragments.

Then what the term "firm union" means is an elastic one. If your passive movement is of such a degree and force that the union is firm, then you can do no harm, and that may be well done, as you know, from the eighth day, provided, that your passive movement is done with very little

force, feeling your way so that the fragment will be firm enough to stand that passive motion. Therefore, in that case, Dr. Cook's general statement will not hold and I entirely agree with Dr. Bacon. I think the very first thing in a fracture of the joint is, after all, the diagnosis of the fracture. And the second thing, after making a correct diagnosis, is to replace the fracture so that it does form firm union. I have seen any number of fractures about the elbow where the fragments were so replaced that they could never form any union at all. Now passive movement there would always do harm, of course, and so would fixation; so it depends a great deal, I think, on what you have to deal with. And it depends a great deal on how you make your passive motion.

I feel that fractures of the joint have had a new light shed upon them by the X-ray. We know now where our fracture is, we know now how we have replaced it, we know whether we have put them in place, or in apposition, so as to get union, and, having those conditions known, we make intelligent passive movements early.

We also know nowadays that a great many of these fragments are so small and so subject to muscular contraction that by no means, by plaster cast or in any way, will you succeed in fastening them in the proper place without having a large callous in consequence of the irritation and displacement; that you will get there either a contracted or anchylosed joint.

I am of the opinion that with the aseptic surgery of today these fragments should be joined properly and immediately, and having seen them done properly, we can institute passive movement early, with no hesitation. I have no hesitation in manipulating such a joint after the 5th or 6th day, and getting good results.

Dr. Allen H. Williams (Hartford): Dr. Donaldson said he didn't agree with Dr. Cook, but he agreed with Dr. Bacon. I agree with Dr. Donaldson, but I don't agree with Dr. Bacon. Dr. Donaldson made a very good point about massage of the muscles. I don't think Dr. Bacon is quite correct when he speaks of the muscles matting together and the soft parts matting together. They will atrophy certainly to some extent, and you will get a certain amount of stiffness. For that reason I think our dressings ought to be removed frequently, and there ought to be a certain amount of massage. I do feel, however, that Dr. Cook is correct when he says in most cases one should keep the bone surfaces practically immovable. I think there is no greater mistake than to put on a plaster cast and leave it, thinking the bone will take care of itself. But I also think that in most cases early passive motion of the bone is a mistake.

Dr. Ansel G. Cook (Hartford): Mr. President, I think we are a good deal nearer together in practice than we are in theory. I always take down my fractures every week, sometimes every day, look at them, and see how they are getting on. There are a great many awful things that have been done with splints and plaster of Paris and bandaging, but that doesn't affect the principle.

On the other hand, it makes a great difference how you make your passive motions. You have seen children swing on doors and gates, wrenching themselves up and down. But that is rather violent passive motion. I think Scudder has the right of it.

However, this discussion is very mild, compared with what I got twelve years ago. I am delighted. I will try it twelve years from now and I think you will be ready for it then. (Laughter and applause.)

Further Observations on Gastric Surgery.

H. M. LEE, M.D., New London.

At the last meeting of this Society I read a paper dealing for the most part with the surgical aspects of gastric ulcer, with the report of an operation in a case of multiple gastric ulcer. That gastric surgery has advanced, in a few short years, as to have become one of the greatest triumphs of modern surgery, and that in the advancement it has been proven to be not only efficient as a radical curatiye measure but also as a palliative measure in certain diseases, giving relief from pain and suffering which no pen can justly portray, forces its triumph upon us and holds our attention. It is my desire, therefore, to bring before you a few facts now established, in regard to the stomach as a point of attack by the surgeon, and to particularly call attention to malignant disease of this

organ.

In view of the fact that in surgery we have a means of radical, positive cure of disease or conditions, and that it is in this sphere where surgery is attempted in the vast majority of cases, the pallative measures we have recourse to in surgery are apt to be overlooked, but if so, surgery is robbed of one of its most brilliant aspects. Nowhere is this department of surgery more perfectly seen than in certain diseases or conditions of the stomach.

Beginning with the operations of gastrotomy in 1840, by Egebert, in 1874, successfully by Jones, surgical interference in stomach cases rapidly advanced up to a certain point, and after such operations as gastrotomy, gastro-plication, operations on the pylorus, had been completed and obtained a standing in surgery, a lull came, lasting for some time. In the year 1893, operations upon this organ took a new start, when Czerny, Mikulicz, and others, attacked the stomach for relief of gastric ulcer. From 1894 to 1898 several operations for relief of gastric ulcers, with excellent results, were accomplished. Upon these brilliant achievements came an opera

tion by Schlatter in the year 1897, for complete removal of the stomach. In the space of two years three operations of this kind had been accomplished. That complete gastrectomy may have been an operation of too radical a nature, seems possible, and appears probable now, but is was a great stride in gastric surgery, and from this extremely radical operation has arisen, what is today, one of the brightest achievements of the surgical art, for there has been developed the operation of partial gastrectomy, which in many cases of malignant disease of the stomach gives a fair chance of cure, and in favorable cases, a complete cure can be accomplished.

As I have previously stated, it is my desire to bring before you the field that surgery opens up to us in the malignant diseases of the stomach, and in so doing, shall quote statistics of men who well might be called pioneers in this work.

I shall refrain from giving histories of cases in my own experience, as well as going into details of various symptoms and diagnosis, limiting this paper to a few technicalities of operative procedures, but above all, appealing to the general practitioner for more early diagnosis and his sanction for radical treatment.

But a few years ago malignant disease of the stomach carried the patient to death, while all that could be done, or was done, was to aid the unfortunate along the way, relieving partially at first, not at all later, till worn out by the suffering, as well as starvation, morphine alone made the last of life hardly bearable, and death gave the only relief.

I want to impress upon you the fact here, that when the pyloric orifice becomes so constricted by a malignant growth that motor insufficiency of the stomach begins, or even before motor insufficiency is well established, the patient is starving, and it is a great point to decide whether the picture before us is not due as much to starvation as to malignant disease.

I am convinced that in the early stage of the disease, starvation is the main factor which pulls the patient down, and would deter many medical men from consenting to radical measures. In the later stages, with the disease advanced beyond a possibility of radical cure, starvation is still a potent death blow.