was almost perfect union. The dressings have been removed and the case has made a nice recovery.

I find in a number of cases of delayed or non-union of bone that it is a difficult matter to determine just where delayed union stops and non-union commences. I have I have found by putting a plate over the bone, unless you are careful in the selection of the screw you use in the plate, a fungous deposit occurs over the plate. Another thing that I find that is objectionable to the use of silver wire in wiring bones together is that a number of surgeons are a little bit too anxious and eager to get through. It is a difficult matter to handle this silver wire in the union of bone so as keep it from breaking off. I have broken it off when bruising the wire down.

The question arises, How long should we wait for union of bone to take place? How shall we regard delayed union or non-union of bone? I recall several cases in which there has been delayed union for eleven or twelve months, and yet afterward there was union of bone. I recall the case of a young man whose leg was caught and badly crushed, producing a compound comminuted fracture. The fragments were taken away, the wound surface cleaned out thoroughly, and I think it was full a year or more before we had union in that case.

Dr. Milton Jay of Chicago: As to the question of waiting until shock has passed away before performing amputations, in this day of surgery I believe the consensus of opinion is to operate just as soon as we can. There are reasons for operating promptly. Where we have a leg that is crushed and bandaged, as we frequently do in railway injuries, we must expect infection, or, at least, there is a chance for infection to occur, although the limb be thoroughly bandaged. We must recollect that the microbes can enter the lymphatic circulation when they cannot get through the veins. Now, if we operate immediately there is no chance for infection. That has been repeatedly demonstrated.

Immediately after an injury has been received, while the patient is in shock, it takes very little of the anesthetic to put the patient to sleep, or perhaps I had better say that it takes much less than it does after he has recovered from shock, and after he has recovered from shock we are bound to produce a second or additional shock, and he is more likely to die of second shock than if you had operated immediately.

Last Monday we had to amputate both legs of a switchman who had been injured. There was a great deal of hemorrhage. Both legs were amputated above the knee. We gave saline injections. The man was comatose, so no anesthetic was used. When the operations were completed the man came to and asked how he was getting along. When I left Chicago he was doing well. I have performed four double amputations immediately. Of this number I had one patient die about a month ago. He died in a few hours from what I

thought was internal hemorrhage.

I want to say a word or two with reference to the paper of Dr. Lanphear, not to criticize it. Professor Gross used to say: "Gentlemen, you may adjust fractures all right, and nature may heal them, but," he said, "nature is a contrary old jade, and she does not know always how to handle them." You cannot make all

fractured bones unite. I have seen quite a few of these cases of non-union. I have known of many cases of simple fractures of the arm and leg, which were properly splinted, and not too tightly bandaged, in which, when the dressings were taken off, the limb would fall apart. You may try again and again to get union, and fail simply because there is some condition of the system or constitutional dyscrasia which we do not clearly understand. But that is the exception. We should not say that we can make all fractures unite, because we cannot do it.

I remember the case of a woman who was run over and sustained a fracture within four inches of the hipjoint. The leg was dressed and put up in a long splint by a good surgeon. I think he changed the dressing once. Four months after the fracture occurred the splints were removed, but there was no union. She was then taken to one of the best hospitals in Chicago, and a good surgeon cut down upon the bone and wired the fragments together. He put the limb up in an ordinary. dressing and allowed the dressing to remain for some five months. When the dressing was removed it was again found that union had not taken place. After ten months I was sent for to see the case. In examining the limb I said to myself that this means a hip-joint amputation, and I so informed the woman, unless she would take the responsibility of trying to get union by again wiring the fragments. She said that she had been lying on her back for ten months, and would gladly submit to another such operation. I found the ends of the bone overlapping each other. The wires were removed; I sawed off the end of the lower bone, made a V-shape, sawed the end of the upper bone so as to remove about 4 inches of the femur. I drilled two holes in each end of the bone and drew them together with a double strand of chromicized catgut. I had an external opening into which I inserted a drain; I applied plaster of Paris, and left a trap through which I could dress the limb every few days. I kept the wooden splints on for three months, then took them off, put on another splint, and to-day this woman has good union and a fairly good leg.

Dr. S. S. Thorn of Toledo, Ohio: In regard to performing amputations during shock, or waiting for reaction to take place, I am reminded of a little story. A man was going along a road, and when he got to a certain part of it, he asked a person whom he saw which was the better road, the fork leading to the right or to the left. The man looked up and said, If you go down the right fork, you will wish you had taken the left, and if you go down the left, may be you will wish you had taken the right. That is the way I feel very largely in regard to waiting for shock to pass away in these cases before resorting to amputation. I was not here in time to hear the first part of the paper, but in the treatment of fractures we are less likely to have an ununited fracture or delayed union if the beginning of the treatment is correct. Impairment of nutrition plays an important rôle in these cases of non-union or of delayed union. Forced anemia is the cause of delayed union in many instances. I have made six amputations on one patient. at one time and the man survived.

Dr. Jay: They were probably all fingers.

died in about three hours, notwithstanding all efforts to revive him. I believe his life might have been saved if he had been seen earlier and operation promptly done. Dr. E. J. McKnight of Hartford, Conn.: Dr. Ristine spoke of the uselessness of medicines, and while he was reading his paper I thought of adrenalin. I am a little surprised that no one has called attention to it, which is destined to revolutionize our treatment of shock.

At the recent congress held in Washington, D. C., a paper was read on that subject, which was very interesting. I do not recall the name of the author. In the paper experiments were cited and cases reported in which adrenalin was used with great satisfaction. Since that time I have used it in two cases; one, in a case of railroad injury, where both legs were run over by a freight car, the right leg badly crushed, the left fibula comminuted to the extent of several inches, the tibia fractured, but no break in the skin. When seen by me the man was in a desperate condition; it did not seem as though he would survive an operation. Adrenalin was used; the right leg was amputated at the junction of the upper with the middle third; the left leg was laid open; loose pieces of bone were cleaned out, and the man rallied beautifully. I never saw a more satisfactory result than in that case. We took a drachm of the ordinary solution to a quart of normal salt solution. This was injected slowly under the skin during and after operation, until nearly a quart was used up.

I used adrenalin in a case of possible rupture of ectopic pregnancy. When seen by me, some distance from her home, the woman was in a rather desperate state. She was just as white as a bed sheet. There was no evidence of any accumulation of blood in the abdominal cavity, nor could we make out that there was extensive hemorrhage. A pint of the salt solution was used and an immediate result obtained. The pulse was 160, but soon declined to 116 or 118, and from that time on she made a very rapid recovery.

I believe that the use of adrenalin will enable us to operate a great many times when we would otherwise lose our patients.

In regard to the paper of Dr. Lanphear, it seems to me that catgut should always be used in uniting bones instead of silver wire. I have had much better results with it in fractures of the patella. The ordinary catgut can be used, and several strands of large catgut are just as good as chromicized catgut, and I have seen excellent results follow its use.

Dr. W. S. Hoy of Wellston, Ohio: I was very sorry that I did not hear the paper on amputations during shock. There are a number of surgeons here to-day who will remember a paper that was read before this Association by a distinguished surgeon, who is now dead, but who was thought well of by all of us. I refer to Dr. Murdoch of Pittsburg. If you remember, a few years ago he presented a paper on the subject of operations during shock, and it was as valuable and interesting as any the Association has ever had presented to it. If I understood the tenor of Dr. Murdoch's paper at that time, he laid down the rule that in cases of severe injury he did not believe in primary amputation

in a number of cases, but that he did believe in intermediate or secondary amputation, on account of the great mortality following primary amputation.

Every case is a law unto itself, and we must be governed in performing amputations by the surroundings we have to deal with at the time. I do not think any good surgeon would amputate during profound shock. If the shock is of such a nature that the limb itself may be the cause of additional shock, if the surgeon is satisfied of that, then it is all right to amputate. But I think in amputations a number of surgeons are too prone to take the leg or an arm off. It is so easily done, and you would be surprised to know the number of cases on which amputations have been performed. I recall the cases of two boys. In one case I amputated the leg just below the knee, in the other above the knee. The parts below the knee looked discolored, and I was a little afraid of it, yet I was able to secure a good stump below the knee. The part sloughed, which I had suspected was devitalized at the time of the amputation. A portion of the bone became exposed after amputation. But the point I desire to make in conjunction with that is this, that the reparative process is so great, the granulations are so great in amputations, that while we think we have a devitalization of the part, that they will make a covering for the stump in nine cases out of ten.

I see no reason, when a man has sustained an injury and is brought in to be operated on, particularly if the limb be mangled badly or crushed, if there is no circulation in the part, why we should not amputate, provided the shock is not of that degree that operation would tend to produce additional shock. I think chloroform is a fine stimulant in shock. One of the gentlemen spoke of the use of saline injections. I do not believe in these injections, unless there is hemorrhage preceding shock, or, rather, the shock being the result of hemorrhage.

In reference to the paper of Dr. Lanphear as to delayed or non-union of bone, there are more causes of delayed or non-union of bone than we think of. Delayed union in some cases is due to constriction of the part by a tight bandage or cast, which the surgeon applies to hold the fragments together. There is anemia of the part, and this is the cause of delayed union in some cases. I recall a case of delayed union of bone that came under my observation some time ago. In this case another physician had adjusted the fracture. He put the arm up in a bent position, the fracture having occurred near the elbow. The fragments were adjusted nicely; the patient went away, and I think in five or six weeks the dressing was removed, but union had not taken place. I do not know whether that physican redressed it or not. The patient was brought to my hospital and the arm was put up in a straight position in a plaster cast; the ends of the bone were rubbed thoroughly, and an X-ray picture taken of the fragments in position; still union did not take place. The physician, who had charge of the case, sent for me to come into the country and operate. I went out there and cut down onto the bone, turned the ends of it out, removed the material interposed between the fragments, cleaned the parts well, sawed the ends of the bone off, and wired the fragments together with silver wire. In twenty-one days after the operation there

was almost perfect union. The dressings have been removed and the case has made a nice recovery.

I find in a number of cases of delayed or non-union of bone that it is a difficult matter to determine just where delayed union stops and non-union commences. I have found by putting a plate over the bone, unless you are careful in the selection of the screw you use in the plate, a fungous deposit occurs over the plate. Another thing that I find that is objectionable to the use of silver wire in wiring bones together is that a number of surgeons are a little bit too anxious and eager to get through. It is a difficult matter to handle this silver wire in the union of bone so as keep it from breaking off. I have broken it off when bruising the wire down.

The question arises, How long should we wait for union of bone to take place? How shall we regard delayed union or non-union of bone? I recall several cases in which there has been delayed union for eleven or twelve months, and yet afterward there was union of bone. I recall the case of a young man whose leg was caught and badly crushed, producing a compound comminuted fracture. The fragments were taken away, the wound surface cleaned out thoroughly, and I think it was full a year or more before we had union in that case.

Dr. Milton Jay of Chicago: As to the question of waiting until shock has passed away before performing amputations, in this day of surgery I believe the consensus of opinion is to operate just as soon as we can. There are reasons for operating promptly. Where we have a leg that is crushed and bandaged, as we frequently do in railway injuries, we must expect infection, or, at least, there is a chance for infection to occur, although the limb be thoroughly bandaged. We must recollect that the microbes can enter the lymphatic circulation when they cannot get through the veins. Now, if we operate immediately there is no chance for infection. That has been repeatedly demonstrated.

Immediately after an injury has been received, while the patient is in shock, it takes very little of the anesthetic to put the patient to sleep, or perhaps I had better say that it takes much less than it does after he has recovered from shock, and after he has recovered from shock we are bound to produce a second or additional shock, and he is more likely to die of second shock than if you had operated immediately.

Last Monday we had to amputate both legs of a switchman who had been injured. There was a great deal of hemorrhage. Both legs were amputated above the knee. We gave saline injections. The man was comatose, so no anesthetic was used. When the operations were completed the man came to and asked how he was getting along. When I left Chicago he was doing well. I have performed four double amputations immediately. Of this number I had one patient die about a month ago. He died in a few hours from what I

thought was internal hemorrhage.

I want to say a word or two with reference to the paper of Dr. Lanphear, not to criticize it. Professor Gross used to say: "Gentlemen, you may adjust fractures all right, and nature may heal them, but," he said, "nature is a contrary old jade, and she does not know always how to handle them." You cannot make all

fractured bones unite. I have seen quite a few of these cases of non-union. I have known of many cases of simple fractures of the arm and leg, which were properly splinted, and not too tightly bandaged, in which, when the dressings were taken off, the limb would fall apart. You may try again and again to get union, and fail simply because there is some condition of the system or constitutional dyscrasia which we do not clearly understand. But that is the exception. We should not say that we can make all fractures unite, because we cannot do it.

I remember the case of a woman who was run over and sustained a fracture within four inches of the hipjoint. The leg was dressed and put up in a long splint by a good surgeon. I think he changed the dressing once. Four months after the fracture occurred the splints were removed, but there was no union. She was then taken to one of the best hospitals in Chicago, and a good surgeon cut down upon the bone and wired the fragments together. He put the limb up in an ordinary. dressing and allowed the dressing to remain for some five months. When the dressing was removed it was again found that union had not taken place. After ten months I was sent for to see the case. In examining the limb I said to myself that this means a hip-joint amputation, and I so informed the woman, unless she would take the responsibility of trying to get union by again wiring the fragments. She said that she had been lying. on her back for ten months, and would gladly submit to another such operation. I found the ends of the bone overlapping each other. The wires were removed; I sawed off the end of the lower bone, made a V-shape, sawed the end of the upper bone so as to remove about 4 inches of the femur. I drilled two holes in each end of the bone and drew them together with a double strand of chromicized catgut. I had an external opening into which I inserted a drain; I applied plaster of Paris, and left a trap through which I could dress the limb every few days. I kept the wooden splints on for three months, then took them off, put on another splint, and to-day this woman has good union and a fairly good leg.

Dr. S. S. Thorn of Toledo, Ohio: In regard to performing amputations during shock, or waiting for reaction to take place, I am reminded of a little story. A man was going along a road, and when he got to a certain. part of it, he asked a person whom he saw which was the better road, the fork leading to the right or to the left. The man looked up and said, If you go down the right fork, you will wish you had taken the left, and if you go down the left, may be you will wish you had taken the right. That is the way I feel very largely in regard to waiting for shock to pass away in these cases before resorting to amputation. I was not here in time to hear the first part of the paper, but in the treatment of fractures we are less likely to have an ununited fracture or delayed union if the beginning of the treatment is correct. Impairment of nutrition plays an important rôle in these cases of non-union or of delayed union. Forced anemia is the cause of delayed union in many instances. I have made six amputations on one patient at one time and the man survived.

Dr. Jay: They were probably all fingers.

Dr. Thorn: Yes, they were all fingers. (Laughter.) I have tried everything that I could think of, and I tell you I have gotten tired of it in following up some of these cases. A great many mistakes are made in putting up fractured limbs in dressings. The bandages are applied too tightly, thus bringing about a forced anemia or starvation of the limb, and I believe this is a fruitful cause of delayed union in many instances. Indeed, I am satisfied that in nine cases out of ten delayed union is the result of imperfect application of the primary dressing. I have very little faith in constitutional dyscrasia as a cause of non-union or delayed union. I do not attach so much importance to specific contamination in the prevention of union as some other surgeons. It has been my experience that it does not interfere or prevent union to any great extent, possibly not at all.

One of the most beautiful results I have ever had following the treatment of a compound oblique fracture was where there was a laceration, and yet the ends of the bone knitted together nicely. In this case I took two strips of silver wire, twisted it around, and left the wires there, and the result was that when the girl had a stocking on you could not tell which leg had been broken. There was complete union.

Dr. George Ross of Richmond, Va.: This subject is very interesting and instructive. I was unfortunate in not being here to listen to the paper on amputation during shock, but I am sure that we shall all have the pleasure of reading it when it is published, and no doubt we shall all read it with benefit. I have got to be a firm advocate of early operations after these injuries. Let me give you an illustration: Two years ago a man was run over and had one of his legs crushed badly up to the knee. When he was brought to the Richmond Hospital he was almost pulseless. Amputation was decided on, and the leg was cut off above the knee joint. Transfusion was practiced, we used three pints of saline solution in this case, together with strychnin, and heat applied locally. After the operation he improved rapidly, so that at the end of three or four weeks he was able to be taken to his home; that is e pluribus unum.

Regarding the question of ununited fractures, I have been exceedingly fortunate in not having seen a case. I have, however, seen a number of delayed union. I remember a man of 67 who sustained a compound comminuted fracture of both legs. Both limbs were put up in plaster, and I have been more or less opposed to the use of plaster of Paris since treating that case. I can recall in my experience many men who are the victims of a permanent deformity consequent upon the application of a fixed dressing. In the case of this old man there was good union in one leg. In the other, to which a retentive apparatus was applied, union failed to occur. I reapplied the dressing, but did not do much in the way of rubbing, but I did do what I regard as very important, namely, gave him phosphate of lime in large doses, nourished him freely, and at the expiration of six months, union had taken place.

Dr. Lanphear emphasized the importance of union of bone. His remarks recalled to my mind a case which was the occasion of a great deal of concern to me, and brings up the matter of duty we owe to one another.

For instance, if I should attend a case of fracture in which there should be non-union, and the patient subsequently passes out of my hands and goes to some other physician, how far shall he go in protecting me? A lady, driving in an automobile, in going over a bridge, sustained a broken thigh at the junction of the middle with the upper third. She was taken to a hospital and was under the care of one of the best surgeons in that section. He visited her two or three times a day, and took measurements regularly; he treated her with Buck's extension, and thought that he had had a perfect result until he took off the dressing. After the dressing was removed, he found that there was shortening of nearly 3 inches, with an angular deformity pitiful to look at. The leg had been incased in a plaster dressing. The woman was subsequently sent to me. They never told me that they had censured this sugeon, but they had done so. I did not criticise the work, but simply said, I am very sorry to see that you have such a short leg and have this deformity, but I am sure the surgeon who treated you did his best; you had a serious injury. I told her that she would have to wear a high shoe, and that probably she would have to go north to have such a shoe made. She went and while in the North was taken to the office of an X-ray expert. I told her that union was perfect, I examined her very carefully, but the deformity was very clear to the eye of anyone. This man examined her, and called in his assistant, who told her that there was non-union. He subjected the leg to the X-ray, and there was considerable deformity, the lower fragment sticking out, with 21⁄2 inches of shortening. Notwithstanding all this, I did not criticize the surgeon who had first treated the case. The lady returned to Virginia, and is now entirely well, as the result of ant operation which was performed by a member of this association, Dr. Hugh M. Taylor of Richmond. Taylor after a most painstaking and laborious effort in chiseling the bone, sawing off the ends, connected them with chromicized gut, and applied a Hodgen's splint. In drilling the holes in the bone, the drill unfortunately broke off, and he could not get the piece out. He rendered everything as thoroughly aseptic as possible, and left it there. But the woman is perfectly well; the fragments are thoroughly adjusted and there is only I inch of shortening. I would commend very heartily the use of chromicized gut as a valuable material for holding bone. The Hodgen's splint was kept on for nearly two months, taken off, and then Buck's extension apparatus applied. The limb is now symmetrical as compared with the angulation she formerly had, and which was pitful to look at, and utterly impossible for her to use it with freedom.

Dr.

Dr. J. C. Wysor of Clifton Forge, Va. In connection with the paper of Dr. Lanphear, I wish to report a novel procedure which was adopted in a certain case by my friend, Dr. Hugh T. Nelson of Charlottesville, Va. The case was one of ununited fracture of the femur in a negro man who sustained an accident. After the limb was put up in the usual way, and union failing to take place, Dr. Nelson cut down upon the bone and wired it, with an unfavorable result. Determined not to be outdone, he got a dowel pin, 6 inches long, cut down on the

outside of the femur, put the dowel pin in the medullary canal, then put the limb up in plaster-of-Paris, with a perfect result. I saw an X-ray picture of the leg after the insertion of the dowel pin, and now the man has a very useful leg.

Dr. J. M. Weaver of Dayton, Ohio: If we could know just exactly the condition of the ends of the bone in fracture, then we might treat our cases more successfully than we do. It is true that the X-ray enlightens us more, perhaps, than any other agent we now use; but we have fractures and fractures. We have a fracture in which the soft parts are more or less damaged, as well as the external portion of the limb. But let us take a simple fracture, where the bone alone is fractured, where there is very little or no injury to the soft parts, we do not know exactly what the condition of the ends of the bone is. It is true, we come to some sort of conclusion concerning them, and we are led to believe from our manipulations and our examinations that they are thus and so, and still they may not be. Take the thighbone, for instance, of a good-sized man; if there is any foreign substance intervening between the ends of the fractured bone, you are not able, in many instances, to determine the exact condition of the ends of the bone. You may know that you have shortening; you know that you have mobility at the point of injury, and that is about. all you do know. It may be that you have great obliquity of the ends of the bone, but otherwise it is very difficult to tell just what the condition is there. Let me cite an illustration.

Some four years ago a brakeman, while running on the top of a box car, was thrown off and fractured his femur. I did not see him at the time of the injury, but the limb was put up by a competent surgeon. The man was in such good health generally that the injury had little effect on his general system. His condition was good. The leg was put up with long splints, extension made, and the limb was the same length as the other, so that a good result was expected in that case. The case was watched closely. At the end of six weeks the dressings were removed to see as to the condition of things, and it was found there was no union. The limb was put up again and kept for a longer length of time, almost three months before the dressing was taken off. At the end of that time the dressing was removed and there was no union. There was just as much mobility at the point of fracture as there had been at any time. It was evident that something else had to be done. We put a cast on the limb, advised the man to use crutches and to go about. In this way he would give the limb a swinging motion, hoping thereby to get up sufficient irritation to induce the parts to unite. He continued in this way for several weeks longer, and still there was no union. We then said we were going to see what was the matter. We cut down on the outside of the limb, introduced the fingers, and found a triangular piece of bone, about the diameter of the femur, entirely detached from either end of the fragments. This fragment of bone was lying between the two ends. Nature had endeavored to bring about a good result; she had dwindled down the upper end of the femur and the lower end, and there was a partial absorption of this portion of the bone, but not

sufficient, and probably it never would have been. Knowing what the difficulty was, it was an easy matter to remove that portion of the bone which was there, to saw off the ends of the bone, whittle it down, and bring the ends into perfect apposition. This was done and a plate applied. I used steel screws, and put on a plate which held the ends of the bone together. After this a plasterof-Paris dressing was applied, and a short time after union occurred. I do not think there would have been union in any other way.

In many of the cases of what we call ununited fractures, I believe non-union is due to the interposition of some foreign substance between the ends of the bone, and I believe it is justifiable in cases of fracture of the femur, for instance, to cut down and find out what is the matter.

Dr. Rhett Goode of Mobile, Ala.: I did not expect to be called upon to discuss these papers, as both the essayists and those who have discussed the papers have covered the ground very thoroughly. However, I would like to make one remark, that there must be a few cases where it is not possible to operate during shock. This feature has been dwelt upon by Dr. Thorn and other members. There are certain conditions in which shock is not always the same. In some accidents shock is so profound, as we know by the patient's breathing, by the absence of the pulse beat, and the pulsation of the superficial arteries, that to perform an amputation would be almost like slaughter. The great danger of such a discussion as we have had here to-day is that the younger men of the profession will be induced to operate upon hopeless cases, not that I would charge them with operating for the purpose of sending in a bill to the company, but that they may be carried away with the idea that they can cure shock in all cases by simply proceeding at once to perform amputations. The consensus of opinion of the members of this organization is that in possibly go per cent the time to operate or to amputate is just as soon as you can get ready.

One of the gentlemen has given us a valuable suggestion in regard to the use of adrenalin in bad cases. In certain cases where I am in doubt, I will wait for the effect of the remedy. There are some cases that are so nearly gone that the slightest additional tax upon their resisting powers will carry them off. Every case is a law unto itself. That is what I wish to emphasize, and we must not lay down iron-clad rules as to when or when not to amputate.

Dr. George F. Beasley of Lafayette, Ind.: I want to say a word or two with reference to the use of plaster of Paris, which seems to have been given a black eye. Plaster of Paris makes a good splint if it is properly applied. If the limb is put in a proper position, and the plaster is put on right, you have a splint that will fit the limb. It is not necessary to constrict the tissues in applying plaster of Paris. If one is careful, he can put on a light dressing with plaster of Paris, re-enforced with a strip of tin, and get a splint that will fit the limb and hold it in the position in which you want to keep it.

With reference to amputation during shock, I recall one or two cases in which there was practically no hemorrhage. If a limb is badly crushed in an accident, there