to the X-ray men for treatment, when surgical measures cannot accomplish any good.

Dr. B. Thompson: I have not had very much experience in the treatment of this class of cases. I have a lady 64 years old under treatment for carcinoma of the breast; it had developed until the glands were very much affected and the growth had become hard and was discharging at the nipple; the doctor who sent her to me for treatment thought it would be detrimental to operate at her age. I have been treating her ever since the 10th day of April, twice a week, extending from that period until the present time. The last treatment was given yesterday, and at this time the growth has become so small that it is about 2x21⁄2 inches around the nipple that is still hardened. What is pleasing as a result of this treatment, is the fact that the deeper growth has given away and at the present time the tumor is very shallow, and movable with the skin in any direction. The discharge ceased after the treatment extended over a period of two months, the pain at the end of six weeks, and her constitution has been improving ever since. Whether it will be a cure, I do not know, but she certainly is very much improved.

I think the trouble with the cases that have been reported as having been treated with the X-ray is that the treatment has not been persisted in for a long enough time. You can treat these cases for a number of weeks and apparently you can see no results whatever. This lady is perfectly willing to keep coming to my office for six weeks longer, if she can be cured.

There was another case that came to me about two months ago. This was a hard growth on the right side of the neck. I used the treatment on this patient for six weeks, but it did not have any effect whatever. I removed the growth Monday and you couldn't see that the X-ray treatment had had any effect upon the tumor. There was no softening, and I think in that case failure would have been complete. The growth was enlarging all the time under the treatment. I have treated a number of cases of acne and some of them have been very bad cases. The X-ray has certainly cured them and they remain cured to the present time. The case that I have at the present time gives me every assurance that I will have a cure. There is one thing certain, it is not an inoperable case to-day; it would be very easy to remove the remains of the glands left. as it is shallow and not attached to anything.

a few exposures, but they have not been cured long enough to determine definitely whether they will remain

So.

Dr. Brockman: I was in hopes Dr. Sells would be in this evening. He has just returned from Kansas City, where the Mississippi Valley Medical Association met, and he says that meeting was made up very largely of X-ray discussions. About half of them claimed it would cure everything, and the other half, that it wouldn't cure anything. In regard to the diagnosis of these cases, I would say, that a large number of these cases of sarcomata were under the care of Dr. Beck and Dr. Coley of New York, and were inoperable, and in all of them a microscopic diagnosis had been made. I speak of these two men because none of you will doubt what they say. When men who are honest, men like Coley and Dr. Carl Beck, report on cases, who have as many as 8,000 of them a year to select from in that hospital, we can depend upon what they say. Some of the reports that Coley makes are wonderful. I remember one case of sarcoma where they started to use the X-ray because there was nothing else to do. They used it until a mass sloughed out and it healed up, and the man is apparently well; he has a smooth scar. They also spoke of the wonderful effacement of cicatricial tissue. I would say that in nearly all of Coley's cases, besides the X-ray, the serum treatment had also been used; some for a long time before the X-ray was used.

Some one asked about my personal experience—it is not enough to count at all. While I have not treated many cases personally, I have been following three or four of them, the first of which was a man about 67 years of age; he came to me on the 23rd of April with a large sore in the middle of his cheek; I did not make any microscopic examination. The case was of eighteen months' standing and the tumor was larger than could be covered by a silver dollar; the ulceration was as large as a silver half dollar. The tumor projected a good deal more than the thickness of my thumb. In looking over the case, I saw that in order to remove it we would have to cut to the lobe of the ear, to the nose, and down almost to the external angle of the mouth. I firmly believe that if we use the knife at all it should be used thoroughly, or not at all. I knew if we did this operation on the old man it would leave his face horribly disfigured, and I was afraid it would recur even then. I said to him that I did not know whether we could do

Dr. Thompson: Not yet.

Dr. Scott: I have had no experience in this matter and have nothing to say, but I would like to ask Dr. Brockman when he sums up, upon the question of chronic eczema. I have formerly had a case or two of eczema that were very persistent, that is, they would heal over, but would continuously recur. I want to know whether or not there would be the same history of recurrence under such treatment.

Dr. Thompson: The cases I have treated with the X-ray have been apparently cured. As Dr. Scott says, they will return. I don't know whether mine will return or not; apparently they are cured and were cured with but

to try it. I treated him once every three or four days, and commenced by using it carefully, about a ten minute seance, and then every day. When I went away the 1st of June for a three weeks' vacation. I left him in charge of a doctor who had more courage than I had, and he used a tube at 4 inches and gave him from twenty to thirty minute treatments, and then in about ten days he had a big burn. When I returned he came back with that sore nearly healed, but the tumor was about all gone. He was given a strong irradiation of twenty to twenty-five minutes with a tube within 3 or 4 inches of his face, and we got up another sore and he went home and came back in three weeks. I have not seen him since, but he has been back to my office and my assistant says

the face is perfectly smooth; the skin is just as smooth as a babe's face, and they tell me that the scar is not more than one-fifth as big as the sore was.

One thing you will have to look out for in using the X-ray about the face, you will destroy the hair and it will probably never return. It leaves it in much the same appearance as the scalp of some of these gentlemen that have no hair. We have in our town two or three cases under treatment, of superficial cancer, that are all improving rapidly.

With the tube just introduced by Cushing, we may be able to get better results in tubercular and cancerous ulcers of the larynx than with the old tube. By it we can irradiate the sore easily at close range without danger of burning the face or mouth. I am anxious to see the results from its use, but we will have to wait six or eight months yet to know what it will do. The same may be said of its use in uterine and rectal cancer.

I do not think that the majority of doctors are using it strong enough. I believe Dr. Thompson will get better results by using stronger treatment in his case. Dr. A. L. Robinson and Carl Beck are preparing papers on the subject and that literature will be out in the course of a month or two. They are men who are good observers and report their cases whether failures or not. I do not know any better way than to try it in all inopera ble cases and report results. Let us find out what is in it.

YEAR BOOK OF A MINE AND RAILROAD HOSPITAL-II.

BY JONATHAN M. WAINWRIGHT, M. D., OF SCRANTON, PA., SURGEON-IN-CHIEF OF THE MOSES TAYLOR HOSPITAL.

The prolonged inactivity in 1902 in the anthracite coal fields has considerably diminished the volume of traumatic surgery available for this report. However, rather than make a break in the contemplated series, it has been considered best to continue it yearly as begun. (See Railway Surgeon, May, 1902.) The paucity of cases may be compensated in a measure by considering some points of special interest more in detail.

During the year ending February 1, 1903, there have been 167 accident cases admitted to the wards. Of these, II have died. Six of these deaths occurred within 12 hours. In those living more than 12 hours, the death rate was 3.1 per cent, or a total of 5 deaths. The causes

of these five deaths were fracture of the base of the skull in four cases and severe burns in the other.

ing the year. Bloodgood interestingly discusses this subject in Progressive Medicine (December, 1902). Bloodgood inclines toward waiting till the injured person recovers from the primary shock. His colleague, Cushing, inclines as strongly to the opposite view (Annals of Surgery, September, 1902), and employs cocainization of the large nerve trunks as a means to prevent increasing shock by the operation.

The question is, of course, still an open one, and the argument from statistics is practically the only one which will lead us to a general rule. Combining the major amputations in this and the former year-book, there have been 16 done at once. These are distributed as follows: Through shoulder, 3; arm, 2; thigh, 7; leg, 2; both legs, 1; Syme's, 1. Of these two, both amputations of the thigh, died; one, as above stated, also had a fractured base, and the other had the wheels of an engine and several cars pass above the knee. It was a considerable time before he could be removed from under the train and he lost a large amount of blood.

During the present year no amputations have been delayed on account of shock. Last year three cases were delayed and all died.

This debated question of when to amputate is one of the most important in traumatic surgery and is one in which it is important to establish a definite rule of procedure, As said before, the arguments must be largely statistical, and must come most of all from railway surgeons.

At best, however, as in all conditions, the rule must be for general guidance and exceptions must be made. These cases lead strongly to the conviction that, personally, the only cases in which the exception to immediate amputation would be made would be those in which recovery is despaired of in any treatment. Where there seems a chance for life it is best conserved by immediate amputation. On the patient's way from the admission room to the ward, he should stop over in the operating room, so that when he is put to bed the infusions and stimulants will fall on good soil and not be counteracted by the continuous depression caused by a ragged, contused area of exposed muscles and nerves, with constant delay is practiced morphine is perhaps the most important oozing, or, what is perhaps worse, the tourniquet. When drug.

Both legs Fingers Toes

Total

I

3

12

Among these there has been one death-a case of amputation of the thigh, complicated by a fracture of the base. of the skull.

The belief expressed in the last paper in the advisability of amputating at once has been strengthened dur

In these there was little of special interest except in the case of fracture of the pelvis, which will be detailed later. Three cases in this series have died, all being fractures of the base of the skull.

Another case of laminectomy without improvement has been added to the three, with like result, which were reported last year. This occurred in a miner from a fall of roof. He sustained a severe laceration of the scalp, simple fractures of the right radius, right tibia and fibula, and of the spine in the lower dorsal region, causing complete paraplegia. When admitted, the patient's condition was so precarious that the laminectomy could not be performed until the tenth day, when a completely crushed cord was revealed. No improvement followed, although the patient is still in good general condition, ten months after the operation. An interesting feature of the case was that union in the leg bones took place in the usual time, showing that the influence of trophic or other nerves is not necessary for bone repair.

DISLOCATIONS.

There have been one each of hip, ankle, wrist, acromioclavicular and first metatarsal joints. All were reducible by the usual methods.

BURNS.

There have been 15 severe burns, with I death.

RUPTURE OF THE ABDOMINAL VISCERA WITHOUT EXTERNAL

INJURY.

Examples of this class of injuries have been very interesting and instructive. The list, though not extensive,

includes one case each of rupture of the diaphragm, liver, jejunum and liver, urinary bladder and kidney. These five cases, of which three died and two recovered, are in detail as follows:

Case I. Rupture of the diaphragm, with hernia of stomach, colon and spleen into the left pleural cavity. Death. See previous series. (Railway Surgeon, May, 1902).

Case II. Rupture of the liver. No operation. Death. The patient was caught in a fall of roof accident in the mines. He was removed as soon as possible to the hospital. On admission he was unconscious and in a desperate condition from shock and hemorrhage. He had a

bad compound fracture of the leg. While this was being temporarily dressed, and while he was being given a subcutaneous infusion, the patient died. Death occurred a few minutes after entering the hospital and about three hours after the accident.

Autopsy showed a superficial excoriation of the right hypochondrium and back. The right pleural cavity contained a little bloody fluid and two ribs were fractured on this side. They had not pierced the diaphragm or lung. The peritoneal cavity was full of blood. In the anterior border of the right lobe of the liver, near the gall-bladder, there was a tear passing directly backward about 3 inches, so that the area of the ruptured surface was about the size of the palm of a man's hand. On the antero-superior surface of the right lobe there were several superficial tears from one-half to two inches long. Other abdominal viscera normal. Death occurred in this case before attention could be given to the abdominal condition, so that the case adds nothing from a diagnostic point of view.

Case III. Rupture of the jejunum and liver. No operation. Death. This was also a fall of roof in the mines. This case was first taken to his home and not removed to the hospital till about seven hours after the accident. Examination showed general abdominal rigidity and tenderness, with moderate distension. Liver dullness was absent and tympany extended high up on the left side also; no external injury. The patient's general condition precluded any operation and he died in five hours without response to active stimulation.

On autopsy the abdominal cavity was found to contain blood and intestinal contents, with early plastic exudate. There was a small tear in the liver at the falciform ligament. The jejunum was torn almost completely across at about five inches from its beginning; other viscera normal. Men can seldom give an account of how things happen when roof falls in on them. However, the probable mechanism is these cases is an acute flexion of the trunk, due to the falling weight, in this case compressing the jejunum between the vertebral column and the abdominal wall.

At

Case IV. Fracture of the pelvis, with extra-peritonea! rupture of the bladder. Operation. Recovery. The patient was rolled between a moving mine car and some stationary object. He was removed to the hospital at once. Examination showed some shock, but, aside from pain on pressing the iliac crests, there was no sign of injury. He was admitted to the ward at 2:30 p. m. 9 p. m., as he had not voided urine, he was catheterized, and only about two ounces of bloody urine obtained. He was again examined and found to be in about the same condition as to shock. He had at this time the pale, anxious, "peritoneal" face. There was slight general distension, rigidity and tenderness. There was a very characteristic absence of abdominal breathing. No external injury and no signs of fractured pelvis except the tenderness on pressure over the iliac crests.

A diagnosis of rupture of the bladder, probably intraperitoneal, was made and operation performed at once, i. e., about ten hours after the injury. Ether anesthesia. An incision into the prevesical space was made, and a This came large amount of fluid blood met with at once. from a cavity to the left of the bladder, into which a finger was passed, and a fracture of the true pelvis found. There were several large, jagged bones projecting a half inch or more into the pelvic cavity. The bladder was then opened and a large amount of clotted blood found. There was a ragged tear admitting two fingers to the right and just above the vesical outlet. The blood and urine had dissected around to the left side, where the laceration of the tissues caused by the fracture had made a path of least resistance for them. No break in the right pelvis could be made out. The rent in the bladder was ignored and the viscus drained suprapubically by a large catheter fixed in position according to the Kader-Gibson method. A cigarette drain was placed to the left of the bladder to drain the cavity there. Recovery was uneventful. The tube was removed from the bladder on the ninth day, and there was never any leakage of urine from the suprapubic wound after its removal. The tear in the bladder had evidently healed at this time. The fracture of the

pelvis could not be detected by rectal examination, nor externally, and did not impair walking in any way.

The fortunate outcome in this case, which was something of a surprise, was due largely to following Alexander's excellent advice in opening the prevesical space and exploring, even when an intraperitoneal rupture is assumed. This will avoid unnecessarily opening the peritoneum, in many cases an error, which, in this case at least, might easily have turned the scale in the other direction.

Case V. Rupture of the kidney. Operation. Recovery. Three days before admission the patient was thrown from a sleigh against a fire hydrant, striking on the right lumbar region. He had severe pain from the time of the injury, and five hours after the accident he vomited greenish fluid. Once during the night he voided bloody urine; no vomiting or hematuria after this. A swelling appeared in the lumbar region and the pain continued severe.

On admission he had a temperature of 101.8 degrees

(rectal), pulse 110, respirations 24. The face was somewhat pale and sunken. There was a large fluctuating mass in the right lumbar region. After admission the temperature and other symptoms improved. As there had been blood in the urine only once, and the patient's general condition did not seem severe enough for a rupture of the kidney, it was considered that the patient had a retroperitoneal hematoma. As this showed no tendency to be absorbed, an operation was performed the third day

after admission.

An incision was made through the most prominent part of the tumor, which led through Petit's triangle. The external oblique and latissimus dorsi were separated from each other and the deeper layers divided in the direction of their fibers. When the transversalis fascia was reached it was found to be tense and bulging. This was opened and about a quart of blood evacuated from between the transversalis fascia and the peritoneum, the latter not being opened.

From the incision made, a good exposure of the kidney could not be made, and, as there was no appreciable odor of urine in the discharge, it was considered best simply to drain the cavity without making a further dis

section.

The operation was well borne, but during the first twenty-four hours it was apparent that urine was being discharged through the drain. At the present time, thirty days after the operation, the case is progressing favorably, although urine is still being discharged through the sinus.

TRAUMATIC RUPTURE OF THE HEART. Ebbinghaus in the Ztsch. f. Chirurgie, reports the case of a girl of 12, who fell from a fifth story window. Death ensued in nine days from subacute traumatic rupture, there was also rupture of the pulmonary valve. Neither was diagnosed during life.

The normal bladder is difficult to infect, the paralyzed and diseased bladder, on the other hand, is very susceptible to infection.-Senn.

INJURIES TO THE HAND AND FINGERS IN RAILWAY ACCIDENTS.*

BY W. T. SPEAKER, M. D., MANSON, IA. The hand being one of the most prominent organs of the body, and the most liable to injury, especially among laboringmen and mechanics, it behooves us as surgeons to study the nature of the wounds, their susceptibility to infection, and the most rational and welldirected methods of treatment. One-third of all injuries received upon railways are lesions to these parts. When we are called to attend these injuries we find them in all degrees of severity, from the simple abrasion or contusion to complete demolition of the hand or fingers. We find a finger or fingers crushed-the thumb being more exempt from injury than the fingers-the hand, in part or whole, wounded in a less or greater degree. These injuries are mostly caused by the hand being caught be coupling cars, and often from heavy weights crushing tween the deadwoods or bumpers while in the act of them while unloading.

When they are caught squarely between the bumpers. the force is sufficient to completely destroy the parts, and the result, as a rule, is complete amputation. But when not thoroughly caught, the hand or fingers may become squeezed, but not crushed. The hand being very vascular and irregular in its outlines, makes a crush or injury at first sight look more than it really is. When the parts are unbroken and very much swollen, an ecchymotic condition is presented. The hand is useless and accompanied with extreme pain and tenderness. Frequently we find a finger or fingers so badly wounded that the entire surface is denuded of its soft structures, leaving the bone protruding, or the latter may be broken or comminuted and be surrounded by torn skin or mangled tissue. When the dorsal or palmar region is involved, Herrick says:

"Tears of the skin will reach up into it, uncovering the tissues of the part. In bad crushes the parts are mangled beyond anatomic recognition-joints disorganized, bones comminuted and tendons twisted about all the debris." Here we usually have severe hemorrhages, owing to the large supply of blood to the hand, but usually there is a general oozing instead of arterial bleeding, unless the palmar arch is severed. When a laceration or incision of the hand or wrist has occurred the hemorrhage should immediately receive our attention, and should be cleansed as well as possible under the surrounding conditions. The voluntary motions of the hand and fingers should be carefully inspected, for it is possible that there may be limitation of motion by the dividing of a nerve or tendon. The location and direction is of great importance in determining the character of the injured part. Injuries to the tendons of the hand or wrist, especially the flexors, are of great importance, and their loss of function often. means permanent disability.

Diagnosis and Prognosis.-There is usually very little difficulty in the diagnosis of these difficulties. . A wound, when severe, is simply a matter of sight, but when we get a contused or unbroken skin the diagnosis is often a

*Read at the ninth annual meeting Iowa State Association of Railway Surgeons, Des Moines, October 22-23, 1902.

matter of considerable conjecture, and if possible the A-ray should be brought into use. In all these injuries of hands and fingers the diagnosis and prognosis should be especially guarded, for, however careful we may be, we must remember the results that may ensue while Nature is in the process of repairing these injuries. The tendons and muscles may be glued together in such a manner as to cause limitation of motion, so that a satisfactory condition may not result in the end, however slight the injury may have been. The patient should be made to understand in the beginning that all that lies in the surgeon's power will be done, and he must abide by their results. Treatment.-As the hand is one of the most important organs of the body, I always make it a point to save every possible part of the bone and integument. The injuries are mostly from bumper accidents; they are generally limited to the marginal surfaces, and when we find shreds of skin flapping loosely the parts can usually be brought into apposition and used advantageously. On account of the vascularity of the tissues of the hand, and as the parts are usually septic, the sooner the affected parts are removed and the injured member properly dressed, the better the chances for good results. As to the treatment, those parts that are simply crushed or bruised should be thoroughly cleansed and antiseptic preparations forced into the cavities. I find the treatment laid down and usu-ally practiced by all our surgeons, and as given by Herrick, Park, Hamilton and others, to be the most rational and successful. All these case's demand careful attention. Complications are liable to present themselves, and especially to be feared is the phlegmonous condition, which, induced by spesis, may creep up the tendon sheaths, appearing in the palm and frequently in the wrist. This will be recognized by chills and fever, with local swelling and tenderderness. These symptoms call for immediate attention; here free incisions should be made wherever swelling appears.

The injuries of this class should be dressed daily and the surgeon should not depend upon antiseptics; while a large number heal rapidly and satisfactorily, yet it is by granulation, and not by aseptic union. Pus pockets should be carefully watched; all pus should be carefully removed and thoroughly cleansed at each daily dressing.

We should begin passive motion early and daily of a gentle character. The sutures should be removed as soon as granulation is sufficient to hold the parts in firm apposition, and all skin and shreds should be removed. Tetanus is rarely met with in railway surgery.

Monarticular Disease. I am convinced that single rheumatic joints never exist. If joint disease is due to rheumatism, more than one joint will become infected; every single joint disease is always purulent, tuberculous, gonorrhoeal, or due to pneumococcus or to some central nerve lesion.-A. M. Phelps.

The abdominal cavity will take care of much more of pus than it will of shock. Make operations short.-MorMake operations short.-Morris.

EUROPHEN AS A DUSTING-POWDER.

BY SPENCER S. FULLER, M. D., RIVERSIDE, ILL.
Ex-Interne Monroe St. Hospital, Chicago.

Of the several useful iodine derivatives Europhen would seem to possess those characteristics which are primarily essential to a satisfactory dusting-powder. The fact that iodoform came to be universally used as an external application would seem to prove its efficiency, but its intolerable odor, and its peculiar irritating effects upon many individuals, have practically caused its disappearance from the list of things desirable in the treatment of wounds. Its virtue is generally conceded to depend upon three qualities, styptic, soothing and the liberation of iodine in the presence of granulation tissue. The styptic effect resulted in the early formation of a crust, forming a protecting covering for a wound, while the gradual but continuous liberation of iodine, which is generally conceded to be a most efficient germicide, second to disinfect the secretions and antisepticize the wound surface.

Europhen, like iodoform, owes its value to its drying property, and to the iodine (27.6%) which it contains. It is a very fine powder, being more adhesive than iodoform, and it is claimed to cover about five times as much surface and it does not cake so readily.

When brought into contact with moisture it is decomposed and free iodine liberated. Its odor is distinctly aromatic, and it is claimed to be devoid of poisonous effects.

I have recently used it in the treatment of a serious burns and lacerated contused wounds in Dr. Bouffleur's service at the Monroe Street Hospital, Chicago, with nearly uniformly good results, the exception being readily explained by the presence of a slough, or a form of infection, which could not have been controlled by the external application of any powder alone.

Case 1. Mr. B., a railroad man, sustained a burn of the third degree, involving two fingers of the right hand, and also an extensive and deep burn of the leg. The wound had been treated with hot fomentations of boric

acid solution at first, and later with boric acid powder. The finger wounds healed slowly and continued to discharge considerably, although the infection did not appear to be of an active type. The surface dried up after one application of Europhen and epidermization was rapid. The effect of the steam was to cause necrosis of a consid

erable area of tissue in the leg, and Europhen did not seem to hasten the healing process until after the slough had all been separated. This was facilitated by maceration, as would be expected. After separation, Europhen quickly dried the surface and healing occurred promptly.

Case 2. Mr. H., a switchman, sustained a burn of first degree of right wrist. Europhen in vaseline applied with prompt relief of all pain, and healing occurred without further treatment.

Case 3. Mr. D., a railway employe, sustained a burn of second degree of back of hand. Boric acid fomentation applied for twenty-four hours, then Europhen, which was followed by healing without infection, or any irritation. Case 4. Mr. G. sustained a crushing injury of a finger.