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adoption of this antiquated theory. The exceptions to its application are innumerable. It can only apply in full force to cases of extreme injury, such as large contusions, crushings, or lacerations of limbs from which, if left alone, recovery is impossible. Consequent upon such injuries the constitution must necessarily sink, and the earlier the operation the greater the probability of recovery, because collapse of the vital powers is the certain issue, and reaction is impossible.
After the lapse of what period of time from the injury may we term the operation primary or secondary, so as to bring it in the category? After the expiration of what time is a primary converted into a secondary operation? By immediate amputation I understand the removal of a limb as practiced on the field of battle when the patient is removed to the rear for the purpose. But if several hours elapse do we still retain the term "immediate amputation?" No distinction is made between an interval of one to ten or twelve hours. If circumstances intervene to prevent immediate amputation is it not an additional argument in favor of the treatment that appeals to Nature, and which calls upon her to put forth her powers for restoration?
Mr. Abernethy having successfully treated three cases of compound dislocation of the ankle-joint, that had been condemned to the knife by other eminent surgeons, used to dwell with forcible eloquence upon the curative powers of Nature in the repair of such injuries. Had he lived in our day he would not have made these the only exceptions to a rule that requires far larger limitations.
It would be well for humanity and science if we could draw a definite line that would determine the amount of reparative energy in any given case. That there is such a line, though obscure to our senses, will hardly be disputed by any one who has observed how common the resort is made to the knife in some countries compared with the practice elsewhere. Such is the complication of the requisite inquiry that the difficulty of decision is indisputable. Nevertheless some approach may be attempted to a more general rule, founded on the nature and extent of the injury, amount of vital force and vital tenacity
of life than has hitherto guided the surgeon in his decision, although the question of local injury will be subject to large modifications founded on age, sex, the character and condition of constitution of the patient.
The following practical division suggests itself and may serve as a guide somewhat to the young surgeon in the decision of this important question: First, such cases as beyond a doubt require amputation. Secondly, such as justify amputation; and thirdly, such as neither require nor justify amputation. In regard to the phrase "justify amputation" would remark that to justify may mean to give the appearance only of justice, and not the reality; to obtain the sanction of the world. A man may have the approval of public opinion, while he does not have his own. He may be safe from public comment or criticism, while he is amenable to the denunciations of his own conscience. By the term "justify" I mean that warrant in favor of the removal of a limb which is obtained from the consideration of an injury placed on the confines of necessity, especially if occurring in early life, advanced age, or in impaired constitutions.
Of the structures entering into the composition of a limb, all of which are subject to rupture or disorganisation, the first importance perhaps attaches to the arterial system. As, however, universal experience has demonstrated that the channel of the main artery may be suddenly obliterated without danger to the vitality of the limb, so the rupture of the main arterial trunk, as shown by the pulseless condition of the limb below the seat of injury, is of itself no warrant for amputation. But if in addition to this the muscular structure at the point of injury is greatly contused, and the collateral channels, arterial and venous, are involved in the injury, it is more than probable the limb will fail in nourishment, the indication of which is loss of temperature. This loss if complete will become apparent in an hour or so, but this is rarely the case; and several hours, or even a day may be required to ascertain the actual extent of the mischief. But the evidence is all important and fully justifies the postponement of the decision.
Next in importance to arteries and in close relation to them stands the nervous system; and in reference to injury to the chief nerve or nerves the same remark will almost apply. We do not amputate the leg because the sciatic nerve is rent asunder. The true principle of conservatism would dictate a pause a period of watching and observation. But as the rupture, either of artery or nerve, is ordinarily a matter of uncertainty, we can only judge by effects; and for these we must wait.
To justify amputation from rupture or laceration of the muscular system of a limb, the injury must be very great, as the constitution does not ordinarily sustain a shock in proportion to the extent of the injury, supposing the integuments to remain unbroken. If, however, the muscles be extensively ruptured, and integuments detached and not susceptible of entire replacement, the power of nature to restore the parts to health may well be doubted. I mean very large lacerations and contusions, with extensive separation of the integuments. and extravasation of blood. I do not agree with some surgeons who regard exposure of the cavity of a joint an important element of failure. I am well aware that it has been and by many is still so regarded. I call to mind the early part of my professional career when a compound dislocation of a joint was deemed a just cause for amputation. Yet there are many cases recorded of recovery as regards the limb, and a few of the joint itself.
Too much importance, it seems to me, is attached to fracture into a joint; as though such a fracture, in the retention of a useful limb, raised a serious obstacle to recovery. That it places the joint in danger cannot be denied, but I do not believe that the advocate for amputation in any given case can derive from its presence an argument of great force, though I do not deny that it should be considered an aggravation of the mischief done. These remarks apply to fracture of bone, especially if comminuted, when superadded to the larger injury of the main artery or nerve, extensive rupture of muscles, or laceration and disorganisation of the integuments.
I have never seen much good result to the patient from
passing the finger through an opening in the skin and turning it about in all directions to ascertain the nature and extent of the injury. Too much probing generally proves a bad thing. I never have myself gained much information by it, nor witnessed others who did. So far as the patient is concerned it appears positively objectionable. True, it may gratify curiosity and make a show of doing something, but it is at the expense of some suffering.
Finally, after weighing well all the circumstances of the case, the nature and extent of the injury, the strength of the reparative forces, etc., in all doubtful cases, I would give the benefit of the doubt to the patient and endeavor to restore the limb. If the leg, thigh, foot, arm, forearm or hand, in consequence of large injuries lose for any length of time their natural warmth, that cannot be restored by any reasonable means, I fear amputation is the only resource.
If we find extensive laceration of the muscles with extensive separation of the integument, and especially if it be disorganised and unsusceptible of replacement, then, I fear, we must amputate without waiting even for appearances of loss of vitality in the extremity; but in a moderately healthy subject I do not consider that any degree of comminution of bone or laceration of muscles, unless very extensive, any fracture into a joint, or compound dislocation of a joint, would justify a resort to the knife, so long as the parts are capable of some general replacement, and the patient can submit to the confinement necessary to his recovery.
Since the introduction of the various antiseptic agents, carbolic and salicylic acids, thymol, etc., into surgical practice, together with the attention paid to drainage of wounds and cleanliness, the percentage of recoveries from grave injuries of the extremities has greatly increased.
By DAVID WARK, M. D., New York City.
The fact that subcutaneous wounds heal readily by the first intention without suppuration, even in persons whose constitutional condition is not conducive to the rapid cicatrisation of open wounds, I believe first directed the attention of surgeons to the importance of preventing the destructive influence of air and air-germs on traumatic surfaces. The method devised by the celebrated surgeon Lister to attain these purposes, however effective it may be when every appliance is at command to enable us to carry out his complicated directions to the most minute detail, I think falls far short of placing at the command of the general practitioner a cheap, effective and universally applicable means of dressing wounds antiseptically. Lister's method has been faithfully tried by the leading ovariotomists of Great Britain, and has been abandoned by all but one. This great surgeon aims to exclude living germs from raw surfaces during an operation and to seal the wound hermetically by special dressings against air and the germs which it carries from the time the knife is applied till cicatrisation be complete. The numerous failures that have occurred in this attempt to very able surgeons who were familiar with every detail prove that it is very difficult. The objections to it from the standpoint occupied by the general practitioner seem to be as follows:
The spray obscures the operator's vision, particularly if he use spectacles, and renders the operation more difficult. The dressings are complicated and cumbersome, because they must consist partly of bulky material capable of absorbing and rendering antiseptic a considerable part of the discharges. For this purpose numerous thicknesses of carbolised gauze, masses of sawdust, dried clay and peat have been employed. When any accident or operative procedure penetrates any tissue from one side to the other, forming a wound having two opposite openings, the Lister dressings are inadvisible from the nature of the case. How can air and air-germs be