fractures. I have learned a great deal from what I have heard. I had one case of fracture that I put up and did not apply any extension at all. If the fractured ends are properly adjusted and in the course of a few days a plaster of Paris cast is applied and the patient given a crutch, you do not need extension. I had no more shortening in that case than in others.

With reference to the country doctor, we are somewhat inclined to be a little timid. We, of course, recognize your advantages in the city, but at the same time I believe there are few of us in the country who are more or less original in devising things to meet the wants of the different cases that we encounter in our practice. We have our opinions, and we are entitled to them. I would not follow anyone's I would not follow anyone's opinion or method of practice, unless I was reasonably certain that he was right. I believe our results have proven that it is best to follow the line of good common sense in all our

treatment.

SOME OBSERVATIONS UPON DIFFER-
ENT METHODS OF DRESSING
OF
TRAUMATIC OR SURGICAL
WOUNDS.*

BY HENRY HOYт, M. D., CHIEF SURGEON,
G. N. AND C. B. & N. RAILWAYS, LOCAL
SURGEON C. M. & ST. P. AND
"Soo" RAILWAYS, ST. PAUL,
MINNESOTA.

One of the most important elements in successful surgery is the selection and proper application of the final dressing upon a traumatic or surgical wound. When the final dressings are adjusted after, perhaps, patient, tedious, but skillful work, the operator turns away with a sigh of relief, almost throwing off, for the time being, the entire responsibility and care of the case, confident that he has done all that his knowledge or science can suggest, and that the late tender, quivering and lacerated parts are absolutely protected and cared for by the dressings till the time when it becomes necessary to disturb them again. During the twenty years that I have practiced my profession, at large portion of that time has been devoted to emergency or railway surgery, and as a matter of course I have used a great many different

*Read at the fourth annual meeting of the C. M. & St. P. Railway Surgeons' Association, at Chicago, Nov. 12 and 13, 1896.

kinds of germicides and antiseptics at various times in the final dressing of all varieties of wounds.

Of late years I have employed, more frequently than any other, either boric acid, iodoform or Borylyptol with sterilized gauze, cotton and bandage. These substances or combinations of the same have given me, till very recently, better results than any other, still they were not perfect. The boric acid patient often complained of such severe pain that the dressing would have to be changed and something else substituted. Of those dressed with iodoform about one in every forty cases would have a characteristic iodoform dermatitis, much to my disgust and the annoyance and sometimes alarm of the patient, who, from appearances in a severe case, would imagine he had "blood poisoning" and was about to surely die. When the real nature of the trouble would be explained to them I would often be severely censured for using the drug. In my practice these results occur oftener in conservative surgery upon crushed injuries of the hands or feet than in any other location. Borylyptol, being a liquid, must be used as a wet dressing, and, while having some excellent results from its use, it is still not perfectly satisfactory. It sometimes apparently produces pain and often the skin adjacent to the wound will shrivel up, lose its vitality, exfoliate and during this process convalescence is delayed. If a wound is not infected either of these dressings must be re-applied at least once a week, and sometimes oftener; if infected, the dressings must, of course, be changed daily.

The removal of the first dressing from a traumatic wound, and especially one from the fingers or toes, hand or foot, is almost invariably exceedingly painful to the patient. We should be as gentle as possible, but let the dressing be wet or dry, its first removal has always been dreaded by me, and I strongly suspect the same feeling has often been shared by my patients. Take a crushed and lacerated finger that had dallied too long with a coupling pin between the bumpers. If dry, the dressing will stick, and if there has been any oozing after the dressing was applied, which is very common, you can easily imagine that a bottle of Page's glue has been mixed with the bandage when you come to remove it. If wet, the capillary endosmosis of the liquid in the

dressing thickens the integument of the entire surface of the finger where there is no injury, renders the injured surface hyperæsthetic, and wet or dry, as the case may be, my experience has been that its first removal is not a comedy. These same objections in part or all, as well as others, can be raised against any germicide or antiseptic that I am familiar with, except one that I shall shortly refer to. I only name the above mentioned substances in order to be specific and also because they are all well known and in general use. I still use bi-chloride of mercury, per oxide of hydrogen, carbolic acid, etc., just as extensively as formerly, except that I do not use them or any one of them in the final dressings.

In the spring of 1896 my attention was called to a circular containing a translation from the German describing a new antiseptic dressing for wounds, by Dr. C. L. Schleich of Berlin. It described a new compound that he has named Glutol, and which is formed by dissolving gelatine in water and drying the solution in the vapors of formalin. It comes in the form of a coarse, whitish powder or granular substance, an indifferent body that cannot be liquified in dry or moist heat, is not irritating or toxic, is odorless, can readily be sterilized, and is used in surgery in about the same manner that we use iodoform. From the description and indorsements, I determined to try it, and at once sent to New York for a supply, not being able at that time to obtain it at home. Since then I have used it in dressing over forty traumatic wounds, principally of the hands and feet, and in six surgical operations, in all of which the results have been most gratifying. I sterilize the wound in the usual manner with either bi-chloride, boric acid or permanganate solution, per oxide or other antiseptic, as the contingency of the case may require, after which I irrigate the wound with sterilized water, drying the tissues with sterilized gauze. I then apply the Glutol in the same manner that we use iodoform, covering the wound with sterile gauze, cotton and bandage in the old way. If the wound is uninfected, in a few hours a dry, firm crust is formed where the Glutol comes in contact with the wounded tissues and recovery progresses rapidly without any further treatment.

When recovery is complete the crust becomes detached from the wound, leaving a

perfect, soft cicatrix. For the treatment of any variety of uninfected wound, this method comes nearer being an ideal one than any other I have ever adopted. In infected wounds, where there is suppuration without necrosis, a few daily cleansings with sterile water followed by the application of Glutol will in most cases rapidly transform an infected into a non-infected wound, the characteristic crust will form. and an uninterrupted recovery follow. Where there is necrotic tissue, after cleansing and applying Glutol, the wound should be moistened with a solution of pepsin, hydrochloric acid and water; the necrosis soon disappears and after a few treatments the wound becomes healthy and the same results already noted will occur. According to Dr. Schliech the dry Glutol is inert and possesses in itself no antiseptic properties. It must come in contact with living animal tissue before it becomes active. He says: "Contact with the tissues, of this preparation, causes a slow, continuous liberation of formalin in the nascent state. the gelatine is absorbed the antiseptic is liberated molecule by molecule, thus forming a method of wound sterilization at once very practical and extremely rational." The more active the cellular life the more successful the treatment.

As

While being thoroughly satisfied with the results of this method in all varieties of wound treatment, I am particularly pleased with it in the extensive laceration of the tissues of the fingers sustained by brakemen or switchmen in the performance of their duties. These injuries often result in the longitudinal bursting of a finger from one end to the other and frequently the laceration is complicated by fracture of the phalanges. My results in the treatment of this particular class of injuries with Glutol are simply perfect. I cleanse the wound, replace the finger in its normal position, put in a stitch where necessary, cover the injured member with Glutol, gauze, cotton and bandage, extend the hand on a light splint and let it alone. In a week or ten days, if the wound is uninfected, I remove the dressings and find no pain, no inflammation, very little swelling and no pus. There is a firm resistent non-infectable crust over the entire wound or wounds, as the case may be. The crust is so firm that if the injury is complicated by fracture we can throw away our splint and rely

dom do anything after the second dressing of a non-infected wound, except to protect the injured member with a light clean roller bandage till complete recovery takes place. Another thing in favor of Glutol is from an economical side. It is not expensive, is used in very small quantities, generally only once, a lot of expensive dressings required by other methods are saved and its application is painless.

In conclusion I wish to say that there may be many in this audience who have had more experience with Glutol than I, and if so, I would like to know if their experience has been as gratifying to them as mine has been to me. If there are any present who have not used it, I believe they will thank me later on for thus calling their attention to this preparation if they once give it a trial.

DISCUSSION OF DR. HOYT'S PAPER.

Dr. A. I. Bouffleur: I am glad, indeed, to hear Dr. Hoyt's able report on Glutol. Its action undoubtedly is of the same order as that of iodoform, as far as the chemical changes which take place are concerned. Iodoform itself is absolutely inert as an antiseptic. It has no virtues as an antiseptic excepting when placed in contact with growing cells. I believe that is the principal reason why it is useful to us, and it explains its effect upon tuberculous granulations. The subject of Glutol or its use has not been carried to that extent which the favorable reports from it would justify, it seems to me. I only know of a few instances personally in which it has been used, and these instances have not been favorable to the substance. The first time, I think, it was used in this city, was in a case of osteomyelitis, in which it did not prevent the formation of pus after a thorough curettement, and packing of the wound with a large quantity of the substance. That was one of the diseased processes in which it was especially serviceable in the hands of the originator. I have talked with a number of gentlemen who have used it, and some have expressed a favorable opinion, others not, but of all the opinions which I have heard upon the subject the experience of the physicians who have used it has been too limited to carry any weight. Dr. Hoyt has used it more extensively than anyone else I know of. I consider it worthy of at least careful consideration and trial by all of us.

Personally, I am an advocate, as you all know, of boric acid, not only because I believe it has mild inhibitory power, but because in solution it inhibits the growth of bacteria deeper in the tissues than any other substance that we have, unless it be acetate of aluminum, which is notoriously unreliable as to its solubility. I do not believe it has any germicidal power. Personally, I believe we should employ some substance which, in coming in contact with the discharge from the wound and being placed in solution, should penetrate the granulations. If we are going to destroy any infection that is present, boric acid does it to a certain extent. It is not a perfect substance to use, and possibly the liberation of the vapor of formalin by the cells themselves from this powder called Glutol, which is formalin gelatin, will fulfill that indication. However, this will be determined by more extensive experience and investigation in regard to its application in various sorts of wounds.

Surgical and Mechanical Relief for the S-calldǝo Hopelessly Paralytic Cripples.

Willard (Medical and Surgical Reporter, October 17, 1896) presents his views as to the measures to be taken in the treatment of paralytic cases, as follows:

I. A limb contracted at the hip, knee or ankle is mechanically unfit for locomotion, but if brought into a straight line with the body it can sustain the weight.

2. Surgical measures, tenotomy, myotomy, osteotomy or excision are frequently required to accomplish this result.

3. Subsequent support by mechanical appliances is usually necessary, together with the temporary use of crutches, wheeled crutches, or other support.

4. By a judicious combination of these measures, a case having sufficient strength in the arms to assist in locomotion need not be considered hopeless.

The Doctor's Debts.

The New York Medical Record is authority for the story that a Vienna physician was recently sued for the amount of a bill which he refused to pay. He claimed, and in this was sustained by the court, that the practice of medicine was a privileged profession and not a trade, and that a physician's property could not be seized for the payment of his debts. The case was carried from one court to another until it reached the court of appeals, and in all the decisions were to the same effect, and the creditor lost his money.

With this issue we begin the publication of the papers read at the Fourth Annual Convention of the C. M. & St. P. Railway Surgeons' Association, held at the Great Northern Hotel, Chicago, November 12 and 13, 1896.

The program, as announced in a former issue of The Railway Surgeon was presented, and we feel warranted in stating that no meeting of railway surgeons has been favored with better papers or a more general and enthusiastic discussion than this one.

The papers were, by request, short and thoroughly practical, the effort being to present the advanced knowledge upon the numerous topics considered or to introduce the subjects for a general discussion.

Heretofore the work of the association has been supplemented by a surgical clinic by some prominent Chicago surgeon, but as there were over twenty papers to be presented that valuable adjunct to a successful meeting was of necessity not utilized. The papers were listened to and discussed by nearly one hundred men,

over 50 per cent of the surgeons employed by the St. Paul system.

The freedom and completeness with which the various subjects were discussed could not but impress a listener with the great individual interest manifested by those present and the great good which such a close personal, friendly contact and thorough interchange of thought must result in. The two great aims of the individual members as well as the body as a whole, seemed to be the advancement of the science and art of railway surgery and the improvement of the relationship between the surgical and other departments of the company.

This association has some peculiar features which seem to have such a direct bearing upon its truly remarkable success that we deem them worthy of mention. In the first place, the question of policy is entirely eliminated by the absence of permanent elective offices. There is only one permanent officer, the secretary, and he is selected by the general manager and special agent of the company, a chairman being elected to preside during the meeting, who in turn appoints three members to serve with the secretary as an executive committee. The last meeting was presided over in a most able manner by Dr. W. T. Sarles of Sparta, Wis.

Another peculiarity of this organization is the absence of membership qualifications, fees and annual dues. All surgeons of the company are ex-officio members, and all the expenses are borne by the company.

This interest on the part of the officials is, to say the least, unusual, and we are sure that the favor which they show their surgeons in addition to granting them transportation for themselves and their wives is most thoroughly appreciated by the surgical staff.

There can be no doubt that the surgeon feels that if the company representatives are interested in the welfare of the injured employes to such an extent he, too, should manifest his interest by contributing to the scientific work of the meetings or at least by being present at them, if at all possible.

This is the largest body of railway surgeons holding annual meetings with which we are acquainted, excepting the National Association of Railway Surgeons, and we are sure that none hold more valuable meetings. We do

not hesitate to commend the plan nor to in-. dorse the excellent work it is doing in the advancement of railway surgery.

It would seem unfair if not unpardonable to close this comment upon the work of this association without a reference to the work and worth of the efficient secretary and father of the organization, Dr. Albert I. Bouffleur, general surgeon of the C. M. & St. P. system at Chicago.

To those who know the doctor and his enthusiastic interest in railway surgery, it is no surprise that his energy and activity in the interest of his company and the surgeons along the line should result in just such an active working body as the one we have described. We believe his work is valued and appreciated by the management, as we are sure it is by the surgeons.

Result After Pirogoff Amputation at the Ankle.

At a recent meeting of the Philadelphia Academy of Surgery Dr. Addinell Hewson presented a man, thirty-six years of age, who, in December, 1895, had been subjected to a Pirogoff amputation at the right ankle, by Dr. Todd of Roxborough, on account of a crush of the foot. Considerable trouble from septic disturbances attended the after-progress of the wound, but after eight weeks the healing had sufficiently advanced to warrant his discharge from hospital, and after-care as an out-patient. The patient now presents a much shrunken stump, with a depression on the anterior and outer aspect where a slough took place. He is able to bear his weight upon the stump, but this is by no means firm enough for him to continue to use it, and consolidation is apparently not yet complete. To show, however, the exact condition of the parts, Professor Goodspeed, of the University of Pennsylvania, kindly took radiographs twenty-one and a half weeks after the injury. Two views were taken, determining conclusively the degree of bony union. In these the attached surface of the calcaneum appears not to extend entirely across the severed ends of the tibia and fibula, but the union is firm to the central portion of the tibia. This union has taken place more toward the posterior part of the severed surface of the tibia, and apparently not at all to the anterior portion of the tibial cut surface, from which was removed the piece of necrosed bone, and it can be seen that the space has not yet been filled up. They also show the tension of the tendo Achillis upon the calcaneum and the possibility of its rotation if the extremity is used to any extent. Owing to the injury as stated above there is

4.5 centimeters shortening. Attention was called to the artificial foot which the patient was wearing. The heel was well stuffed, and a great amount of pressure was removed therefrom by the quasi socket in which the leg was held from the tubercle of the tibia down to the ankle.

Dr. G. G. Davis said he thought the question of the Pirogoff amputation to be an interesting one. Dr. Hewson had stated that the bone had been removed to a greater extent than usual. Personally he believed in removing a very large extent of the tibia and fibula and in going very high up in performing this operation. The object of this is, in case the patient desires to wear an artificial limb, a cylindrical joint can be used in the mechanism of the ankle instead of two lateral joints. If the patient wears an apparatus without any ankle-joint, of course these remarks will not apply to so great a degree. The objection to this apparatus is the extreme breadth of the ankle, which attracts attention, as it is considerably broader than the normal ankle. If the amputation is done above the malleoli, as suggested, then the side irons can be applied close to the leg, and the addition will not make any greater thickness than would the extreme protruberance of the malleoli. If such an operation is done and such an apparatus is applied, one will have a result which is much less visible and will attract much less attention than one like that in question. In performing the Pirogoff operation, he preferred cutting the extremity of the calcaneum quite short. The difficulty in performing this operation is almost always in getting the part which remains attached to the tendo Achillis up against the extremity of the tibia. He did not believe in performing a section of the tendo Achillis, but rather in making the bone section extremely liberal, leaving a comparatively small piece attached to the tendo Achillis and removing the part high up on the leg.

Dr. Hewson added, with reference to section of the calcaneum, that if the incision is made obliquely with the long axis of the calcaneum the difficulty is increased, while if the incision is made vertically, that is, with the long axis to the extremity of the tibia. and fibula, greater ease in adjusting the fragments results. He agreed with Dr. Davis that a vertical section should be made, but his experience in these cases was that surgeons do not wish to take away any more of the calcaneum than they have to. When the final adjustment of the parts is being made, it may be found that there is not sufficient of the calcaneum to make the part comfortable, and, consequently, a second section has to be made. By using a more vertical incision, less difficulty in adjusting the bones results.-Annals of Surgery.