Crushing injuries of the hand demand careful judgment as to what to do. Of the fingers never amputate unless examination shows that the tissues are so lifeless as to make gangrene inevitable. Many fingers may be saved by careful aseptic treatment that appear at first sight to be lifeless. Clean out the bits of separate bone and the ragged edges of soft parts suture accurately and dress antiseptically-of the hand amputate only the parts that are destroyed save every quarter of an inch. If the central metacarpal bones and tissues are pulpified and the fingers destroyed remove them and narrow the hand, or if possible remove the shaft of the bone and substitute (if the periostum is not entirely destroyed or if too great a space does not exist) decalcified bone or fresh aseptic chicken bone as advised by some. I would rather operate four or five times on a hand and save a part that appears slight and insignificant than remove it at one time even if it looks prettier.

The treatment of burns is often the opprobrium of our profession. Everybody has a different method, which indicates that nearly all are incomplete. I have had the best results from the use of strong solution of picric acid. The hand or part of hand burned is cleaned as thoroughly as possible, dressed in copious dressings saturated with solution of picric acid and covered with rubber protective or oiled silk. Relief of pain is frequently immediate and healing, is prompt usually without suppuration. The dressings need not be disturbed for several days, when they may be removed. Small burns may be relieved by application of essential oils. In deep burns, after separation of the sloughs, skin grafting should be employed after the well known methods. After burns about flexures of joints appropriate splinting must be employed.

Frost bites should be treated by gradually raising the temperature by rubbing with snow (the homeopathic antidote). In cases of gangrene of course mutilation is compelled.

In performing amputations, wherever possible form the flap from the palmar surface and never have it too short. This preserves the sense of touch, and besides the palmar skin is best adapted for bearing the brunt of infringement.

In any surgical proceedure about the hand or fingers asepsis is a sine qua non. But especially is this true in interference with region of the little finger and thumb, particularly their palmar surface. The flexor tendons of these two members are contained in sheaths which are directly continuous with the palmar bursa. Infection of either of these digits is very prone to extend into that structure, causing all of the unfortunate sequelae of palmar abscess.

Amputation of the fingers as well as all other painful procedure on them may be rendered painless by the use of cocaine or by freezing with ethyl chloride. In using cocaine a small quantity may be injected along the course of the nerves on each side of the finger, but closer to the palmer surface than dorsal. A rubber constrictor prevents toxic symptoms.

In amputating in contiguity remember that the joints of the fingers are hinge joints formed by a more or less globular head articulating with a concave surface of the adjacent inferior bone, and the extremity of the globular head of the metacarpal or phalangeal bone can only be determined by flexing the joint. Then the level may be determined and your flaps formed accordingly.

While all traumatisms with breach of the skin may be considered as infectious they may be rendered so nearly free from contamination as to be practically aseptic wounds. With wounds that are the seat of germ action, (as all become unless properly treated) surgical treatment is very different. Render them as aseptic as possible, provide free drainage and subdue inflammatory action. For this there is nothing better than the hot dressing preferably made antiseptic by some mild agent, as Boric acid or soda bicarbonate. These should be used hot and copious and made to contain their heat and moisture by means of some impermeable tissue as gutta percha or oiled silk, and must be changed frequently.

Occasionally, in spite of most careful treatment, but more frequently as a result of slipshod, hurried methods, ideal results do not occur. Infection takes place and healing is delayed.

Such cases must then be relegated to the class of inflamed wounds and treated as such.

"Superficial suppuration is controlled readily by cleansing the wound and drainage. This should always be followed by the hot wet dressings. Periostitis or other deep seated inflammation should be treated by early incision. Waiting for the pus to approach the surface is bad practice and has sacrificed many fingers. An early free incision cuts short the disease and saves the consequences of caries and necrosis of bone. Such an incision should be made with a scalpel and not punctured with the point of a bistoury. In this connection I would say that I seldom use a bistoury for the purpose of opening an abscess in any region. My reasons are that the incision in the skin made by a bistoury is seldom more than a puncture whereas we wish a gaping wound, also less liable to injure important structures. Remember that a free large incision in such cases heals as quickly as a small one and rarely needs to be followed by a second.

Diseased bone should be removed by a sharp spoon, or in favorable instances by the Hcl. treatment. Should paronychia develope, evulsion of the loosened nail must be performed. Palmar abscess should be opened early under general anesthesia and free drainage by tube established after thorough cleansing. Remember the time of normal incision. When resolution occurs passive motion of the fingers should be employed. If stiffened fingers result from tendon adhesions, forced movement should be employed until they are felt to give way.. This must be followed by frequent passive movement until normal function is restored.

Should an articulation be opened in any injury, or should articular surfaces be partially destroyed, an effort must be made to preserve the function by rendering it aseptic, etc., closing the capsule with fine silk or catgut. In case drainage is deemed necessary, as it often would be, a few strands of silkworm gut should be used. As soon as the injury has healed (ten to fourteen days) passive motion should be practiced to prevent anchylosis. Remember the cause of anchylosis is more frequently the effect of inflammation than of injury...

FRACTURES, DISLOCATIONS AND SPRAINS.

Dislocation of the various joints of the hand are fairly common, much less so than fractures. The common dislocation of the phalanges is backward, although they may be displaced forward. The diagnosis is readily made. Reduction is seldom difficult and is best accomplished by over extension; in backward dislocation, bending the fingers backward until the joints surfaces are opposed, and combining this extension with traction, which is often necessarily quite forcible. A great deal more can be accomplished by gentle manipulation, than by strong energetic movements.

Dislocation of the carpometacarpal articulation of the thumb is usually reduced readily, but is often retained in position with difficulty, while the metacarpo phalangeal articulation is frequently only reducible by subcutaneous division of the flaxor brevis tendon.

Carpal dislocations are so rare that they hardly need consideration. The osmagnum occasionally is dislocated, but in such cases the condition is nearly always complicated by fracture often comminuted. Reduction by extension and direct pressure is the rule. Any dislocation of course presupposes ruptured lacerated ligaments and always should be followed by immobilization. After the injured structures have healed passive motion and massage must be employed until funtions are restored.

Sprains of the various joints of the hand are common and must always be treated by immobilization until the lacerated ligaments unite. Splints, plasters, starch bandages meet the indications well. In favorable cases strapping with adhesive plaster may be useful, as in sprain of the ankle.

Fractures of the phalanges are readily reduced and easily retained in position by splinting. For this purpose, a well applied starch bandage has met the indications in my own experience. Fracture of the metacarpals should be treated by a palmer splint with padding in the palm of the hand. Great care must be taken to avoid tendon adhesions by frequent removals of the dressings and exercise by passive motion.

In conclusion let me impress upon you the necessity of careful detail in the treatment of these small and apparently insignificant injuries. A surgeon is not always measured by his successful laparotomies. The celebrated Michael Angelo was once asked why he, the greatest of sculptors, spent so much time on the hand of a figure, that being such a "little thing." His reply should be our motto, "The little things make perfection, but perfection is no little thing."

"Jeg i glad."

Anesthetics.*

By Warren D. Howe, M. D., Canon City.

In large cities and hospitals the surgeon has at his command the services of the skilled anesthetist, the specialist in anesthesia, a man who is trained to a high degree for this particular work, who gives all his time to it and to nothing else. In the country this luxury is denied the surgeon; the patient is deprived of this additional factor of safety, and the general practioner, whose education along this line is not special, is often called upon to assume one of the greatest responsibilities incidental to a life that is filled with responsibilities. That he meets this demand upon himself and his skill successfully and with an almost unappreciable death rate is but a matter of every day duty.

In the large city hospitals much elaborate and costly apparatus is at hand for the administration of the anesthetic agent and for combating any emergency that may arise.

The country practitioner, on the other hand, in office or private house, is limited to the means he can employ for these purposes, so that the endeavor should be made to secure the greatest safety to the patient with the greatest simplicity of technic.

The controversy as to the relative safety of the various agents used for producing general anesthesia has waged practically since the discovery of Ether and Chloroform. In addition

*Colorado State Medical Society, October, 1900.