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positive and known, with general conditions permitting, we should amputate, but when the vitality or usefulness of the parts or the condition of the local tissues is questionable, even with favorable general conditions, we should postpone our mutilating operation until we are able to arrive at a safe conclusion. I make this as a general proposition to which we will all find some exceptions. The environments of the patient may be such as to posi.tively preclude any efforts at properly treating lacerated tissues, while incised tissues might heal promptly, or the alternative of immediate operation or loss of the case may be forced upon us, in which case the degree of our uncertainty must be weighed with care and the wishes of the patient taken into consideration. In still other cases it may seem advisable to include doubtful tissues in amputation flaps, in the hope that at least a part may survive and thus provide a stump which an incision through safe tissues would remove altogether.
I am pleased to say that in the last few years I have had no difficulty in obtaining permission for postponement with efforts at rehabilitation; in fact, the laity are so well informed as to the possibilities of modern surgery, that in my experience they often request that we try and save all we can.
The case of M. J., which occurred in the practice of a friend of mine, to whom I am indebted for the history and photograph, as well as the privilege of reporting it, illustrates the fact that it is impossible to decide just what tissues to trust. The arm was badly crushed and amputation imperative. The operator decided to try and save a stump, and in order to do so was compelled to utilize contused muscle and skin, some of which sloughed, but the parts were kept aseptic and recovery was comparatively but little delayed. Figure 3 shows the typical appearance of the sloughing stump after amputation, followed by necrosis. This case illustrates three points, viz.: First. Operations through doubtful tissues are uncertain and liable to be followed by extensive sloughing, which may in turn require re-amputation. Second. Circumstances may render it advisable to operate even through seriously damaged tissues. Third. Even sloughing tissues, if properly treated, do not necessarily endanger the vitality of the adjacent sound tissue nor the life of the individual.
These cases are but two of many which illustrate some of the phases of this question, and while I do not wish to tire you by reports of numerous cases, I will ask your indulgence to the extent of hearing that of J. W., who was injured about three years ago while standing on the foot-board of an engine, by having a drawbar of a passenger coach driven through his thigh. He was over six feet tall, young, and a specimen of perfect manhood. All the tissues on the inner and posterior aspects of the thigh were extensively lacerated and destroyed for a distance of from eight to fourteen inches. The wound on the inner side of the thigh was 16 inches long. All the inner and both ham
string groups of muscles were pulpified and disorganized, and the sciatic nerve was wanting for over six inches. The inner and posterior aspects of the femur were entirely free and uncovered. The skin of the whole thigh was loosened so that my hand could be passed beneath it at will, and was perforated where the point of the drawbar impinged, and at several other points on the outer side of the limb, which are shown in the illustrations. There was but little active hemorrhage, but the shock was the most profound I have ever observed which was not followed by death. It was so great, in fact, that even the femoral pulsation could not be determined. The destruction of the great sciatic nerve probably accounts for the great amount of shock, which was of the
nervous form. This was one of the most awful appearing wounds I have ever seen. Surely this case was one for immediate amputation, so far as the limb was concerned, and one for delay when the critical condition of the patient was considered. It was with difficulty that I dissuaded the hospital surgeons from amputating at once. Amputation, in my opinion, meant death. Nothing was to be lost by postponement and possibly we could save his life and perchance his limb also. The patient. grasped the proposition as a drowning man might a straw. Notwithstanding his shock, a small amount of ether was given, and, as is
usual in such cases, the patient's condition was greatly improved thereby. The vessels were picked up and ligated. A few shreds of the muscles were tacked across the chasm, which the removal of the large amount of muscular tissue had left, so as to protect the popliteal artery, which was intact. As the parts would surely slough, no effort was made to restore the continuity of the nerve. The whole limb was surrounded by gauze compresses saturated with hot boric acid solution, which was to be replenished frequently so as to provide continuous immersion and irrigation with a mild antiseptic and potent inhibitory agent.
Our days and weeks of toil with the open
opposition of internes and nurses was rewarded by saving that leg. A failure to keep up the application allowed a marked degree of toxæmia to occur on the third day, but this was readily controlled by the carrying out of the details of the treatment. As fast as necrosis occurred the sloughs were removed.
The large wound area was partially closed in with Thiersch's grafts, but the amount of scar tissue was so great that a small area refused to close for some months. The patient recovered with an anesthetic and paralyzed foot, but is there any man who will deny the wisdom of our course? Not only his life, but his limb, too, was saved. What more could we ask? If there is a doubter present I will state, for his benefit, that the sensation and muscular action have been partially restored and that the limb is so useful that he walks with scarcely a noticeable halt in his gait and has for two years been performing the active duties of a night switchman. Cuts 4 and 5 illustrate the appearance of the parts about eight months after the injury, before the wound had entirely healed. While advocating conservative measures in many cases of contused tissues, I do not wish to be understood as recommending their universal employment. We should use conservative measures when there is some probability of saving something useful for our patient, or as a protective measure during the hours when delay for any reason is necessary, and only when we are able to carry them out in the fullest detail.
While the conditions we have to deal with are complex and of the most serious importance, the treatment which I have indicated is old, simple and easy of employment, especially with reasonably intelligent assistants.
The great dangers in delaying operative measures are necrosis, infection and sepsis, and therefore our therapy should be directed to limiting or obviating these conditions. It may be safely said that practically all contused and lacerated wounds are infected, and as damaged tissues are especially susceptible to the effects of pyogenic and putrefactive bacteria, it should be our endeavor, first, to prevent bacterial growth; second, to prevent absorption of their products by removal thereof; third, to favor the circulation of the part, and thus increase the combative power of the tissues and favor repair, and fourth, to counteract the ef
fects of the absorbed ptomaines upon the general system.
The rational treatment of an infected wound is based upon disinfection and drainage. The more perfect and continuous we can keep these two elements in operation, the more limited the damage and the less the sepsis. Continuous drainage can be effected by submersion where practicable, or by constant irrigation through a tube or, if necessary, by the addition of the solution to dressings, surrounded by impervious tissue, at short intervals. Circumstances will render each method useful, and if conscientiously maintained the results will be practically the same. The effect of the constant moisture upon contused tissues is so well known that it is unnecessary to dwell upon it; suffice it to say that the primary relaxation of the circulation with the subsequent contraction of the small capillaries which promotes an approach to normal circulation in the damaged tissues, is a most salutary effect. With normal circulation, both arterial and venous, there is little chance for necrosis, and with necrosis limited we should be able to successfully combat the local conditions. The most important indications in favoring the circulation of a part, are rest, relief of tension and elevation. The first limits the amount of arterial blood, while the others favor the return circulation. We should always look out for the free return of the venous blood, because venous and not arterial stasis is the determining element of necrosis in infected wounds.
Wherever there is extravasation of blood into the tissues, and those tissues are of questionable vitality, the imperative indication is to make free incisions, thus promoting circulation by relieving pressure, and enabling us to apply agents which will inhibit bacterial growth in the damaged tissues. Having placed our injured tissues under the most favorable mechanical conditions, we should next select our antiseptic agent. Those who favor the submersion plan of treatment argue that an antiseptic is practically unnecessary, but if there is anything in the beneficial effects of a constantly applied innocuous antiseptic, surely contused tissues are ideal ones for its employment. The substances which have yielded the best results have been boric acid crystals in a saturated solution, and acetate of aluminum solution in the strength of one-half of one per
cent dissolved in cold water. The uncertainty of the solubility of the acetate of aluminum has caused me to rely upon boric acid crystals, which are readily soluble. Boric acid solutions penetrate tissues very readily, and experiments have demonstrated its inhibitory action. to a considerable depth into the tissues. The limb, and especially the wet dressing, should be kept at a reasonably warm temperature.
In conclusion I beg to summarize the treatment of contused tissues in wounds, as follows: I. Relief of tension by incisions.
2. Prevention of venous stasis by elevation of the limb.
3. Prevention of arterial engorgment by quieting the nervous and circulatory systems. 4. Prevention of bacterial growth by the early removal of all necrotic tissue and the employment of some potent but innocuous inhibitory agent.
5. The mechanical removal of the bacteria and the prevention of the absorption of their ptomaines by free continuous drainage maintained by some form of constant irrigation or submersion.
DISCUSSION OF DR. BOUFFLEUR'S PAPER.
Dr. P. Daugherty: We had a very animated discussion in Chicago, one year ago, on this subject, over a paper read by a gentleman from Pittsburg, who is not here to-day. Dr. Murdoch's position, at that time, was severely criticised by a number of men present. I think at the time that some of the members failed to understand the doctor. Dr. Bouffleur to-day has taken very much the same position Dr. Murdoch did at that time, being probably a little more conservative. Dr. Bouffleur maintains that every case must be a law unto itself; that we can formulate no rules to follow in all cases, but that every case must be examined, and the surgeon must determine from what he sees in that case, what is the best course to pursue. Old David Crockett's rule was: "Be sure that you are right and then go ahead." Dr. Bouffleur's rule is that when you believe you are right, then go ahead. He makes one point that I admire, viz., he is not afraid to operate in damaged tissues, provided by operating on them he can save a valuable stump or save valuable portions of the limb. I have never been afraid of damaged tissue, where I could conserve anything by it, because we have a means of checking or prevent
ing sepsis. Another point the doctor makes is that he never amputates so long as there is a possibility of saving the limb. Probably I have been a little too conservative in this respect. I have saved some limbs that appeared to be utterly worthless, but were of practical utility afterward. If we amputate a limb that we may have saved, we are culpable.
Dr. W. S. Hoy: In the first place, I desire to compliment Dr. Bouffleur on one thing that he is a young man just in the very zenith of his manhood. Most young men are inclined to rush in and do amputations for traumatisms sometimes when it is not necessary. He has to-day tried to inculcate a good rule regarding these injuries, and that is to delay. I think the delay necessitated by shock has a great tendency to cool the feverish desire on the part of the surgeon to amputate. I made the remark at Chicago last year, and I repeat it to-day if anything, with more emphasis, that I do not believe any surgeon, who has the good of his patient at heart, will amputate a limb when there is a possibility of saving it. It is a comparatively easy thing sometimes for a surgeon to amputate a crushed limb, rather than to try and save it by long treatment. It is true that we cannot tell accurately the tissues that are involved above the seat of the injury, but it is a bad rule to sacrifice any more of a limb than is absolutely necessary.
The doctor spoke of the antiseptic treatent of these injuries. Physicians to-day, in using antiseptics, are using them entirely too strong, especially the bichloride of mercury.
Let me say, in closing, that I do not think we should ever be actuated to amputate any large member during profound shock. If my patient has got to die because of a mangled limb, I would rather have him go to his grave with it than to amputate it during profound shock.
Dr. Pierce, Illinois: The world is certainly moving, and medical science is progressing. When I studied medicine we were taught that compound fractures of the femur required amputation. That was many years ago, when I went into the military service. Some time after that, we were taught that a gunshot wound of a great joint required amputation, and I have cut off many limbs that I could have saved, had I known as much then as I do now. Conservative antiseptic surgery has replaced the necessity of amputation in com
pound comminuted fractures, and in gunshot wounds of the great joints, to a large extent. We are here to-day to discuss whether or not a limb can be saved that has been run over by a railroad train. If we had taken a vote a year ago on that question it would have been unanimous that the limb must be sacrificed, particularly where a railroad train has run over it. The essayist is of the opinion that he ought to try to save limbs that have been crushed by the wheels running over them. Whether he has gone a step too far or not, I am still in doubt. It seems to me hardly practicable, hardly possible, to attempt to do much in the way of conserving a limb which has been crushed by the iron horse. But I rise more particularly to detail some experience of my own in the way of saving a lacerated limb that was injured by a reaper. About two years ago last August, while in the harvest field, a little girl had her foot cut off to the extent that all of the tissues, except about an inch of the integument in the posterior part of the leg, the tendo-Achilles and the posterior tibial artery were cut off. Four inches of the anterior surface of the tibia and fibula were cut out in V-shape by the mowing machine. The little girl was anxious to have her limb saved and the parents refused to have it amputated. The consequence is she has her limb yet. It was treated with the most careful surgical antisepsis. A small section was cut off at each end of the tibia and fibula to effect apposition. The limb was then carefully bound up and treated aseptically, and the little girl now goes to school and has the use of the leg. She is obliged to wear a shoe with a brace to it, but no other apparatus or splint. There is nothing to indicate lameness, except a slight irregularity in the movement of the foot. She walks to school a half mile every day and plays and runs about with the other children. There is nothing but cicatricial tissue connecting the foot with her body, except the tendo-Achilles, and a small section of the integument and the posterior tibial artery.
Dr. James B. Hungate: I wish to add my testimony to that of Dr. Bouffleur in saying that it is practicable to save a limb after it has been run over by a railroad car. A case in point: A train backed over a brakeman's foot. It was not going fast at the time, but two wheels of the car passed over the foot. I saved the foot by removing some of the bone,
strictly sterilizing it, and keeping the foot in hot antiseptic water. He was sent to the hospital in Kansas City. He has now a reasonably good foot, and is doing duty as a brakeman on a passenger train. I do not go so far as to say that every limb can be saved, for it all depends upon the circumstances surrounding it. You may or may not save a limb. There are exceptions to the rule. Some of the employes are imbued with the idea that because I saved this man's limb I can save anything. But this is not true. We must be governed by the individual case, and the indications it presents.
Dr. Peck: The gentleman who has just preceded me has borne testimony to one part of railway surgery that I wish to endorse, that is, it is possible to save a foot that has been run over by a railroad car wheel. It would not apply to the iron horse. When the iron horse has gone over a man's foot, the foot is gone. I say this for the reason that I have had some experience in dealing with such cases. Our trainmaster is walking on a foot to-day over which a car wheel passed. The car had to be backed up and the foot or shoe pried away in order to release it. The head of the fibula was removed, as well as a portion of the adjoining bone, and he is walking without a limp to-day.
I succeeded in saving the limb of an employe of the Reading road who had a car wheel pass over it in the presence of several of his associates. The man was afterward killed in a railroad wreck as fireman. A third case: An Italian who left the hospital two weeks ago had a car wheel pass over his foot immediately above the shoe top. The man weighed two hundred pounds. He is walking about to-day with a comparatively good foot. Young as I appear, I have had twenty-eight years' experience in the service of railway surgery, and during that time have had ample opportunity to carefully observe the cases that we are called upon to treat, and I wish to say that in all my experience I have not heard a more thorough, more exhaustive, more practical paper on this branch of the work than the one I have heard to-day.
Dr. J. N. Jackson, Kansas City: In recent years I have both listened to and read many articles upon the subject of conservatism in traumatic surgery, and yet to me the subject is ever new and interesting. I think there
nothing that marks the progress of modern surgery so much as the ability of conserve limbs which were a few years ago sacrificed. In dealing with traumatism of the extremities the subject of amputation comes up. It should be viewed from two aspects. First, from the aspect of necessity, and second, from the aspect of expediency. In those cases of traumatism to the extremity, where the tissues have been absolutely devitalized by the injury, the question of amputation is one of necessity. There we have before us a part whose function absolutely cannot be restored. Amputation in this class of cases is imperative. There is, however, a second class of cases in which conservatism may be carried too far, and would here dissent from the statement of Dr. Hoy, who said that wherever a limb could be saved it was the duty of the surgeon to save it. In dealing with traumatism of the extremities, we should remember the principles which I once heard enunciated when this subject was under discussion, namely, that true conservatism puts life first. In dealing with a case of traumatism the first thing to decide is, whether to amputate or save the limb. If life is going to be threatened by radical efforts in either case, we should take the course which will protect the life of the individual. In the second place there are a class of cases in which life is not to be solely considered, in which there is no danger from amputation or efforts of conservatism, yet we must not lay down the rule that even in this class of cases every limb should be amputated or saved, because we do not know. There are cases of traumatism in which the limb can be saved, and yet it is worse than useless, so far as the conservation of the function of the member is concerned. Such functionless limbs had better be sacrificed; they' are in the way of the individual. If we can save a limb and make it a useful member, then it is our duty to devote time and skill to the saving of it. But if we have before us a shrunken, withered, misshapen limb, it should be amputated and its function conserved by the application of an artificial extremity.
I agree with Dr. Bouffleur as to the question of saving limbs, and that there is really but one important problem in connection with it, and that is nutrition or circulation. We can save practically any limb, providing the nutritive elements or materials for repair are being car