Boarding car Collisions

1,255

369

117

1,174

1,156

2,789

10,707

442

457

Crushed in tunnel.

99

28

8

Flipping car

16

Hitching on car

13

An examination into accidents in Chicago and their causes has been made by the recently organized committee on public safety of the Civic Federation. Through an expert in statistics the committee has classified the 10,707 cases of death or injury from accidental causes reported by the police for the year 1903.

Street railway accidents, according to the report, are more numerous than those from any other assigned cause. They form 19 per cent of all the reported accidents. Accidents caused by falling are nearly 12 per cent of the total, and accidents due to personal violence nearly II per cent. Steam and elevated railways were responsible for less than half the number of accidents reported for street railways, or only 8.5 per cent of the total. A recapitulation of the accidents and the number of victims follows:

LIGATION OF THE INTERNAL ILIAC ARTERY.

Nearly a century has elapsed since this operation was first performed by Stevens of Santa Cruz (1812). It has usually been tied for hemorrhage, and the results have not been very encouraging. Lidell collected 27 cases with eight deaths, and d'Antona* found that in 25 recent cases the mortality was 40 per cent.

This author reports a remarkable case of bilateral sciatic aneurism, for which both internal iliac arteries were tied in succession and recovery ensued. Incidentally he insists on the following signs for differentiating between gluteal and sciatic aneurism. Relation of a tumor to a line between the top of the great trochanter and the postero-inferior iliac spine; position of the bruit in the same line; neuralgia appearing early in sciatic aneurism, due to the direct contact of the tumor with the sciatic nerve; hard edema accompanying this form of aneurism and caused either by vasomotor paralysis or excitation of the vasodilators.

Vulliet, who reports a successful ligation of the internal iliac for secondary hemorrhage from the sciatic artery. A man was stabbed in the buttock, and the bleeding arrested by plugging with iodoform gauze. Three weeks later profuse secondary hemorrhage ensued, which ceased by the use of compression and extension. This recurred twice in the following week. To stop the bleeding Vulliet determined to ligate the artery by the intra

* Archives Internatonales de Chirurgie, I, p. 69. +Ibid, I, p. 446.

peritoneal route rather than through the original wound. After the operation the patient had symptoms of paralysis of the sciatic nerve (dropping of the toes, marked muscular atrophy), probably due to partial section of the nerve. Massage and electricity were used, and when the patient was discharged his condition was much improved. He was able to walk without any pain and without crutches, there was a small area of anesthesia over the dorsum and the great toe, dorsal flexion was still incomplete and the muscular atrophy was much diminished.

The author prefers the intraperitoneal route, which is rapid, simple, causes less hemorrhage, and the ureter is the only structure to be avoided. The extraperitoneal route has for its chief advantage the leaving the peritoneum intact. This is not so important now as in the preantiseptic era, moreover, this method is longer, more difficult and mutilates the muscles more.

Firs Aid and Emergency.

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

RAILWAY ACCIDENTS.

The Norfolk and Western Railway Company issue the following instructions to be observed in case of accidents:

"Employes will observe the following medical directions in cases of accidents:

"A. In accidents to persons, the ranking employe of the road present will take command and direct proceedings for the relief of the injured.

"B. When there is danger from fire, remove all persons promptly from the train, looking first to those who may be helpless from injury or jammed in the wreck.

"C. Take hold of the injured gently but firmly and without fear. Lay the injured one down on cushions, blankets, clothing or straw, where he will have perfect ventilation and not be in a draught or strong current of air. Loosen the clothes about the neck and body to permit easy breathing, and place the injured part in a position most comfortable to the sufferer. Do not permit strangers to approach and talk to or ask the injured one questions. Place him, if possible, in charge of one or two friends and keep him warm with proper covering. "D. As soon as practicable, summon the nearest surgeon of the company and notify the superintendent by telegraph. State the number of persons injured and the nature and extent of the injuries, as clearly as time will allow, in order that the surgeon may come with what is needed.

"E. Bleeding.-If the bleeding is from the limbs, keep them bent and the bleeding points elevated as much as practicable.

"F. In case of broken bones, place the injured part in the most natural position, or, if this cannot be done, then in the position most comfortable to the patient. Having done this, seek to steady the limb either by splints of wood or by a pillow folded around the limb and tied in the desired position. In case of broken ribs, relief will he afforded by a wide bandage around the chest drawn as tightly as can be borne. When a broken bone is suspected do not move the limb about to find out if this

cases of weakness from shock or loss of blood keep the patient warm.

"I. Cold water, ice, tea, coffee, milk or soup may be freely allowed to all injured ones who wish them.

"J. In moving an injured person, place a board, door, shutter or mattress, with one end at the patient's head, and lift or slide him gently on it. If the patient can sit up, he may be carried in a chair or upon the locked hands of two persons, around whose necks he throws his arms to steady himself.

"K. When forwarding a patient who has been seen by a surgeon, obtain from the surgeon a written statenient as to his opinion of the nature and extent of the injuries, and attach this statement, along with the name of the injured one (if it can be obtained), securely to his clothing.

"L. When the injured person is able to be moved, take or send him to the nearest surgeon of the company in the direction in which the first train is moving. It can then be decided whether the patient will be treated there or taken to some other point.

“M. When the injured person is not able to be moved, place him in charge of the station agent, section master or some official of the road, and summon the surgeon of the company most easily obtained.

"N. In urgent cases, if no surgeon of the company can be promptly had, summon the nearest physician to take charge of the case until the company's surgeon arrives.

“O. In a general emergency, summon the surgeons of the company in both directions and wire the superintendent if more surgeons are needed."

It should be made an imperative rule in every factory that all injuries must be reported to the foreman at once, no matter how small or trifling. He or his assistant will apply the necessary first aid. If in any way doubtful as to recovery, the case should be referred by him to a competent surgeon, not the nearest, but the best. Chewing tobacco, dirty cobwebs, soot, mud, turpentine, coal oil, black oil, or any other oil, arnica, dirty rags, handkerchiefs in use, or rancid salves should never be used as a dressing for any wound.

Syncope or faint, fright and bleeding are the first difficulties to overcome in injuries. When your subject falls let him lie until he becomes conscious: then give him a drink of water, not whisky. Never apply ammonia or any strong stuff to his nose, nor sprinkle him with water; such treatment does no good. When the injured person is able to sit up wash his face and ears, and, when you observe him getting pale, make him stoop over low so his ears get red; he will then perspire and feel better and his faint goes away. Should it return, repeat your experiment. Encouragement and kindness is the most successful remedy for the frightened; especially children should be handled carefully. Never add to their misery with cruelty and unkind remarks.

Bleeding is the bogy man of surgery. Don't get scared by blood; when too severe, just hold the cut shut with your fingers and it cannot bleed.

Don't try to stop the bleeding by cutting off the circulation between the heart and injury. That is an old surgical superstition that generally causes more bleeding than if left alone, because it cuts off the veins. Tie the wound shut securely, as we will instruct you later in this series. A recent report of a first-aid surgeon shows that in over 36,000 injuries of all varieties, principally glass cuts, which bled severely, none have bled

Extracts and Abstracts.

AN X-RAY TUBE WITH ADJUSTABLE FOCUS.

R. V. WAGNER, M. D., CHICAGO.

If one examines the outline of a shadow from a light emanating from a large area-e. g., a gaslight-it will be seen to compare favorably with the outlines on a fluoroscope or on a picture, when the X-ray is used from a tube having the anode out of focus. On the other hand, the outlines of a shadow emanating from a small area-e. g., an arc lamp-resemble the outlines of a

than to focus a Crookes tube by guess, as to the distance the anode should be from the cathode, because of the skill required on the part of the glass-blower to seal in the stem supporting the anode, so as to hold it where he thinks it should be; his judgment of where it should be is purely guesswork because there is no way of testing, until the tube is exhausted and properly excited.

The new feature of my tube is in having the anode mounted on a threaded stem which can be magnetically operated through the glass, so as to move the anode up or down or circumferentially with the surface of the tube, to obtain an absolutely accurate focus (Fig. 3).

The little armature on which the magnet acts cannot possibly get out of adjustment, and will hold the anode in any required position, either in focus or out of focus,

fluoroscope or on a picture, when an X-ray tube having a sharply focused anode is used (Figs. 1 and 2).

The X-ray emanates from the molecular bombardment of the rarefied air in the tube on the surface of the anode. The structures of rarefied air are repelled from the concave disc or cathode forming the cathode rays or stream. This cathode stream striking the surface of the anode or disc in the center of the tube produces the X-ray. Το obtain a sharp focus the anode must be a given distance from the cathode, just as an object must be a given distance from a lens to be in focus.

In making a Crookes tube by all methods used heretofore, it has been practically impossible to get the anode the required distance from the cathode, so as to obtain a sharp focus, as the stem supporting the anode had to be sealed in the glass by guess, and the tube exhausted before it could be tested, when if the anode was found defective in respect to its focus, it was too late to remedy the defect, without going to an expense nearly equal to that of making a new tube. A microscope can not be focused accurately by a person who guesses at the distance the lenses should be from an object, without looking through them. This would be much easier, however,

Figure 5.

as the operator may desire for some therapeutic purposes.

When a cheap metal is used for the anode, it must of necessity be out of focus because it will not stand up under the strain of having the molecular bombardment confined to a very small area, as is the case when the anode is in focus. Platinum is the only metal that will do for a sharply focused anode, as it not only stands a very high degree of heat, but is not broken down by the molecular bombardment, like inferior metals, e. g., nickel steel.

In my tube the anode (Fig. 4) is completely covered

by a plate of platinum made very thick at the focus. This plate of platinum is electrically welded to the metal forming the body of the anode, and will stand an unusual degree of heat, and unlimited usage, even with the sharpest focus.

With my method of magnetically adjusting the anode, it is possible to make every tube alike, and to accurately focus the same after the tube is finished and in operation just as you focus a microscope by looking through the lenses, instead of guessing at the adjustment by observation as to the distance of the lenses.

In order to appreciate the vast difference in X-ray work due to the proper focusing of a tube, the sharpness of definition can be carefully tested (Fig. 5) by taking an ordinary wire screen, 20 holes to the linear inch (called a 20-mesh sieve), hold the fluoroscope 24 inches away from a tube, and it will be found that with a poorly focused tube the screen will have to be brought very near the surface of the fluoroscope in order that the mesh be clearly distinguished. The nearer it is necessary to bring the screen to the surface of the fluoroscope, the more the tube is out of focus; but the farther away the screen may be held and the mesh clearly distinguished, the more accurate is the focus of the tube. With a perfectly focused tube the holes in a 20-mesh screen will stand out perfectly clear at least 12 inches away from the fluoroscope, having the fluoroscope 24 inches away from the tube.

A few simple tests that will enable anyone to distinguish a good tube from a bad one should be carefully considered. X-ray workers posted on the requirements of a good tube will agree that it is more difficult to obtain a good tube to-day than it was a few years ago, before low-priced competition arose, and that two tubes made in appearance exactly alike, with practically the same degree of vacuum, and the same quality of glass for the bulb, will give entirely different results, on account of the difference in the focus effecting the definition in radiographic work. Every operator will find that out of a large number of tubes, as made heretofore, but one will do good work, and one that he is willing to adopt as his "pet tube."-Jour. A. Med. Assn.

TWO CASES OF DOUBLE SYNCHRONOUS AMPUTATION.

BY MONTGOMERY RUSSELL, M. D., SEATTLE, WASH.

The first case here given is an example of a slow train injury and the other of a train in rapid motion. In accidents caused by slow trains, as in switching and coupling, the force of velocity is much less, and these wounds are different in certain ways from those received by fast trains, and are more nearly similar to wounds received from other machinery and heavy bodies. In bumper accidents, or in the case of a leg or arm being run over by a train or car at slow speed, it will be found that the parts have been squeezed or pulpified, leaving a margin marked by the edge of the bodies between which the member has been caught, and it will be discovered by dissection that the tissues adjacent to the lesion are practically normal. The damage seen is generally the full damage done, and can be so considered in treating the same.

In the case of a fast train passing over a limb, a different state of affairs is often presented. The lesion may in some instances be apparently just as sharply defined, but the fact is that destruction has been accomplished way beyond this margin, and what appears to be uninjured tissue is in reality destroyed, or so devitalized that it will die, by reason of the shock to which it has been subjected through the impact to the part of such a powerful force. This condition exists for varying distances from the line of apparent injury, according to the speed and weight of the train. The actual cause of death of these tissues, beyond

the line of the wound, is the plugging for varying distances, of the large artery of the part by a coagulum of blood. This often causes gangrene rapidly to supervene, necessitating amputation of limb higher up. The speed of the train must therefore be considered in cases of this kind, in order to arrive at a definite conclusion as to how severe it may be and as a guide as to how it should be treated.

Case 1.-A. L., age 22 years, unmarried, brakeman on freight. While switching car on C. & P. S. R. R. at C. & S. brewery, between 5 and 6 o'clock a. m., slipped and fell under car next to engine, the wheels passing over both thighs, mangling and crushing them to pulp. He was brought to the city on a Northern Pacific switch engine and removed at once in the ambulance to Providence Hospital, where I amputated both legs, as soon as he had recovered somewhat from the shock. I amputated the left at junction of upper and middle thirds. He nearly died. on the table during the operation, but revived after injection of stimulants and transfusion of normal salt solution in the medial basilic vein of the arm. He never recovered entirely from the shock, and was conscious for only a few minutes before his death, which occurred at 2.30 o'clock p. m.

With the exception of considerable ecchymosis of the skin over the thighs, the appearance did not indicate the amount of damage to the bones and soft parts, which were comminuted and pulpified.

Case 2.-E. N., age 18 years, unmarried, switchman on C. & P. S. R. R. While standing on railroad track watching a car that was being switched, was run over by fast train, the car wheels passing over 'left leg, completely severing it at about the middle third; also crushing and mangling the right foot. The accident happened so quickly that he did not know his left leg had been cut off until he saw it lying on the track beside him. He was immediately taken to the hospital, suffering considerably from shock, but soon responded to the usual remedies. I amputated the right foot at the tarso-metatarsal articulation and it did nicely, giving him a good, useful stump. The left leg was cold and clammy to the knee, and the bone shattered considerably above the apparent point of injury, and in order to get into sound tissue, I amputated at junction of middle and lower thirds of the thigh. The amputation of this leg above the knee proved to be a wise provision, saving another amputation later on, as the popliteal artery was found filled with a long plug of coagulated blood, completely shutting off the circulation below the obstruction.

This young fellow made an uninterrupted recovery and gets around fairly well, with an artificial leg and a brace in shoe of right foot.-N. W. Medicine.

and loud was the eclat from the benches when, with a long, flashing blade, the surgeon, by a few deft sweeps, severed the limb from the body.

It went hard with the student up for his final in surgery who was not familiar with the disarticulation in foot amputations particularly.

We then had the "primary, the intermediate and the secondary amputations:" to-day we have what is better than all-no amputation at all after traumatisms until we are assured beyond any possible doubt that the parts to be severed are totally dead, till they are mortified and decomposition has begun.

We should disabuse our minds of the common impression that an amputation calls for high surgical art, for it does not. No surgeon lives, or ever did, who can give an assurance that a flap will not slough, that bulbar hyperplasia of a nerve-trunk will not follow, or necrosis of the denuded bone-shaft result. Nay! any tyro may amputate a limb secundum artem, but real skill and good judgment are always called for to preserve it.

One is astonished to note yet that some of our best known writers encumber the pages of their text-books with elaborate illustrations of several amputations which in pre-anesthetic and pre-aseptic time might be justified, but to-day, except for their historic interest, have no possible excuse for their existence in surgical literature. This is most palpably and notoriously true of amputations of the foot or parts of it.

This becomes obvious at once if we will recall the fundamental principles which should govern us here, viz., to preserve every possible portion of living tissue. By an intelligent resort resort to exsection, resection, the utilization of a crushed toe, stripped of its phalanges and tendons for a flap, that the mutilating, destructive tarsometatarsal disarticulation of Lisfranc may be dispensed with, for example. Patient, persevering effort in crushes through the arch will often enable us to cast aside the classic Chopart and spare medio-tarsal joints which constitute the body of the foot, its strength and elasticity.

The whole heel may be crushed off, and yet by the judicious employment of osteo-plastic surgery, a very useful limb may be preserved.

Any amputation of the foot which involves a destruction of the ankle-joint must be generally condemned, and hence both the Pirigoff and Syme should be relegated to the limbo of oblivion.

At all hazards and under all circumstances, after crushes involving the tarsus or disease spreading into them, a determined effort should be made to preserve the ankle-joints. In pathological conditions, especially in young adults or growing children, there is quite invarıably a redundancy of integuous surfaces, the extensive loss of which in traumatisms constitutes one of the most formidable difficulties in our way.

In all this class of pedal disorganization one must invariably warn the patient, relative or friends that timea prolonged period of it-is required when conservative lines are followed; they may be reminded, also with advantage, that the processes of "rapid recovery" after amputation from all local irritation and pain are generally a delusion, as but very few stumps remain free from exquisite sensibility and neuralgia; moreover, the most perfectly constructed artificial limb is but a very poor substitute for the sacrificed limb.

In the foot, the loss of any one of its digital appendages is of no serious consequence, except the big toe, for the reason that no cosmetic defect follows, the parts being hidden by the shoe, besides but little if any impediment in function results.

A wide latitude is permitted us here in amputations, wholly without warrant, in the fingers or thumb.

Let us, therefore, in any shape spare every possible portion of the foot. Its functions being simple as contrasted with the hand, viz., to support and carry the body, and by losses of its joints, distortion in outline or

loss of various segments of it may exist, and yet so little lameness ensues as to be scarcely discoverable in locomotion.-Daily Med.

DRAINAGE IN SURGERY.

BY JAMES E. MOORE, M. D., MINNEAPOLIS.

A few years ago surgeons drained almost every wound and thought they had solved the problem, although the immortal Lister always deplored its necessity. A little later they found that it was not always necessary and was sometimes harmful, which made it a very live topic for discussion. At the present time the prevailing opinion is that drainage is necessary only in exceptional cases, and that when it is not necessary it is harmful. In 1891 when the writer contributed an article to the Medical Record, entitled "The Use and Abuse of Drainage in Surgery," in which he advocated the abandonment of the universal and promiscuous drainage then in vogue, he was honored by criticism from many eminent surgeons, the late lamented Fenger being among the number. It is quite possible that we might better drain more frequently than we do now. In this as in every question of technic the personal equation must be taken into consideration. A skillful and experienced surgeon may safely close a wound without drainage where one less skillful or experienced would not dare to. Individuals, like the whole profession, have learned that the more they know about surgery the less they drain. The character of the surgery and of the wounds twenty years ago were such as to require drainage more than now.

Chassaignac introduced drainage tubes in 1855 to drain off pus, and in my early experience in surgery they were very much needed for that purpose. When surgeons first learned from Lister that pus was not a necessary part of the healing process but evidence of the presence of germs which it was their duty to destroy they used strong chemicals which delayed union and caused an excessive flow of serum which had to be drained off. After the dawn of aseptic surgery, surgeons began to learn that an aseptic wound does not need drainage and that drainage in such a wound may be the source of subsequent infection. In Keily's clinic in Johns Hopkins Hospital germs of some kind were found in 44 per cent of all drainage tube tracks. The old maxim, "when in doubt drain," is still true, but we are less frequently in doubt now. Where pus is present or where infection exists we must drain for the same reasons that old time surgeons drained; but without these indications it is not necessary. If we could always know when infection exists this rule would cover the whole ground, but unfortunately, asepsis is but a relative term, for every wound is an infected wound. What we really mean by an aseptic wound is one in which the quality or the quantity of the germs is such that nature can destroy them without artificial aid and it is beyond human ken always to tell just when this limit has been reached. It is no discredit to surgery that drainage is sometimes necessary, for even nature's methods are occasionally at fault, as in acute osteomyelitis without an open wound.

Notwithstanding the fact that drainage is no longer a routine in our technic the answers to the questions when, when not and how to drain are of very grave importance. It would be great presumption upon the part of any one surgeon to attempt to answer these questions definitely, but if we each tell our practice under given conditions and as far as possible give our reasons for it we shall become mutually helpful and necessarily come nearer to perfection.

Drainage of external wounds and of the abdominal cavity are very different affairs, because in the former it is often a matter of expediency and can if necessary be established some time after the operation, but in the latter