Before the train time he 'phoned me again to bring instruments, as he had found on a second visit that the trouble was rapidly spreading and would doubtless need amputation. At nine o'clock p. m. examination revealed the following: Entire foot gangrenous and giving off the usual offensive odor; the soft tissues in the lower half of the leg full of gas, crackling under the touch, and in fact presenting the usual appearance of spreading traumatic gangrene. There was little or no pain, temperature 104, pulse 150, expression anxious. An immediate amputation was done about 5 inches below the knee, ample gauze drainage was placed and moist antiseptic dressing directed. Very little anesthetic was required. On being placed in bed the patient's condition seemed very critical, strychnia and digitalin were given hypodermically and whisky by the mouth. For several hours the skin was cold and clammy in spite of artificial heat, the respiration was sighing, pulse very rapid and weak. For a week the physical condition was not good, but under good feeding he has now so far recovered as to be about on crutches. The wound healed nicely. This case was marked throughout by the absence of pain or rather by the small amount of pain suffered.

In either case I believe that immediate amputation was all that would have saved life, and a few hours' delay would have been fatal. In the case of the boy systemic poisoning would have certainly been fatal before the line of demarcation would have formed. In the first case reported, while there was some indication of this line of demarcation, the very bad condition of the soft parts even at the point of amputation clearly showed that further delay would be fatal.

DISCUSSION.

Dr. D. C. Brockman, of Ottumwa, Iowa: In regard to the surroundings of the first case, I think there can be no fault found with them, or with the dressings. The patient was brought into the hospital within an hour after he was injured, and the amputation was made far enough from the injury to be perfectly safe. The technic was of the strictest, and the operation was performed in the General Hospital in which there was no septic case at the time.

The blebs on the stump grew within twelve hours after the amputation, and reached to the knee; there were no blebs about the flap. It was one of those unexplained cases where there was devitalization from some unknown cause.

Another case something like this occurred some three years ago. A young man was run over by a street car and one ankle was badly crushed, the other foot was not seriously injured. The doctor who had charge of the case attempted to save the bad foot. As I said, the injury to the other amounted to very little. In 48 hours both legs become gangrenous above the knee. On one leg the skin was not broken, but it became gangrenous to the same extent as the other. Whether this was due to the electric current, or to some condition incident to the poison absorbed, I can not say.

Dr. S. Bell, of Beloit, Wis.: We have been taught that we must wait for the line of demarcation before operating. I believe we can do better, unless it is in such cases as Dr. Brockman has related, where the whole body seems to be poisoned by some toxin. My method is to lay the fleshy part wide open and wash thoroughly with hydrogen peroxid and inject carbolic acid along all the red lines. If the gangrene extends very far, I follow this by filling the whole limb with commercial alcohol. I believe we can limit the progress of the disease in this way. I follow this treatment with wet dressings of hot alcohol.

Dr. D. Macrae, of Council Bluffs, Iowa: In these cases of gaseous gangrene, if you amputate only a little above the line of demarcation you have not gone above where the gangrenous material may be. It is always safer to be sure you get above this. In the leg go above the knee joint, because the tissue is not so loose at the knee joint as it is in the leg.

Dr. D. S. Fairchild, of Des Moines, Iowa: The question of thrombosis must be taken into account. Where there is very little hemorrhage one often finds the vessels plugged with a thrombus, and this will account for some of the cases of gangrene.

Dr. Spilman (closing): Regarding the conditions and surroundings, we considered the physical condition of this man as being not very good from the first, and perhaps the sys

temic conditions had a great deal to do with the gangrene which followed. But in the case of the little boy, the medical gentleman who attended him is a young man well qualified to carry out the technic of antiseptic surgery, so that no criticism is to be made there. I did not see the case until after amputation. It was a case in which the gangrenous condition extended far above where the real gangrene tissue appeared. Of course, we went above that apparent line, which seemed very apparent, because it was very evident in the swelling. We could feel the gas up to a certain point, and then the limb appeared to be normal, and it was there, well above the gas, that we amputated and got union by first intention.

As to the question of thrombosis, in the case of the man who had the two amputations we had some trouble with hemorrhage. There were a number of bleeding points and one gave way which was perfectly dry when we did up the stump. For some reason it did not bleed at the time of the first amputation. I do not know why it broke open later. When we opened up the flap it was spouting.

ACETOZONE IN GENERAL SURGERY.

BY JAMES H. FORD, M. D., Professor of General Surgery, Central College Physicians and Surgeons; ex-President International Association Railway Surgeons; Indianapolis, Ind.

After an extensive experience with the use of acetozone solution I am convinced that it has qualities which make it of value in general surgery where suppuration is encountered.

This chemical substance is one of the higher peroxids, and exerts its peculiar effects when brought into contact with moist organic matter. It is soluble in water, and when in solution hydrolyzes rapidly and breaks up into less complex compounds.

It has been my custom heretofore in treating suppurative cases to wash out the cavity or suppurative tract with solutions of hydrogen peroxid, afterward removing the peroxid with distilled water. Investigations have disclosed the fact that acetozone has a germicidal power much greater than hydrogen peroxid, and at

the same time it is harmless; whereas hydrogen peroxid is known to cause a destruction of infected tissue which has lost its tone, due to its exposure to pus and pus germs. It occurred to me to substitute acetozone for the peroxid, which I have done in a great many cases. I now use it in every case where infection has occurred.

I have prepared the solutions when needed for injection into pus tracts by dissolving from 5 to 10 grains of the powdered acetozone in from 6 to 8 ounces of warm distilled water, then injecting this solution into the fistulous tract with a glass syringe, allowing it to remain in contact with the affected area; after a short time washing out with distilled water. I find that acetozone used in this manner acts very well. In some cases I have used as an irrigating fluid large quantities of a weaker solution made by adding 15 grains to two quarts of water. My experience has taught me that there is no destruction of tissue, no damage to adjacent parts, and complete sterilization of the infected tract or surface and ready healing of the parts by the use of acetozone in the manner indicated.-Therapeutic Gazette.

Railway Surgical

THE

JOURNAL

PUBLISHED MONTHLY BY E. H. BAUMGARTNER

SECURITY BUILDING, CHICAGO, ILL.

SOME RECENT DEVELOPMENTS IN RAILWAY HYGIENE.

The attorney-general of Oregon has lately deIcided that the state board of health has no power under the law to compel railway companies to clean out their cars before entering the state. This body claimed the coaches, espe

Surgeon-General Wyman of the Marine Hospital Service has been inquiring into the sani

in Association.

ENTERED IN THE POSTOFFICE AT CHICAGO, ILL., AS SECOND-CLASS MATTER.

OFFICERS OF THE A. A. R. S., 1904-1905

President....... JOHN E. OWENS, Chicago.
Vice-Presidents. R. W. CORWIN, Pueblo, Colo.

GEO. D. LADD, Milwaukee, Wis.

H. C. FAIRBROTHER, E. St. Louis, Ill. Treasurer....... .T. B. LACEY, Council Bluffs, Ia. Secretary..... .H. B. JENNINGS, Council Bluffs, Ia. Executive Board-D. S. FAIRCHILD, Des Moines, Ia.,

Chairman; A. I. BOUFFLEUR, Chicago; S. C.
PLUMMER, Chicago; A. L. WRIGHT, Carrol, Ia.;
W. S. Hoy, Wellston, Ohio; J. R. HOLLOWBUSH,
Rock Island, Ill.

throughout the country. From many reports from State and municipal health officers there seems to be a unanimous opinion that many diseases are contracted by the traveling public.

The railway companies are taking steps to lessen this condition of affairs. Mr. C. A. Goodnow, general manager of the Chicago & Alton, reported that a new device has been experimented with by his company, and proving successful, will be installed. In March last the Pullman company appointed a superintendent of sanitation. The duties of the new official include, among other things, the testing of new devices for sanitation and disinfection, until a satisfactory one is found.

For some time past a device for cleaning houses, theaters and other buildings by compressed air has been successfully used in Chicago. The Central Railroad of New Jersey has recently installed a similar apparatus on a large scale. A large vacuum plant has been built in the yards at Jersey City and several miles of pipe laid. Flexible hose which can be brought either through the car windows or the doors, is attached to the pipe at frequent intervals. To the end of the hose is fastened a metal nozzle, and when this is passed over the seat cushions, carpets, etc., the dust is sucked up at once. On the way back to the vacuum plant the dust-containing air is forced through two reservoirs. The first separates out nearly 90 per cent of the contained dust and dirt, the second contains a bichlorid solution, so the air is finally free from dust and purified. It is stated that two cars can be cleaned by this plan in the same time and for the same cost as one car by the old way.

Dr. S. G. Dixon, of Philadelphia, has been

appointed to fill the newly created office of State Commissioner of Health. One of his first official acts was to make all medical examiners in the Pennsylvania Railroad Voluntary Relief Department, and also all connected with the Philadelphia & Reading Railway Relief Association, special medical inspectors. These appointments carry with them no salaries from the State, but the coöperation between the health department and the railroads has been shown to be very advantageous in the prompt handling of cases of contagious diseases on trains, in the shops or in stations. Chief Medical Examiner Dr. Samuel W. Latta, of the Pennsylvania, stated that following every case of contagious disease discovered on any Pennsylvania train, the car was thoroughly fumigated, washed down with bichlorid solution, then left open for twelve hours before it was put in use. Dr. Casper Morris, Chief Medical Examiner of the Reading, assured Dr. Dixon that every care was also taken on his road thoroughly to disinfect all trains following the discovery of a contagious case, and that vaccination was carried out on a large and thorough scale among not only the employes but in many cases among the families of the employes.

Finally the Interstate Railway Sanitary Commission Company of Kansas City was incorporated May 15. The purpose of the company is to collect information as to the sanitation of railway trains and stations. The capital stock of the company is $2,000.

RAILWAY'S BAN ON DOCTOR. The Connecticut Railway & Lighting Co. has posted the following notice: "Whenever you have occasion to summon a physician to attend an injured person you will please bear in mind that the company bas an arrangement with most of the practising physicians of Ansonia, Derby and Shelton, to respond to emergency call. Dr. W. H. Conklin is an exception to this rule. Superintendent Beardsley." Dr. Conklin has had many railway cases, and in recent suits his testimony had weight with the court in awarding damages. He has had the notices mailed to the conductors and motormen because he does not wish the men to forget the rule when an accident occurs and call him, which would jeopardize their places.-(Med. News.)

Translations.

THE TREATMENT OF COMPLICATED FRACTURES OF THE LEG.

BY DR. CHAPUT, SURGEON TO THE HOSPITAL BOUCICAUT, PARIS.

(Translated for THE RAILWAY SURGICAL JOURNAL.) We call fractures "complicated" when they are accompanied by wounds communicating with the fracture itself. The wound is the most important complication of fractures, because it is the most frequent and because other complications such as lacerations of the blood vessels, suppuration of the focus of fracture, gangrene of the limb, etc., are nearly always due to wounds of the soft parts, and only exceptionally follow simple fractures.

Complicated fractures have no resemblance whatever to simple fractures, suppuration in the latter is as rare as it is common in the first class. Hence, the term "complicated" brings to the surgeon's mind all the possible complications, infection, hemorrhage, and gangrene at first, to say nothing of the fistulæ, pseudoarthrosis and vicious union later on.

I shall take as a type complicated fractures in the lower third of the leg, and shall first show why it is useful to make a distinction between the extent of the wounds and their mechanism.

Small wounds are not so serious as largeincised wounds are more benign than those due to some contusing agent, which are more exposed to gangrene; the wounds produced from within out by the fragments themselves, are not, as a rule, infected, while those from without in generally are; wounds by modern projectiles are less dangerous than those of large calibre, since they do not shatter the bones so much. Lastly wounds produced secondarily from the prolonged pressure of a fragment are less grave than immediate wounds, because we can avoid infection by appropriate dressings.

There are several principles to guide us: In the first place if the patient is caused much suffering by the examination, we should without any hesitation resort to lumbar anesthesia by stovain. In the second place, I wish to insist on the especial advantages from the use of

peroxid of zinc, either in the form of gauze or powder, in the treatment of these fractures. Next I wish to warn against irrigation with antiseptics which lowers the vitality of the cells, and at the same time raises that of the microbes, furnishing them the necessary moisture.

The prognosis of these fractures has changed decidedly since 1877. Before that time every compound fracture necessitated amputation, which was generally fatal, hence surprise was great when Volkmann in this year published a series of 75 cases of compound fractures without a death, treated by systematic large opening and antiseptic cleansing of the fracture focus.

Volkmann's doctrine need not be followed too closely, and it is not necessary to resect largely all open fractures. On the contrary, I advise operation as seldom as possible. This may have more unpleasant consequences than a simple dressing.

In short, immediate operation may of itself cause infection of a focus which left alone, might have remained aseptic. Even when we operate in simple fractures, especially those of the patella, it is indispensable according to Championnière not to operate before the fourth or fifth day, since intervention in an area contused by trauma is exposed to infection. There is another reason for delaying operation as long as possible, namely, complete removal of the spiculæ often causes considerable loss of substance in the tibia, with marked shortening or absence of consolidation as a result. In simple fractures all the spiculæ are used in the formation of the callus, and our aim should be to preserve them where possible.

In old alcoholics, operations are often followed by suppuration, gangrene or delirium tremens. By operating at once we invite the onset of these nearly always fatal accidents, by operating late, on the contrary, the responsibility of the surgeon is not so great. For the same reasons when we do operate, the incision should be as small as possible to lessen the chances of infection.

What I have said refers to a fracture seen in the beginning. It is of course entirely different when we have to do with an infected focus-here we will have to make large openings, resect the fragments, remove all spiculæ (no matter, how numerous), and drain all the

infected recesses. Thus we enter the category of infected wounds, which should be freely opened, drained and freed of foreign bodies (in this case the spicule).

I shall divide complicated fractures as follows, those with:

(1) A punctiform wound.

(2) A wound an inch or so in extent. (3) A large wound with relative integrity of the vessels and muscles.

(4) A large wound with contusion of the soft parts.

(5) Secondary infection of the focus.

I. In fractures with a punctiform wound, cure is the rule with thorough asepsis, if the deep hemorrhage is not too great. The course to pursue is to anesthetize the limb by injection of stovain into the spinal canal, shave, wash with soap and alcohol and dry. I object strongly to introduction of any liquids whatever into the fracture focus under pain of having a fatal infection. I also object to sealing up the wound with collodion which encourages suppuration.

In my opinion it is much preferable to dust the wound with peroxid of zinc, place over this a thick layer of peroxid of zinc gauze, covering this-not with cotton, but a simple gauze bandage, so as not to delay the application of the plaster bandage which should be done at once. If we have no plaster, we can use cotton strengthened by wooden splints.

II. When the wound measures an inch or so in extent it is generally produced by the upper fragment. We can distinguish three varieties: (1) The fragments do not protrude.

(2) The upper fragment is protruding but reducible.

(3) The upper fragment is protruding but can not be reduced.

(1) When there is no protrusion of the fragments, it is somewhat delicate to determine exactly what course to pursue. As I said before operative intervention may sacrifice quite an extent of bone which should have been preserved, and it is possible also that an operation may give rise to suppuration which would not have developed with aseptic but non-operative treatment. On the other hand, to wait for the appearance of sequelæ before operating is to expose the patient to much more serious de