a riot would follow the introduction of a leper into a rail

way car.

The word tuberculosis, he contended, makes little or no impression, in face of the almost certainty that not less than 150,000 of those now living in the United States will be dead of consumption within another twelve months, and three times that number will be attacked in the same period. People, he said, do not take precautions against influenza, which kills a thousand where leprosy kills one. All intelligent observers could clearly see the possible harm which might attend the transportation in railway trains of cases of smallpox, yellow fever, bubonic plague, diphtheria, scarlet fever, typhus fever, and leprosy, and in consequence, public opinion would not tolerate such a thing. An equal understanding in regard to pulmonary tuberculosis, influenza, and typhoid would develop a public opinion demanding that rational regulations intended to prevent transmission must be rigidly enforced. Special compartments for persons sick with communicable diseases were impracticable.

The management of the Pullman Company, in controversion of the criticisms of the sanitary condition of their cars, has sent out this statement of just what the process of cleaning is: As soon as a Pullman car arrives, at its destination it is entirely stripped, the carpets are beaten and aired and the interior of the car is thoroughly scrubbed with soap and water. The blankets are taken out of the car and are thoroughly blown out with com

pressed air at a 90-pound pressure. It is impracticable to wash them after every trip, but they go to the laundry several times a year, which is oftener than in the case with hotel blankets. All linen is renewed each trip. Every case of sickness in a car, however trivial, is followed by the antiseptic cleansing of the section occupied by the sick person, and the entire car is sprayed with formaldehyd. As a further sanitary precaution, in the newer cars of the company, purely decorative draperies are being omitted, and the necessary ones, such as berth curtains, are being made of lighter material which does not hold dust or odors.

RAILWAY AMBULANCE.

One of the new features of Parisian life is an ambulance of improved shape, introduced by the military and fitted to run on tramway lines. Jolting entirely disappears. It is hoped that the municipality will adopt it.

water.

A CHEAP METHOD OF REMOVING SILVER STAINS FROM WHITE FABRICS.-Moisten for two or three minutes with a solution of bromin 5 in water 500. Then rinse in clear If a yellowish stain remains, immerse in a solution of sodium hyposulphate 150 in water 500. Rinse in clear water. This formula has been found especially useful for hospitals and laundries.-Med. Record.

THE VALUE OF THE FINGER JOINT.-Five hundred dollars is the value placed on a man's finger-joint by a jury in Newark, N. J. Henry Klein, a hatter, in Newark, was the plaintiff. While at work on September 21, 1902, Klein's left hand was caught in a forming machine, and one finger was so badly crushed that it was necessary to amputate it at the first joint.

First Aid and Emergency.

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

FOR THE SAFETY OF RAILWAY MEN.

Two bills which will prove of great interest to the railway operatives of Canada will be presented before Paaliament.

(1.) Ralph Smith, Nanaimo, has in a bill entitled "A Safety Appliance Bill," and is intended to reduce the annual death roll among railway employes. Among other things it provides for a uniform automatic coupler of a standard height on all cars, engines and tenders, for air brakes on all cars, and step-ladders on the side and end of every car. The lack of the latter is said to be responsible for many accidents. In support of this bill Mr. Smith quotes from the Government Year Book, which shows that lost year the casualties among Canadian railroad men from various accidental causes amounted to 117 killed and 1,075 injured.

Hon. A. G. Blair, interviewed with regard to this bill, stated that the whole matter would be under the control

of the proposed railway commission.

(2.) Mr. Guthrie, South Wellington, has introduced a bill to amend the Railway Act. He explained that the bill was intended to safeguard the interests of railway employes, which, under existing legislation, were somewhat jeopardized. Railroad employes objected that in many instances they were compelled to become members of insurance and benefit societies as a condition of their en

tering the employ of a railway company, also that having regard to the amount charged against their wages by these societies, the amount of insurance they received. in case of accident or death was entirely inadequate. On becoming members of these societies at present in existence on many Canadian railroads they had to forfeit their common law rights against their employers on account of injury or death through negligence of the company or their fellow servants. The law at present was not very clear on this point.

On the Grand Trunk, which employed about 25.000 men, a benefit society was formed under special legislation to which all employs of the road were compelled to belong. One rule of this society provided that in case of accident from any cause the company should be exonerated from liability. This had given rise to much litigation without any definite result. The same question had arisen on the Intercolonial Railway, and a Quebec court held that the widow of the deceased employe could recover damages, but this decision was reversed by the Court of Appeal. While such finding might be according to law, they were opposed to the trend of all modern legislation, which was in the direction of giving greater protection to employes, especially with regard to proper redress in case of accident, whether caused by neglect of the company or its employes.

The bill provides that any attempt made by the employers to contract away liability should be under the supervision of the court, and not stand in law, unless the agreement was shown to be made on a separate and distinct consideration as to the trial judge should seem reasonable. It also made it optional with the employes

whether or not they should become members of such insurance socieites, and that those employes already members should have power to withdraw on reasonable notice. It was intended that the provisions of the bill should apply to all government railways.

A PLEA FOR SPEED

FOR SPEED IN OPERATIONS.

It cannot be too often or too forcibly brought to the attention of the surgeon that danger from sepsis and shock is increased by the length of time of an operation. More especially is this fact of importance when exploratory work for the purpose of diagnosis is as common as at the present date. The danger of infection increases, it might be said, in geometrical proportion, to the time occupied in operation. Short and rapid work with the knife also avoids the serious results brought about by the long handling of the tissues, and also allows little opportunity for the entrance of bacteria. The shorter and quicker the operation the better the general condition of the patient, as well as that of the local wound, and therefore the less the chances of sepsis, even in the presence of many and virulent microbes. The converse of this proposition is true the longer the time is taken for the anesthetic and the operation, the weaker the patient's powers of resistance, the poorer the local tissues, and the greater the chance of growth of even a small amount of bacteria and a resultant infection. It is hardly a valid excuse for a surgeon to assert that he is a slow operator. If so, then he is not the proper person to be trusted with the chances of human life and death. An operator who is a dissector, handicaps by his tedious delvings the safety of his patient; and although he makes a beautiful dissection, the time which he has taken to do this has so depressed the resistance power of his patient that the liability to infection is seriously, and, at times, fatally, increased. There are very few operations in which it is necessary to rely upon the slow technique of the dissecting table. Anatomy is undoubtedly the keystone in the structure of modern surgery, and it is with no intention of undervaluing it that we say that the best surgeon is the one who can operate rapidly and carefully, using both his senses of sight and touch, and with a full knowledge of physiology and anatomy, remembering that the subject is a living body, not a cadaver. He must, above all things, appreciate the importance of bringing his client through the ordeal "Tuto, cite et jucunde.”—Med. Critic.

An old couple were sitting in a seat and the conductor noticed that they were gazing intently at the top of the Pullman car. Accosting the old lady, he said: "What is the trouble, madam?" "Wall," she said, "I see the clothes line up there, but I ain't got no pins to hang up my clothes with."

Always regard rib injuries in old people with anxiety. There may be, and usually is, pre-existing emphysema and bronchitis which will hamper the breathing greatly. -Fenwick.

A detention ward is being added to the Northern Pacific hospital at Missoula, Mont.

Extracts and Abstracts.

THE PRESERVATION OF LIMBS WHICH HAVE BEEN COMPLETELY RUN OVER BY RAILROAD WHEELS.

BY THOMAS H. MANLEY, M. D., PH. D., NEW YORK CITY, PROFESSOR OF SURGERY IN THE NEW YORK SCHOOL OF CLINICAL MEDICINE.

We witness every degree of injury to a limb which has been crushed under the wheels of various moving vehicles; but when a limb is caught and passed over completely by a railroad car it is, as a rule, completely cleft through; it is usually caught and crushed obliquelyhence the extent of shattering is great and the bloodbespattered parts become a shapeless, mangled mass. It is interesting to know if a limb can survive which has thus been injured by a railroad: i. e., sustained the weight of one or more tons-and yet escape total disorganization. Several such cases have come under my observation— if the testimony of the injured can be relied upon. I was inclined to be skeptical about it until I instituted an investigation bearing on this point, through the Railway Age, appealing for this information to a large number of surgeons who have had extensive experience in the treatment of railway casualties. Very many well attested cases have come to my knowledge, from eye-witnesses, wherein both wheels of a loaded street-car had passed over a foot without leaving anything more than a bad strain, or surface lacerations or deep contusions; but that the wheels of a freight-car could be sustained by a limb without its total destruction seemed to me impossible. Now, however, with the information in my possession, through the courtesy of several well-known railway surgeons, I have no further doubt on the matter.

From a medico-legal standpoint it may be well that a knowledge of this fact be more widely understood. My first response came from Dr. A. M. Daniels of Buffalo, N. Y., chief surgeon of the Erie system. He

says:

"I have had three cases. Case No. I: Frank Kinsella, age 62 years, residence, 848 Seneca street, Buffalo, N. Y. On April 28, 1884, he was lying across the rail of a switch filled with cars and looking down over a culvert, watching some laborers at work. An engine backed down and struck the string of cars, and one wheel of an empty box car went over Kinsella's left thigh at the middle third. I saw him promptly and found the thigh fractured in two places, once at the junction of middle and lower thirds and again about three inches higher up. The muscular tissues seemed partially divided, but skin was nearly intact. A line running entirely across showed the course of the flange of the wheel; and there was a one-half inch opening upon the inner side. This patient refused to go to the hospital and I was handicapped by his home surroundings. I found a limited circulation below point of injury and therefore made the effort to save the limb-resulting in a good recovery with about two inches shortening; but with a high heel to his boot he walks with a very slight limp.

"Case No. 2: James Fogarty, age 28 years, residence,

846 Clinton street, Buffalo, N. Y. On August 2, 1893, he had his left leg run over four inches above the ankle by an empty 'coal dump' car, resulting in a very bad compound fracture; but the circulation in the foot warranted the effort to save it. Some pieces of bone were removed soon after the injury. Extensive inflammatory action followed. Small pieces of bone exfoliated at intervals for several months, but he has fully recovered and returned to duty as a switchman about two months ago. I saw this patient yesterday and he walks perfectly.

"Case, No. 3: James H. Monahan, age 24. Residence, 600 Eagle street, Buffalo, N. Y. Employe of Erie Railway Company. On May 4, 1892, while standing at the end of a 'gondola' car, with a companion (who was killed) was knocked down and a wheel or wheels passed over the right leg at the middle third and also very badly crushed the left leg at the same point. The patient claims in the most positive terms that both legs were run over, but as I could not find the 'flange line' upon the left, am inclined to think he is mistaken, although the leg was terribly injured. My notes taken at the time are: Compound fracture of right leg at middle third with extensive laceration of all extensor muscles, some of them being torn from their bony attachments. The integument very badly torn and separated from the muscles. Limited circulation in foot. The left leg almost a duplicate of the right, except that there is no fracture. Both feet in a position of talipes-equino-varus.' As there was positive evidence of circulation below the points of injury, I decided to make the effort to save both legs, and after carefully 'trimming' out all of the destroyed tissue possible, reduced the fracture as best I could, applied the most approved dressings and had the satisfaction of having the best results. The patient now walks readily, but with somewhat of an ‘ataxic' gait."

Here we have the record of three cases from one surgeon. In two we find that the cars were "empties." In the first a double fracture of the femur with a fleshwound and-"limited circulation below the point of injury" was found, which encouraged the surgeon to spare the limb. In the second case there was a very bad compound fracture but-"the circulation in the foot warranted the effort to save it;" and full repair succeeded, so that he now walks perfectly. In the third case both limbs were crushed; in one there was extensive laceration of muscles, some of them torn from their bony attachments, but "as there were positive evidences of circulation below the point of injury" an effort was made to save the limbs and both were saved, and he now walks with merely an ataxic gait.

The second of the above three remarkable cases reflects great credit on the high scientific acquirements of Dr. Daniels.

They all inculcate several fundamental principles of modern, conservative surgery:

First-They demonstrate that a limb may be preserved after sustaining the great weight of a railroad car. Second-That the preserved limb may recover nearly if not complete function.

Third-They impress the importance of persevering

effort, providing only that the circulation to the parts beyond is intact.

In an experimental study some years ago on the influence of trauma on the limbs of frogs, I found that every description of fracture slackened or totally arrested the circulation in the webbing of the foot; when exceptional violence was employed the current in the microscopical vessels remained stilled for from twenty-four to fortyeight hours and then became re-established. Moreover we know from our experience with ligation of a main arterial trunk and complete occlusion of the vessel, after a time in healthy vessels a collateral route is established and full vitality restored. For this reason when we are in doubt, let us delay amputation! In the meantime, while maintaining strict asepsis, let us apply artificial warmth and aid Nature's powers of resuscitation.

I am very much pleased to add the testimony of Dr. W. B. Rogers of Memphis. He says:

"In reply to your second question, I will say that I have had three cases well authenticated, by the testimony of the witnesses as well as the appearance of the parts, that a car wheel had passed across the limb. In neither case was amputation done, and all three cases recovered with useful limbs; and in two instances the man's limbs were wholly unimpaired in function. I have seen several instances where the wheels of a car would pass across the heel of a man with a heavy boot on, in which amputation was not deemed necessary, the part recovering."

All recovered-and only one had any impairment of function! The cases were well authenticated. They are, therefore, an object lesson to us, warning us of the terrible responsibility we assume when we proceed to sever a limb, badly crushed, without permitting the recuperative powers of Nature ample scope.

Dr. Alex. Craig of Columbia, Pa., submits two more Thus :

cases.

"In reply to an inquiry, I would say I have served the Pennsylvania Railroad Company as one of its surgeons for the past twenty-five years, and during that time I treated one person (now our assistant trainmaster) whose right leg was run over diagonally by the wheel of a freight car; and a good useful leg was saved. I also had one patient in the service of the Reading & Columbia Railroad, who, after recovery from a similar accident, returned to the service as a locomotive fireman. In both of these cases the wheel passed over the leg between the knee and ankle."

Dr. Sayre Harnden of Waverly, N. Y., the well-known, live surgeon and late president of the New York Association of Railway Surgeons, writes me:

"I recall three cases where the wheel traversed the whole length of the lower extremity without crushing. In one there was a compound fracture of the tibia. I have seen more than twenty cases where the feet were run over, terribly injured, but not requiring amputation. A strong boot, or buckskin glove saves a limb often.”

That a locomotive should pass over a foot without destroying it seems incredible; yet here is a case! Dr. Thomas H. Briggs of Battle Creek, Mich., sends the following report of this remarkable accident:

"Frank Gilton, a conductor of the C. J. & M. R. R., on

August 7, 1893, had the drive wheel of an engine pass over the ball of his left foot, producing a compound, comminuted fracture of the tarsal, cuneiform and cuboid bones. I removed the loose fragments and portions of muscles and tendons, cleansed the parts, closed the wounds and dressed with gauze, surrounded the limb with wool, placed it on a splint, applied warmth and secured a complete recovery without a drop of pus. He now has a useful foot. The engineer told me he distinctly felt the engine run upon the foot and drop off again."

This, indeed, is startling testimony of the marvelous resistance of the foot to tremendous force; the drivewheel of a locomotive passing completely over it. The soft parts were opened and two or three bones fractured, but by intelligent treatment the patient recovered with a useful foot instead of a Pirogoff or Chopart amputation as of old.

But few realize what extensive damage the bones of the foot may sustain, provided only the integuments are intact, and a useful member result. All the toes may perish, and all the tarsal bones except the astragalus and calcaneus be sacrificed, and yet the person walk with scarcely a limp.

Dr. Chas. B. Fry of Mattoon, Ill., communicates with me as follows:

"Mattoon is situated at the middle of the St. Louis division of the Big Four Railway, and of the Peoria, Decatur & Evansville Railway. The shops of both roads are located here, and nine-tenths of the trainmen of both roads reside here. I have been surgeon for these companies for the past fifteen years, and have had a very large number of injuries to treat. I can recall only two cases in which the patients themselves have claimed that a railroad car-wheel had passed over their limbs without permanent disability resulting therefrom. In one case the patient claimed that a wheel of an empty box car passed completely over the ankle. There was no fracture or displacement of any bone, and no laceration of the skin or tissues. He recovered in about two months without any immobility of the joint. In the other case, the man claimed that a wheel, starting at the foot, ran over the whole length of the leg to about six inches above the knee. In this case the soft parts were badly contused, but there was very little laceration of the skin and no fracture, and he recovered without permanent disability. As to my personal opinion, based upon the experience I have had, I believe that it is impossible that a wheel of any railroad car, even an empty flat car, should pass completely over any part of any limb of a human being, either transversely or obliquely, without producing such injuries. as would necessitate the amputation of the limb."

Here we note a decided doubt, after a long and large experience, though he treated the cases wherein the histories pointed to the limb's having been run over-and he gives no good reason why the injured men should submit a misstatement.

Dr. R. P. Tye of Chickasha, I. T., sends a note of another remarkable case, as follows:

"In the case of Fred Vitieg, one car wheel passed over his leg from above the knee obliquely to near the ankle. There were well-marked evidences of the impact

of the wheel and flange on the one side of the leg and of the rail on the other. Mr. Vitieg and the bystanders declare that the wheel passed directly across the leg, but the bones were not broken! The soft parts sloughed to a large extent, but he recovered with leg on which he walks, though the muscles are so contracted as to cause him to limp."

Here we have a limb traversed by a car wheel in an oblique direction from the knee to the ankle, the bone shaft escaping while the soft parts are more or less crushed so that later there is sloughing, but the man recovers with a very good limb, only some rigidity remaining.

More marvelous is the subsequent report: A leg was run over, throwing the train of cars off the track, yet the man escaped without a fracture!

Dr. Warren B. Outten of St. Louis, chief surgeon of the Missouri Pacific System, contributes the following: "Sam B-, a negro switchman in the freight yards at St. Louis, while some empty coal cars were being shunted or kicked to a siding, was struck and knocked over, his ankle being caught under the first wheel which left the rail, as did the cars following. But Sam was no worse for his recontre; except for a large flesh wound where the flange of the wheel tore through the soft parts and a painful sprain which laid him up for a month, he was uninjured."

This class of cases seems to border so on the miraculous that to those who do not encounter those of parallel character, the cases may seem impossible or even absurd. My friend, Dr. R. H. Cowan, assistant chief surgeon of the Norfolk & Western Railroad, than whom few have. had larger experience in traumatism, assures me that he has had several cases of a similar character, i. e., those in which the bone shaft escaped but the soft parts were reduced to a pulp by wheel crush. In one instance, related to me by him, a young man's forearm was seized with gangrene on the third day after a bumper crush. On amputation through the mddle of the forearm he was surprised to note the absence of muscle on the extensor surface, the bones being quite nude. After the limb was amputated he found a large mass of muscle rolled up in a heap under the skin of the dorsum of the hand, mostly torn from the condyles of the humerus.

Dr. W. B. Apply of Cohocton, N. Y., sends me the record of three unusual cases-thigh run over with no fracture, and a wheel passing over a man's fingers without producing fracture!

“On February 16, I was eye-witness to a man who had a leg run over by one wheel of an empty car which did not produce a fracture, only lacerations, from which the man recovered with a perfect leg. Another man had both thighs run over by a loaded car, producing a compound fracture of both femora. This man recovered the use of both legs and in three months was able to bear his weight on them. I account for the slight injury to the limbs by the slow motion of the ears. In still another peculiar accident a train man attempting to get on his train fell into an open culvert, caught hold of the rail above and held his weight while one wheel passed over the fingers, only bursting the ends but fracturing no bones; perfect recovery."

The following case reported by Dr. H. M. Workman of Tracy, Minn., is another instance of the same class of violent compression force without production of frac

ture:

"George W. Custer, age 40, switchman, on September 21, 1883, while uncoupling a caboose, fell and one pair of its trucks passed over the upper third of one thigh. There was no fracture! There was a great deal of suppuration, but he finally recovered."

Here in the one case we find Dr. Workman an eyewitness of the accident-only the soft parts being lacerated and full recovery following. In the other, although the formidaable injury (a double, open fracture of the femora) was s)ustained, the limbs were saved. In another, yet though the fingers were crushed and pulpy and bursted, the phalanges were not fractured and recovery ensued. As the principal vascular supply to the digits is on the lateral aspect it is obvious how they escaped graver injury from a crush which did not grind the bones into small fragments.

From Dr. J. M. Hyde of Nelsonville, Ohio, comes this interesting account:

"Pearl M. Pierre, age 21 years, small and slim in build, weighing about 110 pounds, was a brakeman in the yards at this place. On the morning of August 26, 1890, while pushing cars in on a siding, he gave signal to 'kick' them in, pulled the pin and before gaining his balance the engineer reversed his engine, giving the car on which Pierre stood a very sudden and hard jerk. Pierre fell to the ground, scrambled and ran on his hands and knees or feet for a few yards, when the on-coming coal car struck him; he attempted to get outside the rails, but was caught with both legs across the rail, two trucks passed over both legs (two wheels). He was brought quickly to our office (only one-fourth mile from scene of accident), and was placed on operating table where Dr. Primrose and myself examined him. We found as follows: He must have been on his back (from marks of injury), the wheels crossed the right thigh at junction of middle and lower third obliquely from above downward, producing a horribly lacerated compound fracture, pushing lower fragment upward and outward, the upper fragment downward and inward, tearing the flesh into shreds. There were marks of the wheel plainly to be seen. The right knee was partially dislocated outward, the outer condyle lying or resting where the inner one should be. The wheels passed over the left leg about midway between the ankle and knee, the imprint of the wheel being plain; another horrible compound fracture resulted in even more laceration of tissues than in the right leg. We decided that a double amputation was the only thing to do and was about ready to operate when his parents arrived and said he 'should all die together.' Dr. Prichard was then called to assist in the case, and it was decided that no operation should be done. He was dressed antiseptically as far as possible, the fractures held by board splints made of shingles; they could hardly be applied without having them make pressure over a lacerated wound, so that in three days all splints had to be abandoned. We then thought the legs would 'rot' off, so we put both legs up in large flaxseed poultices, very warm, suspended them in swings hung from the ceiling, and packed sand bags along sides of limbs

to keep them in line. About two months elapsed before any dressing requiring bandages could be used; but early in the spring of 1891 he began to use crutches and about spring of 1892 he could walk fairly well without assistance. He now runs as mail or baggage agent. There were six or eight men saw the car wheels go over him; the car was a coal car of 18-ton capacity."

THE LESSON.

From the foregoing we have ample evidence that a limb or limbs may sustain the weight of a rolling car wheel or even the drving wheel of a locomotive without being totally destroyed or sometimes of even suffering serious damage. These, however, are very rare excep tions. In the greater number the extent of disorganization is great and the mangled parts present a harrowing aspect. Very often the poor injured patient is in extremis and life is fast ebbing away when he is brought to the hospital or home; again his agony is so great that he can bear no tedious manipulation of his wounds and we must as painlessly as possible place him in a position. of comfort until shock has passed off or mortal changes set in.

In former times when we were called to a case of extensive shattering of the bone and mangling of the soft parts, with a history that a railroad car had run over the limb, no time was lost in preparing for an amputation; but at present, with our effective prophylactic acids, vastly improved hygienic surroundings and an enlarged konwledge of the processes of osseous repair, while any possible evidence remains of the circulation being intact beyond the site of injury, we merely ligate bleeding points, cleanse and embalm the limb, and then place it in a position of comfort.

In dubious cases of bad railroad or other crushes involving an extensive, local mangling of a limb, we should disregard all rules for the mechanical adjustment of the shattered bones and in supporting the limb consult rather the patient's feelings than run the risk of aggravating exhaustion by tedious application of any description of splinting; here a cushion, there a bolster or pillow, affords the greatest ease and the least embarrassment to the tortured tissues, which for a time need undisturbed quiet as much as does the body itself.-American Journal of Surgery and Gynecology.

THE RELATION OF APPENDICITIS TO
INJURY.

BY HAROLD N. MOYER, M. D., CHICAGO.

A case recently came under my observation in which claim was made for damages, and the suit was brought for an attack of appendicitis. No opportunity was afforded for examining the individual, but the declaration which was filed in the case and the facts available show that the patient, who was a carpenter, seven days before an attack of appendicitis stepped into an opening and fell to the floor, receiving an injury to the right side of the body and abdomen. During the day of the injury and following it he was regularly employed, until the seventh day after the fall, when he went to his home and subsequently developed an attack of appendicitis, for which he was operated upon and recovered. The case raised the question as to how far injury might be a cause