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In a case of compound fracture and dislocation of the ankle, gangrene necessitated amputation; and two subsequent amputations were forced by necrosis of the tibia to the knee. The shock arrested circulation in the bone and necrosis was a sequence.
To know just what to do in a railroad injury calls for more sagacity and experience than ordinary men possess. I may say in the way of explanation and apology that I have learned to be conservative and rarely promise much in a powerfully-shocked case. Although friends frantically beg for my opinion in a given case, I studiously and sternly decline to venture a prognostication. Often I am pushed to give a rational account of the cause of the sudden death, but I cannot, for it is not in my power. I simply know that a man cannot stand the knocks and shocks of many railroad disasters.
In the mild cases of shock there is often a feeling of nausea; perhaps vomiting will occur, and then reaction may rapidly take place. A disposition on the part of wounds to bleed is a favorable sign. A lacerated limb which will not bleed is in danger from gangrene.
In crushing accidents, with considerable shock, it is not easy to decide what may be best. If an amputation is executed and the patient dies the next day, the surgeon may wish he had delayed a little; and if he postpone and the patient die he may think he ought to have amputated early.
It is to be borne in mind that railway injuries are not to be esteemed safe till well along toward a cure. A "back-set" is not uncommon ten days after the reception of the injury; and secondary hemorrhages have occurred as late as the fifteenth day.
Patients accustomed to excess of alcoholic stimulants have a poor chance to survive railroad injuries. I have known delirium tremens to come on the fifth day and carry a somewhat hopeful case to the brink of death. In such cases it is best to overcome the delirium with small allowances of whiskey. In a paroxism of delirium I have known a patient to tear off a dressing, and strike a bleeding stump till it bled dangerously.
Sloughing, or death of mutilated parts in masses, is often encountered, and if the surgeon is not expert in the use of antiseptics and disinfectants his patient will be beyond aid. Experience teaches that the effect of grave injuries extends outside the discolored and mutilated region; therefore the surgeon is wise who makes provision for the extended invasion.
A hand that has been crushed between bumpers may seem. quite natural, yet be a bag of broken bone, with the soft parts thoroughly pulpified. Even though the fingers can be moved, it is by muscular force exerted above the injury. To attempt to save such a hand would be malpractice. If amputation is not performed grim death will show its horrid teeth. That characteristic rigor is premonitory of impending evil. When the tetanic grip is once on it rarely lets go.
We may give chloral, gelsemium, and reputed anti-spasmodics, yet these agents are too weak for so potent an enemy. It is an instance in which the weak things of this world will not confound the things that are mighty.
Again, a case seems to be progressing favorably till an unforeseen chill is experienced. "What is the trouble?" will be asked, and the answer is not given with assurance. The surgeon apprehends an invasion of erysipelas, yet the complication while masked cannot be fully identified. The dry tongue, the arrested secretions, hot skin, elevated temperature, and rapid pulse indicate a febrile paroxysm of a grave type. Yet the peculiar swelling and discoloration, the evidence of localisation, have not manifested themselves. In a few hours the testimony is all in and the verdict rendered. The exhibition of Baptisia as an antiseptic will accomplish nothing. It seems like mockery to trifle with such inadequate agencies. The patient is too thoroughly overcome to be medically impressible. Might as well "throw physic to the dogs."
In another display of cases, that insidious invader, pyæmia, sneaks in and upsets well-based calculations. The skin presents a bilious or yellowish tinge; a sweetish smell is exhaled, and a suspicious drowsiness comes on. The patient does not care to eat and is most content with drink and sleep. Now look for a secretly-forming abscess, perhaps of the liver. If
no tender spots be found indicating local suppuration, there is purulency somewhere. Here is where the credulous dispenser of drugs would prescribe iron, quinine, mineral acid and sulphite of soda; yet he might as well aim a popgun at a herd of flying buffaloes. The means are not adequate to the ends.
This arraignment of “Railroad Surgery" is not flattering and seductive, and may be too discouraging. Yet it is intended to be impressive as well as instructive; and to be thus, I could not help citing the worst cases that have come under my observation.
I would be a false guide if I reported only such cases as recovered. I have had hundreds of such, but they do not fall within the province of this article. It has been my design to array the dangers of a kind of surgery that is rapidly on the increase, and to show wherein it differed from that of ordinary practice.
In conclusion I would state that injuries sustained on railroads are often followed by litigation-claims for damageshence the surgeon for the "road" is expected to serve as a witness in behalf of the corporation. He must therefore anticipate severe handling on the part of the lawyers of claimants, who generally take suits for personal damages on “shares.” If the surgeon's management of injuries be not defensible he is about sure to find it out. For the attorneys of the prosecution will call to their aid the most reputable surgeons of the country. The responsibility, then, of a railroad surgeon are of a double nature, and should be paid for accordingly. He wants something more than a complimentary "pass." He should have more substantial rewards.
WHEN SHALL WE AMPUTATE?
By J. W. PRUITT, M. D., Russellville, Ark.
When we should amputate is one of the most important questions of surgical science. It has engaged the attention of the wisest and best surgeons of every age, and still to a
great extent it remains unsettled. It must be determined, if at all, by the degree of reparative power of the vital forces, and this can only be estimated from an intimate knowledge of physiology, aided by hygiene, as well as the various antiseptic agencies of modern surgery. Mr. F. C. Skey, of St. Bartholomew's hospital, well remarks: "I am persuaded that in proportion as we study disease and make ourselves familiar with the curative resources of nature, the greater will be our faith in her power of reparation and in her desire to exercise it;" and further: "This is the greatest of all questions, for it involves serious and permanent mutilation of the body; and, of all subjects of operative surgery, it is that which demands the most deliberate judgment, the highest standard of professional morality, and the broadest and soundest views of the vital forces of the body."
If we compare the present with the past we will find that the principle of conservatism is widespread; amputations were once frequent where they are now rare. Injuries that formerly condemned a limb to immediate amputation are now found amenable to treatment. Nevertheless, with all our knowledge of the vital forces and the resources of modern surgery, have we reached the goal of perfection in our judgment? May we not truthfully say there is more yet to learn than has been learned?
Looking at this subject through the past century, and taking the reports of the large hospitals of the world, we find that three times as large a percentage of operations were performed in some as in others, and that, too, with far more favorable surroundings. Where was then the standard of surgery to guide in the amputation of surgery? There certainly was no definite one, and the limb that was preserved in one hospital was sacrificed in another. The question can only be solved by an enlightened experience, which is not within the reach of all. Hence the inconsistency of professional practice, which so often is the cause of legal investigation and scientific inquiry.
In regard to the latter it would appear to arise from various causes operating upon the mind of the operator, and deter
mining his course. The first, and perhaps most impressive in its influence, is the different degrees of allowance placed by different surgeons upon the recuperative powers of nature in the cure of diseases. Men take different views of the power of the vis medicatrix Naturæ. With some it holds the relation of a vicegerent; with others a handmaid. The minds of physicians and especially of surgeons are not always convinced that nature, and not medical men, cures diseases and repairs injuries, and that our province consists solely in aiding her where needed. Within the last century amputations were three times more frequent than in the present. This is not because severe injuries are less frequent, nor that diseases have proved per se more tractable, but because the knowledge of physiology, hygiene, and therapeutics has advanced to a degree unknown to our predecessors.
In the next place, I believe, there now exists a higher tone. of feeling in the professional mind than formerly, a greater regard for the value of human life, and sympathy for human. suffering. As a rule the greater the experience of the surgeon the fewer the operations, and his greater reliance on natural agencies. I am very certain that their influence in the repair of injuries is not yet fully understood. The acquisition of this knowledge is necessarily elaborate and slow, but none the less sure.
Again, our opinions have been shaped and modified with what I conceive to be the erroneous views held by our forefathers on the subject of what were termed secondary operations. The theory of this almost universal rule of surgical practice was this: that it was better for the constitution to bear one shock than two; and no reflecting man will deny it. It therefore resolves itself into the necessity of an immediate decision-now or never. Now saves life, but at the expense of a limb; Never risks life, and it is our first duty to preserve it. But this plausible theory is only true in the abstract and not in the application. It may be true to the letter but certainly it is not to the spirit. Patients have recovered too often with useful limbs from grave and serious injuries, under the resources of modern surgery, to admit of the general