has been substantial, and their results of cases treated will bear the closest scrutiny. The Medical Fortnightly. A Neat Spherical Gauze Sponge. In a recent number of the New York Medical Record, Dr. G. W. Perkins of Ogden, Utah, says: Since the general use of heat for sterilization, gauze has largely replaced marine sponges in surgical work. Flat pads made up of several layers of gauze, and spherical sponges made by enclosing masses of loose gauze or absorbent cotton in an envelope of gauze, are the forms in which it is usually employed. The flat pads are easily folded in such a way as to place all raw edges of the fabric in the inside of the pad, and a few long stitches serve to keep them there. The spherical sponges which I have seen described and figured have been made by simply tying the enveloping layer of gauze and cutting off the excess a short distance beyond the ligature, thus leaving this cut surface with threads of the gauze projecting. This seems to me undesirable, because some portions of these threads might become detached and be left in the wound or cavity in which the sponge had been used. In casting about for a way to obviate this disadvantage, I first made the sponge as above described, but went one step farther by carrying around the projecting stump a circular purse-string suture, and in tying this pushed the stump into the center of the sponge, thus burying it out of sight. This answered very well, but left a hard lump at one side of the sponge, which sometimes interfered with grasping it in a spongeholder. I next tried the following maneuver, by which I succeeded in making as neat and satisfactory a sponge as one could wish for. Instead of ligating the pedicle of the envelope of gauze, I twisted it once or twice and grasped it with a small hæmostatic clamp; then cut away the excess close to the outer side of the clamp and placed my purse-string circular suture about half an inch distant from the stump, and as I tied it pushed the clamp holding the stump of the pedicle into the sponge, disengaging and withdrawing the clamp just before the suture was drawn tight. The result is a symmetrical, sub-spherical mass of loose gauze, without raw edges on its surface and without hard lumps in its substance, which has in my hands admirably answered its purpose. This is merely an adaptation of the Dawbarn method of inverting the unligated stump of the appendix into the cæcum, and I dare say has been used before by other surgeons; but as I have never seen it in print, I offer the suggestion for what it is worth. Notices and Reviews. Book Notices. Lea Brothers & Co. of Philadelphia announce a new edition of this well known text book, to be issued during the present month, and in which such changes have been made as are necessary to represent the advances in anatomical knowledge and anatomical teaching. The sections on the brain, spinal cord and viscera have been entirely rewritten, and new matter and new engravings added.—The Medical Age. BOOKS AND PAMPHLETS RECEIVED. "Wharton's Minor Surgery and Bandaging," by Henry R. Wharton, M. D. "The Newer Remedies," by Coblentz; D. O. Haynes & Co., publishers, New York. "Transportation of Injured Employes," by Frank H. Caldwell, M. D. Reprinted from the Journal of the American Medical Association, February 29, 1896. "Eye Symptoms in Nephritis, as Seen With the Ophthalmoscope," by William Cheatham, M. D. From the American Practitioner and News, August 22, 1896. "Report of Relief and Hospital Department of the Plant System." "A Contribution to our Knowledge of Albumosuria," by M. L. Harris, M. D. Reprinted from the Chicago Medical Recorder. "Abscess of the Lung, with Report of Seven Cases," by E. Fletcher Ingals, M. D. Reprinted from the Journal of the American Medical Association, August 22, 1896. "Hypertrophy of the Pharyngeal or Luschka's Tonsil," by E. Fletcher Ingals, M. D. Reprinted from the Journal of the American Medical Association, September 29, 1894. "Operations Performed in the Eye Department of the Medico-chirurgical Hospital," by L. Webster Fox, M. D. Reprint from the Ophthalmic Record. "Choice of Methods in Performing Hysterectomy," by Fernand Henrotin, M. D. From the American Journal of the Medical Sciences. October, 1895. "Anti-toxin; Some Practical Remarks in Regard to Its Use," by G. F. Washburne, M. D. Plato said very well: "Physicians were the only men that might lie at pleasure, since ou health depends upon the vanity and falsity of their promises.-Montaigne. First Vice-President... F. J. LUTZ, St. Louis, Mo. 239 239 239 W. R. HAMILTON, Pittsburgh, Pa. Second Vice President....J. H. LETCHER, Henderson, Ky. Third Vice-President.... ..JOHN L. EDDY, Olean, N. Y. Fourth Vice-President....J. A. HUTCHINSON, Montreal, Canada Fifth Vice-President...... A. C. WEDGE, Albert Lea, Minn. Sixth Vice-President.. RHETT GOODE, Mobile, Ala. Seventh Vice-President...E. W. LEE, Omaha, Neb. Secretary. C. D. WESCOTT, Chicago, Ill. Treasurer. .E. R. LEWIS, Kansas City, Mo. Executive Committee:-A. I. BOUFFLEUR, Chicago, Ill., Chair man: J.N.JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa. No. 10: A PLEA FOR DELAY IN THE AMPUTA- BY ALBERT I. BOUFFLEUR, M. D., SURGEON C. M. & ST. P. Ry. Co., ETC., CHICAGO. From the frequency with which some of the phases of the subject of amputations is presented to medical bodies, and especially from the fact that this association was favored so recently as at our last meeting with an exhaustive paper on this subject as a whole, by one of our most honored members, which was. followed by a lengthy general discussion, it might seem proper that I should offer an apology for choosing any phase of the subject for consideration on this occasion. Such, however, is not the case. When, where and how to amputate form the most important subjects which the railway surgeon has to consider, and therefore the discussion of these questions is always pertinent. In general surgery we naturally look upon mutilating procedures with justifiable humility, but in traumatic surgery, in which the operating force has frequently performed the amputation before the case reaches us, we can look upon the procedure with an equally justifiable degree of pride. The question as to primary or secondary amputation has been discussed at such great length and with such frequency, and withal so enthusiastically, that we should all be convinced one way or the other, unless all propositions are more or less defective. In all the discussions I have ever heard on this subject, the condition which has seemed to separate those of different opinion, as the great wall separates China from Siberia, is that known as shock. One surgeon will *Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May, 1896. advocate early, immediate amputation, regardless of the presence or the absence of shock, and even regardless of surrounding circumstances; while another will advocate postponement until reaction has been well established. It cannot well be that the experiences of individual surgeons have been so diametrically opposite concerning the same condition. When we take into account the fact that shock is but one of the elements of danger it is not surprising that our results should have differed in dealing with similar injuries. We rarely, if ever, even hear of the cause of the shock being taken into consideration, and yet we all know that shock from hemorrhage is a greater barrier to an immediate operation than shock of FIG. I. APPEARANCE OF INNER ASPECT OF LEFT FOOT AND THE AMPUTATION STUMP. FEMUR DISPLACED UPWARDS FOUR INCHES. a purely nervous origin. As a matter of fact, the administration of an anesthetic, which is so dangerous a measure in shock from hemorrhage, may prove beneficial in purely nervous shock. Shock is not the only condition which should determine when we should amputate and if we attempt to formulate a rule relating only to shock, the exceptions will, I fear, be more frequently operative than the rule itself. In all the arguments, pro and con, there must be some truth, and in my humble opinion the truth is distributed all the way from one extreme to the other. A substance that may serve as food for one person may poison another, and likewise the immediate operation may save one patient, while an operation deferred several hours, or even days, may be the only hope of another. The patient in his entirety should be the object of our consideration and not merely the single manifestation-shock. While the proper relation of operative procedures to shock is of most vital importance, since it so directly affects the life of the individual, we must not lose sight of the fact that the individual's life may prove to be a burden to himself and his family without the assistance of one or more members which would be sacrificed by a premature operation; limbs which might perchance be restored to life and utility if placed under favorable circumstances. That limbs, and especially fingers, are, even in these days, frequently unnecessarily sacrificed, cannot be successfully refuted. One need not look far to find surgeons who are performing amputations on the same principles that were taught decades ago, when the effects of the ever-present suppuration made conservatism and attempts at restoration of function worse than useless-dangerous. The old argument that delay meant sepsis and that sepsis left death in its wake, should surely not be given much weight in these days of enlightenment. Antiseptics and drainage have eliminated all danger of serious results from the reasonable postponement of an amputation. The surgeon, who practices on the basis of modern bacteriological knowledge, does not fear the slight toxæmia which results in all cases when dead or dying tissue is left in contact with the living. There can be no doubt, it seems to me, that an amputation is only indicated in traumatic surgery when the soft parts are so crushed and disorganized that repair of the injury is absolutely impossible, or if it should take place the injured member would be useless. I believe the last condition is a most pertinent one, since it is quite as serious a mistake to err on the side of saving useless numbers, as it is to sacrifice one which might have been of some use. If we accept this proposition we are then brought face to face with the conditions of the particular case before us, which must, at least in so far as the local conditions are concerned, be considered as a rule unto itself. While it is true that in many cases we can decide at once as to the necessity for amputation, yet in a large number of cases it is absolutely impossible to formulate a positive opinion until at least 24 and possible 48 or even more hours have elapsed. I desire to emphasize the fact that, while the general condition of a patient is manifested by signs and symptoms which admit of reasonably accurate interpretation, the indications as to the extent of the local injury are so uncertain and unreliable that a limb which presents all the clinical evidences of death may in a few hours glow with the warmth and color of life. As an illustration of this fact I will recite the records of a case in which the force of circumstances compelled me to defer amputation against my best judg ment. J. J. was injured near Chicago on February 12, 1891. While climbing up the side of a box car on a new piece of track, a tree knocked him between the cars and two pairs of trucks of a flat car loaded with stone passed over him. He was brought to the city, a distance of six miles, and was taken to the surgeon who was at that time my associate. As the result of his years of experience and a careful examination he deemed that amputation of the left foot, over which a car wheel had passed, was absolutely necessary and that the good circulation in the right foot warranted some conservative operation upon the right leg. The patient refused operation absolutely and was turned over to me by the officials of the company. Upon examination I found several scalp wounds, a fracture of the inferior maxilla and of the left clavicle and a dislocation of the right hip, with fracture of the retaining portion of the acetabulum. The right leg had been run over by a wheel, and in addition to very extensive lacerations of the muscles, the tibia and fibula were fractured in two places about three inches apart, and the fragments were detached. The circulation in both the anterior and posterior tibial arteries was, however, very good, and the nerve supply of the part was nearly intact. The left foot was crushed by the passage of a wheel over the instep with the flange near the ankle joint. The foot was blanched, cold and senseless and it was impossible to detect any circulation in the part below the injury; in fact, the foot was to all appearances dead. That both of the plantar vessels had been divided seemed probable from the profuse arterial hemorrhage which occurred through each of the lateral wounds. The tarsal bones were all ground up. The conditions were explained to the patient and while he then thought an operation necessary he refused to permit the same until his father should arrive on the next day. The parts were thoroughly cleaned with soap and brush and the wounds irrigated with 1-3,000 bichloride solution. Having experienced some success with moist heat in the treatment of contused and lacerated tissues, I thought it a good opportunity to observe the effects upon a whole limb. The injured parts were surrounded with very large compresses of sterilized gauze and covered with rubber tis sue. APPEARANCE OF THE OUTER ASPECT OF SHORTENED FOOT, SHOWING MANY SCARS AND THE AB SENCE OF THE INSTEP. The limbs were elevated and artificial heat applied to the left one by means of a hotwater bottle. Through apertures in the dressing 4 to 6 ounces of a saturated solution of boric acid crystals was poured every one to two hours. On the following day (some twenty hours after the accident), the patient and his father consented to the removal of the left foot. The right leg was first operated upon. The fragments of bone removed and remaining parts wired together, causing three inches shortening. With the expectation of amputating the left foot, we exerted ourselves to approximate the tissues of the right limb anatomically as much as possible, although at that time we had some doubt concerning the ultimate outcome. We wished to give one to have him every possible chance foot left. The operation completed, we prepared to amputate the left foot. On removing the steaming dressing, we found to our joyful surprise that the foot was of a nice pinkish hue, although still anesthetic. The crushed bones were removed and the shortened foot was again placed in its warm extemporized bath. On the second day there appeared evidences of extensive necrosis in the right leg, which extended on the following day. On the fourth day the leg was disarticulated at the knee joint through what were apparently safe, though contused soft tissues. As the corresponding hip joint was totally FIG. 3. AMPUTATION THROUGH CONTUSED TISSUES. CHARACTERISTIC APPEARANCE AFTER SLOUGHING. disorganized we selected the disarticulation, which is not the best amputation in those parts, unless the patient prefers to wear a peg leg. The left foot progressed favorably and at a subsequent time when one. of. the metatarsal bones was removed for necrosis, no evidence of the plantar arteries could be found in the distal part of the foot, indicating that they had been destroyed. The flaps of the knee stump became necrotic and sloughed considerably. The parts were finally covered by Thiersch's skin grafts, as the patient refused reamputation. Surely the unexpected happened in this case; the limb which we had expected to save was lost and the one which several of us had considered dead was restored to life and has since served the rest of the body with but little annoyance. Figure I shows the inner side of the foot and the amputation stump. Figure 2 shows the scar on the outer side of the left foot, and the appearance of the shortened foot. The foot which normally required a number nine shoe, now requires only a number five and a half. There is nearly three inches shortening in the length of the foot. The vessels which supplied the abundant circulation of the right foot had evidently been injured, as a result of which the circulation was interrupted a few days later, while the foot whose supply vessels had been divided was revivified and sustained by the primary dilitation and subsequent contraction of the capillaries which, I hold, was rendered possible only by the application of the hot boric acid solution. Being compelled to postpone operation caused us to save what proved to be that unfortunate man's only remaining foot. As to the shock in this case, I will state that notwithstanding his numerous fractures, both simple and compound, and the loss of much blood the man was not profoundly shocked and could have been safely operated upon at any time after I saw him. This case also illustrates the fact that it is not always possible to tell the precise point at which an amputation should be made until some hours, or even days, have passed. If there is any rule or principle which is universally applicable in all amputations, I believe it is that we should save all that we possibly can, providing the same can be rendered useful. In order that we may secure a good serviceable stump, it is desirable to operate through tissues of undoubted vitality (in known quantities), and yet it would be an unjustifiable procedure to always amputate above the lines of contusion, because tissues sometimes manifest a remarkable recuperative property. Therefore, I am of the opinion that the local conditions should be given nearly as much, if indeed not equal prominence with the general condition in our decision of "When to Amputate." When in doubt, the wise surgeon, like the wise navigator, proceeds cautiously, and only when he is sure that he is right does he push boldly ahead. When applied to amputations, this principle means, to my mind, that when the line of destruction is |