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

him every possible chance to have one 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 anæsthetic. 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

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

I

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. make this as a general proposition to which we will all find some exceptions. The environments of the patient may be such as to positively 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

FIG. 4. INNER SIDE OF THIGH SHOWING LOCATION OF CONTACT WOUND AND THE APPEARANCE OF SCAR EIGHT MONTHS AFTER INJURY. SCAR ROLLED FORWARD BY PATIENT'S HAND.

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 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