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rely, it would be better for us and better for them and for their employes, upon whom we use those things.

Dr. Stockton: The question seems to be this: If the company takes hold and establishes a supply house, so that we can get the best supplies for the surgeons of the Chicago, Milwaukee & St. Paul Railroad, and we can get our dressings as cheaply from the company as we can from any supply house, most of us, I think, would favor the establishment of such a central depot. A great many men buy dressings outside of surgical houses, and there are many fellows who sell dressings, medicines and everything else they can sell at cut rates, consequently the goods are cut down proportionately to their price. They are poor goods; the dressings are inferior. I would rather have a clean sheet than some of the dressings now sold. I do not believe we should use such inferior dressings. If the company could establish a supply house, so that we could obtain the best dressings as cheaply as we can get operators' dressings that traveling men are selling around the country at the present time, it would be a great improvement. I take it, there is not a surgeon on the Milwaukee system who would dress a wound with a dressing that was not of the best class of dressing material. Rep resentatives of supply houses come to us and say that their dressings are as good as those that can be obtained from Johnson & Johnson, but we find, after applying such dressing to wounds, they are inferior. Those men have simply lied to the surgeons.

For ex

Dr. H. B. Hemenway: I take the opposite side from that which some of the surgeons here are inclined to take, for the reason that the more material we have around the office, the more objectionable it becomes. ample, some surgeons here are connected with two or three railroads, and if they undertook to get supplies from the Chicago, Milwaukee & St. Paul road for its work, and then supplies from the Northwestern for its work, and another set of supplies for ordinary work, it simply duplicates one's supplies; it encumbers the office with packages that are not absolutely necessary. Again, let us take a case that is treated in the hospital. The dressings are rendered sterile in the hospital, and there is no objection to their use; in fact, it is much more convenient to use them. Looking at the matter from a purely business standpoint, I do not see how it is going to interest the C., M. & St. P. Railroad Company to go into the surgical instrument and dressing business as a general business.

Dr. Bouffleur: The company is not going into that

business.

Dr. Hemenway: I do not see any use in increasing the number of firms unless we are supplied at a reasonable cost with all the dressings we want. Of course, if that side of the question is taken, it is another proposition. Inasmuch as Johnson & Johnson have been specified, I want to ask a question of those who are better posted than myself. Bauer & Black of Chicago are spreading their goods through this section very freely and thoroughly. I have had practically very little experience with their goods, and I would like to know if their goods are as reliable as those of Johnson & Johnson?

but that simply sterilized dressings are what he wants. If that is the case, it seems to me we can buy so-called cheesecloth, or surgeon's cheesecloth. In the city in which I live they sell it in the dry goods stores; that is, surgeon's cloth. It is like cheesecloth, and the other I use personally in my office, outside of the hospital, I prepare myself. If one has not a sterilizer, it is an easy matter for him to boil some water and he can prepare, from time to time, small quantities of it. One can procure jars such as are used in surgical houses, prepare his gauze in the same manner, and put the gauze in these jars and seal it up. I believe the chief surgeon wishes us to discuss whether or not we should have a supply depot here and there to furnish material to the various local surgeons along the line; in case they want it, let them pay for it, provided they do not care to prepare the material themselves, whether it be gauze or what-not. This would, therefore, be apropos to the discussion we had this morning, following in with the question of the work of the division surgeon, etc. A provision of that kind should be decided on and the various local centers should have control of the supplies that are required for this purpose. Let each man send in his requisition and buy his supplies wholesale.

So far as the application of non-sterilized dressings is concerned, it seems to me the safest material to use is that which you prepare yourself. I know I would not in hospital practice attempt to take any bottle of gauze and use the gauze. I would be afraid of it, although it might be thoroughly aseptic. If I am caught that way, I invariably have the gauze boiled before I use it. I believe it is better to us it wet, then you are sure it is sterilized, than to use it dry, when you are not so sure.

SEVERE INJURIES TO A DEAF MUTE.*

BY RUSSELL C. KELSEY, M. D., OF WHITE ROCK, S. D.

I report this case because it contains many novel conditions. On May 26, 1900, the north-bound passenger train on Fargo Southern branch of the Milwaukee system overtook Mr. G. A. S., who was walking between the rails, about one mile south of White Rock. Mr. S. is a deaf mute; stands 5 feet 4 inches; very muscular and sturdy; a hard-working farmer. He had not the slightest knowledge of approaching danger until possibly just the instant before being struck, when it is probable that the jar of the roadbed caused him to turn. I believe that he was walking slightly on the right side of the track, because he was thrown to the right, and that he turned to the right on receiving a possible warning of the train's approach, because the right leg was broken just at the joint where the pilot would strike. He was thrown 20 or 25 feet, and lodged on the outer edge of the ditch which runs parallel with the track. He was brought to my office by the trainmen on a car door.

Examination revealed the following injuries: Several scalp wounds containing gravel; transverse fracture of both bones of right leg at about the union of the middle with the lower thirds; the fibula was comminuted; compound comminuted fracture of the right radius; the olecranon was severed from the ulna and both bones were dislocated backward. Both bones of the left arm were *Read at the tenth annual meeting C., M. & St. P. Ry. Surgical

Dr. Donald Macrea, Jr.: With reference to what has been said regarding the establishment of a central depot for furnishing surgical supplies, I do not think the object of the chief surgeon is to ask for anything special, Association, Chicago, December 18-19, 1902.

fractured diagonally, the ulna at the union of the middle and lower thirds, the radius at the union of the middle third with both the lower and upper thirds, leaving a loose piece which gave much trouble. There was a severe sprain of the cervical vertebræ, and on the next day the spine of the right scapula was found to have been fractured.

On account of the fact that Mr. S. was a deaf mute, and that both arms were injured, we were entirely unable to communicate with him in any way, except that he could groan to express pain. There was no especially prepared splint material at hand. While waiting for assistants, I improvised from heavy sheet zinc a trough splint for the right leg, using sufficient cotton to make it fit and to absorb perspiration. For the left arm I used the usual two flat splints; for the right arm an anterior angular splint was used, after necessary antiseptic treatment, but this was soon changed for a posterior angular splint, with movable joint. The scalp wounds received the usual antiseptic dressings, and for the cervical sprain we simply adjusted the head with pillows. On the second day the fracture of the right scapula was discovered as a result of the patient's efforts to call attention to that injury. One can scarcely realize how difficult it was to come to an understanding of the injury to the scapula when the slightest movement of the head caused intense pain in the neck. For a long time he struggled to inform us, and each time our attention was directed to the neck; finally, however, his son thought he meant the shoulder; then the injury was soon discovered. As he was already pretty well braced up, it was a conundrum what to do with the scapula; the arm was splinted to such an extent that it could not be changed; finally adhesive strips with some small compresses proved a very good dressing. It must be remembered that under no circumstances could he be changed from the dorsal position except to rise to a sitting posture. The weather was hot, the house small, sanitation poor, and there was no trained assistance.

The results were as follows: The right leg bones united in the usual time, and the result is satisfactory; only a slight callus remained, action perfect. The right arm ankylosed at a convenient angle; little attempt was made to maintain motion; rotation is perfect and he can reach his mouth with the knife and fork; the left arm gave much trouble; pain was a very annoying symptom. The ulna and radius united, notwithstanding I gave much attention to preventing that. The right scapula is perfect except a nodular callus on the spine, which can only be discovered on examination.

On the fourth day he seemed to be failing rapidly, but thorough evacuation of the bowels with enemas, followed by stimulation, resulted in marked improvement. Frequent bathing was necessary, and I wish to say that in nearly all fractures I bathe the affected parts nearly every day, when painful, with the result that if hot water is used and the bathing thoroughly done, accompanied with gentle massage, it is seldom necessary to use opiates; in any ordinary case the patient sleeps well. I never put on plaster until pain is entirely absent and the danger of swelling is passed.

Since writing the above, Mr. Sullivan, the engineer, states that Mr. S. was on the right-hand side of the track

and that he turned to the right; he could not state whether he struck head down or not. He also states that a man walking on the track and away from an engine will remain on the track longer than if he is walking toward the engine. Knowing this fact, even though there is ample time to stop the train when a person is first seen, the engineer will usually run on, as in this case, expecting the person to get out of danger, until it is too late to stop. At the point of this accident there is a steep down-grade. There were in all five separate scalp wounds, a severe sprain to the neck and seven bones fractured, three of which were comminuted. When Mr. S. was picked up he still tightly gripped the basket he was carrying.

HYPODERMOCLYSIS.*

BY DR. J. R. G. HOWELL OF DOTHAN, ALA.

Probably a better title for this paper would be: The uses of the normal salt solution, for I shall speak briefly of the three modes of administering this remedy. The employment of the normal salt solution has become so common in both general practice and surgery, and its field of usefulness has been found to be so broad, until it is not probable that I will be able to say anything that can be construed as instructive. If it is possible for me to accomplish two things, I will judge myself richly remunerated.

First, I hope to provoke a general discussion of this subject that will be helpful to those of us most in need of instruction; and secondly, I would like to impress every member of this assembly with the fact that normal salt solution in some mode of administration is almost indispensable where shock in considerable degree exists, whether large quantities of blood have been lost or not. Shocks both real and imaginary, together with innumerable sequelæ have proven a stumbling block to railway surgeons and incidentally to railway lawyers.

What is shock? Pages have been written to define it. Gould says: "It is a sudden grave depression of the system produced by operations, accidents, or emotions.” (1) Thomas describes it as "a condition of sudden depression of the whole of the functions of the body, due to powerful impressions upon the system by a physical injury or mental emotion." (2) Quain's definition is identical with that of Thomas. (3) Erichsen describes shock as follows: "It is a disturbance of the nervous system, whereby the harmony of action of the great nerve centers, especially of the sympathetic ganglia, and through them the various organs of the body, becomes deranged." (4) Erichsen is further quoted as stating that "shock is due to a general exhaustion of the nervous centers consequent upon an extremely violent impulse." (For this quotation, however, I cannot vouch, for I have lost the reference.)

The human mechanism is certainly below par, no organ of the body performing its function properly, and the great sympathetic nerve system acting as telegraph wires. to report bad news from one organ to another. The heart must first be brought toward normal action, and this is aided by giving it more fluid to act upon. We are told that after death the arteries and a portion of the heart

Read at the thirteenth annual meeting C. of Ga. Ry. Surgeons' Associaiton, Columbus, Ga., April 14, 1903.

are empty. Shock is one step toward death. If the heart is gradually given more fluid upon which to act, it can perform its function with more accuracy. How can a heart make a normal stroke with abnormal contents? The natural remedy is the gradual filling up of the blood vessels with a solution nearest to the normal, and at a temperature that will augment a gradual return to the normal. We should prepare the solution with 30 grains of chemically pure sodium chloride added to 16 ounces of water that has been recently boiled, and after the salt has been added, filter this solution, using no vessels nor instruments but those that are scrupulously clean.

This solution should be of a temperature approximating 100 degrees Fahrenheit. I cannot agree with those who recommend very hot solutions injected into the blood vessels direct. The introduction of an abnormally hot solution through the venous system into the heart must of necessity produce shock of itself. Furthermore we must be guarded in the quantity injected direct, for large quantities of what is in fact an abnormal substitute, although we call it normal, can hardly fail to have a harmful effect. A very important suggestion has been made, and that is this: as you introduce the needle allow the solution to flow. This has three laudable points: First, it insures absence of air injected into the blood vessel; secondly, it clears away any impurities that may have caught on the point of the instrument or the surface of the wound; and thirdly, it will get rid of the cool solution near the end of the tube, a thing very necessary if the weather and surrounding air should be cold. I would not advise the use of saccharine ingredients in this mode of administration.

The second mode of administration of the normal salt solution is that indicated by the title of this paper, Hypodermoclysis. For this operation I use an ordinary fountain syringe with a bifurcated rubber tube, a needle being on both of the distal ends of the tube. In the absence of the above mentioned instrument, an ordinary aspirating needle thrust in the end of the syringe tube just as the ordinary nozzle would be inserted will answer every purpose. These instruments should be thoroughly clean as well as the point of introduction.

The field of introduction can very quickly be cleaned with razor and other emergency articles kept in your Central of Georgia Railway emergency case. I would like to mention just here that I keep a few things in my emergency case that are not required by the rules, and among them is water and an outfit for hypodermoclysis and rectal injections. This solution is prepared just as for infusion, 30 grains of chemically pure sodium chloride to 16 ounces of water that has been recently boiled, and the solution is filtered after the salt has been added. The infra-axillary region just posterior to the median line is my choice for introduction. I observe the same precaution here as in infusion, that of allowing the solution. to flow as the needle is introduced. This solution must be fresh. I had an abscess once following the use of a solution only 48 hours old in cool weather. I use this at a temperature not exceeding 105. Even in extreme cases I would not introduce over one quart in each side.

The third mode of administering the remedy is by rectal injection. This can be done with more haste and with

less prudence as to cleanliness. I invariably use this mode in conjunction with hypodermoclysis. The solution is prepared by using 60 grains of salt and one ounce of granulated sugar to the quart of water. This solution is injected very hot into the rectum, generally as high as 110 degrees Fahrenheit. I have been afraid to use the saccharine ingredient in either of the former operations. Now the question arises, when shall we use this remedy? My answer is when you have shock and before the patient dies. It is too late after he is dead. I advise its use previous to an operation. It is often needful during an operation. We are sometimes compelled to move a patient, and nothing contributes more to the safety of the undertaking than to practice hypodermoclysis before removal. I have seen what might be called the cumulative effect of shock, or delayed recovery from shock, both as a post-operative condition, and independent of an operation. In these cases we can do no better than repeat the use of normal salt solution. In our surgical journals we occasionally see the report of a case that was operated upon soon after the injury, and perhaps in the same journal we see where operative measures were postponed for shock to pass off. Both patients died. When I see such reports I am constrained to wonder if they used normal salt solution promptly, or did they rely upon the hypodermic needle for help out of the dilemma. My honest belief is that the judicious use of the normal salt solution will reduce the death claims from accidents.

BIBLIOGRAPHY.

(1) Gould's Students' Medical Dictionary, tenth edition, page 575.

(2) Thomas's Medical Dictionary, first edition, page

650.

(3) Quain's Dictionary of Medicine, Vol. 2, page 756. (4) Erichsen's Science and Art of Surgery, eighth edition, Vol. 1, page 297.

THE MALINGERER.*

BY W. B. PRATHER, M. D., OF SEALE, ALA.

I suppose every doctor has had those cases to treat, many of them, no doubt, giving considerable trouble. The first patient of this kind that I had to treat was when I had practiced but a few years. I was called hurriedly one night by the girl's father. He reported that his daughter had been taken suddenly ill and unless I hurried she would be dead before my arrival. Upon my arrival she was found lying on the bed in apparently a comatose condition. The pulse was regular, smooth and natural; the respirations, also. I called her; she would not answer. I suspected she was malingering. I opened my case, took out a vial of aqua ammonia, applied it to her nose; she knocked my hand away. I applied it again; expecting it, she gradually turned her head aside. I called her; she answered. The parents thought I had wrought a marvelous cure.

The next patient was a negro in our county jail. He had been apprehended for burglarizing a store. Knowing he had to serve time, he was trying to arouse sympathy. I applied the ammonia to him; he knocked my hand away.

Read at the thirteenth annual meeting C. of Georgia Ry Surgical Association, Columbus, Ga., April 14, 1903.

"possuming" would not avail him anything. I have mentioned these cases in private practice and will now mention three cases that have occurred in my practice since I have been a member of the Central of Georgia Railway Surgeons' Association.

The first patient was a negro who jumped off of a moving train and claimed that his back was sprained and that his bowels were bruised, so much so that during the act of defecation the stools would be bloody. I paid this negro two visits, each time finding him asleep. When I would awake him he would complain terribly. Every organ in his body, so far as I could ascertain, was in a perfectly normal condition. He had no bloody stools, I am satisfied his back was not sprained and that all he was after was to beat the company out of all he could. I so notified the parties, but I learned that the company gave him fifteen dollars.

The next patient was a white man who got his hand slightly mashed, as the train slowed up at a station, by the door shutting to. I was on the train at the time. The conductor asked me to see him; he, however, would not let me see how badly he was hurt, but said he would have his family physician see him. This man was not hurt to the extent of even a broken skin. He tried to sue the company, asking several lawyers in my town to take his case, but I am happy to say that we have no shysters in our town, so he gave up the suit.

The third case, a negro man, was knocked or pushed off the steps of a train which was just starting, by a passenger late in getting off. He complained terribly of a sprained back. The company gave him twelve and a half dollars, over my protest, for I was satisfied he was not injured.

I report these three cases to show to what dishonesty some people will resort for gain.

Had these three men been injured in their ordinary pursuits they would hardly have complained. But it was a railroad hurt, they could see an opportunity to get money

without work.

I recollect that while a student Prof. John G. Westmoreland related some cases of soldiers in the Civil War. The soldiers had learned that to complain of pain in the back would go further to mislead a doctor than almost any acute complaint; hence, a great many would report on the sick list, and it was surprising to see how many had pains in their backs. Some of those soldiers, rather than do duty, would have their backs blistered or submit to almost any torture.

Generally speaking, you can tell a malingerer. If a man is in much pain his pulse and respirations will indicate it. A man can hardly suffer much pain without acceleration of the pulse and respiration; besides, he cannot sleep tranquilly like an infant.

The so-called "railway spine," so much discussed a few years ago, was largely a feigned disease. As proof of it, many patients quickly recovered after the awarding of damages by a jury. One reason we have so much malingering in railroad patients is from the fact that many of the public are ready to sue a railroad company on almost any flimsy excuse.

Last year a negro woman, through her attorney, sued the Central of Georgia Railway for $500 for a sprained

wrist, caused by her own carelessness, as proven by witnesses of her own color. The jury very promptly and correctly returned a verdict in favor of the company, and yet, in spite of the testimony against her, some people argued that the road should have paid.

Ever since I have been a member of this association I find that the company sees after the injured individual willingly and cheerfully, and, in addition to surgical attendance, often boards them until they are able to return to work.

Hence we, as surgeons of the road, should see that the company is not imposed upon, but whenever we find one worthy case, help the company do all that can be done

for him.

THE VALUE OF RADIO-THERAPY IN CANCERS.

In a paper read before the American Dermatological Association, Dr. Charles W. Allan reports the results obtained in forty-seven cases of cancer. Ten were breast cases; one rectal; one, uterine; one, glands and tissues of the neck; three, sarcoma, and one supposed to be sarcoma; thirty were dermatological cancers; two epithelioma of the chin; nine of the nose or nose and cheek; three, multiple-one being in a subject of xeroderma pigmentosum; five were upon the cheek near the eye, four of the lip; two of the arm. The results were as follows: Ending fatally Discharged cured

Ceased treatment improved
Ceased treatment unimproved
Improved and under treatment

Total

5

.25

3

5

9

.47

From all of which the author concludes that it is a good treatment for many cases. It is especially of value in the treatment of those cases in which the patient will not consent to operation; however strongly urged.Journal of Cutaneous Diseases.

ADRENALIN AS A HEMOSTATIC IN SERIOUS HEMORRHAGES.

BY DR. OTTO LANGE.

With 25 Cc. of Solution Adrenalin Chloride the author was able to save the lives of six patients who were threatened with death from hemorrhage. The first patient was a hemophilic young man, constantly bleeding from a cut in the thumb. The hemorrhage was checked for twentyfour hours, by the use of gelatin internally and by the rectum, but recurred. The wound was then dressed with gauze impregnated with 1:2000 Adrenalin solution, when the hemorrhage stopped at once.

The same result followed the application of the gauze in two cases of hemorrhage during the changing of the dressings of an appendicitis incision. The secretion from the wound was much decreased after the application of Adrenalin. Two other patients received Adrenalin internally in the treatment of recurring hemoptysis or hematemesis. After taking 30 drops of Adrenalin twice in two hours, the hemoptysis ceased permanently. The same effect followed in a case of morning hematemesis from a gastric cancer.-J. Amer. Med. Assn.

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going, together with credentials of membership, to Mr. T. Layton, agent Pullman Company, Indianapolis, return passes will be issued.

HEADQUARTERS.

The headquarters for the meeting will be in the Claypool Hotel, on the site of the historic old Bates House, corner of Washington and Illinois streets. This is located within easy walking distance of the meeting place, being about one-half mile away in a straight line. It is only three squares from the Union Depot.

HOTELS.

Besides the Claypool there are:

The Denison, Ohio and Pennsylvania streets, European, $1 to $4 per day.

English Hotel, Monument place, facing the soldier's monument, European, $1 per day up; American, $2.50 per day up.

Spencer House, Illinois street, opposite the Union Depot, American, $2, $2.50 and $3 per day.

Also the:

Grand Hotel, Illinois and Maryland streets.

Imperial Hotel, Capitol avenue and Ohio streets. Oneida Hotel, Illinois street, opposite the Union Depot. Circle Park Hotel, Stubbins, etc.

DEATH OF DR. GARDNER.

Dr. Matthew Gardner, chief surgeon of the Southern Pacific Hospital Association, died at San Francisco, April 18, from the effects of appendicitis.

SALINE INFUSION.

J. Byrne summarizes the indications for saline infusions as (1) to supply volume to the blood, and fluid to the tissues. They are thus indicated when the body has lost blood by hemorrhage, or fluid by intestinal flux, wasting diseases, continued fevers, etc. (2) To stimulate the vasomotor apparatus and are hence indicated to combat shock and allied conditions. (3) To act as hemostatic, so valuable in hemorrhage, especially internal hemorrhage. (4) Elimination or dilution of toxins. The quantity of solution to be used depends on circumstances, and varies from a few ounces to several pints. The chief guides are are (1) improvement in facial color, and expression, or return of consciousness. (2) (2) Improvement of the pulse with increase in tension and volume and diminution in rate. The infusion may have to be repeated in a few hours in case the patient shows signs or relapse. -Cleveland J. of Medicine.

FOOT VALUED AT $4,000.

A verdict for $4,000 damages was returned by a jury in Judge Tuthill's court, Chicago, recently, in favor of John Masonis. The defendant is the Chicago & Eastern Illinois Railroad Company. Masonis, it is said, had a foot crushed under the wheels of a train belonging to the defendant company, near the intersection of Thirty-first street on the morning of January 22, 1900.

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