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are forced to admit that any suggestion bearing on the treatment of its injuries deserves consideration. Just here let me remark that our learned and worthy teachers are responsible for much time that is wasted by students, in attaching so much importance to the description of various-named operations in the "green room." Fortunately the members of this body have all passed safely through that soul-harrowing apartment, and the younger members have also run the gauntlet of the State Board, and hence all are in a position to act on the dictates of common sense. Without further preamble or apology, then let us come directly to the point.
We have before us a patient with a crushed or mangled foot. Shall we operate at once, or wait? The principles of conservatism, which modern surgery makes possible, demand that we wait to give nature an opportunity to demonstrate the exact extent of the injury. Nature should be assisted by the surgeon using all the resources at his command to restore to life contused parts. These will include hot irrigations, hot antiseptic lotions, and packs-heat and antisepsis in every available form. When the time for operation is at hand, I would suggest that we temporarily forget, if we have ever learned them, all the classical amputations described in the textbooks such as Hey's, Lisfranc's, LeFort's, Miculicz's, Chopart's, Pirogoff's, Syme's, etc., etc.- and keep in mind instead the following ideas and purposes:
1. To save every bit of tissue possible.
2. To treat the foot as a whole.
3. To make the bone sections wherever sufficient soft tissue can be secured to cover the severed ends.
This doctrine, I am fully aware, is in conflict with timehonored authorities and precedents; but in these days of scientific progress such an objection may be in its favor. No less an authority than John A. Wyeth, after describing at length, in his textbook on surgery, the operations of Syme, Malgaigne, Pirogoff, Chopart, Forbes, Hey, Lisfranc and others, and recording the conditions justifying the election of each one, at the last meeting of the New York State Association of Railway Surgeons, willfully neglected the merits of all. At that meeting, while discussing a paper by Dr. Henry Flood
on "Amputations of the Foot," he said that he had for some time treated the foot in amputations as if it were one bone, and was glad to find men of large practical experience agreeing with him; also he does not believe in immediate amputations, and very seldom performs one in crushing injuries. Dr. Manley of New York voiced the same sentiments, even going so far as to say: "The so-called classic amputations of the textbooks should be wiped out once and for all; they have done more harm than good." Dr. Flood, the essayist, had advanced the idea that we should treat the foot as we do the hand, saving all tissue possible, regardless of classic types of amputations. He sounded a note of warning in reference to the Esmarck bandage and tourniquet, saying that they produce an artificial edema, which is deceptive as to what tissue is really alive, and are frequently followed by necrosis due to interference with the circulation. A liberal use of hemostats obviates the necessity of tourniquets, except for a very brief time.
Another point that should be borne in mind is the blood supply of the flaps. Many a secondary amputation has been necessitated by a failure to regard circulatory anatomy in the sweeps of the knife. This gives me an opportunity to emphasize again the study of anatomy; for, with an accurate anatomical picture of the foot in mind, it is easy to make incisions that will not endanger the life of the stump.
In closing permit me to say that this is preeminently an age of conservatism in surgery; and it would be a sad reflection on the intelligence of the medical profession were it not so. With our present knowledge of asepsis and antisepsis, it is certainly not asking too much that we save now where formerly we sacrificed. At the time when nearly all the classical amputations were first described, antiseptics were practically unknown, and surgeons could not afford to take risks with doubtful tissue. In the light of modern research, and in the confidence born of accurate knowledge, the surgeon, while he cannot quite restore dead tissue to life, can at any rate accomplish results that to his predecessors were impossible. Thus it has come about that his skill is measured not by the number and mechanical perfection of his amputations, but rather by the bruised and broken members he has saved for those to whom they were essential as a means of existence.
BY A. M. TRAWICK, M.D.
Hippocrates, born on the island of Cos, B. C. 460, was the most celebrated physician of antiquity. He belonged to the Asclepiada - being the seventeenth in descent from Esculapius. He received his instruction in medicine from his father and from Herodicus. Besides being a practitioner of medicine, he was a great philosopher. After spending some years in traveling through Greece, he settled and practiced his profession at Cos; finally, at about the age of eighty, dying at Larissa. Hippocrates was guided in his profession by the highest principles of honor and humanity. The Hippocratic oath, the formula of which is ascribed to him, bound all who sought to practice the noble healing art in the most rigorous bonds of honor and brotherhood. This is the oath :
"I swear by Apollo, the physician, and Æsculapius and Health and All-heal, and the gods and goddesses, that according to my ability and judgment I will keep this oath and this stipulation, to reckon him who taught me this art equally dear to me as my parents; to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of this art to my own sons, to those of my teachers, and to disciples bound by stipulation and oath, according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my art. I will not cut persons laboring under stone, but will leave this to be done by men who are practitioners
* Read before Tennessee State Medical Society, Nashville, April 11, 1899.
of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption-and further, from the seduction of the females or males, of freemen and slaves. Whatever in connection with my professional practice, or not in connection with it, I see or hear in the life of men which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men in all times; but should I trespass and violate this oath, may the reverse be my lot."
After practicing medicine for more than a score of years, and studying men almost as much as medicine, and noting the motives that prompt the actions of men in connection with the practice of medicine, and in studying this in connection with the Hippocratic oath, I am able to reach some conclusions:
1. Hippocrates, in the opening sentence of the oath, recognized the divine source of the power to heal.
2. The sacredness of the oath, which involves the idea of a professional obligation, is indicated by his appealing to the gods by name as witnesses to his supreme purpose to hold aloft the highest standard.
3. We also are made to realize his recognition of the high position occupied by the medical preceptor, and the reverence due him as one who conveys the knowledge of the high art.
4. Hippocrates emphasized the obligation to transmit a knowledge of medicine and the power to heal to those who are qualified both by ability and principle to use such knowledge rightly.
5. He brings out the sacredness of life, and the obligation of a physician to save and preserve it by proper treatment.
6. This physician of ancient times showed his deep conviction of moral obligations to restrain and keep under control the power conferred upon him and his profession, which might be used to the injury of others.
7. The highest ideal of both personal and professional life is held up to view.
8. When called in counsel by a brother physician, I should treat him as my host.
9. When I call a brother physician in counsel, I should treat him as my guest.
10. There is a clear recognition of the limitations of the departments of medical and surgical professions respectively, and an expression of an honest purpose to keep within those limits. In this we find the primal elements of an ethical system which has come down to us through the centuries.
11. Hippocrates not only realized, but urged, the sacredness of the physician's trust, and his duty to preserve inviolate the purity and sanctity of the patient's home.
12. The sacredness of professional secrets is incorporated in this oath, especially those secrets the divulging of which would be injurious to the honor and reputation of the patient.
13. The reward which comes from right living, and the inevitable consequences of wrongdoing, are set forth, together with the privilege of enjoying the one or a willingness to abide by the results growing out of a life spent in the service of others.
14. That if these obligations were binding upon a man living in an unenlightened age, they press with the greater responsibility upon us, and are the more binding upon those in the practice of a great profession which has become illuminated and exalted by the Christian ideals of the nineteenth century.
15. We should therefore thoroughly study the word selfishness, and should abstain from every appearance of such a hideous characteristic. And in close connection with selfishness, but far more damning to the best qualities of the physician's life, stands that most to be dreaded of all evils-jealousy. The jealous man of all others carries the marks plainly to be read and known of all men, that he is the smallest man in the entire community, and is more to be pitied than feared.
16. To sum it all up in a few words: We must remember that the physician comes in the closest and most sacred relations of life. He sees men and women in their hours of weakness; sees them when judgment and will are overthrown by disease; sees them when the intellect is so shattered and