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VOL. X.

CONSERVATISM IN THE TREATMENT OF

CRUSHED EXTREMITIES.*

BY JERE LAWRENCE CROOK, A. M., M. D., OF JACKSON,
TENN. DISTRICT SURGEON I. C., SURGEON N. C.
AND ST. L.

The beneficent influence of modern surgical methods is nowhere more strikingly exemplified than in the treatment of crushed and broken extremities of unfortunate victims. Conservatism in the treatment of these injuries is the attitude which differentiates modern from earlier surgical methods. Aseptic and antiseptic technic have reversed conditions, substituted salvation for sac

Case of G. C.

rifice, and limbs of living flesh and bone for those of wood or cork and leather.

In the comparatively recent past for a surgeon to hesitate and withhold the knife in the presence of a crushed and mangled limb was tantamount to an acknowledgment of his inability to meet the emergency and perform the amputation. Not only was this true, but such a policy on the part of the surgeon would have invited septicemia and courted death for his patient. Now, happily for the hapless victim of factory, mine or railway disaster "Nous avons change tout cela" and he who *Before the American Academy of Railway Surgeons. at Chicago, Ill., Oct. 1-2, 1903.

No. 12

saves one limb is accounted more skilled that he who amputates a dozen.

In view of the fact that the vast majority of emergency calls which fall to the lot of the railway surgeon originate from crushing injuries of the extremities, I have deemed this subject a pertinent one to present to this body. I am quite sure that I can best present it by briefly reporting a few cases that have fallen in my hands and leaving further discussion to those whose experience and ability make their words of far greater

T

Case of K. D.

value to the fellows of this academy than anything I might say.

Case 1.-J. C., age 22, switchman I. C. R. R., while attempting to make a coupling allowed a foot to remain an instant too long on the rail and the wheels of a box car ran over it, producing a compound fracture of the metatarsal bones and crushing all the toes. While amputation seemed to be indicated, a conservative policy was pursued and the injured member was carefully cleansed and dressed antiseptically. Two months' careful

attention to the case resulted in saving the injured foot, except the ends of two toes which were amputated by nature. Had an immediate amputation been performed all of the foot would have been sacrificed in order to get healthy, uninjured flaps.

Case 2.-K. D., negro, age 34, section hand I. C. R. R. On July 3, 1903, while standing on a flat car loaded with steel rails the car was suddenly struck by another car, 'causing the rails to move forward and pinion the victim's legs against the end of the car. A compound, comminuted fracture of the right tibia resulted, and the left gastrocnemius muscle was severed. The patient was carried to the hospital, anesthetized, and the limb thoroughly cleansed. The wound was enlarged, the numerous sharp fragments removed, and the ends of the broken tibia rounded. After this was done there was a space of 21⁄2 inches between the ends of the bone. The gastrocnemius muscle of the left leg, which was severed at the time of the injury to the right leg, was sutured with catgut, and the skin closed over it. Patient now has good use of both legs, and for the past two months has used no brace nor support of any kind.

Case 3.-George C., age 23, fireman M. & O. R. R. On the night of November 19, 1902, while running alongside of track in Jackson (Tenn,) yards, caught his foot in a wire and was thrown to the ground. As he fell his left arm struck against the rail and was run over by the tender of a passing engine. Except a heavy gauntlet glove and his sleeve there was nothing between the wheels of the tender above and the rails below to protect the arm which lay between these two unyielding steel surfaces. That flesh and bone could suffer such a crush without being ground off entirely is a matter of wonder, but that such an arm should be saved as a useful member of its owner's body is almost beyond belief. The skin was lacerated and burst in a few places, but the bones were crushed into numerous fragments and gave the same sensation to the touch as a chunk of ice which had been crushed by pounding in a piece of cloth; no pulse could be felt on either side, and the fingers and hand were cold. The print of the rail and the wheel were plainly visible just above the wrist in a diagonal line across the arm. The suffering of the patient was the most intense I have ever witnessed, morphin, chloral and bromid of potash being required in large doses for several days and nights for ease and sleep.

He was given one grain of morphin in three doses before he was anesthetized and as soon as the chloroform was withdrawn he began to scream again, and required repeated large doses to quiet him at all. Under anesthesia the arm was thoroughly scrubbed with soap and water, followed by sublimate solution until it was as clean as possible. It was then dressed with thick layers of sublimate and sterile cotton, and splints applied after straightening the arm in a normal position, molding and manipulating the bone fragments by the sense of touch.

The next morning a portion of the hand was warm, but there was no recovery of sensation. It was several days before I could determine whether or not the arm could be saved. Blisters appeared as high as the elbow, but these advance sentinels of mortification were promptly pierced and treated antiseptically, and at all dressings every precaution was taken to prevent septic infection.

At the end of a week nature had won the victory, and recovery gradually occurred. The progress of the case was marred only by a local necrosis of the muscle and tendon on the inner surface of the first metacarpal bone. At that point the remainder of the muscle is bound down to the bone and interferes with full extension of the thumb. This I have offered to relieve by operation, but the patient has not yet consented to it. The photographs show the appearance of the arm to-day, ten months after the accident.

DISCUSSION.

Dr. R. Harvey Reed of Rock Springs, Wyo. : It affords me a great deal of satisfaction to hear members of the academy give their experience, such as the doctor has just given, in regard to the preservation of injured extremities. It shows the progress we are making as surgeons and the benefit we can be to the laity and to the railroad companies we represent, as indicated by our

motto.

I have in mind a case which is practically a parallel to the one given by the essayist. In this case a steel coal car loaded with 50 tons of coal passed over the leg of a young man about two inches above the ankle. This young man was the brother of the superintendent of the division in which I was located. There were four persons who saw two wheels of the car run over the limb. At the time I was at Ogden and was telegraphed for by the president of the company to go to Rock Springs for the purpose of amputating the limb of the brother of the superintendent. I took the first train out and on my arrival went to the hospital, examined the limb, and found the fragments of the foot out of line and the soft parts. badly mangled. I, however, found the foot was warm, and made up my mind that it was my duty to save the leg and foot if I could. I have made this a point in this kind of surgery, for I contend that if you take the foot or arm off of a laboring man you make a pauper of him and it is your duty to prevent that if you can. I placed the limb in one of the old-fashioned fracture boxes, with bichlorid dressings, having placed the bones in apposition as near as possible, but, as the essayist has said, I could not put them in perfect apposition because it was impossible to do so. The result was the man got well rapidly and is now working on the Union Pacific Railroad as a brakeman, with about an inch shortening of that limb, which is a good deal better than a wooden leg. Another case was one of our miners who sustained an injury while prospecting in the hills, two miles from the railroad. He was working with a can of powder, and there was a premature explosion. An ordinary iron wedge, about that long (indicating), and 2 inches square, was shot through the limb and pulled out at the other side, crushing the tibia and fibula and tearing the soft parts. The man was brought to town, with the expectation of having the limb amputated. He was out of humor because I would not take off the limb, but there was good circulation in it and there was a good chance to save it. I took out several pieces of bone and implanted others by means of Senn's method. To-day there is shortening of little less than 34 inch. I saved the limb and it is a useful one. It is always wise to do conservative work in these cases if it is possible to carry it out.

I also recall the case of a young man who sustained an injury by means of a spinning wheel that exploded, knocking off 7 inches of the ulna, tearing the arm horribly; the radius was fractured. The question of amputation came up. We put him under the ordinary antiseptic treatment; no pus formed, and as the result the man is doing work for the company to-day, with a somewhat crippled arm, but which is a good deal better than

no arm.

Dr. Evan O'Neill Kane of Kane, Pa.: I think that to-day, with our modern aseptic surgery we hardly need to say much more in regard to the advantage of trying to save limbs instead of removing them. It is extremely unpopular to say that the thing to do is to slash off an injured leg or arm, and the surgeon who attempts to take a limb off meets with very many difficulties at once. It takes courage for him to remove a limb, and I think he needs a plea made for him. Conservative surgery being all the fashion, and accepted as the proper thing, it is much easier for any surgeon in any case to say, when he sees a badly mangled limb, "I will try to save this,"

making himself safe in regard to the possibilities in the case. It is an easy thing for him to go ahead and try to save it. He knows very well if it cannot be saved he can be given credit for having tried to save it, and he knows very well that he is not going to be censured if he cannot save it. The majority of patients say at once "I would rather die with it on than have it off," and he knows that he will have the support of all the members of the family, as well as the patient, in trying to save it. Hence, it is unlikely that any surgeon who is called in will take the responsibility of saying, "No, you should not save this. You will lose the man's life by it." Hence, the physician is most likely to say nothing if he feels it is a dangerous question as to whether it ought to be preserved, but he is likely to disagree with you if you should say the limb must come off. Of course, dead men tell no tales, but if a man should die on account of the surgeon having tried to save his limb, he is not likely to be censured for it.

It is a different thing, however, if a surgeon to-day has the backbone, in an effort to do his duty to his patient, regardless of what people may say, to take off a limb when he knows in his heart that to save it would really endanger seriously the man's life. He knows very well that if he takes it off it will always be said by the man himself and his family, it is a question whether the limb could have been saved, that Doctor So-and-So said it could have been saved if he had been there, and the patient will say that he knows many other people who had their limbs saved, so that they could move their fingers or toes. There are plenty of physicians willing to say a certain limb could have been saved with care. Even if the surgeon decides to take off an injured limb he has to face the possibility that the man may die after the amputation. He has much greater probability of a suit for malpractice by so doing, because the statement is made by others that this man might have had his limb saved, but the surgeon, without waiting long enough, lops it off. The railroad surgeon may sometimes receive the censure of the company he represents for amputating a limb that someone said might have been saved. They may begin to fear that he is one of the slashers, and that he takes off limbs when he might save them. For these and other reasons the doctor who amputates a limb is placed in a very peculiar and painful position, yet he is one who deserves the greatest credit for doing it, because he feels that in so doing he is doing his duty, regardless of the danger and censure.

Dr. A. H. Brumbaugh of Huntington, Pa.: Every good surgeon in practice meets with such cases as have been mentioned, and there ought to be one rule observed, and that is to save a limb when it is possible to do so. Dr. Reed has well said that when you amputate a laboring man's limb you make a pauper, yet every portion of a limb should be saved that is possible in amputating extremities. The parts beyond a joint should always be saved, so as to maintain the continuity of the tendinous attachments. For instance, a finger should not be removed at the joint, but, if possible, immediately beyond it, so as to maintain the attachment.

I had a case similar to the one that has been described, excepting in my case the bone was not crushed, and the small sinuses permitted me to press out all the comminuted parts. The nerve was destroyed, and the arteries, and in my attempt to save the hand dry gangrene set in to the ends of the fingers and continued until it involved the greater part of the hand, and, finally, I had to remove the hand immediately back of the wrist joint, and save a useful member for subsequent work. that is to say, the man continues to use the arm beyond the elbow-joint and it serves him a useful purpose.

I had another case of a man whose leg was crushed between the end of the car and the step, comminuting both bones and severing one of the arteries. He thought it should be amputated, I thought not. I differ with

the last speaker in that he says it takes more courage to amputate a limb than to save it. I think it takes a great deal more courage for a surgeon to attempt to save a crushed limb than it does to amputate it. It is a simple thing to amputate a limb. It is easy, but it is a difficult matter to decide when a limb can be saved. In the case I speak of there was not over 5/8 inch between the step and the end of the car where the bones were crushed. I straightened and strengthened the limb the best I could upon a splint, and subsequently every part of the crushed tibit and every part of the crushed fibula came away as dead bone, and yet the man's leg is the same length exactly. He is able to walk on it. Callus was thrown out around these pieces, and beside them, maintaining the integrity of the leg. Such cases as these we all meet with, and it is better to practice conservative surgery in every instance where it can be done.

Dr. F. A. Butler of Harvard, Neb.: I was very much pleased indeed with the excellent and scientific paper of Dr. Crook; also with the results obtained in the case he reported. This matter of non-amputation is one of considerable importance to practitioners who are located in some of the smaller towns and cities, where they do not all have the advantage to practice surgery as it is practiced in the larger medical centers, where there are hospitals and excellent assistants at hand. In the smaller cities and towns practitioners are expected to save limbs if it is possible to do so. We know that in some cases it is better to amputate limbs than to save them, while in other instances we can with care and good treatment, coupled with perseverance, save limbs that might otherwise be sacrificed.

The President: I would like someone in this discussion to allude to the time consumed in saving these limbs. The remarks of the last speaker would imply that sometimes we can save a limb that is badly crushed, although the indications are for amputation.

Dr. O. B. Quin of McComb, Miss.: In connection with this paper it is necessary to determine whether or not an injury is of such a degree that it requires amputation of the limb. It is perfectly right that we should be very careful and endeavor to save limbs. The extent of the injury should determine whether or not we are taking some chances on losing the man himself by resorting to conservative surgery. I have had some little experience myself as a country practitioner along the line of conservative surgery. I have worked hard to save a limb and to maintain the continuity of some of the extremities and to give a poor fellow a useful member. My experience is that our failures are not often written up in papers that are read before this or similar bodies. I recall cases in which I have consumed several months in an endeavor to preserve an injured limb, and, finally, for the benefit of the injured person, I had to amputate it. I am rather inclined to think, from my past experience, that if my judgment had been better, and I had been sufficiently competent to have known just the extent of the injury at the time (which we must confess is very hard to know always), it would have been better to have performed amputation primarily and given this man less pain, his family less anxiety, and myself a great deal less trouble.

The President: There are two sides to this question of conservative surgery, and I would like to hear from some other member.

Dr. R. Harvey Reed of Rock Springs, Wyo. It has been my misfortune to handle something like 125 accident cases every month-broken legs, crushed legs, crushed arms, and all kinds and characters of accidents that happen to men who work in the mines, and it has been very difficult for me to decide as to which cases should be treated conservatively and which subjected to amputation, so as to protect myself as well as the interests of the company. On the other hand, when I undertake to save a limb that seems impossible to save, I take

attention to the case resulted in saving the injured foot, except the ends of two toes which were amputated by nature. Had an immediate amputation been performed all of the foot would have been sacrificed in order to get healthy, uninjured flaps.

Case 2.-K. D., negro, age 34, section hand I. C. R. R. On July 3, 1903, while standing on a flat car loaded with steel rails the car was suddenly struck by another car, causing the rails to move forward and pinion the victim's legs against the end of the car. A compound, comminuted fracture of the right tibia resulted, and the left gastrocnemius muscle was severed. The patient was carried to the hospital, anesthetized, and the limb thoroughly cleansed. The wound was enlarged, the numerous sharp fragments removed, and the ends of the broken tibia rounded. After this was done there was a space of 21⁄2 inches between the ends of the bone. The gastrocnemius muscle of the left leg, which was severed at the time of the injury to the right leg, was sutured with catgut, and the skin closed over it. Patient now has good use of both legs, and for the past two months has used no brace nor support of any kind.

Case 3.-George C., age 23, fireman M. & O. R. R. On the night of November 19, 1902, while running

alongside of track in Jackson (Tenn,) yards, caught his foot in a wire and was thrown to the ground. As he fell his left arm struck against the rail and was run over by the tender of a passing engine. Except a heavy gauntlet glove and his sleeve there was nothing between the wheels of the tender above and the rails below to protect the arm which lay between these two unyielding steel surfaces. That flesh and bone could suffer such a crush without being ground off entirely is a matter of wonder, but that such an arm should be saved as a useful member of its owner's body is almost beyond belief. The skin was lacerated and burst in a few places, but the bones were crushed into numerous fragments and gave the same sensation to the touch as a chunk of ice which had been crushed by pounding in a piece of cloth; no pulse could be felt on either side, and the fingers and hand were cold. The print of the rail and the wheel were plainly visible just above the wrist in a diagonal line across the arm. The suffering of the patient was the most intense I have ever witnessed, morphin, chloral and bromid of potash being required in large doses for several days and nights for ease and sleep.

He was given one grain of morphin in three doses before he was anesthetized and as soon as the chloroform was withdrawn he began to scream again, and required repeated large doses to quiet him at all. Under anesthesia the arm was thoroughly scrubbed with soap and water, followed by sublimate solution until it was as clean as possible. It was then dressed with thick layers of sublimate and sterile cotton, and splints applied after straightening the arm in a normal position, molding and manipulating the bone fragments by the sense of touch.

The next morning a portion of the hand was warm, but there was no recovery of sensation. It was several days before I could determine whether or not the arm could be saved. Blisters appeared as high as the elbow, but these advance sentinels of mortification were promptly pierced and treated antiseptically, and at all dressings every precaution was taken to prevent septic infection.

At the end of a week nature had won the victory, and recovery gradually occurred. The progress of the case was marred only by a local necrosis of the muscle and tendon on the inner surface of the first metacarpal bone. At that point the remainder of the muscle is bound down to the bone and interferes with full extension of the thumb. This I have offered to relieve by operation, but the patient has not yet consented to it. The photographs show the appearance of the arm to-day, ten months after the accident.

DISCUSSION.

Dr. R. Harvey Reed of Rock Springs, Wyo. : It affords me a great deal of satisfaction to hear members of the academy give their experience, such as the doctor has just given, in regard to the preservation of injured extremities. It shows the progress we are making as surgeons and the benefit we can be to the laity and to the railroad companies we represent, as indicated by our

motto.

I have in mind a case which is practically a parallel to the one given by the essayist. In this case a steel coal car loaded with 50 tons of coal passed over the leg of a young man about two inches above the ankle. This young man was the brother of the superintendent of the division in which I was located. There were four persons who saw two wheels of the car run over the limb. At the time I was at Ogden and was telegraphed for by the president of the company to go to Rock Springs for the purpose of amputating the limb of the brother of the superintendent. I took the first train out and on my arrival went to the hospital, examined the limb, and found the fragments of the foot out of line and the soft parts

badly mangled. I, however, found the foot was warm, and made up my mind that it was my duty to save the leg and foot if I could. I have made this a point in this kind of surgery, for I contend that if you take the foot or arm off of a laboring man you make a pauper of him and it is your duty to prevent that if you can. I placed the limb in one of the old-fashioned fracture boxes, with bichlorid dressings, having placed the bones in apposition as near as possible, but, as the essayist has said, I could not put them in perfect apposition because it was impossible to do so. The result was the man got well rapidly and is now working on the Union Pacific Railroad as a brakeman, with about an inch shortening of that limb, which is a good deal better than a wooden leg.

Another case was one of our miners who sustained an injury while prospecting in the hills, two miles from the railroad. He was working with a can of powder, and there was a premature explosion. An ordinary iron. wedge, about that long (indicating), and 2 inches square, was shot through the limb and pulled out at the other side, crushing the tibia and fibula and tearing the soft parts. The man was brought to town, with the expectation of having the limb amputated. He was out of humor because I would not take off the limb, but there was good circulation in it and there was a good chance to save it. I took out several pieces of bone and implanted others by means of Senn's method. To-day there is shortening of little less than 34 inch. I saved the limb and it is a useful one. It is always wise to do conservative work in these cases if it is possible to carry it out.

I also recall the case of a young man who sustained an injury by means of a spinning wheel that exploded, knocking off 7 inches of the ulna, tearing the arm horribly; the radius was fractured. The question of amputation came up. We put him under the ordinary antiseptic treatment; no pus formed, and as the result the man is doing work for the company to-day, with a somewhat crippled arm, but which is a good deal better than

no arm.

Dr. Evan O'Neill Kane of Kane, Pa.: I think that to-day, with our modern aseptic surgery we hardly need to say much more in regard to the advantage of trying to save limbs instead of removing them. It is extremely unpopular to say that the thing to do is to slash off an injured leg or arm, and the surgeon who attempts to take a limb off meets with very many difficulties at once. It takes courage for him to remove a limb, and I think he needs a plea made for him. Conservative surgery being all the fashion, and accepted as the proper thing, it is much easier for any surgeon in any case to say, when he sees a badly mangled limb, "I will try to save this,"

making himself safe in regard to the possibilities in the case. It is an easy thing for him to go ahead and try to save it. He knows very well if it cannot be saved he can be given credit for having tried to save it, and he knows very well that he is not going to be censured if he cannot save it. The majority of patients say at once "I would rather die with it on than have it off," and he knows that he will have the support of all the members of the family, as well as the patient, in trying to save it. Hence, it is unlikely that any surgeon who is called in will take the responsibility of saying, "No, you should not save this. You will lose the man's life by it." Hence, the physician is most likely to say nothing if he feels it is a dangerous question as to whether it ought to be preserved, but he is likely to disagree with you if you should say the limb must come off. Of course, dead men tell no tales, but if a man should die on account of the surgeon having tried to save his limb, he is not likely to be censured for it.

It is a different thing, however, if a surgeon to-day has the backbone, in an effort to do his duty to his patient, regardless of what people may say, to take off a limb when he knows in his heart that to save it would really endanger seriously the man's life. He knows very well that if he takes it off it will always be said by the man himself and his family, it is a question whether the limb could have been saved, that Doctor So-and-So said it could have been saved if he had been there, and the patient will say that he knows many other people who had their limbs saved, so that they could move their fingers or toes. There are plenty of physicians willing to say a certain limb could have been saved with care. Even if the surgeon decides to take off an injured limb he has to face the possibility that the man may die after the amputation. He has much greater probability of a suit for malpractice by so doing, because the statement is made by others that this man might have had his limb saved, but the surgeon, without waiting long enough, lops it off. The railroad surgeon may sometimes receive the censure of the company he represents for amputating a limb that someone said might have been saved. They may begin to fear that he is one of the slashers, and that he takes off limbs when he might save them. For these and other reasons the doctor who amputates a limb is placed in a very peculiar and painful position, yet he is one who deserves the greatest credit for doing it, because he feels that in so doing he is doing his duty, regardless of the danger and censure.

Dr. A. H. Brumbaugh of Huntington, Pa.: Every good surgeon in practice meets with such cases as have been mentioned, and there ought to be one rule observed, and that is to save a limb when it is possible to do so. Dr. Reed has well said that when you amputate a laboring man's limb you make a pauper, yet every portion of a limb should be saved that is possible in amputating extremities. The parts beyond a joint should always be saved, so as to maintain the continuity of the tendinous attachments. For instance, a finger should not be removed at the joint, but, if possible, immediately beyond it, so as to maintain the attachment.

I had a case similar to the one that has been described, excepting in my case the bone was not crushed, and the small sinuses permitted me to press out all the comminuted parts. The nerve was destroyed, and the arteries, and in my attempt to save the hand dry gangrene set in to the ends of the fingers and continued until it involved the greater part of the hand, and, finally, I had to remove the hand immediately back of the wrist joint, and save a useful member for subsequent work, that is to say, the man continues to use the arm beyond the elbow-joint and it serves him a useful purpose.

I had another case of a man whose leg was crushed between the end of the car and the step, comminuting both bones and severing one of the arteries. He thought it should be amputated, I thought not. I differ with

the last speaker in that he says it takes more courage to amputate a limb than to save it. I think it takes a great deal more courage for a surgeon to attempt to save a crushed limb than it does to amputate it. It is a simple thing to amputate a limb. It is easy, but it is a difficult matter to decide when a limb can be saved. In the case I speak of there was not over 5% inch between the step and the end of the car where the bones were crushed. I straightened and strengthened the limb the best I could upon a splint, and subsequently every part of the crushed. tibit and every part of the crushed fibula came away as dead bone, and yet the man's leg is the same length exactly. He is able to walk on it. Callus was thrown out around these pieces, and beside them, maintaining the integrity of the leg. Such cases as these we all meet with, and it is better to practice conservative surgery in every instance where it can be done.

Dr. F. A. Butler of Harvard, Neb.: I was very much pleased indeed with the excellent and scientific paper of Dr. Crook; also with the results obtained in the case he reported. This matter of non-amputation is one of considerable importance to practitioners who are located in some of the smaller towns and cities, where they do not all have the advantage to practice surgery as it is practiced in the larger medical centers, where there are hospitals and excellent assistants at hand. In the smaller cities and towns practitioners are expected to save limbs if it is possible to do so. We know that in some cases it is better to amputate limbs than to save them, while in other instances we can with care and good treatment, coupled with perseverance, save limbs that might otherwise be sacrificed.

The President: I would like someone in this discussion to allude to the time consumed in saving these limbs. The remarks of the last speaker would imply that sometimes we can save a limb that is badly crushed, although the indications are for amputation.

Dr. O. B. Quin of McComb, Miss.: In connection with this paper it is necessary to determine whether or not an injury is of such a degree that it requires amputation of the limb. It is perfectly right that we should be very careful and endeavor to save limbs. The extent of the injury should determine whether or not we are taking some chances on losing the man himself by resorting to conservative surgery. I have had some little experience myself as a country practitioner along the line of conservative surgery. I have worked hard to save a limb and to maintain the continuity of some of the extremities and to give a poor fellow a useful member. My experience is that our failures are not often written up in papers that are read before this or similar bodies. I recall cases in which I have consumed several months in an endeavor to preserve an injured limb, and, finally, for the benefit of the injured person, I had to amputate it. I am rather inclined to think, from my past experience, that if my judgment had been better, and I had been sufficiently competent to have known just the extent of the injury at the time (which we must confess is very hard to know always), it would have been better to have performed amputation primarily and given this man less pain, his family less anxiety, and myself a great deal less trouble.

The President: There are two sides to this question of conservative surgery, and I would like to hear from some other member.

Dr. R. Harvey Reed of Rock Springs, Wyo. It has been my misfortune to handle something like 125 accident cases every month-broken legs, crushed legs, crushed arms, and all kinds and characters of accidents that happen to men who work in the mines, and it has been very difficult for me to decide as to which cases should be treated conservatively and which subjected to amputation, so as to protect myself as well as the interests of the company. On the other hand, when I undertake to save a limb that seems impossible to save, I take