pin and throwing it under the car, but he made a misstep and fell, and instead of throwing the pin under the wheel his right hand went under the wheel and was taken off. The only thing that could be saved was the thumb; enough of the tissues being retained from the palm to turn over the stump. I think this case was turned over to Dr. Marks and he may know how it came out. The patient made a good recovery, but a few weeks afterwards he began to have pain in his hand at the point of the injury; it seems some of the nerves had remained in the cicatrix; we had saved the thumb and the thumb was worth a good deal, but finally it was decided that the hand must come off above the wrist and it has been taken off. There is where the surgery was a little too conservative. It would have been better to take the hand off at the time.

Dr. Marks: Couldn't the nerve have been taken out without taking off the hand?

Dr. Garlock: I will say the wound had been opened and an attempt made to take out a portion of the nerve, but it was not a success and he had commenced suit against the company for damages to his hand, and his attorney advised him to get some other surgeon besides the railway surgeon to examine the case, because he wanted to have a witness on his behalf; consequently the case went out of my hands.

Dr. Bell: I don't understand from what Dr. Garlock says, why the hand was taken off. Was it to relieve the patient of pain?

Dr. Garlock: Yes.

Dr. Sugg: There is one point brought out by Dr. Johnson; the condition we find the hands and fingers of machinists and railway employes in when they come to us, covered with dirt and grease, and the difficulty in cleaning them. Some years ago I was present at a lime kiln where crude petroleum oil was used. There was a tank of it there. I noticed that the men were continuously washing in the crude oil; when they got a bruised hand they washed that in the oil, or a dirty hand, and they came. Out clean, and it struck me it would be a good thing to put on hands when they came to us dirty and crushed and for a number of years I have cleaned such hands with crude petroleum oil, and have found it works excellently well.

There is another thing I would like to call attention to that perhaps some may be interested in; that is in regard to skin grafting. I noticed some years ago an article by Dr. Manly of New York, in which he advises the use of parings of corns for skin grafting. Some times, in the case of farmers, the horny-handed sons of toil, we could get considerable skin in that way.

Dr. Plumbe: I want to speak in regard tc this question of dressing, dry dressing and wet dressing. If I had an injury that was superficial and that I was certain was aseptic and in which there was no danger of any pocket, and in which I wouldn't probably have to make any incisions or remove any blood clots afterward, and where there would certainly be no oozing, I would use a dry dressing; otherwise I would use a moist dressing. I would prefer in that case a saturated solution of boric acid for a primary dressing and after the primary dressing an irrigation of a weak solution of bichloride of mercury. I have seen one or two cases of local dermatitis, following the use of a solution of bichloride of mercury; in one case it followed the use of a solution of not more than one in two or three thousand. There is a difference in patients. For a wound which was septic and severely lacerated I would use a hot saturated solution of boric acid, injected, if necessary, with a syringe, into every cavity I could find and then apply sterilized gauze, kept constantly wet with the same solution. In some cases I might use irrigation.

In regard to conservative surgery. Thirty years ago many of the injuries we treat successfully now would have been necessarily fatal. During the war many men died from amputation; nowadays there would be no excuse and a surgeon would be liable for malpractice if he lost such cases. Therefore we can now save hands and fingers and other por

tions of the body, which years ago we would not have attempted to save. Now amputation should be the exception and not the rule; a hand or finger or limb must be severely mashed before I would amputate it.

In regard to alcohol. The use of alcohol became, some twenty-five years ago, in many of the hospitals in the East, quite a fad for almost all kinds of wounds. I have seen an amputated arm placed in a trough filled with diluted alcohol and water, I don't know how strong it was, and kept there for the purpose of a dressing, and surgeons used it for irrigation, by applying a cloth or sponge kept constantly wet with alcohol. It seemed to have a very good effect. As we know very well, al cohol is an antiseptic. I use alcohol in an operation, strong alcohol, as an instrument bath instead of carbolic acid. I formerly used carbolic acid but sometimes from putting my hands into it many times my fingers got so numb that they were practically useless. I don't know as it makes any difference, if we want to use continuous irrigation, whether we use salt and water or whether we use boric acid or what we use, as long as we use sterilized water; there is the point; it is not so much the antiseptic we use for the purpose of irrigation as to know that the liquid we use is not septic.

Dr. McDill: I would not like to see the discussion closed without reference to a material I have used during my hospital experience and since for ten years. I would like to call attention to a solution of acetate of aluminum as a very efficient microbe killer, a substance which has great penetrating power, and, at the same time, is neither locally nor constitutionally toxic; it is also cheap.

Dr. T. C. Clark: There is one class of wounds not mentioned here which is most important in the hand or foot; that is, punctured wounds. Upon the proper treatment of these wounds frequently depends the welfare of the patient. I remember reading, soon after the close of the World's Fair, a resumé by the surgeon in chief there, of the punctured wounds of the foot treated by the medicai corps. I think there were six hundred cases of punctured wounds of the foot, mostly from stepping on nails. The treatment of those cases was that of freely opening the wound, washing it perfectly clean and then introduc

ing a probe with cotton on the end, thoroughly saturated with carbolic acid, washing out the wound and dressing it with a dry dressing. This is the practice I have followed before, and since reading that report. The necessity was impressed upon me by a case I had in which a laboring man stepped upon a nail. I was called to see him two weeks after this occurred. The wound had entirely healed but the man was in a state of spasms; the muscles of the neck were rigid and the throat contracted; I removed him to the hospital, but he died that night. That was a case of tetanus due to a nail wound. Perhaps we have more wounds of that character than any other wounds of the hand or foot. The essential point of the treatment is to see that they are thoroughly opened and cleaned and it is a good plan to syringe them out or swab them out with a 95 per cent. solution of carbolic acid.

I had a case recently of a little girl who stepped on a garden rake; one tooth pushed clear through the foot and another nearly through; I opened the wound and made an opening clear through the one, only partially through and washed it out thoroughly; I used alcohol in that case and swabbed the wound out and applied a dry dressing made for the purpose. They are simple wounds, as far as the damage is concerned, but are liable to be extremely disastrous.

Dr. Binnie: I want to indorse what the gentleman said about punctured wounds of the foot. It has been my experience to see two cases of tetanus resulting from such wounds and since then I have had several such wounds to treat. I take cocaine first and inject it into the wound until I destroy sensibility, and then I incise it. I don't let the patient go away until he is free from pain and the nervous symptoms have subsided. I had two cases last summer caused by rakes and two by shingle nails. I have come to the conclusion that it makes a good deal of difference in what part of the foot these injuries occur. I think about the center of the ball is the worst, the place just behind the toes. I think they are about as dangerous wounds as we can get. I would advise cleaning them out thoroughly. In regard to protonuclein, I have used that some in bad lacerations and have had very good results from it. There is another class

of wounds that we sometimes get and that is burns. It has become a sort of fad with me -may be there is nothing in it-I use a little belladonna applied in liquid form to prevent a hardened cicatrix; I think it prevents drying and puckering to a very great extent.

Dr. Whitford: In regard to punctured wounds, I have observed we hardly find any symptoms of tetanus where the periosteum is not destroyed. Any punctured wound that reaches the periosteum is liable to cause

Where it does not it is no more liable than any other open wound. In regard to the treatment, I believe I recommended something last year that a good many of the surgeons present agreed was good, to apply spirits of turpentine, pure; I will guarantee you will not get tetanus from a punctured wound, whether it reaches the periosteum or not, if it is applied thoroughly and promptly. One thing I notice has not been mentioned, that is, treatment for painful lacerations, painful wounds, where there is intense pain following. I have a preparation which I have used which I would like to call attention to: One ounce of carbolic acid into an ounce of raw linseed oil, combined with whiting, used as a dressing; five minutes afterward the pain will generally subside.

Dr. Binnie: In regard to tetanus, I attended a lady two years ago who was in a terribly nervous condition and I was very much afraid of tetanus from a puncture by a shingle nail, which I made sure did not go near the periosteum. I think she would have had tetanus if she had been left alone. I doubt very much if it is necessary that the periosteum should be injured to get tetanus. I have no doubt that we would be more liable to get it in an injury of that kind, but I think it must be settled that we can get tetanus without going anywhere near the periosteum.

Dr. Bouffleur: I happened to see the patient that Dr. Johnson reported, and for that reason I was anxious that he should present the case at this meeting, because it certainly proved the wisdom of his course in treating it. It was a remarkably useful member that he saved for that conductor; whether he always remains a conductor or not he will have a hand, that is, for all practical purposes, just as good as ever. There is no doubt but what we have a good many of just such cases. I

had one, I hope to show you a photograph of. It was one of considerable interest. The whole hand was taken except the thumb, with the second metacarpal bone left in position without anything to cover it. Instead of amputating it at the wrist we left the major part of the stump open, and transferred a small piece of skin over the end of the bone, and while the prospects for a favorable outcome were certainly not good, yet by careful nursing and subsequent skin-grafting we succeeded in saving the thumb, and with the metacarpal bone and the index finger that individual has since performed the duties of a switchman. Although it took, I think, about three months to get it in proper shape, at the same time we succeeded in saving the hand, which he has since used to earn his living as a switchman.

In regard to the various antiseptics, there is just one caution I wish to give in regard to acetate of aluminum. I have used it a great deal and was somewhat astonished to find out that the average preparation which we get in a drug store is not soluble. I dare say there is not one preparation in ten in a drug store that is soluble. Furthermore, if we want to use acetate of aluminum we had better make a cold solution instead of hot. Acetate of aluminum is one of the substances not soluble in hot water. I like acetate of aluminum and like the effects of it, but from the fact that the preparations which we buy are so uncertain, and also from the fact that we cannot make a warm solution of it, I have personally discarded the use of that substance. Each antiseptic, of course, has its advantages; some of them have positive disadvantages; personally I like the effect of bichloride. There are, I dare say, some gentlemen present who are personally very much opposed to the use of carbolic acid; bichloride is a decided poison and irritant to me, so that by the immersion of my hand in bichloride for an operation, perhaps extending over a half of three-quarters of an hour, I am sure to have dermatitis following the next day. I have met with a number of doctors who are affected the same way by carbolic acid.

As to the advisability of primary amputations, I believe I have expressed myself on a former occasion somewhat fully on this point. Personally I very rarely perform a primary amputation. I think that our present knowl

edge justifies the general rule that we should not sacrifice anything that can be saved in the way of hands or feet, or, for that matter, any part of the body that we can make useful. The point that Dr. Garlock made that occasionally we carry things too far I believe is a good one. It is better not to save a limb or finger than to save it and have it useless, and perhaps in the way. I knew of a case of a middle finger which was injured to the extent of the loss of the flexor tendons. The finger sticks out straight, no matter what the individual does, and is a positive detriment to him. It would have been better to have amputated it, although the finger itself was not much injured. So the rule, I think, is justified at the present time not to amputate any tissues which can be made profitable or that can be made useful. We have all been taught by Our teachers and text-books very nice ways and methods of making amputations, but they lose sight very frequently of the fact that we do not have the choice of how we shall shape our flaps or the way we shall make our amputations. That is usually decided before we get to the patient. Therefore, I think it a better rule than to follow the ones given in our textbooks, to shape our flaps so that the cicatrices will be out of the way of irritation. In that way we will obviate a good many of those uncomfortable sequels of amputation. I was taught that we should never make an amputation with a cicatrix on the palmar surface of the finger, but we all know, as railway surgeons, that to save as much as possible in length, it is necessary to bring the seam on the end of the finger, or at least the palmar surface. To save in length you must bring the cicatrix around on the anterior surface.

To avoid sensitive points I do not anæsthetize patients for the amputation of fingers, not even with whisky, for the reason that if the patient is not anæsthetized you can readily locate them by the use of the fingers and remove them. Very frequently if you do not remove them you will have a tender cicatrix, while if you do you will have a comfortable cicatrix. I think in the last two years I have had only one tender cicatrix, and that in a case where I did it in about ten minutes, when I was in haste to get a train. The general rule that I have mentioned in regard to the

amputation of tissues is, I believe, a thoroughly justifiable one. If I am mistaken in that, I would like to have some one correct me or enlighten me on the subject.

The Persistence of Exuberant Granulations Due to the Remnants of Ligatures.

Dr. V. H. Munson of Putnam, Conn., reports the following interesting case in a recent number of the New York Medical Journal: F. A. W., a stalwart man of thirty-five years, was drawn into a belt at a sawmill about three months ago. The belt burned its way through all the muscular and vascular tissues of the popliteal space and had nicely polished the bone ere he could be rescued. As a result, circulation from the articular arteries having been destroyed by a previous accident, gangrene set in on the second day following and the man was removed to the Day Kimball Hospital. The leg was freely laid open by means of several deep incisions, and thoroughly irrigated with a 1 per cent solution of creolin. This was not done with any hope of saving the limb, as there was no pulsation whatever below the knee, but by means of drainage to reduce the temperature, which was then 103 degrees F. Soon after his temperature fell to 100 degrees and Dr. Holbrook was called in consultation. As amputation was advised, Dr. Overlock and I removed the limb at the upper third of the femur, on October 3, 1896, by means of the circular flap operation. The large arteries were tied with very large sterilized, braided silk ligatures. The drainage tubes were removed in five days and the stump healed very well with the exception of a small polypous growth of "proud flesh." This was cauterized frequently during the ensuing month, but still persisted in breaking out again. Alum, carbolic acid, nitric acid, lunar cautic and the thermo-cautery were applied, but nothing seemed to have any permanent effect. Six weeks from the time of operation another similar growth appeared on the opposite (internal) side of the stump, which pursued the same obstinate course as the other. Finally, on January 1, I determined to cut off these superfluous growths. Upon my doing so, a slight quantity of pus came from one, and, seeing something white and glistening, I caught hold of it with a strong forceps and removed one of the before-mentioned silk ligatures. Upon searching the other wound, I caught hold of another similar piece of silk and removed it. Then, irrigating with 1 to 40 carbolic acid solution, I applied a little aristol and dressed with sterilized gauze. On January 10 the stump had entirely healed.