1 24 Russell Sa^e ;fowMd3+|o>, D^p^of ci,j/j ^^.e***.. Copy ^ FOURTH OF JULY INJURIES AND TETANUS THE SEVENTH ANNUAL COMPILATION BY THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION A PLEA FOR A SAFE AND SANE FOURTH Reprinted, luith additions, from The Jotirnal of the American Medical Association, September 18, 1909, Vol. LIU, pp. 948-956 copxright. 1909 American Medical Association Five Hundred and Thirty-five Dearborn Avenue CHICAGO Pu"biiah3ff SEP 3c isn FOUETH OF JULY IKJUEIES AND TETANUS [EDITOEIAL] THE ANNUAL FOURTH OF JULY EECORD . In this issue of The Journal appears the seventh annual compilation of deaths and injuries resulting from the celebration of the Fourth of July. The fact that the celebration was spread over three da3^s this year, since the Fourth came on Sunday, may be partly responsible for the increased number of tetanus cases, the total being nearly double that of last year. Except in a few progressive cities which passed prohibitory or restrictive ordinances, however, there seems to have been a relaxation of authority regarding the use of fireworks, chiefly in Illinois, Massachusetts, New Jersey, New York and Peimsylvania. More serious has been the ab- sence or non-enforcement of restrictions on the use of blank cartridges, which, of course, accounts for the increase of tetanus cases. Tetanus antitoxin, although extensively used, was still not employed as much as it should have been, either as a preventive measure or after active symptoms began. In several instances, according to report, doctors still resorted to the old methods of treatment long known to be of little value. Several instances were reported also in which doctors did not lay open the wounds until after tetanus had developed, and, there- fore, too late to be effective. In some instances the later operation revealed imbedded in the wound the wad which should have been removed at the first treatment. The following simple rules have already had wide cir- culation, but should be carefully followed in the treat- ment of every blank cartridge or puncture wound : TO PREVENT LOCKJAW 1. Freely incise every wound. 2. Carefully and thoroughly remove from the wound every particle of foreign matter. 3. Cauterize the wound thoroughly with a 25 per cent, solution of phenol (carbolic acid) in glycerin or alcohol. 4. Apply a loose wet boric acid pack. 5. Inject subcutaneously 1500 units of antitetanic serum. 6. In no case should the wound be closed. It should be allowed to heal by granulation. The dressing and packing should be removed every day. Although the numbers of dead and of injured are larger than or as large as last year, there is, neverthe- less, abundant evidence of an increasing public senti- ment in favor of more rational methods of celebration. Two more cities, Washington and Cleveland, passed and enforced prohibitory ordinances, and Chicago enforced a restrictive ordinance, with the result that no casualties were reported for Washington, only four slight injuries for Cleveland, and less than half the usual number of accidents and no deaths for Chicago. These results show that prohibitive measures are more effective than mere restrictive ordinances, although restrictive meas- ures are much better than doing nothing. Efforts to provide safe amusements have been more extensive this year than ever before. Worthy of special mention is the plan adopted by Springfield, Mass., which shows the great opportunity offered by the annual cele- bration of the Fourth of July to instill in the minds of the youth of our land a spirit of genuine patriotism. The parades, the floats representing historical incidents, the picnics, and, last but not least, the annual chorus drill under skilled leaders in preparation for the mass singing of national airs and popular songs — all these methods, if more extensively employed, would add greatly to the value of the Fourth-of-July celebration in our national life, and help to do away with the present death-dealing methods of celebration. Those who are working toward better methods have reason for encour- agement and should persevere. City authorities should assist by prohibiting fireworks. The only objections seem to come from the ^T^usiness interests" involved. By the combination, therefore, of substitution and re- striction, a more enlightened celebration of our national Independence Day will be assured. STILL TEMPORIZING WITH THE BLANIv CARTRIDGE PISTOL Blank cartridge wounds canse more deaths in the annual celebration of the Fourth of July than all other factors combined. In seven years, 794 deaths have been caused by this one factor! Most of the victims were bright active boys, aged from 6 to 18 years, and they were doomed to die the most awful death known to medical science, a death the agony of which is probably not paralleled even by the tortures of the Inquisition. If this annual sacrifice were really necessary, it would be far more merciful to pick out the hundred or more youths each year and deliberately shoot them. But this annual outrage is not necessary; it is entirely prevent- able, and the prevention rests with our city govern- ments. For seven years The Journal has heralded these facts to the world. They have been given even wider publicity by some of our public-spirited newspapers. During the past two or three years the public press gen- erally has taken up the cry, and now no one can plead ignorance of the awful facts. Nevertheless, the average city government still views with the blind eye of callous indifference the fatalities for which it is morally re- sponsible. Some cities have, indeed, passed prohibitory ordinances, but have not enforced them vigorously. To permit the use of blank cartridges and blank cartridge pistols in the celebration of the Fourth of July is abso- lutely criminal. The city council which fails to pass and to enforce ordinances prohibiting the use of these instruments of torture will hereafter be open to the charge of criminal negligence. The plea of ignorance is no longer good; to temporize further regarding the sale and use of blank cartridges and blank cartridge pistols is to aid and abet torture and murder. These are strong words; but to use mild ones would be to trifle with the anguish and horror in scores of homes — a horror and anguish but faintly reflected in the appalling statistics on the subject. The only effec- tive way to deal with the murderous blank cartridge pistol is to pass and to enforce an absolutely prohibitive ordinance in each city. ISTo more temporizing should be tolerated. The agonizing deaths from this cause should cease. THE VALUE OF TETANUS ANTITOXIN Among the reports of the cases of tetanus that we have received we have frequently found the statement that tetanus antitoxin was not used because "the doctor said" that it "was useless," or "of doubtful value/' or "in an experimental stage." Therefore, although we have been to some pains at several times to set forth the exact status of tetanus antitoxin according to the best avail- able evidence, it would seem worth while again to dis- cuss the subject while it is so acutely before us as it now is. To put the matter in a nutshell, it may be stated dogmatically that the value of tetanus antitoxin as a prophylactic agent is very great, and its efl&ciency nearly absolute; as a curative agent it is by no means worth- less, and undoubtedly it saves not a few lives when properly used. Apparently, to judge from the reports at hand, many physicians have not yet learned to dis- tinguish between the results obtained by the prophylac- tic use and by the curative use of tetanus antitoxin; the usual futility of the latter has been incorrectly as- sumed to apply to the former. The example of using tetanus antitoxin for preventive purposes was first furnished by the veterinarians, who have to contend with tetanus much more commonly than we. Knowing that in certain stables the horses which received wounds were very likely to develop teta- nus, they found it desirable to try to prevent this seri- ous complication by injecting antitoxin into all horses that had received wounds. The results that they ob- tained were from the first so striking that now antitoxin prophylaxis is invariably used to prevent endemic and epidemic outbreaks of tetanus in horses. For example, in one stable in which from six to eight cases of tetanus developed yearly, it was decided to give every horse with wounds about the feet a prophylactic dose of antitoxin; during the following five years three hundred horses were so treated without a single case of tetanus, al- though one horse which received no antitoxin developed the disease.^ Vaillard^ says that in a series of 13,124 prophylactic injections in horses not one contracted, tetanus. In man it is not so "easy to estimate the results of tetanus prophylaxis, for, outside of Fourth-of-July tetanus, we do not often get a chance to observe this 1. Wells, H. G. : Medical News, June 1, 1901. 2. Bull. Acad. M6d., Paris, 1908, Ixxii, 581. disease in epidemic proportions, but such evidence as we have is almost equally favorable. Suter^ has col- lected 700 cases in which but one light attack of tetanus was observed among all the patients given antitoxin. In France, where this practice seems to have been especially general, there have been a few cases of tetanus in spite of prophylactic injection, but the entire evidence is emphatically in favor of the value of this procedure; indeed, Vaillard claims that in only five cases m the literature to 1908 can the antitoxin prophylaxis be con- sidered a complete failure. The Society of Surgery of Paris recently reported that in a group of Pans hos- pitals there had occurred in the last seven years but eleven cases of tetanus, all of which were m persons who by some mischance had not received the customary preventive dose of antitetanus serum, which is the rou- tine practice there after a street accident. Kocher went so far as to say before the German Surgical Society that he would consider any physician entitled to reproof who failed to use this measure in a case of injury with con- tamination of the wound by street dirt. In this country, the prophylactic treatment of Fourth-of-July injuries has been, so far as we can learn, invariably successful, and our annual mortality list from "patriotic" tetanus has occurred because of the lack of this measure in the cases of the victims. It is to be expected that a few cases may occur in spite of antitoxin, especially when it is given several days after the injury is received, because by this time the disease may be well advanced and the blood loaded with tetanus toxins, even several days before the appearance of symptoms.* But even in these cases the prognosis will be much better if the antitoxin is given before rather than after the symptoms have developed. To neglect to use antitoxin as a curative agent is also unwarranted in the light of our present knowledge, even although the results are by no means so striking as with diphtheria antitoxin. There is no question that more of these patients recover with antitoxin than without, even if the number is not great. Especially efficacious seems to be the intraspinal route of administration, for by this means the antitoxin is brought into close contact 3. Arch. klin. Chir., 1904, Ixxv, 113; Beltr. klin. Cbir., 1907, "' 4.'Madsen: Centralbl. f. Bakteriol., 1908, xl. No. 3. 8 ■with, the place where it is most needed, and it is well known that antibodies injected subcutaneously or into the blood directly do not find their way into the cerebro- spinal fluid in large amounts. Clinical results support this theorization, and Hoffmann^ reports a series of thirteen eases with 58 per cent, mortality in which the antitoxin was given subcutaneously, whereas of sixteen patients given intradural injections only two died, and these from complications. Undoubtedly some of the earlier disappointments witli antitoxin prophylaxis and treatment were the result of the uncertain activity of the antitoxin preparations then on the market, a defect which has been remedied in this country by the system of standardization developed by the Hj^gienic Labora- tory of the Public Health and Marine-Hospital Service. [THE REPOET] SEVENTH ANNUAL SUMMAEY OP POUETH OP JULY INJUEIES Por the seventh consecutive year we are presenting statistics of injuries received during the celebration of the Pourth of July, with particular reference to tetanus resulting from these injuries. Considerable effort has been made to secure reliable data, and all serious cases have been carefully investigated, so that, so far as the figures go, dependence may be placed on them. We have received thousands of letters from physicians in all parts of the country, reporting cases which otherwise could not have been included in the statistics. There are doubt- less thousands of other cases not reported, although chiefly minor injuries. Our thanks are due for the many careful reports which have made these statistics more complete and the figures more reliable. The data are presented in the same manner as heretofore, in order that comparison may be made. MORE CASES OP TETANUS There were 150 tetanus eases this year, almost double the record of last year, when 76 cases were reported. This is the largest number since 1903, when there were 415 cases. It is significant to note that the number of blank cartridge wounds correspondingly increased from 5. Beitr. klin. Chir., 1907, Iv. Table 1. — Cases of Tetanus Name. Sex. Benbow M Gardner M Corbin M Smith M Padgett M Hendricks. M Allen M Brown M Binaraman. M Cook M Ebright M Ford M German M Gestel M Granat M Haffey M Menson M Morris M Muelford M Neff M Qiiinn F Keed M Eemiliard M Simmons M Stoffel M Verbelia M Callahan ,M Czer winski M Dolson M Kennedy . , M Lacey M Lurok M McCoy M Thompson M Webster M Parks M Allen F Clark M Miller M "Van Meter M Williams M Yocum M Gill M Pitts , M Behrman M Cavey M Cause of Age. Wound. Site of Wound. '^ 03 3 a CALIFORNIA 16 Bl. ctg 45 Firecracker. ..Hand ..Hand ,. . 10 ,. . . 11 D. D. DELAWARE 13 Bl.ctg 17 Bl.ctg . . Hand. . ' ' ..Hand ■•■(6) 8 7 D, D, FLORIDA 12 Bl.ctg ..Hand D, IDAHO 27 Gunshot. .Ankle 10 D. 11 Bl. 14 Bl. 8 Bl. 13 Bl. 14 Bl. 11 Bl. 8 Bl. 13 Bl. 10 Bl. 15 Bl. 9 Bl. Boy.Bl. 11 Bl. 19 Bl. 14 Bl 13 Bl. 17 Bl. Boy.Bl. 12 Bl. 12 Bl. .Finger (4)13 D. ~ " D. D. D. D. ctg.. ctg Hand ctg. Hand ctg Hand ctg ctg Hand 19 D ctg Hand 12 D ctg Hand 7 D. ctg Thigh (10)22 R. ctg Hand 30 E. ctg Finger 7 D. ctg Hand ctg Hand, (7) 9 D, ctg Hand 10 D. ctg Hand 25 K. ctg Hand ctg Hand 9 D. ctg Hand 13 D. ctg Thigh (7) 9 D. ctg Hand 15 D. INDIANA 11 12 13 12 13 15 Bl.ctg Hand... Bl.ctg. Bl.ctg. Hand... Bl.ctg Bl.ctg Hand.,. Firecracker . . Thumb. Bl.ctg Bl.ctg Leg.. .. Bl.ctg Hand... is T) 9 1). 7 1), 7 1). 7 1). S 1), 20 1). 8 D, IOWA 11 Bl.ctg Hand. 9 D. 6 Bl.ctg ....Hand . . . . 14 D. 16 Bl.ctg ....Hand . .. 11 i). 16 Gunshot . . Knee 7 i). Boy.Bl. ctg I>, 8 Bl.ctg Penis ...(7)10 D, 9 Bl.ctg ....Hand 9 D. KENTUCKY 8 Bl.ctg Hand... MAINE 13 Bl.ctg Hand,.. MARYLAND 18 Bl.ctg Finger. 14 Bl.ctg Hand... 11 D. .(10)48 14 10 S?Q Cause of Site of |3 d . Cole M 10 Bl.ctg .Hand 7 i>. Damm M 1.5 Firecracker. . .... 16 i). -Lawler M 11 Bl.ctg .Hand McEorie M 12 Bl.ctg. .Hand D. M M 13 10 Bl. ctg 9 1), Schaff Bl.ctg .Hand 7 D. Sheridan M 12 Bl.ctg Stewart M 1.5 Bl.ctg .Hand i). Straft'on M 16 Bl.ctg .Hand.... 18 D. MISSOUEI Adair M Boy. Powder expl ..Arm .... 18 T>. Cooper. M l(j Bl.ctg .Hand..... .... 10 D. Enloe M 13 Bl.ctg .Hand 9 i), Hogan F 2H Bl.ctg. .Hand i>. Judson M 10 Bl.ctg .Hand 7 D. Neland M 10 Bl.ctg .Hand ...,(5)11 D. Solomon M 10 Bl.ctg .Hand .... n u, Taylor M 11 Bl.ctg .Hand .... 11 D MONTANA Kelly ..-. ....M 23 Bl.ctg .Hand .... 10 D. Mulholland M 16 Bl.ctg ..Hand i). Staten M 7 Bl.ctg. .Hand .... 10 D. NEBRASKA Dlargy M 12 Eocket Hand D. Pop M Adult.Bl.ctg .Hand .... 10 i). Watkins M 13 Bl.ctg .Hand 9 U. NEW HAMPSHIRE Boyle M ] 17 S'EW Bl.ctg JERSEY .Hand ....(7) 9 D, Campbell M 12 Bl.ctg .Hand..... ....(6)14 D. Da Costa M Gunshot .Finger. . . .... 10 i). Fischer M 14 13 Bl.ctg Cannon .Hand .Thigh.... 7 .... 10 1). Francke M D. Frisco M 13 Fireworks Goldstein M 8 Bl.ctg 9 i). Guthrie M 9 Bl.ctg .Hand ....(6) 8 D. Hunt M U Bl.ctg .Hand 8 i). Jasperino M 14 Bl.ctg .Hand .... 18 K. Keley M 13 Bl.ctg .Hand 7 i). Long M 12 Bl.ctg .Hand..... 8 D. Mclntyre M 14 Bl.ctg . Finger. . . . .... 10 D. M 14 Firecracker., Bl.ctg ..Hand .Hand :.■.■.■ (8)10 Miner M D. M 13 12 Bl.ctg Bl.ctg .Hand .Hand 8 ....(8)11 I), Eiccio M D. Walters M 12 Bl.ctg .Hand 7 i). Weigel M 11 Bl.ctg .Hand .... 30 E. Wilson M 12 Bl.ctg .Hand ...(12).. K, 11 Name. Sex. Age. Cause of Wound. Site of Wound. NEW YORK Brightman M Jeriorski M Last M Mafredonia M Ohlowald M Otis, M Schroeder M Schultz M Stanway M Tatar M Wiegland M Combow M Getroast M Lewe M Manuel M Marcum M Parkos M Seaman M Sells M Sliman M Stokely M Tindall M Underwood.. M 14 12 11 12 12 13 13 10 15 10 14 Bl.ctg Hand... Bl.ctg. Hand... Bl.ctg. Hand... Bl.ctg Hand... Bl.ctg Hand... Bl.ctg Hand... Bl.ctg Hand... Gunshot Thigh . . Bl.ctg Finger. Firecracker. ..Hand... Bl.ctg. Hand... Powder expl. .Hand.. . , Bl.ctg Hand... Bl.ctg Hand... Bl.ctg Hand ... Bl.ctg Hand ... Bl.ctg Finger.. Fireworks Bl.ctg Hand... Bl.ctg. Hand... Bl.ctg Hand Bl.ctg 12 Boy. Bl.ctg Hand PENNSTLYANIA Breich M Coles :M Donovan M Farber M Houpt M Koslovski M Kowalick M Maxwell M Scott M Werts M 16 15 13 18 15 11 6 13 Bl.ctg Hand Bl. ctg Leg.. Bl.ctg 15 Bl. ctg Finger. Bl.ctg Groin. . Bl.ctg Hand.. Bl.ctg Hand.. Bl. ctg Finger. Boy. Firecracker . . . Leg 13 Bl.ctg Finger. o >, "42 c8 ;^ cap 3 S o Q-^ K 12 D. 20 1). 7 1). 1). 9 D. 6 D. 11 1). (7) 9 1). 14 I). (8)10 D. U. 16 E. 10 1). (7)10 i). 8 1). 1). (5)14 D. 18 1). 10 1). 1). 9 1). 12 1). 16 D. 8 D. 6 i). 15 1). 22 D. 6 [). 11 D. 12 D. 10 i). Phebus. SOUTH DAKOTA kI 11 Bl.ctg... . Finger . WASHINGTON Brown M 11 Nelson M 13 Perry M 14 Roth M 10 Bl.ctg Hand Bl.ctg Hand Bl.ctg Hand Bl.ctg Hand 7 D. "6 D. WEST VIRGINIA Comedy M 13 Llewellyn M 9 Parshall F 15 Robinson M 10 Bl.ctg Hand , Bl.ctg Hand , Firecracker. ..Hand Bl.ctg Hand , 16 6 D. WISCONSIN Briscoe M Darling M Dakonich M Golden M Micka M Peterson M Rhein F Kutz F Zettman M 12 Bl.ctg Finger (6) 8 11 Bl.ctg Hand 11 15 Bl.ctg Hand 9 11 Bl.ctg Hand 8 13 Firecracker . . . Hand (8)13 16 Bl.ctg Hand 8 11 Bl.ctg Hand 9 30 Bl.ctg... 8 . . Powder expl 1 Figures in parentheses show incubation period. 12 816 last year to 1,095 this year, and that the states hav- ing the largest numbers of blank cartridge injuries have also the largest numbers of tetanus cases (Table 5). It is interesting also to state that from blank cartridge TABLE 2. — Comparison with Previous Years 1903 1904 1905 1906 1907 1908 1909 Alabama . . . Arizona .... California . . Colorado . . . Connecticut Delaware . . . Dist. Colujpb Florida Georgia Idaho . Illinois Indiana Iowa . Kansas Kentucky . Louisiana Maine . . . Maryland Massachusetts, Michigan Minnesota Missouri Montana Nebraska New Hampshir New Jersey . New York . . North Dakoti Ohio Oklahoma . . Oregon .... Pennsylvania. Rhode Island South Carolina South Dakota Tennessee . . Texas Utah Vermont . . . Washington West Virginia Wisconsin Wyoming Total . . States having cases .... 1 49 11 14 11 4 2 1 16 29 15 29 2 4 e 2 8 36 I 67 1 2 82 3 3 10 415 15 6 2 1 17 105 20 3 3 1 12 13 104 16 8 4 1 1 1 3 4 2 3 1 1 10 8 7 1 1 89 12 73 12 1 1 1 10 9 76 2 1 1 20 9 1 11 3 3 1 19 11 12 10 30 21 23 25 23 20 150 25 wounds there was a higher percentage of deaths (10.3) than from gunshot wounds (6.1 per cent.). The most common cause of the wound is the blank cartridge, and the usual site is the hand. The duration 13 given is the number of days between the injury and death or recovery. Following the injury it required from 5 to 15 days before the symptoms of tetanus appeared, the average of all fatal cases being about 7 days. The longer incubation period doubtless indicates a less virulent germ and, therefore, a better chance for recovery by treatment. In one case the symptoms began on the fourth day, while in another case they appeared on the fifteenth. Following the appearance of the symptoms death resulted in from 2 to 9 days, the average of all cases reported this year being about 3i/2 days. In 4 cases the entire duration of time between inoculation and death was six days or less. The average duration for all fatal cases reported was IOI/2 days. The list of tetanus cases is given in Table 1. TABLE 3. — Causes of Tetanus Cases. Blank Giant Can- Fire- Powder, Year. Cartridge. Cracker, non. arms. etc. Total 1903 363 17 5 3 27 415 1904 74 18 5 1 7 105 1905 65 17 4 5 13 104 1906 54 17 1 7 10 89 1907 52 8 6 4 3 73 1908 58 5 4 3 6 76 1909 130 9 1 4 6 150 TABLE 4. — Causes of Deaths Aside From Tetanus Fire Powder, from Tor- Gun- Fire- pedoes, Giant Can- Other Year. shot. works. etc. Crackers. non. Causes. Total 1905.. . 37 23 6 5 7 17 95 1906.. . 38 18 18 3 3 3 83 1907. . . 20 31 13 13 3 22 102 1908.. . 30 22 19 23 7 ~7 108 1909.. . 17 37 16 7 7 6 90 Tetanus cases occurred in 25 different states, or in 5 more than last year, and the same as in 1906. For the fifth consecutive year Illinois reports the largest num- ber, having 20 cases this year, 12 each in 1908 and 1907, 16 in 1906 and 20 in 1905. In 1903 and 1904 Pennsyl- vania reported the highest numbers. For the fourth consecutive year ISTew Jersey reports the next highest number, having 19 cases this year, 10 last year, 8 in 1907 and 10 in 1906. Ohio reports 12 cases this year. Michigan and N'ew York each had 11 cases and Penn- sylvania 10. Table 2 gives a comparison of the number of cases in each state for the seven years. •SJiaoAi -ejg puB aapA\orH -IN 05'*© .CO \a i-i CO 1-1 CO ■<*l (M CI iH T-l • CO 00 •jqSjs JO ssoi • . . . • (N •smBap ib;ox CO 1-1 CO CO i-l 00 rH T-l CO rH CO ■* CO • ■* •sasnBD jaTjijo moj^ iH iH CO iH rH la CO -CO •snuBjaj THOj^ : ; : '^ \ ; '^^ ; : irHj^orHco rH rH » C5 25 § o «-r; *w ri \r*. rn rn _ o fl p -3 ?i 5 <\ *-*COlMC0COb-(MT-l 00 rH 00 03_ in CO CO Tti' in CO •* ■* CO CO CO ^ l- t- iH CO ■* I- OO 05 C-l C^I O t- iH tH IN (M N IM 1-1 CO rH -CO t- CO • T-i • o\ • th CO in CO (M rH iH 1-1 iH B ^ ^ !>^ • a c« cs 'a 3 -t; ^ I— ( cd <^ *!> ^,5oQ Si a>ajiue)aJ±^ a -5 a > CO a ■d -i-> o rn • CD »0 ''^ CO o o o o o o o 02 0^0^0^0^ ^ Gi C3 Oi Os Oj !> iH iH 1-i tH r-l 16 Blank cartridges still continue to be responsible for the great majority of tetanus cases, 130, or 86.5 per cent, of all cases this year, being due to that cause^ as compared with 73.3 per cent, last year and 71 per cent. in 1907 and 60 per cent, in 1906. Nine cases this 5^ear resulted from giant firecracker injuries, 4 cases from gunshot wounds, 1 case from toy cannon injury and 6 from other forms of fireworks. Of the 150 cases of tetanus due to Fourth of July in- juries this year, 125, or 84 per cent., were reported to have ended fatall}^, as compared with 72 per cent, of deaths last year, 85 per cent, in 1907 and 84 per cent, in 1906. TETANUS FROM OTHER THAN" FOURTH OF JULY INJURIES Besides the cases of lockjaw due directly to Fourth of July injuries, many other cases were reported this year which occurred during the Fourth of July season, but which were due to penetrating injuries from nails or splinters, to crushing injuries or other causes. There were 128 such cases reported this year, as compared with 166 last year and 94 in 1907. The report of these cases emphasizes the fact that in the treatment of all penetrating wounds the possibility of tetanus should be borne in mind and prophylactic measures employed. ■Of the 128 cases of tetanus due to other than Fourth of July injuries, Pennsylvania reported 21, Illinois 18, Ohio 13 and New York 12. Altogether 25 states re- ported cases, as compared with 28 last year. Table 8 on page 953 shows these cases by states and will be inter- esting in comparison with Table 2. DEATHS FROM FIREV^^ORKS^ ASIDE FROM TETANUS Besides the 125 deaths due to tetanus, 90 persons were killed by various forms of fireworks, making a total of 215 deaths, an increase of 52 over last year and 57 more than in 1906. Seventeen were killed outright this year by firearms, 16 were killed by explosions of powder, 7 by giant firecrackers, 7 by toy cannon and 7 by various causes, such as blood poisoning, by sky-rockets, chemi- cals, etc., while 37 were literally burned to death by fire from fireworks, many of which were caused by the so- called "harmless" varieties of fireworks. As heretofore, 17 all accidents not directly due to the discharge or han- dling of fireworks or other means of noise production on or about the Fourth of July have been omitted. Table 4 TABLE 6. — Total Deaths axd Accidents bt States Dcrixg Seven- Yeahs 1903 1904 1905 1906 1907 1908 1909 Alabama 2 7 1 2 1 i i Arizona 1 .. 4 5 o 5 3 Arkansas . . 3 4 . . 5 1 California 100 138 142 96 121 136 89 Colorado 39 44 26 23 25 13 18 Connecticut . . . 162 133 132 169 63 105 86 Delaware 1 5 14 8 16 12 13 Dist. Columbia. 2 10 24 5 12 21 Florida 1 2 2 .. .. ~. { Georgia .. .. 4 2 4 Idaho 4 4 3 3 4 4 2 Illinois 366 423 542 598 468 558 546 Indiana 160 211 217 250 . . 255 164 Iowa 168 137 328 255 231 174 91 Kansas 63 88 56 61 64 72 86 Kentucky 30 72 17 21 18 33 17 Louisiana 2 3 7 8 4 Maine 31 32 29 15 11 16 22 Maryland 21 22 13 10 23 21 10 Massachusetts.. 637 193 467 329 168 430 430 Michigan 144 157 288 193 163 203 177 Minnesota 157 102 174 95 9." 65 69 Mississippi .. .. 2 2 1 Missouri 147 84 218 325 299 375 352 Montana 5 17 40 3 6 11 9 Nebraska 46 63 43 47 58 46 42 Nevada 1 2 .. 1 4 New Hampshire 37 23 9 29 13 13 23 New Jersey . . . 228 204 350 398 402 472 488 New Mexico 4 5 1 6 .. 1 New York 522 549 566 681 752 647 897 North Carolina . . . . 1 1 North Dakota.. 10 8 29 11 8 13 4 Ohio 443 327 329 490 375 543 323 Oklahoma 1 3 7 14 194 9 12 Oregon 16 13 9 11 5 9 21 Pennsylvania .. 533 744 721 969 491 987 986 Rhode Island.. 64 30 11 21 39 39 42 South Carolina . . . . . . 1 . . . . 4 South Dakota. . 4 10 15 5 8 10 9 Tennessee 4 1 5 6 4 5 4 Texas 2 2 4 11 7 11 4 Utah 23 22 25 18 30 12 18 Vermont 45 14 10 14 18 19 12 Virginia 11 5 8 .. 5 4 Washington ... 21 25 15 25 23 38 32 West Virginia.. 19 16 34 64 27 29 35 Wisconsin 190 215 230 155 150 187 157 Wyoming 1 2 8 3 .. 1 1 shows a comparison of the causes of death other than from tetanus for the past five years. In Table 5 will be found a summary of all injuries, including tetanus, and of all causes, arranged by states. _: t-i-l N iH CO C50 N QDOONl-T-INOiOl-OJMOT-ITtft-OOOCOO • 00 00 (N t- 1- tH 00 lO rH iH t- Tt< rH S Ol t-00 OOiH tH CD 05 50 01 OOO-^lrHCOCD-^t-eOOOlOlOlNOiHCOtO -CO lO tH ■* lO OO O (M 05 rHO 0000 O CD CO rj( 00 CO (N to CO «0 IM 00 00 CO t- T-l 02 in CD CO O t- 1-H in 0> CO IM iH CO COCOODCD050r-linrHOOrHOOiMCSiCOTHC003CO t-^t-^in in 00 iH_iH (N CO »H OO >> Cl t-^CO Ol t-^in OO OO W t> in CO 05 to COOt-rHOlt-i-ICiaJClT-fOSrHCOt-eOrH ©croo"odininTHb^coinT^rtrri?'odoo"t>?o«oincor-rooot^«3 OC5001CJ05050000GCOOOOCOt-t-t-t-t-t-t-t-t-CO«5!OCD«550'fflCO«>Q5COCOCOW?OininiGininin ,*!> .60 c •S a-^ SS S& O SH.M g a >7" ji-so o oj " o o a> eS o M i+J^ o M CD Z o-£?Ph : .on M-«5 ? , MCCCh m tu g MJ3 ei 1=1 HM^M&BIUalllEHPH & \2 05 »2 "3 '3 02 rQ 30 Beneath the totals at the bottom of the table are given the totals for the six previous 5'ears in order that com- parisons may be made. The grand totals are also given. Table 6 is arranged to show a more ready comparison by states of the total deaths and accidents for the six years. Pennsylvania holds the blackest record with 986 casualties, Kew York coming second with 898, followed by Illinois with 547, New Jersey with 488 and Massa- chusetts with 430. Altogether there were 5,307 accidents this year, or 316 less than last 5^ear. NON-FATAL INJURIES There were 5,093 non-fatal injuries this year, or 368 less than last year. There were 16 people totally blinded this year, being 5 more than last year, but 9 less than the highest number in 1905. There were 36 who lost one eye each, 41 who lost legs, arms or hands, while 176 persons lost one or more fingers. The giant firecracker holds the first rank as a cause of mutil- ating wounds and is responsible for the majority of losses of eyes, hands and fingers during the annual cele- bration of the Fourth. In the awfulness of its destruc- tion, the giant firecracker is equaled in a few instances only by the explosions of home-made cannon. The fact that the wounds made by the giant firecracker are so lacerated and laid open is probably the reason it does not cause more lockjaw. Then, also, these cases are taken to the physician, while the supposedly insignificant wounds made by blank cartridges are neglected. This year 1,614 accidents, including 7 deaths and 9 cases of lock- jaw, were due to the giant firecracker. Firearms caused 341 accidents, including 17 killed and 4 cases of lockjaw. The percentage of deaths was 6.1. Of the total number thus injured, 133 were struck by stray bullets from the reckless shooting of firearms by others and 5 deaths resulted. Toy cannons caused 437 injuries, including 7 killed and one case of tetanus. TOTALS IN CHIEF CITIES Table 7 shows the number reported killed and injured in the largest cities during the past three years. The population figures were taken from the U. S. Census 21 Bureau's estimate of 1906. This table -o-ill be of special interest from year to year, since it will show the results of the adoption and enforcement of ordinances prohibit- ing or restricting the use of fireworks. Philadelphia had 9 deaths this year, the largest number reported for any one city, 'New York had 7 deaths, Boston, Pittsburg and Lawrence,, Mass., each had 5, while 4 each were reported for St. Louis, Kansas City, Mo., and Camden, K. J. Of non-fatal accidents this year, New York leads with 559, followed by Philadelphia with 508, Boston with 167, St. Louis with 163, Newark with 150, and Chicago with lis. RESULTS OF EESTEICTIVE LEGISLATION For several years Baltimore has practically prohibited all forms of fireworks, and the small number of casual- TABLE S. — Cases of Tetaxds from Other Causes 1908. 1909. 190S. 1909. Alabama . . Nevada Arizona . . New Hampshire Arkansas 2 . . New Jersey 7 S California 4 4 New Mexico 1 Colorado 3 .. New York IT 12 Connecticut 2 2 North Carolina .. . . 1 Delaware 2 1 North Dakota 1 Dist. of Columbia Ohio 23 13 Florida 2 . . Oklahoma Georgia 1 Oregon 1 Idaho . . Pennsylvania 21 21 Illinois 17 18 Rhode Island 1 Indiana 6 4 South Carolina Iowa 2 7 South Dakota 2 2 Kansas 4 . . Tennessee 3 Kentucky 5 5 Texas 4 1 Louisiana 1 . . Utah Maine . . Vermont Maryland 3 . . Virginia 4 1 Massachusetts .... 3 5 Washington 2 Michigan 4 .5 West Virginia 1 Minnesota 4 2 Wisconsin 5 4 Mississippi . . Wyoming Missouri 12 5 • Montana Total 166 128 Nebraska 3 States reporting cases. 29 25 ties shown in Table 7 are the result. In fact, it has been stated that, even of the few accidents reported, most came from suburbs and outlying districts which were not directly under the city ordinances. Immediately following last year's celebration, when 12 persons were killed by fireworks, Cleveland passed a prohibitive ordinance, in spite of the protests of fire- 23 works dealers. The wisdojn of that legislation is shown by the fact that no deaths were reported this year and only four minor injuries. Washington, our national capital, has set a splendid example by enforcing a prohibitory ordinance, with the result that this year not a single accident was reported. Instead of prohibiting all fireworks, Chicago passed a restrictive ordinance limiting the sale to fireworks to a few days preceeding Jnly 5 and limited the size of fire- crackers. The use of blank cartridge pistols was strictly forbidden. Comparatively few licenses to sell fireworks were issued, and, according to reports, the ordinance was well enforced. No deaths were reported this year as com- pared with 12 last year and 16 in 1907. The number of injuries still remains high, although it is a splendid showing compared with Philadelphia, New York and other cities, where very little, if any, restrictive efforts were made. Eestrictive ordinances were reported for other cities, but no such marked results were apparent. WHERE THE RESPONSIBILITY RESTS The responsibility for the vast majority of deaths and injuries clearly rests with city governments, and this annual carnage could doubtless be prevented" without ex- treme difiiculty. Prohibitory ordinances are most effec- tive and permanent, as shown by the results in Balti- more, Washington, San Francisco and Cleveland, and even restrictive ordinances, if strictly enforced, are rather effective, as shown by the results in Toledo, Chi- cago and other cities. But the enforcement of restrictive measures is more difficult and requires more constant vigilance on the part of the police. By the sound, it is difficult to know whether an explosion is due to a fire- cracker 3 inches long or to one 5 inches long, or whether it is due to some other forbidden form of fireworks. Under the prohibitory ordinance any explosion would be recognized at once as a violation of the law. Again, the smaller sized firecrackers which have been considered so harmless caused the clothing to catch fire in many of the 37 instances where persons, mostly girls and young chil- dren, were burned to death. Even the 'Tiarmless" spark- ler caused three of these deaths, which were far more agonizing than if caused by gunshot wounds. The police commissioner of one of our large eastern cities is reported to have openly declared himself in 23 sympath}^ with the noise, the tumult and the shooting of firecrackers in the celebration of the Fourth of July, When the results of the celebration in that city were known, it was found that 5 lives had been destroyed and 167 persons were injured, some of whom had eyes blown out, hands, fingers and ears torn off, or were otherwise marred for life. Of the 5 who were killed, 2 were shot down and 3 became human torches, burned in order that the people in that city might "wann up and let the world know they were alive !" With what relief, therefore, we turn to another but somewhat smaller eastern city, Springfield, Mass., which has set a glorious example in the proper celebration of our national birthday and has taken advantage of Amer- ica's greatest opportunity to develop true patriotism and to bring closer together the various nationalities which make up so large a portion of its population. The Springfield celebration, which meanwhile cost the com- mittee only $3,500 in contributions, has already been so well described^ that detailed mention is unnecessary. ANNUAL PEEPARATION FOR CASUALTIES Thousands of dollars are being spent each year in preparation for the casualties of July 4. So exten- sive has become this preparation that, as some one has pointedly remarked, it resembles the preparation for a great battle. How much more enjoyment would result as well as uplift and profit if the same energy were ex- pended in preparation for more modern methods of celebration ! RADICAL ACTION NEEDED Our annual sacrifice in the celebration of the Fourth may be compared to the facts related about the Minotaur of old to whom the Greeks were required to sacrifiee periodically large numbers of the fair youths and maid- ens of Athens. America suffers by the comparison, how- ever, since our sacrifice is annual, whereas that of the Athenians was only once in nine years ! Eadical meas- ures were used then when Theseus slew the Minotaur. Eadical measures are needed now and the barbarous Fourth should go. The sentiment favoring the enlight- ened celebration is rapidly on the increase, but hood- lums require more than coaxing — they must be handled 1. Atlantic Monthly, June, 1909. 24 b}' the police. More restrictions were placed on the use of fireworks this year than ever before. The celebration in many cities was limited to the one day and the sale of fireworks was limited to 2 or 3 days. Many forms of fireworks were prohibited in many cities and zones of quiet were provided for hospitals. And results were ob- tained, since from all parts of the country come reports that there was never a more quiet and orderly celebra- tion. Although the deaths and injuries are as many as ever, there is nevertheless much to encourage those who are working for truly patriotic methods of celebrating our national independence. They should persevere in their efforts. PEESS OPmiONS EEGAEDING THE FOUETH OP JULY CELEBEATION x^ever has public sentiment been so thoroughly aroused regarding the antiquated and death-dealing methods of celebrating Independence Day than at the present time, judging from the flood of newspaper clip- pings which continue to pour into the office commenting on the statistics of deaths and injuries from this j^ear's celebration, published in The Journal a few weeks ago. Among these comments are many able editorials which we should like to publish entire if space permitted. The following extracts, however, show how strong has be- come the sentiment favorable to any measures which would effectively suppress all dangerous and noisy meth- ods of celebration. The reasons showing that now is the time Avhen cities should pass ordinances prohibiting the use of fireworks are clearly set forth in the following from the New York Tribune: There remains to be made, with all possible earnestness, the suggestion that now, right away, is the time for action if the good example of those three cities is to be extended next year and if the United States is to be rescued from what has be- come a, grave national reproach and an impeachment of our humanity and common sense. It would be futile paltering to wait until a few days before next Fourth of July and then try to stop the mischief. The only rational course is to enact ordinances or state laws at the earliest possible date, as far as possible in advance of the need of their application, so that makers of and dealers in explosives will have fair warning and they and the public will be prepared for a Fourth of July without the usual murderous racket. The publication of such 25 statistics as those Avhich we have quoted should mark the signing of the death warrant of the toy pistol and all its death-dealing kin. So widespread and emphatic has become this demand for the suppression of dangerous and antiquated meth- ods of celebration that cit}^ councils may be assured of strong support in the adoption of rigidly restrictive or prohibitory ordinances, and now is the time when action should be taken. Strike while the iron is hot. The Newark (N. J.) News not only gives us an encour- aging report regarding Trenton, IST. J., and urges New- ark to adopt a similar ordinance, but also reports an- other death due to the supposedly harmless "sparker,'' the description of which, however, is mild compared with the reports of the awful deaths due to lockjaw caused in this year's celebration. The comment is as follows (italics ours) : Trenton has enrolled itself in the list of cities which loill henceforth enjoy a safe and sane Fourth of July. Its council has adopted the ordinance, introduced at the first meeting after the recent Independence Day celebration, prohibiting the sale or use of toy cannons, toy pistols, firecrackers and fire- works of all kinds, except by persons to whom the Mayor grants special permits, upon occasions of public celebrations and exhibitions. That Trenton's mayor will approve of the ordinance there is no reason to doubt. The last victim to die of injuries received at the recent In- dependence Day celebration was Anna Hetzel, a little girl in Dover. She was a child of ten years, and while setting off one of those vicious things known as a "sparker" her clothing caught fire and she was terribly burned before the flames could be smothered. She lingered in pain that was at times agon- izing, until August 12, when she died. The following from the York (Pa.) Gazette is charac- teristic of many comments which have been made re- garding the present methods of celebration : If we are to indulge our savage instincts, at least let us be honest about it. Let us revive the old worship of Moloch and send the spirits of the children adrift in eternity as an offer- ing to this devil. Such action would be consistent at least. But this is not the solution of the problem. The freedom which was purchased by the blood of Bunker Hill and York- town was not shed that soulless murder-mongers of to-day might deliver over to death and torment tens of thousands of their fellow-beings. This is not freedom but the worst kind of anarchy. This is the thing that must be stopped. 26 The good results obtained by restrictive ordinances in several cities will doubtless lead to similar measures being adopted elsewhere, as shown by the following, also from the New York Tribune: We have referred to the efforts of some places to stop this infernal work. Three cities thus made themselves notable. Washington had a prohibitory ordinance, and suffered no casualties whatever. Cleveland also tried prohibition, and had only four slight injuries. Chicago had a merely re- strictive law, which reduced the usual number of casualties by more than one-half. The example of these three cities affords a ray of hope amid the general gloom of the year's record. It shows that it is quite feasible to put an end to this yearly torture and slaughter in the abused name of patriotism, and that it is best done by absolute prohibition of such devices as toy pistols and blank cartridges — -which are practically loaded with tetanus germs. Many of the comments favor the absolute prohibition of fireworks in the Fourth of July celebration, as illus- trated by the following from the Waterbury (Conn.) Republican : It would seem that 133 years of this demonstrative, danger- ous manner of celebrating the date of the independence of the country were sufficient, and if the people will not of their own volition substitute therefor a saner way of keeping the an- niversary they should be obliged by law to do so. From the Knoxville (Tenn.) Sentinel: The only safety is absolute prohibition of the use of any explosive, however harmless it may seem, except in an official celebration managed by experts. It would be better, however, to substitute something else for powder and dynamite. Ac- cidents will keep on marring the national holiday until other forms of celebration are devised. Cleveland has a justifiable pride in the effectiveness of its prohibitive ordinance. The Cleveland Plain Dealer says : Undoubtedly the sane Fourth idea is spreading. The Amer- ican people has nearly outgrown its habit of teaching patriot- ism with gunpowder and dynamite. All that was needed was a start in the right direction, and Cleveland went far toward making the national start by offering an example of the beauty of a noiseless, bloodless Independence Day. That there is no longer any reasonable excuse for per- mitting deaths and injuries which are wholly unneces- sary is emphasized by the following from the Atlanta (Ga.) Constitution: 27 Holiday use and abuse of fireworks and firearms of the dan- gerous sort can and should be eliminated; it can be accom- plished without the least unreasonable interference with the innocent pleasures of childhood. Protection of the children is a duty of municipal government and, in this instance, it can be performed without expense or cost. Although the control of the sale and use of fireworks seems to be chiefly a city function, there are some which believe that state legislatures could more effectively solve the problem. The Washington (D. C.) Post says: What is needed in this connection is country-wide prohibi- tion of the dangerous devices that are misused on the national birthday in a barbaric display of so-called patriotism. It is not enough for cities here and there to put them under the ban. State legislatures should adopt the necessary restrictions forbidding their manufacture. Only by such means will the traffic which has cost the United States many thousands of lives be brought under control. The Sandusky (Ohio) Journal says: Apparently the regulation of Fourth of July celebrations cannot be left to municipalities, but should be subject to state legislation. In too many cities and towns the belief pre- vails that the boys should be permitted to "have their fun," and the fact that a hundred or more must suffer an agonizing death as a result is overlooked. It is time that the state legis- latures take notice of this and put an end to the terrible slaughter. Of all tlie comments made, the opinion was unani- mous that present methods of celebration were barbarous and inexcusable, and that efforts toward suppression should be continued. It remains to be seen whether the effective action taken by Baltimore, AYashington, Cleve- land and Chicago will also be taken by other cities or whether the aAvful sacrifice of this year shall have been in vain. LIBRARY OF CONGRESS 011 801 643 9 PRICES Single copy, postpaid $ .04 10 copies,, postpaid 35 50 copies, postpaid 1.50 100 copies, express collect 2.25 600 and over, express collect, per 100 2.00 5M-2-10.