decided by the damage it has done, its size and its

nature.

A thorough examination and complete record of an injured eye should always be made, and the vision of the fellow eye recorded, with any anomalies that may be found, as these cases are often the cause for damage suits.

Many times the ophthalmologist by careful treatment, by exercising conservatism and forbearance, can save for his patient useful vision, or at least his eyeball. 100 State street.

INJURIES OF THE EXTREMITIES.*

BY JOHN BINNIE, M. D., OF POYNETTE, WIS. The first thing to consider will be some form of classification according to the kind of force, weight and machinery, producing the injury. But it will be impossible in this paper to name all the various kinds of force, thus making my classification imperfect. I will therefore content myself with three general classes: First, crushing forces.

Second, cutting and lacerating force.

Third, falls from high places or vehicles or other conveyance.

The injury in each class may vary greatly in severity. There are so many conditions and circumstances that affect the degree and extent of such injuries from slight to the gravest degree, that each case becomes a law unto itself. They are produced by machinery of some kind generally in motion, such as car wheels passing over an extremity with an unyielding surface underneath, or it may be a wagon or carriage wheel with the earth as the under surface which may vary greatly in its resistance. The extremities may be caught by some falling body, as falling timbers or walls. These will be crushing accidents.

Second class. The person may have a hand or other part caught in some revolving machinery, such as thrashing machines, corn huskers, etc., and the part be cut, lacerated and torn into fragments. In these cases the soft parts may alone suffer, or bone and all may be destroyed. This form like the preceding will vary greatly in degree from slight to the most severe; an extremity may be literally torn from the body.

In the third class a person may be thrown from a vehicle, or may fall or jump from some high place. These injuries generally produce simple or compound fractures. Seldom comminuted, generally complicated with injury of the trunk. We should always be very guarded in our prognosis in this class as the internal injuries may not be manifest at first in all their gravity.

The severe injuries in either class will demand the surgeon's best judgment, not only as to what to do, but as to when and how to do it for the best interests of the patient's present and future condition. Any given case may be a clear one for amputation. Shall it be done immediately or wait a few hours? The patient's condition may be such that it is not advisable to amputate at once; the part may be the cause for delay. One may be

*Read before the tenth annual meeting C., M. & St. P. Ry. Surgical Association, Chicago, December 18 and 19, 1902.

unable to decide as to the absolute necessity for an amputation. In severe crushing accidents, shock is immediate and severe, as a rule. When amputation is required, in such cases, the time and condition of the patient and the point where to amputate will be very important questions to decide. They will involve: Shock and reaction, contraction of tissue, and adaptability for an artificial limb.

While we should be very careful to save as much as possible, we must be mindful of the great liability of the tissues to contract after primary amputations in these crushing injuries, necessitating a secondary operation, which is very unpleasant to both patient and surgeon. The thicker and heavier the parts, the greater contraction. The tissues are devitalized considerably beyond the injury. If the case will admit of delaying a few days, I think the tissues will revitalize nearer to the injury than if an immediate amputation is done.

In the second class, lacerated and torn injuries do the work as soon as possible. Shock is not so sudden nor do I think as severe; the parts are benumbed and the patient will bear the necessary dressing better. These injuries become more painful as time goes on, and the ragged and torn tissues are open to infection and die rapidly if left exposed to the air. Exposure to cold. atmosphere means death of tissue that might otherwise. be saved. Hot water, and as rapid dressing as compatible with thoroughness is all important in these cases as a rule. If one must delay for any cause be sure to protect the parts with a good covering of moist heat and antiseptic lotions to maintain warmth or prevent infection. The points that determine for an amputation are destruction of blood vessels, nerves and bone, important in the order named; second, crushed joints, which are always serious. Of course the indications for amputation should be clear and unmistakable, otherwise the question of saving the part is to be very carefully considered. That he is the best surgeon who saves the most, is no doubt true. Nevertheless it has its exceptions, especially in injuries of the hands and fingers. Fingers that cannot be saved without being ankylosed, in many instances had better be off. We must remember that each finger or part of a finger has an individual value. For instance, the little and ring fingers do not have the value of the others, and if they are to be ankylosed, especially if in bad positions, are sure to be in the way and better off, while the index and middle fingers may be very useful members if the thumb is all right.

Severely injured joints will be almost sure to be ankylosed if the patient recover.

This makes it very necessary for us to consider their future usefulness and the best position to place them in. The knee should be straight; the ankle in most natural position to walk with; an ankylosed ankle if in good position is scarcely noticeable. The elbow should be more or less bent; the wrist as near straight as possible. Ankylosis in the lower extremities if in fair to good positions is very much better than in the upper extremities, no matter how good the position may be. The early and persistent application of passive motion is the best and only means to prevent ankylosis, and I would use it even at the risk of increasing the deformity, if I could secure

partial or complete motion. It is surprising what results one will sometimes secure by persistent passive motion in these cases. When a limb is ankylosed, no matter how bad the position, the patient will seldom submit to an operation to correct or remove it afterwards. They will rather go round cursing you for not amputating, or doing different at the time of the accident.

The next question is how best to treat cases where we are in doubt as to the absolute need of amputation, in order to give the patient the chance to have a fairly useful limb. In crushing injuries, I would place the parts in as near the natural position as possible, apply supports to the sides of a lower extremity-bags of warm sand or the like to steady it, and apply hot water very thoroughly for from six to twelve hours. Then plenty of cotton or other light material, dress as loose as compatible with safety, but aim to maintain the natural heat. Where the skin is much broken I would use listerine, borolyptol or dilute alcohol. These may be applied either separately or combined, the object being to maintain heat and an aseptic condition. With these dressings you can control inflammation in a great degree. In some cases there will be death of tissue in spite of any treatment, but heat well directed is the best agent to stimulate life in weak tissue. Heat, rest and antiseptics, with a good constitution, will often surprise the most experienced in their reparative powers.

The reason I speak as I do in regard to amputations, is because in these days of antiseptic surgery, nature will sometimes repair parts in such bad positions that they would be better off both for looks and utility to the patient. The older surgeons may have amputated too often, and we may be going to the other extreme. I am well aware that it is a poor member that is not better than an artificial one. But we mortals are so prone to go from one extreme to another, that we are seldom just right in our teaching. Far be it from me to say aught against conservative surgery. But there are times when it may

be most conservative to amputate. In the third class of injuries of the extremities we will generally find simple or compound fractures, seldom comminuted. The injuries of the trunk are often the most severe. In fractures reduce them, place the parts in as perfect coaptation as possible. The best guides that we have succeeded are: The parts look natural and are nearly or quite free from pain. A fracture well reduced should not be very painful; if very painful we can almost certainly depend upon it that something is not just right. The bones are not in perfect coaptation, or some tissue is being impinged. Under these circumstances never rest satisfied, the dressing may be too tight. I think we often dress fractures too tight and hinder repair.

I never dress recent fractures in plaster of Paris, because if done before swelling has occurred it may become too tight, and if much swelling exists it is sure to become too loose. I have seen bad results occur from both conditions, when applied by men who considered themselves experts. The best thing in my opinion to dress a fracture with is brains. There are many patent splints and devices to dress fractures with, and each has its friends. No paper can lay down positive rules for all conditions.

The surgeon must act upon his own judgment, often with little time for thought; the surroundings and circumstances are often very unfavorable. I am not alluding to the surgeon in a well-appointed hospital with all modern appliances at his command, and trained nurses ready to render any assistance necessary. No, he is out in the country, and has received a sudden call. Some one has been hurt 6 or 10 miles away, he does not know the nature or extent of the injury. The night is dark, roads bad, everybody is excited, several neighbors present, (some of them you wish were at home or some where else). The case is a fracture of the femur or a hand blown off by the bursting of a gun. The surgeon has but little with him suitable; amputating case and splints are at home miles away, no town or other assistance nearer. The surgeon must keep cool, be very civil to all present. He must use all the antiseptic precautions possible, as they are accepted surgical principles, or suffer blame. So he procures hot water and soap and cleanses his hands as best he can, then the field of operation, using bicarbonate of soda or saleratus if nothing better can be had, finishes with bichlorid solution if he happens to have the tablets with him, if not he uses normal salt solution.

If it is a fractured femur he procures some board and makes splints, tearing up an old sheet for bandage. If a hand has been blown off, if he has a metacarpal saw in his pocket case he proceeds to amputate if the case is very urgent, or ligates the vessels and waits until morning. The light is poor, only kerosene lamps and few of them, the house and all surroundings bad. Fence board or shingles make splints and the shell of a corn stalk a good finger splint.

These are no exaggerated conditions, nor uncommon circumstance to the country surgeon. He is expected to be prepared for every form of accident at a moment's notice. While every intelligent person knows it is impossible in such circumstances to do everything in the best manner, the only wonder is that he gets as good results as he does.

DISINFECTION OF RAILWAY CARRIAGES.

At the recent International Congress of Hygiene and Demography, Dr. Redard, principal medical officer of the Paris railways, maintained that disinfection by gas-for example, the vapor of formaldehyd or sulphurous acid gas —had no effect whatever upon tubercle bacilli and was therefore useless. Hot air at 262 degrees F. was one of the best disinfectants, so were mercuric chlorid, calcium chlorid, sodium and potassium hypochlorite.-British M. Jour.

SPITTING IN CARS.-The Railway Commissioners of New South Wales have drawn up a new law which became effective August 1, 1903. This reads as follows:

"Any person in any railway or tramway carriage who shall spit into or upon any such railway or tramway carriage shall be liable to a penalty not exceeding £2.”

It is interesting to note, as the British Medical Journal remarks, that the restriction applies not only to smoking cars, but to all others.

BY EVAN O'NEILL KANE, M. D., OF KANE, pa.

This knife, manufactured for me by Feick Brothers of Pittsburg is of medium size; has a rounded cutting point and short oval blade, and shank long, narrow and almost round. The back of the blade also cuts, but is shorter and has a sharp heel.

This knife enables the operator to cut to great depths without having to enlarge the skin opening, it only being necessary to bring the handle from the horizontal to the vertical as the depth increases..

One can thus perform a laparotomy through a much smaller opening than would otherwise be necessary. As the cutting surface is short there is no danger of rewounding the divided tissues above the immediate operative field, and the long, narrow, rounded shank neither bruises nor obstructs the view. The cutting surface on the back enables the operator to cut backwards without having to turn his knife, and the sharp heel makes it easy to clear the wound angles from within out, without it being necessary to incline the knife.

This knife will be found especially valuable in all work at great depths in a confined area, as in disarticulating the hip-joint; in the ligation of deep seated vessels; in appendicetomies and other abdominal work (particularly upon. stout subjects when it is desired to make a small opening); in vaginal hysterectomies, perineal lithotomies, and in work upon the cervix uteri. It is not a good blade for ordinary amputations, having too short a cutting surface, but as conservative surgery has made amputation out of fashion, this is no great drawback.

SOME IMPROVEMENTS IN THE METHOD OF LOCAL ANALGESIA.

BY A. E. J. BARKER, F. R. C. S., ENGLAND.

The author refers to certain observations by Braun on a method of overcoming the drawbacks incident to the usual mode of producing local anesthesia. This method is based upon the old experience that anything which retards or diminishes the circulation of the blood in a part enhances the potency of the analgesic agent. Experiments were made with adrenalin, a very small quantity of which was injected with B-eucain (or cocain) into the author's arm, and subsequently into the arms of patients. After twenty minutes the part was quite blanched and wholly insensitive to pain, remaining so for about two hours. Adrenalin alone, used in this way, had no analgesic effect, while the results of the use of the combined solutions of B-eucain and adrenalin were far superior to those produced by B-eucain alone.

The most convenient way to prepare the solution is as follows: Powders each containing 3 grains of B-eucain and 12 grains of pure sodium chlorid are kept in thick glazed

*Read at tenth annual meeting American Academy of Railway Surgeons, Chicago, October 8-9, 1903.

paper, ready for use. When needed one powder is dissolved in 32 fluid ounces of boiling distilled water, and I cc. of Parke, Davis & Co.'s solution adrenalin chlorid is added when the fluid is cool. The solution is left in the glass beaker in which it has been boiled, which is carefully covered and placed in a vessel of warm water to keep it at blood heat. The injection is made by means of a simple syringe of glass and metal of 10 cc. capacity, with rubber washers, which can be sterilized by boiling.

To illustrate his method the author describes an operation for the radical cure of inguinal hernia. The hernia is first reduced and the index finger is thrust into the external ring as far as possible. Along this finger the needle is entered and the inguinal canal is filled with 10 cc. of the solution. An endeavor is made to inject it all around the neck of the sac so as to reach the genital branch of the genito-crural nerve. The needle is then entered at the external end of the line of incision in the skin, and is made to infiltrate the superficial layers of the latter down to the root of the scrotum, making the resulting wheal at least an inch longer at each end than the incision is to be. Injections are then made at a point 1⁄2 inch to the inner side of the anterior superior spine, the needle being thrust toward the ilio-inguinal nerve, and at a point about 1 inch above the middle of Poupart's ligament where the iliohypogastric nerve is most conveniently met. Then the thigh is flexed and another syringeful is injected along the ramus of the pubis and the root of the scrotum or labium. It is necessary to wait twenty minutes after the last injection for the full effect of the adrenalin to develop. The whole field of operation should be blanched and insensitive to pricks, but not to touch-analgesia, not anesthesia. The incision may then be made with confidence that no pain will be felt. The absence of oozing of blood is noticed. Only large vessels bleed at all.

Success depends upon a mastery of the principles, and practice in the details of the method. It is not enough to inject the fluid under the skin generally. Due regard must be had to the position and course of the nerves supplying the structures to be dealt with. The adrenalin compound, by slowing the circulation, prevents the anesthetic agent from being rapidly washed away. The writer has used this method in 30 operations, including hernia, orchidectomy, varicose veins, psoas abscess, loose body in knee, grafting and cystic edenoma of the thyroid.-London tumor of neck (actinomycosis), colotomy, Thiersch skin

Lancet.

TEMPERANCE IN RAILWAY EMPLOYES IN PRUSSIA.The Railway Department of Prussia, which controls pracing of non-alcoholic beverages by its employes. Large tically all the railroads, is taking steps to encourage drinkmachines for making sparkling lemonade and large coffee urns have been installed in the shops as well as the sleeping quarters. The beverages are furnished at cost.

Be cautious in fractures of the ribs about exhibiting opium if the sputum is very viscid, or very abundant. In the former case its tenaciousness is increased by the drug; and in the latter the nervous reflex is dulled, and the stimulus for the constant removal by coughing is

lessened.-Fenwick.

Traumatic hernia, or hernia "a effort" of the French, is of considerable importance in railway and accident insurance circles, where claims are filed for this disability, though it is really not due to the accident. This question is of especial importance in Europe, where, as notably in Germany, workingmen's or industrial insurance, is in vogue.

While there is considerable disagreement among authors on several points, the consensus of opinion is that this variety of hernia, to be properly classed as traumatic, must occur through a laceration in the abdominal wall, and when it appears at one of the usual sites for hernial protrusions it is probably not of traumatic origin.

According to Sultan, several conditions must have been present before we can decide on the accidental origin of the hernia.

I. The patient must have unduly exerted himself, or have been actually injured.

2. We must be sure there was no pre-existing hernia at the site of the new protrusion.

3. The pain in the vicinity of the new hernia must have been so sudden and severe as to cause the patient to stop work. Moreover, the attending physician must have discovered the presence of unusual tenderness in the same vicinity on his first examination.

4. These accidental hernias are small, as a rule, in fact, they rarely reach the size of a lemon.

Sultan adds that there is seldom any hemorrhage or swelling about the hernia.

Guermonprez has recently* reported a case which seems to furnish nearly all the necessary requirements to be included in the class of traumatic hernias.

A man of 43 years was caught between a post and a wagon, while the wagon was on a down grade. He remained at home in bed for one day before being examined. During this time there was said to have been some rise in temperature. When first seen' an opening was found in the right side of the abdomen, oval in shape, with the long axis from above down. This had all the appearances of a ventral hernia, and pressure with the finger admitted the latter, as in hernia at the umbilical ring. On palpating the inguinal ring it did not appear to be patent. There was an area of ecchymosis some two inches in diameter above the protrusion, and the latter became spontaneously reduced when the man was lying down, only to reappear when he assumed the upright posture.

The patient staid in bed for several days, and the hernia underwent spontaneous cure.

HIP-JOINT AMPUTATION; PREVENTION OF HEMORRHAGE.

In performing an exarticulation at the hip by Rose's method, a large amount of blood in the intraosseous vessels remains uninfluenced by an elastic bandage and ligature, and, according to Riedel, is lost when both the femoral artery and vein are ligated at an early stage of the operation. This loss of blood proves highly deleterious to the patient, especially if his vitality has been impaired by a previous exhausting disease or severe injury.

The problem of preventing this loss is solved by ligating the artery only at first and postponing the ligating of the vein until the last stage of the operation. In this way the negative pressure existing in the thoracic cavity and large venous trunks is enabled to withdraw the blood from the intraosseous vessels before the completion of the operation, so that after ligating and dividing the femoral vein, only a few drops of blood are lost from its distal end. Therapeutic Gazette.

Never forget that rupture of the membrana tympani, or even fatal consequences, may ensue from roughness in removing foreign bodies.-Fenwick.

*Gaz. des Hopitaux, July 21, 1903.

First Aid and Emergency.

(Conducted by CHARLES R. DICKSON, M. D., Toronto, Can.)

THE CHICAGO & ALTON'S EMERGENCY SERVICE.

BY HOWARD CRUTCHER, M. D., CHICAGO. Consulting Surgeon of the Chicago & Alton Railway and Surgeon, Chicago Baptist Hospital.

The thought occurs to me that I am not, perhaps, the one best qualified to write this article. Personal interest is prone to warp human judgment, and our successes are more pleasant to dwell upon than our failures. In a former communication to this journal I laid the blame for most of the medical follies of the railways at the door of the laymen who own and operate the lines. It is my present purpose to acknowledge in this place the invaluable service that I have received from laymen in the evolution of a practical service for the Chicago & Alton. To Mr. Felton, Mr. Barrett and Mr. Crothers I am most deeply indebted, but to many an humble layman, unknown and unnamed, I hereby acknowledge my deepest thanks.

It is proper to say at the outset that the whole idea of an emergency service originated with President Felton and not with myself. He told me what he wanted, in a general way, but imposed no conditions, either as to equipment or as

I do not mean to add something to it, but possibly to make it still smaller, less costly and still more to the point.

Simplicity is absolutely essential in all emergency service. One night, in an out of the way place, I stepped into the cab of a switch engine and said to the fireman, "I see that you people have put on an emergency package for little injuries; how does it work?" "Well, sir, we ain't tried it yet: we just use a quid of tobacco, put on some waste, and send 'em to the doctor." I left the cab somewhat humiliated, but consoled myself with the reflection that some of the packages that I had seen would not even have been honored by a place in the engineer's box. The fireman had explained that my little package was carried "because it took up no room and the man who got it up had no doubt good intentions."

This incident shows in a way how difficult it is to get untrained men to handle unfamiliar things. In time, doubtless, the merciful advantages of the small package will be generally recognized, but I do not expect any such result to come in a day or a year.

Next to the ponderous and complex emergency box, perhaps the greatest absurdity is the average stretcher that is carried in all well-equipped baggage cars. Some of these stretchers are so stupid in design that one is compelled to wonder where such freaks ever originated. To discuss their various absurdities would carry this article beyond the limits of reason. The essentials of every one of these appliances must be ample length, full width, abundant strength, and

to expense. It is a singular fact that our expenditures in this line should have been made largely for the benefit of those who have no legal or moral claim upon the company. tramps and trespassers. My present impression is that nine out of ten packages returned to me for inspection have been opened for the benefit of some trespasser, seldom an employe, and rarely a passenger.

We have in service an emergency package, a small tin box easily carried in the pocket, intended for the free use or laymen, and a passenger train chest, carried on all firstclass passenger trains, intended for the use of surgeons. The latter need not be discussed at length. It is sufficient to say that the educated surgeon will find the chest equipped with all the necessaries for the performance of all necessary emergency operations. The cost of the chest is under fifteen dollars. Its maintenance cost is trifling.

The emergency package, a pocket size tin box, contains a box of wound powder, a gauze pad, a roll of absorbent cotton, a stout muslin bandage, and some safety pins. It is not necessary to consume valuable space in narrating the tedious processes by which this box and its contents were evolved. It is enough to say that the average layman is not skilled in the treatment of injuries, and that any complicated outfit would be sure to defeat its own purpose. Inside the box is placed a leaflet of directions, written in plain language. On the back of the directions is a cut of a Spanish windlass, showing a simple method of stopping bleeding from an arm or leg. The completed package makes a decidedly attractive appearance, and costs about 30 cents. This package was piaced upon all cabooses, in all cabs, at some of the stations, and in the switch yards. It has been of decided value. I have watched its working with deep interest and am on the lookout for some chance to improve it. By improving it,

sufficient handles. With these points well in mind, I devised a canvas stretcher, herewith illustrated. It is 75 inches long, 27 inches wide, has eight handles, will support 600 to 1,000 pounds, weighs a trifle over three pounds, and when folded may be carried over the arm as a lantern is carried. It is made of brown canvas for obvious reasons. While the appliance is wholly my own conception, I named it in honor of my company. Its use is not restricted by any patent or copyright. While I do not believe it to be perfect, it does possess some decided advantages to which everyone is freely welcome.

I have aimed to set forth in brief fashion the main features of the subject, with no thought that our service is perfect, and certainly with no desire to do more than to aid in some slight degree the evolution of a simple and effective emergency system, creditable alike to the surgeons and to their superiors in the railway service.

A WARNING TO LAWYERS.-The Supreme Court of Wisconsin, in passing on an appeal in a personal injury suit, felt itself compelled to rebuke the methods that had been used by general Edward S. Bragg, who had been General attorney for the plaintiff in the lower court. Bragg had made allusions to the great wealth of the Chicago & Northwestern Railway, the defendant in the case, to the number of people killed and injured by its trains during the year and to the character of some of the officers and employes of the road. Such allusions, the court said, tended to unfit an ordinary jury for rendering justice.