suffice. Wound infection implies a condition more or less serious as regards both the life and the function of the part involved.

Bearing in mind the presence of these microorganisms in the air and on the surface of the body and the ease with which they gain entrance to the body will assist us in the prevention of this sometimes desperate condition. Preventive surgery is just as practical as preventive medicine; especially is this true as regards the treatment and management of the small wounds.

To save a limb after a serious injury, such as would result from a severe crush, is far more surgical than to amputate it.

The same is true as regards wound infection. If you would have your patients escape septic conditions, which so frequently follow the receipt of simple wounds, give them the same attention and care that you would to the more serious ones.

Educate your families in the proper care and dressing of these small wounds, and at the same time inform them of the danger which may result from the application of a piece of tobacco that has been chewed in a filthy mouth. Tell them of the good effects which will result from a thorough cleansing with soap and water, and the application of that simple household remedy, turpentine.

If these measures were followed by the laity we would see less disastrous results following wound infection.

However, there will be instances of punctured wounds, in which the organism is rapidly diffused by the lymphatics, aided and assisted by the motion of the part, as described by Ochsner, that will go on to a destructive process, the tissues becoming infiltrated early, the lymphatic channels inflamed, as evidenced by the red streaks extending up the limb, when the patient has high temperature, rapid pulse, rigors and chills or chilly sensations, that will call for decided action on the part of the surgeon and practician.

It is of this class of cases that I wish to speak with

especial reference to treatment. The time to capture the murderer is before he has made way with the life of the individual.

Don't sit by and see the life of the patient ebbing away, trusting to flax-seed or mush poultices, with aconite or veratrum viride internally, but do something to prevent the onslaught of the enemy.

Here, the principle advanced by Ochsner, of Chicago, in his paper before this Society one year ago is of great benefit.

Nevertheless, rest alone has not accomplished the results that I had anticipated. But thorough cleansing with some known antiseptic, incision and drainage, combined with complete rest for both mind and body, have left but little to wish for.

It is this old question of incision and drainage, a relief of tension, a diversion of the lymph stream outward rather than permitting it to flow on in the system, carrying death and destruction before it, that I would call to the attention of the general practician. First, I wish to speak in regard to the incision. If the end of the finger is the point which has received the infection, and you have been fortunate enough to see the case early, whether the streptococci or the staphylococci are present it matters not, you can generally say which coccus is present by the appearance.

If the streptococci is present you will find the red streaks going up the arm, much pain complained of and constitutional disturbance present. Whereas, if the staphylococci is present, the symptoms will be less pronounced.

In either case, cocainize the finger thoroughly. (Here a knowledge of the distribution of the nerve-supply will save the patient much pain.) Do not try to infiltrate the inflamed area, for this is both painful and difficult, but inject the cocain directly into the nerve as it passes down on either side of the base of the finger, much after the method employed in the removal of a toe-nail.

When the finger is no longer sensitive, incise freely,

cleanse thoroughly with some antiseptic, preferably peroxid of hydrogen, as this agent exerts a particularly powerful influence in destroying and in preventing the multiplication of the bacilli. Take for instance a case that has extended far beyond the primary point of infection, in which the muscular aponeuroses have become necrotic, the muscles infiltrated and hardened, and in which one or more sinuses are discharging a seropurulent fluid, and fever has become hectic, parts have become swollen and the function is entirely lost.

Hot poultices have been applied, and iodin has been painted over the parts in the hope of abating the inflammation.

In a case of this type, no amount of rest or application will be of any benefit. Drastic and heroic treatment must be used if you wish to save the life of the patient, much less the limb or part involved. Here is where free incision is necessary, incisions of sufficient extent to allow of the removal of all broken-down tissue. Free hemorrhage usually accompanies this procedure and may call for the application of the elastic ligature, which will make it possible for you to do your work in a much more thorough and satisfactory manner. It is sometimes surprising how extensively the muscular aponeuroses become involved and destroyed in such types of infection.

This is in all probability explained by the fact that the amount of blood-supply to such structures is very limited; consequently they are the first to suffer. However, all structures are more or less involved. The joints are frequently attacked as in one of the cases which will follow. In one, however, the knee-joint escaped a most violent attack, which extended above and below, resulting in great loss of substance, but which was resisted by the joint capsule. Striped muscular fibers seem to escape the infection, by the fact that as yet no lymphatic vessels have been found in them. In Dr Ochsner's paper great stress was laid upon rest, and in the cases reported his results were certainly

very gratifying. Since his paper was presented I have endeavored in like cases to get the most perfect rest possible, but have not succeeded in obtaining such brilliant results as Ochsner. When I made ample incision, followed by thorough cleansing with peroxid, together with absolute rest for the part, my results have been all that I could ask. In but one case has the limb or function of the part been sacrificed. I do not believe that hot poultices have any place in this form of surgery, and the application of the preparations called antiphlogistin, etc., are worse than useless.

Case I: H. G., 19 years of age, was referred to me by Dr Watt, of Delaware. His occupation is that of a student. His father died of tuberculosis. The cause of his mother's death is unknown; one brother and one sister are living and both are healthy.

The patient suffered from the usual diseases of childhood. Some years ago he had typhoid fever. Prior to his present illness his health was perfect. On February 15, 1903, while engaged in some work which necessitated the use of a drawing-knife, he produced an incised wound about one inch long, and one-fourth inch deep on the inner side of the left thigh, just above the knee. A chew of tobacco was bound upon the wound as a temporary dressing. It was very painful that night, and the next day he could scarcely walk. A physician was sent for at this time, who coapted the wound with a stitch or two.

One week later the boy began to feel weak and faint and the limb began to swell. On February 27 he experienced a pronounced chill which was followed by a high temperature and a profuse sweat. The chilly sensations and sweating continued and the pain and swelling increased. The leg was then poulticed and painted with iodin. There was no diarrhea and no vomiting, but he was nauseated, and took little, if any, nourishment. On April 14 his physician made an opening above and below the knee, giving exit to a quantity of pus.

Hot poultices were continued, but his condition did not improve and he was sent to the Protestant Hospital on April 21.

When he entered the Hospital his temperature was 100°; his pulse was 132 per minute, small and weak. He was

extremely emaciated and markedly anemic in appearance; the tongue was coated, very dry, and cracked; the bowels were constipated and he had no appetite. His entire limb was boggy and swollen to twice its normal size, and very painful and tender upon palpation. The knee-joint was apparently ankylosed, with several sinuses discharging pus, above and below the same. His countenance and facial expressions were anxious; in fact, his general appearance led me to believe that he would not recover. On the afternoon of the same day that he entered the Hospital he was removed to the operating-room, put to sleep with anesthol, and an incision about ten inches long was made along the inner side of leg below the knee. A like incision was made above the knee to the outer side of the thigh; in addition, two smaller counter openings were made. These incisions enabled me to remove with a curet all of the necrotic tissue, which consisted principally of the aponeurotic coverings of the varicus muscles, together with the connective tissue and deep fascia.

All the muscles of the leg and lower part of the thigh were separated by the diseased process. Fortunately, however, the capsule of the knee-joint had not suffered.

The venous hemorrhage was so profuse that it became necessary to apply the elastic ligature during the latter part of the operation, as the loss of even a small amount of blood was undesirable.

After wiping out the various muscular interstices with gauze, the wound was flushed with peroxid of hydrogen, and again dried and the wound packed with gauze, which had previously been soaked with iodoform glycerin emulsion; the entire limb was enveloped in cotton batting, and a firm roller-bandage was applied. He was then put to bed, and given a saline infusion of 1000 cc. He rallied nicely and has had an uneventful recovery. The first dressing was not changed until the fourth day. After that, the wound was dressed daily. He was discharged from the Hospital on May 29 cured, the limb having regained its normal function and the wound entirely healed. Streptococci were found in abundance in the pus.

Case II: Mr C. A., aged 18 years, was referred to me by Dr E. B. Mead, of Sedalia. He is white, of good family and of good habits. On January 3, 1903, he cut the ring-finger of his left hand very slightly on a barbed wire.

On January 8, while working at his father's saw-mill,