down into the pan to clean it out. The engineer not knowing he was there started up the crusher. Jordon at once made an outcry which was heard by the engineer and the machine was stopped as soon as possible-in time to save his life indeed, but not until his right leg between the knee and ankle had been caught beneath the crusher and an extensive compound fracture produced. Upon being telephoned for I drove out to the works, about ten miles distant, where I found the patient stretched out in a dingy one-room hut occupied by about a dozen of the laborers. Knowing that it would be futile to attempt treatment here, I contented myself with a cursory examination and after washing out the wound slightly, applied some gauze and cotton, adjusted a temporary splint and put the man in a wagon to be brought to the city. On reaching the hospital I made preparations for a more minute examination under anesthesia, and amputation if necessary. I found the following condition: The right leg had evidently been caught by the descending revolution on the inner side with a somewhat slanting force, the outer side being but slightly injured, while the soft parts on the inner side were almost torn off. The line of laceration began about two inches above the inner malleolus, followed along the crest of the tibia to the junction of the upper and middle thirds, then curved downward and backward on the inner side to a point just behind the insertion of the inner hamstring muscles. Nearly all the inner aspect of the limb was laid bare, the soft parts being stripped off as the lightening strips off the bark of a tree. The tibia was entirely denuded of periosteum for at least six inches, and at the juuction of the lower thirds had sustained a much comminuted fracture. I could pass my finger between the posterior surface of the tibia and the muscles for some distance; also between the gastrocnemius and soleus muscles which were torn apart and between the gastrocnemius and the integument behind. All these parts were severely contused or rather crushed and the whole surface was full of dirt and clay which had been literally ground into the tissues. My consultants advised immediate amputation at the junction of the upper and middle thirds. I observed however-First, That the outer side of the leg where is situated the anterior tibial artery, and also the posterior aspect with the posterior tibial and its branches, were but little injured, thus fortunately preserving and insuring good nutrition of the parts. Second. The man's general condition was good and would warrant conservative delay. On the other hand was the certainty of some sloughing; the possibility of sepsis; an extensive surface of bone completely denuded and open to necrosis, a fracture thoroughly exposed with the consequent possibility of non-union. a large area to be healed by granulation and lastly a long and tedious course of treatment even if ultimate success were possible. But the value of a limb is not to be estimated by time or labor, and knowing that amputation could be made as well later, should conservatism tail, I determined at least to make an effort to save the limb. I therefore proceeded to cleanse the wound as thoroughly as possible, removing loose spicule of bone, curetting out imbedded clay and dirt, and thorougly irrigating and scrubbing the entire limb from knee to toes. In order to lessen the area of exposed surface I produced partial coaptation of the soft parts by strong silk sutures, considerable tension however being required. What hæmorrhage was present, and forunately there was not much owing to the unimpaired integrity of the large vessels, was controlled by hot water irrigations or ligation. After closing the laceration as much as possible, the fracture was carefully adjusted, antiseptic gauze and cotton were applied and finally a strong plaster of Paris cast from toes to above knee. On the second day the cast was fenestrated which indeed meant the removal of nearly all the inner side, but the other dressings were not disturbed. On the fourth day an elevation of temperature led me to remove the dressing when I found some pus and beginning slough. The wound was irrigated as well as possible in the cast every day for about a week, when to hasten detachment of the area of sloughing and produce exosmosis, I did what may seem strange in statement, that is "poulticed the fracture" with boiled carbolized flax-seed poultice. The result was beautiful, my wound was soon cleaned and healthy granulations at once sprung up: my forced coaptation had lessened the area for granulation nearly one half, but still I had a surface nearly as large as my hand. Of the tibia about three inches including the seat of fracture was exposed still, thus affording me the unusual opportunity of inspecting the process of bone repair, which I may add proceeded as rapidly as may be expected even in a simple fracture. After the area of sloughing had been made clean and healthy, I returned to ordinary aseptic or antiseptic dressings. The granulations springing from the soft parts gradually spread on to the bone until at the expiration of ten weeks union was firm, all but about one square inch surface of bone was covered with granulations, and the skin growing from the sound margins about one inch in eachd irection, had reduced the raw area fully one half or more. From here on the process was more slow and tedious as nature had nearly reached her limit. The plaster cast, which had to be newly applied a number of times on account of weakness from fenestration and the moistening from irrigation, was now dispensed with entirely, and attention turned to the wound alone. Gradually the granulations filled up the level and the skin pushed out as far as possible and then stopped. I now began to encounter some trouble at the point just below the seat of the fracture where the tibia began to undergo peripheral necrosis or exfoliation, no indication however of medullary trouble. I found it necessary to use the curette quite frequently and removed a number of small spicule of bone. This procedure after a somewhat tedious course, finally checked the necrosis or rather removed it and granulation proceeded. I would undoubtly have hastened the process of the case had I under anaesthesia laid the part open and thoroughly scraped out the diseased area, but deferred unwisely to the patient's wish. Before the class of the University Medical College at the hospital in September, the area of granulation was skin grafted by the small graft method. This it was found necessary to repeat several times as the surface being immediately over the tibia and poorly supplied with blood vessels, did not readily respond to the demands. Finally however success was obtained and the man left the hospital without crutches and with an entire limb which will probably in time be as good and strong as it ever was. A tedious process indeed, but a good limb strong as the uninjured member is worthy of much time and labor. I have detailed this case at some length, not as an unusal case, for many of you have had equal success in worse ones, but rather as a text for a discussion on these thoughts suggested. teum. 1st. Necrosis of bone does not necessarily follow removal of perios 2nd. Non-union is not a necessity because a fracture is and must remain compound. 3rd. Suppuration does not mean septicemia. 4th. Soft parts undergo remarkable repair. 5th. Nutrition or blood supply is the one question in these cases. 6th. Primary amputation is rarely demanded. DISCUSSION. Dr. Chas. Lester congratulated Dr. Jackson upon the report, and said that the result certainly justified the immense amount of trouble to which he had gone to save the leg. The principles laid down by the essayist in his clos ing remarks were certainly right and the proper ones to follow, although they often entailed a vast amount of trouble with little prospect of thanks from many patients. Dr. T. B. Thrush remembered having assisted Dr. Jackson in the treatment of this case, and believed that he had not described the case with sufficient emphasis as to its bad points at the time it came in to the hospital. It was certainly a frightful leg. The soft parts were ground into a pulp, the periosteum was torn off, the skin crushed, and the whole limb looked as if nothing could be done to save it. It was certainly impossible to get all the dirt out, although Dr. Jackson and his assistants worked for an hour or more trying to get the pieces of rock, sand, clothing and other forms of dirt out of the wound. Remembering this the early union secured was certainly surprising. The result shows what knowledge, patience and skill can do in the treatment of even apparently hopeless cases of compound comminuted fracture. Dr. C. F. Wainright wished to compliment the author on having presented the first report on fractures that had ever been given in the history of the society. He emphasized the fact that there should be more such papers, particularly upon kindred subjects in minor surgery, as well as reports of major operative work. The question which in this case presents itself to one's mind is, was not it possible to save this leg because the injury was low? If the bone had been crushed nearer the knee nothing could have saved his life except amputation. Non-union usually occurs when the accident injures the bone in that part through which the nutrient artery flows. This fact should always be remembered in trying to save crushed limbs. When the circulation in the soft parts has been preserved and the injury to the bone is beyond the point where the nutrient artery makes it exit, much can be done in the way of conservative surgery. Dr. D. R. Porter remarked that he was surprised at the amount of conservatism which had been shown here to-night, not only in the discussion on this paper, but upon the other cases which had been reported. In this particular case the result and the paper showed good common sense. This is especially true of the use of the antiseptic poultice, which is certainly a very good thing in preventing the extension of inflammation. By immersion in warm solutions Frank Hamilton used to save many cases of railway injury. The heat kept up the circulation and saved the limb, whereas if the patient had been put into a cold bed and the limb allowed to take care of itself death of the parts would certainly have occurred. Dr. J. A. Bond reported a similar case that he had seen some years ago in consultation with Dr. Drake, in which the latter wished to amputate both legs, which had been crushed by a cable car, the wound being filled with mud and filth. On account of the shock amputation was delayed; later the point where amputation should be made could not be agreed upon, so the limbs were dressed as if with the intention to save, with the expectation of amputation if gangrene should set in. The wounds were cleaned, put in Clark's swinging splints, and, wonderful to relate, the patient got well and thirteen weeks later was exhibited at the Jackson County Medical Society. It was then pronounced by all the surgeons who saw the case as an example of dangerous surgery: yet as in Dr. Jackson's case, "nerve" in attempting to save, and carefulness in detail, saved the patient's legs. Dr. M. P. Sexton commended the paper of Dr. Jackson, and said that it emphasized the importance of minor surgery, which had been too much neglected. Dr. John Punton thought that the good result in this case was due as much to the thorough drainage which was instituted as to anything else. The case illustrates the fact that pus does not necessarily mean sepsis, a point upon which there has been much discussion of late. It seems to be a fact that if pus has free exit septicemia is not likely to occur, whereas if the wound be closed. up and the ptomaines from the cocci of pus remain in the tissues, sepsis results. Dr. Kyger said that no doubt it was mainly a question of arterial supply, as Dr. Wainright had said. If the vessels are impaired the circulation is not able to take care of the products of these germs, and septic processes occur. When the circulation is good, as in the case reported by Dr. Jackson, there is little danger of secondary trouble if the ordinary measures of cleanliness be carried out. The case reported is certainly a triumph for conservatism in the treatment of such cases. Dr. C. Lester Hall criticised the title applied to Dr. Jackson's paper, since the case reported is not one of minor surgery, but one that can properly be characterized mammoth surgery. It is certainly more far-reaching than many cases reported as massive surgery. In a similar case, though not quite so bad, but yet quite formidable, so much so that many would have advised operation because of the excessive denudation of the periosteum, a good result was secured, and without necrosis of the bone. The patient made a good, though tedious, recovery, illustrating the fact that the bone may be denuded for a considerable distance and not necessarily die. Dr. Jackson in closing said that there had not been as much discussion of the principles involved in the case as he would have liked. There are several points that are of interest, among which may be mentioned: FIRST. The use of the curette for cleansing the wound; washing with antiseptic solutions certainly does not clean out the mud, dirt, etc, properly. If they be left for relief by vis medicatrix nature they can only be gotten rid of by suppuration and sloughing, and during this process much tissue has usually to be destroyed; so that it is true conservatism to use the curette and scrape away much of the injured tissue at the same time that the dirt is taken away; SECOND. The poultice has been condemned by Senn and others since it is an elegant culture field for germs; but it must be remembered that by the use of poultices exosmosis is promoted, and in mangled wounds, where pus formation is certain to occur, it seems that it would be best to hasten it by the use of heat and moisture so as to prevent sepsis. By the addition of a considerable proportion of carbolic acid it does seem as if the poultice could be rendered antiseptic. Furthermore, it can be changed every hour, so that it will not act as a culture field for the germs. THIRD. The mere presence of pus does not mean septicemia. If it be retained it does; but by the application of the antiseptic poultice we promote the flow of pus and in that way prevent the septic process. When frequently changed it certainly does no harm. FOURTH. In this case skin grafting was deferred too long. It should have been done as soon as good granulations were found in the wound. By resorting to the Thiersch method at an early opportunity this patient might have been saved weeks of time in his convalescence. FIFTH. The one great problem in such cases is the question of nutrition. If the part beyond the injury be found warm and the pulse can be detected, the extremity can be saved. If it is cold and bloodless, indicating the destruction of the vessels supplying it, it is necessary to amputate, and many times far above the site of injury. In railway accidents particularly this is the case, the vessels being torn off at a point many inches and in some cases even a foot or more above where the injury to the external part is found. SIXTH. The case illustrates the necessity for free incision to prevent the supervention of gangrene. There can be little doubt that if this wound had been left unopened there would have been a very much more extensive destruction of tissue than was the case. COMMUNICATIONS. SYPHILIS "LOOKING BACKWARD, FIVE THOUSAND YEARS." The above caption suggested itself by the receipt of the following communication. "20 MT. VERNON ST., BOSTON. Dear Dr.-Are you the Dr. Geo. McLean, who visited the World's Fair, and afterwards wrote about 'Syphilis among the Cliff Dwellers'; In the KANSAS CITY MEDICAL INDEX? I want to ask you if you ever saw the skulls (of Austrians?) affected by syphilis in the Pathologisches Museum "in the Algemeines Krankenhaus" in Vienna? There is every variety of necrotic process shown in the skull. Some with great holes on the side, and what seemed most wonderful, holes every where on the cranium, like the holes in a coarse sieve. How many years must this disease have been among the people, to produce such effects? How did the individuals live long enough to permit such awful erosion of the bones? Recent writers claim that the sailors from Columbus's ships took the disease back to Europe from "Hayti," Syphilographers credit the East with its first starting point. What do you think of the (well known) fact that both the lesser and the greater "Pox" have been run out by inoculation in Japan? In Austria all the soldiers are under stature small like Japs. Syphilis is said to have already infected 80 per cent of the Austrian people from the Emperor down. The similarity in the physical condition of the two people is a fair premise for an argument that the disease originated in the far East and spread Westward. I should like to hear of your opinion. Respectfully yours EDMOND D. SPEAR." Thinking that perhaps, (although this subject may be considered old, and worn thread bare) it might, in some respects, be of interest to the profession at large, after due deliberation, I wrote to the gentleman asking his permission, to give him my answer, if any, through the columns of the KANSAS CITY MEDICAL INDEX, and send him some copies direct from the publisher. In due time I had the honor of receiving the following: Dear Dr.-Yours replying to my letter received. I wrote more for my own interest than for that of the public; however I am willing that you should make whatever use you see fit of the communication. Sincerely yours EDMOND D. SPEAR." For which courtesy the gentleman has my heart-felt thanks. The history of pre-historic syphilis, like every other traditional event, that we read, or hear about, Philosophy, Mythology or the Practical, has been transmitted orally from father to son, down along the ages, centuries before word-painting, hieroglyphics, or writing of any kind was thought of, is not reliable, and is involved in almost impenetrable darkness. We are however, perfectly safe in stating that syphilis, like quails, has followed man, through all his migrations and mutations ever since the days of Moses. According to Buret, we have ample proof that syphilis affected the Hebrews in the old Bible times. Reference to which will be found in the book of Proverbs, Ecclesiastes, Leviticus and in several books of the old Testament. China, like Kansas, is a paradoxical land; there Buret informs us, syphilis flourished in all its phases five thousand years ago! The same author informs us that syphilis started originally with the Aryans who visited and conquered India. In reading about countries we become acquainted with the names of explorers, of battles with the names of generals, of syphilis, for obvious reasons, with the names of people, and of nations. We read in the Encyclopedia Brittanica, ninth Ed., Vol. xii, p. 776, that there was a pre-historic race in India; when the Aryans first discovered that country, they found the land inhabited by a race of colored people, just as Columbus when he discovered this continent, found the red man occupying the soil. The aborigines of India were black, of a very low type in the scale of intelligence, the Aryans on the contrary were white or fair skinned, a noble race who gained the supremacy, peopled the land, aud reduced the colored race into slavery. An early example of "White supremacy, and Negro suborina tion !! As time went on. the Aryans who were naturally of a roving disposition, became scattered, some went to Persia, others went to Palestine, Arabia, Egypt, and all over Europe, conquering and subduing wherever they went, establishing their own language, religion, and social customs. Hence in works on Physiology, we read of the Aryans, Indo-European, and the Indo-Germanic, all springing from one common parent. Even our own Anglo-Saxon tongue belongs to the same generic root. We are also informed that the words which are nearer, and dearer to us than any other, "Home," "Father," "Mother," "Brother," and even our dear little "Sister," are said to be in the original, a "Milk Maid." "Whether found on the banks of Ganges or transported on the banks of the Thames river, on the banks of |