DOLW

passed up on outer aspect of thigh, hip and abdomen, as high as the eleventh rib, 16 to 18 inches in extent, which was inflicted by the flange of wheels, as his body lay parallel to track. Shock was not extreme, and certainly not commensurate to the extent of injuries; a pulse ranging between 98 and 110; it had volume, and was not the evanescent pulse so frequently met with in shock; no emesis or excessive thirst, a condition to my mind strangely at variance with such excessive injuries; there was no mental disquiet or incoherent speech, or wild anxious expression; his mental condition unclouded, as he very coolly observed while undergoing examination, "had I known that arm was a goner, I'd got my head under the wheels sure."

If there can be with such extreme injury as this, such a condition as "delayed shock", this case might with propriety be admitted in that category. Subcutaneous injections of brandy and ether were administered. His condition, while possessing, in my judgment, no elements which promised success, still it did not in my opinion absolutely forbid an operation. If an operation had to be performed, it was better to proceed as early as possible, for I could not conceive how his condition could improve under delay. The hemorrhage, while not excessive, still was persistent and hurtful. An operation was determined upon and consummated within two hours after accident. The thigh was amputated in its upper third within three inches of the hip joint-antero-posterior flaps by transfixion-it was with much difficulty that healthy and unlacerated tissues were were determined, for after flaps had been made the ecchymosed integument (before referred to) upon side of thigh, hip and abdomen, was entirely separated from the muscles beneath; the hand could be introduced in this traumatic cavity along the side of the thigh, hip and abdomen, as high up as the eleventh rib,a space nearly six inches broadand between sixteen and eighteen inches long. An incision was made through the skin into this cavity midway between the crest of the ilium and the lower border of the eleventh rib, clotted and effused

blood removed, and space thoroughly cleansed with carbolic lotion and drainage tubes introduced.

Owing to the great quantity of contused and lacerated tissues in close proximity to stump, the possibility of injury to abdominal viscera, the extent of injury to skin of left side, and the condition of left arm, and the suppurating bubo in right groin, the case presented comparatively no hope; it was deemed best to treat stump by the open flap method and extreme cleanliness. The left arm was disarticulated at shoulder joint; tissues in the immediate vicinity were so pulpified as to debar the idea of getting a good flap; after removing all defective tissue, a very attenuated anterior flap had to subserve its purpose. The operation seemed to be borne as well as could be expected; during the progress of the case the pulse vacillated between 110 and 130 per minute, and temperature from 100° to 105°. The parts were dressed daily and all necrosed tissues removed as rapidly as possible, carbolic lotion and hot water dressings applied, morphine in one-fourth of a grain doses given as required for the first five or six days, along with a moderate amount of stimulant.

Upon the ninth day, a cellulitis intervened, which extended along anterior aspect of abdomen as high up as umbilicus, extending to right side, bubo in right groin sloughed out to the size of a silver dollar-the cellulitis extended to buttocks, burrowing abscesses formed, and freely incised under testicle, buttocks and other parts, and drainage applied wherever deemed effective. Bed sore insignificant, rubber ring applied under buttocks and body slightly elevated, tonics freely given, quinine and the potassio-tartrate of iron used both as a lotion and internally for its specific effect. The case progressed favorably under this treatment, and terminated in recovery after 16 weeks of treatment.

This case certainly presents several points of interest, the extent of injury, the almost complete removal of both extremities of left side, the extensive separation of integument and fascia from left side, the cellulitis and its extent, the suppurating glands in right

groin, and the early performance of amputation and the minimum quantity of shock. The manner of his locomotion with this deformity is novel but effective; he uses a crutch under right arm, and seems to possess excellent equilibrium. He can walk without apparent fatigue. Putting his crutch in advance of him he swings his body and right leg in advance of that, making steps ranging between 30 and 36 inches. He is now in good health and increased flesh.

Prognosis in this case was announced as unfavorable, and persistently so, but became retro-active-the result however, mitigated our poor capacity in this direction.

CASE II.-NON-IMPACTED INTRA-CAPSULAR FRACTURE OF LEFT FEMUR, CONTUSED AND LACERATED WOUNDS OF RIGHT LEG, FOLLOWED BY EXTENSIVE GAngrene. SKIN GRAFTS AND EPIDERM, SUCCESSFULLY APPLIED.-RECOVERY.

W. F., æt. 42, native, engineer, I. M. R'y Company. While on duty, F., as an engineer, was in transit; a cloud burst in advance of train, washed away culvert; it being night, and of such quick occurrence, that before F. was aware, engine was being rapidly precipi. tated in the breech. F.'s right leg was caught between engine and tender, lacerating its anterior middle third, but not fracturing leg, contusing it from ankle to knee joint, and at the same time producing an intra-capsular fracture of left femur, contusing outer and lateral aspect of thigh, hip and buttocks. The tender being loaded with its supply of coalthe coal being forced down, wedged and supported F. in his painful position; his fireman was caught between end of engine and tender, killing him instantly, and formed, as F. expressed it, a "human buffer," which prevented engine and tender from coming closer together crushing off his right leg. F. remained in this painful position for over an hour, until relieved by the wrecking car. He was then taken to P., the nearest town, and his wounds dressed temporarily. Thirty hours after ac cident I examined F.; pulse, 120, temperature, 102°, flushed and feverish, mind clear, exces

sive pain, found tissues around wound of right leg gangrenous, extending in every direction; it extended upon the anterior aspect of leg as high up as tuberosity of tibia, on both posterior and lateral aspects of the limb, and com| pletely around ankle joint; along with this condition, a non-impacted fracture of left femur; the limb was shortened two inches, rotation outward excessive, eversion of foot by its weight alone; undue freedom of motion, and an inability upon the patient's part to raise leg; Bryant's ilio-rectangular femoral test applied; the test line showed considerable diminution. The case was plainly non-impacted when I saw it, and the history verified it, as F. stated that he made frequent endeavors to remove his right leg from between engine and tender; thinking that it was in consequence of the coal wedged around it, he had excavated coal from round his left leg, but stated that he found it impossible to move leg, and that when extricated, he had attempted to step upon this leg, but found it impossible to do so, as the hip joint appeared to give way under it. F. was a large portly man, weighing 242 pounds, and not over five feet, eight inches tall. An attempt was made to apply Hodgen's suspension splint, but, owing to the intervention of traumatic delirium of such violent form as to require restraint, was unable to apply any form of apparatus to limb for nearly 96 hours. During the delirium, pulse ranged up to 120 and 130 per minute, and the thermometer marked as high as 104.6°. After delirium ceased, Buck's extension was applied with sufficient weight to merely keep the leg extended; a persistent hiccough intervened and continued some 72 hours, which failed to yield to musk, chloral, carbolic acid,

etc.

About this time a large effusion appeared over left hip-joint, which, on being aspirated, proved to be colored serum. During the traumatic delirium, gangrenous tissue was removed from right leg as rapidly as possible, and upon the 18th day but little remained, and the limb presented the following aspects: an immense granulating surface which extended from its anterior surface below ankle

Showing extent of gangrene upon external aspect of right leg.

Here was presented an immense granulating surface which had to be repaired; fortunately the gangrene had been superficial, involving only integument and fascia. The patient was informed that it was extremely doubtful as to whether this limb could be made useful.

Skin grafts were used; some eight grafts were applied along anterior aspect of leg, the derm being supplied by his son; these grafts were planted close to the peninsula within a quarter of an inch, on right side of leg. Two

Showing extent of gangrene upon internal aspect of right leg. were applied off and on as deemed necessary, some eighteen grafts being applied altogether, and the whole granulating surface was well covered with skin, except a space over internal malleolus, about the size of half a dollar, which seems no ways inclined to heal. The patient, however, does not complain of any excessive inconvenience, still is constantly troubled.

After four months of treatment patient was discharged, with a comparatively good right leg, and two inches and a half shortening of the left femur, which was a result more pleas ing than the comparatively good success of right leg.

Now, reviewing what was accomplished by the use of skin grafting in this case, I am inclined to the belief that, notwithstanding that the result is apparently good, still I imagine that the future will bring no comfort to this patient, for I cannot conceive how time can better the condition of this leg, and certainly think that there is a limit to the replacing skin on such a surface as this. I think that the extent of surface was too great to completely fill, and think it only a matter of time that excessive pain and inconvenience will compel our patient to suggest the idea of removal; however, our patient is satisfied, and has again resumed his avocation as engineer.

H. F., brakeman, aged 22, I. M. R'y. H. F. on March 3, while engaged in coupling cars, was endeavoring to fix link in draw-heads, was standing in front and between draw heads trying to knock pin out; some one gave signal to back up which was suddenly done, impaling F. between cars, and link forced through thigh and held in this position, and dragged along, until his cries directed attention to his dangerous situation. H. F. was examined about an hour after accident, the link had passed through posterior part of right thigh at junction of middle and upper thirds, glancing over femur without fracturing it, and emerging on a line parallel with outer border of femur, tearing through a greater portion of the vastus externus, fascia lata and tensor vaginæ femoris muscles at this point and tearing a triangular flap of the integument entirely from the greater trochanter of the femur, obliquely across the

thigh to within three inches of the border of the patella, inflicting a contused and lacerated wound ten to twelve inches broad, fifteen to sixteen inches long. Shock extreme, weak intermitting and contracted pulse between 118 and 120, clammy skin, pinched countenance, pallor. Warmth applied to body, ether injected subcutaneously, morphine given gr. doses after reaction; loss of blood very slight; wound dressed, all pulpified and lace

Present appearance of right thigh indicating extent of cicatrix.

rated tissues removed where possible and advisable.

This point in the treatment of extensive lacerations so frequent in railway surgery is one which is often neglected. I have repeatedly seen injuries of this kind hermetically sealed with quantities of shredded tissues, and which were in as complete a necrotic condition as they could well be, and certainly were unfit to remain and only served as sources of irritation and danger. I am convinced that in injuries of this kind a thorough and pains