the responsibility of the life of the man, because it is not always possible, even with the best antisepsis and asepsis to prevent septic infection, which means death of the patient. I have two cases in point at the present

time.

In

A Greek was crushed in a tunnel some 75 miles west of Rock Springs, and he was brought to the hospital. On examination I found that the limb was absolutely cold from a certain point down, and it was also paralyzed. In the first place we have to consider that in these cases we must have blood supply, either direct or collateral. Second, we must have nerve supply, and especially from the vaso-motor nerves, to give nutrition to the parts. If the natural blood supply is cut off we may just as well take the limb off and the quicker the better. this case the Greek refused to have his leg taken off. In about three days from the time he was admitted he was showing septic infection, temperature rising, the man becoming delirious. In ten days from the time he was admitted, under the pressure of his friends, the limb was amputated. It was badly crushed below the knee. I made the amputation above the knee and was unable to get good tissue. I cannot recall a single case of a man who under such circumstances has lived after an operation or without it. This man died three days after the operation. In septic infection we have paralysis of the heart; we have a weakening of the entire system, no matter what is done for the limb. The man is infected from top to bottom, as it were.

I could narrate several other cases in which the parties refused to have amputation performed when it was necessary. Everyone of these cases die in practically the same way. The whole economy becomes disintegrated by septic infection, and my experience is that when we find a man whose nerves and arteries are cut off, the sconer we amputate the better. If there is no possibility of establishing collateral circulation and restoring the nerves, wait until you find there are blebs beginning to form below the better tissue and amputate, the sooner the better.

Dr. Crook (closing the discussion): With reference to the remarks of Dr. Kane, that it requires courage to amputate, I think, in the great majority of instances, where we have to perform amputation at once, the limb has already been ground off practically, or injured to such an extent that any ignorant bystander can see that there is nothing to do but to amputate. There is no doubt in these cases as to what course should be pursued. The cases of doubt are the ones always where we should give nature an opportunity to see what she can do. I do not believe, however, in taking much risk, as one of the gentlemen has well said, because, when we have got the nerve supply and arterial supply absolutely shut off, the man is going to die. In such a case I would state to the patient or his friends here is a case in which I do not see the need of waiting. If the friends insist on waiting, let them shoulder the responsibility. If the next day or two, after attempting to use conservatism, you find the hand or foot, as the case may be, has taken on mortification, is foul smelling and cold, and the friends refuse to have amputation performed, the responsibility can be placed on the patient or his friends, or If they will not let me you can get out of the case. amputate when I think it is absolutely necessary to do so I will let somebody else take charge of the case. It is casier for the surgeon to perform a clean amputation than to drag along week after week in attempting to save a limb. The question of time is usually settled inside of ten days. If a piece of bone should necrose remove it. If there is any complication operate on it, as the case may indicate. Frequently in two days, or if you wait in some cases forty-six hours, you can tell whether it is possible to save a limb or not. The question of courage is in favor of the man who uses conservatism.

CONSERVATIVE SURGERY OF THE FINGERS.*

BY J. P. CRAWFORD, M. D., OF DAVENPORT, IA.

At first this seems like a matter of small importance to present to your consideration for discussion. But, when we realize the value of these appendages in all kinds of manual labor, the mechanical arts, as well as the professions, and the great liability to compromise these tissues in railroad accidents, it is of great importance that we become familiar with the best methods and means to conserve their integrity, and restore impaired functional activity. Naturally, from the degree of force to which the fingers are subjected, we have traumas of all kinds and degrees, from superficial contusions, abrasions, lacerations, incised and punctured wounds, to more extensive contusions of bone or soft tissues or both, even to complete severance from the hand. Also scalds and burns followed by most disastrous contractions and deformities. To meet these varied forms of trauma, and secure the results that modern surgical methods are able to afford, calls for a high order of surgical skill and mechanical genius.

In such an instance, the first mission of the surgeon should be to restore the finger or fingers to permanent usefulness, rather than hastily sacrifice tissues for convenience or esthetic effects. As most accidents subject the injured tissues (where there is a solution of continuity, in the presence of germs) to infection, surgical cleanliness locally should be immediately instituted. If microorganisms have already gained entrance, and swelling and lymphangitis are rapidly spreading up the lymphatics toward the axilla, a prompt and continued application of hot boric acid solution compresses will render great service in reducing the same. In the meantime all local, pent up, infectious exudates should be early drained.

The apparent necesssity of sacrificing tissue is usually in cases where there are extensive contusions, where the fingers are practically mashed, both bone and soft tissue. Yet when the nutrition is not entirely cut off, it is marvelous sometimes how these mutilated fingers will regenerate after immobilizing them in good position, and keeping a moist dressing applied constantly. If the blood supply and nutrition to the injured part proves in

*Read at eleventh annual meeting C., M. & St. P. Ry. Surgical Association, Chicago, Dec. 18-19, 1903.

sufficient for restoration, secondary operation can be resorted to as the conditions demand.

A general principle in amputation is to have the flap sufficiently long to easily cover the end of the bone. And the ideal flap in a finger amputation should be an anteriot or palmar flap. But in conservative work on the fingers we most often deviate from the general rules. Ordinarily tension on the flap or a granulating and cicatricial covering tends to make a sensitive stump; still, if the preservation of a little more bone will add greatly to the functional usefulness of the hand we can well afford to have it covered with granulating tissue at times, rather than sacrifice a single line more of bone. A good rule of technic in finger surgery is to sacrifice as little as possible in primary operations, and meet the absolute exigencies of the situation in intermediate or secondary operations.

CONSERVATIVE TREATMENT IN HAND AND FOOT INJURIES.*

BY D. S. FAIRCHILD, JR., M. D., CLINTON, IA.

Traumatism to the extremities constitutes the greatest percentage of injuries met with by the railroad surgeon, and while it may appear primitive to deal with a subject which every railroad surgeon feels he is fully master of, yet, experience has proven that in many instances radical measures have been instituted, the principal view on the part of the surgeon being to hasten repair and recovery, thereby affording promptness in releasing the injured from treatment.

Again, too little confidence has been placed in nature's powers in the process of repair, and as a result tissue has been sacrificed which it might have been possible, after persistent effort, to have saved, thereby lessening the loss of function to the injured members. At the other extreme, too much dependence has been placed on the restorative processes of nature, and, not appreciating the damage which has been done, and the possibility attending infection, wounds have been closed by tight suturing, or sealed by other methods, to later on either slough, or be followed by deep as well as superficial suppuration.

Wounds met with by the railroad surgeon are seldom aseptic, and therefore, to close them without even a slight chance for drainage is necessarily seldom practiced. It is true that wounds of the hands or feet heal rapidly under ordinary conditions, and are equally or more resistant to microbic infection than any other part of the body, but it must be taken into account that there always remains on the surfaces in these regions (especially in and around the nails), infinitely a much larger number of micro-organisms as well as of greater virulence under normal conditions. The railroad surgeon has in addition still another factor to consider, and that is, wounds of the hands and feet coming under his attention are always mixed with dirt and grease, so much so that at times an attempt to entirely remove them would not only inflict pain, but increase the injury to the already damaged tissues. All these points must be considered, as they play an important part in accomplishing successful conservative surgery.

Since January 1, 1903. I have been called upon to prescribe in the treatment of 367 persons injured on railway right of way. Out of this number 97 received injuries to the hand, 45 to the foot; a total of 142, of which 64 were open wounds; of these 16 to the foot, and 48 to the hand.

The greatest proportion of injuries received are sprains and contusions, healing under the usual treatment, without loss of function deformity, or loss to any of the parts; but there comes a different class of injuries wherein it becomes necessary for the surgeon to exercise consider

*Read at eleventh annual meeting C., M. & St. P. Ry. Surgical Association, Chicago, Dec. 18-19, 1903.

able dexterity and skill to adopt a line of treatment which will prevent as much deformity and loss of function as possible.

It is reasonable to assume that injuries to the hand will require more thought and care for their preservation than those of the foot, and conservatism here should be practiced to its extreme limits, as every finger and joint are necessary for the full grasping power of the hand, more especially so in reference to the thumb, as the usefulness of the hand materially depends on the physiologic condition of this digit. The loss of the thumb alone on an otherwise normal hand is sufficient cause for rejection in the company's service.

In anticipation of the possibility of slight ankylosis of a finger, it should be immobolized in a flexed position during the process of repair, and in event of such occurrence the grasping powers of the hand will not be interfered with.

Deformities in the foot and toes may not cause interference with ordinary demands in the performance of their normal duties, while with the hand, on the contrary, no matter how trivial the injury may have been, it will be followed by a certain degree of disability.

Among the different classes of injuries, those most often met with are of a crushing nature. These vary greatly in severity, some healing under ordinary surgical care, but there is a class that calls for our special efforts wherein more serious conditions are involved, and it is in this class of injuries that members have been sacrificed, and other times deformities left which could have been avoided if proper regard for censervative treatment had been observed.

Injuries to these distal extremities to both soft and hard tissues may have the appearance of being so seriously damaged that nothing short of amputation would suffice to effect relief, when it might have been possible to have saved a great portion, if not all. These crushed and mangled tissues may have the appearance of total destruction, but after anchoring by suture, later may have reestablished their circulation, or enough so to be very serviceable as an aid in furnishing granulations for the complete healing of a wound which had partly sloughed.

Members have been sacrificed to form a flap of good, healthy tissue, when the damaged soft parts might have been anchored, and left to nature, even though the wound could not absolutely be covered over by a flap, hoping that enough might take hold, become healthy tissue, and contribute to the complete filling in by granulation, thereby saving as much of normal condition as possible. extreme ends of the fingers and toes are often found to be nearly severed, seeming almost impossible to do otherwise than amputate, yet coaptation and suture have resulted in a complete recovery.

The

Angular, lacerated and torn flaps found about the hand and foot seem to have been absolutely devitalized, have been anchored and left with nature to care for, and have produced but partial union with sloughing of the remaining portion; this, however, may be overcome by implantation of skin grafts to the exposed area, and in the end perfect a complete cure.

Great care should be given to the prevention of scar contraction, which might interfere with proper function and free use, such as the contraction of a finger onto the palm of the hand, or the hand on the wrist, also deformities of the foot or toe. A contraction of this kind to the finger or toes may be a great source of annoyance, interfering more or less with their use, and amputation may become necessary, even after long and persistent efforts to avoid it. This can be greatly obviated by over-correcting the position during the process of repair.

Other conditions are met with where parts have been entirely crushed, burned or torn, leaving a onesided flap. The transference of these flaps can in the majority of these cases be carried out with very satis

factory results, thereby relieving further sacrifice of tis

sues.

A case of this kind is under my attention at the present time, where all the superficial tissue was completely burned off the palmar surface of the hand, with the loss of the distal end of phalanges of middle and ring fingers, leaving a one-sided but comparatively healthy tegumentary flap on the dorsal surface. As soon as sloughing was at an end and granulation under way, a mattress suture was introduced into these flaps, bringing them over onto the palmar surface, anchoring them to the palm. Skin grafts were then slid under these anchoring sutures covering the remaining raw surfaces, which extended nearly around the fingers, including all the webs. Within less than two weeks' time all grafts, as well as the flaps had united, resulting in a very useful hand, the fingers regaining their freedom of motion, crippled only to the extent of loss of the first joint of the two fingers.

Another case in the same class came to my attention where all the palmar surface of the hand and fingers was destroyed, involving destruction of the phalanges as well. In this instance, the remaining portion or the dorsum of the fingers was brought down on to the palm and anchored, and by filling the exposed spaces with a few grafts, the hand healed without delay, giving us a free, smooth and sound healthy skin surface, avoiding the undesirable and ill effects of contracted and painful scar tissue.

An interesting case of this kind is one of a trainman who received an accident which caused stripping of the greater part of the integument and fascia from the dorsum of foot, and the crushing off of all the toes with exception of the outer surface of the great toe; this was carried over on to the arch of the foot and anchored, and by the implantation of skin grafts the foot healed without further loss. The foot can now be used in ordinary shoes with the end filled with hair, and he walks without hindrance, only a slight limp or halt is noticeable when running.

On May 24 of this year I was called to see a boy of 18 who while alighting from a moving train fell with one foot under the wheels, crushing the great toe and adjoining one off at the metatarsal articulations; the soft parts extending back on the foot were also torn into irregular flaps. The fragments of the crushed toes were disarticulated and the irregular flaps brought up to cover as much as possible, and anchored to await nature's decision. As was anticipated, some sloughing took place; as soon as this was at an end skin grafts were substituted, with complete recovery July 4, with absolutely no impairment in the use of the foot, and he goes about walking or running without a limp. He wears an ordinary shoe, but keeps the toes filled with hair.

The most interesting case coming under my attention was one of a brakeman who had been standing on the pilot of an engine, and his foot was caught either under the pilot or the truck wheels, it was impossible to learn. which. The 4th and 5th toes were crushed near metatarsal joints; 3d toe through second phalanx; a deep laceration in foot between big toe and second toe; a deep laceration on dorsum of foot extending from toes to ankle. Deep laceration on inner surface of foot, which was practically separated from the deep plantar tissues, enough so to admit free exploration of all the bones with the finger, but attached at the two ends, and on outer surface. No bones broken except the phalanges, and no very important vessels injured, but the laceration had opened different planes in the soft tissue. In the treatment gauze drains were used and the various planes anchored with a single silkworm gut for each laceration, and dressed in moist antiseptic dressings and left to await results. Considerable labor was spent in bringing about reaction and hastening granulation, but as was to be expected, more or less sloughing was present. The foot

was carefully nursed, and every possible effort used to maintain vitality of the tissues; after the line of demarcation had been established and sloughing ceased, healthy skin flaps were then made, and shifted about over the foot to divide the covering up of the raw granulating surfaces as much as possible. This operation was repeated at intervals with the aid of grafting until the foot was entirely covered by healthy skin tissue, and at the end of nine months' treatment, he was returned to his regular duty as a freight brakeman, suffering no inconvenience.

This case demonstrates forcibly what can be done in the treatment of crushed wounds with anchorage, and the establishment of avenues for drainage. Otherwise, if closed with approximation it would probably have resulted sooner or later in an amputation.

Many conditions may be encountered where pedicled flaps may be utilized with great advantage. This privilege will not only afford us the benefit of the prevention of scar tissue and its contraction, deformities, pain, etc., but will be a means to hasten recovery.

Instances are also met quite often where it is possible to divide flaps, and slide them out on raw surfaces, saving important structures, and material loss of function.

Considerable experience in the past few years in emergency surgery has convinced me it is the duty of every railway surgeon to give more consideration to this conservative plan of treatment. If the result in a few cases has not been ideal, we cannot, under our present aseptic precautions, consider our labors lost, only as a matter of time.

The loss of function to the hand or foot is in proportion to the absence or deformity of their parts; the more that can be saved and the lesser the deformity, the more is the injured and company benefited, as well as the services. of the surgeon appreciated. It is the surgeon who knows when and where to amputate that the railroad company more particularly desires, than the one who knows how to perform the most brilliant amputation disregarding conservatism.

With these crushed and lacerated wounds we have in addition many complications existing to which our attention is necessarily demanded for complete success. Among these the severing of tendons is of extreme importance. The extent of tendon involvemnt cannot be definitely determined by the outward appearance of a wound. An injury to the skin is often very deceptive in estimating the size and gravity of the injury, owing to its great elasticity. Large portions may be crushed and torn, and yet the tendons escape, while in the smaller ones the injury may have been received in such a manner as to completely sever any number.

Conservative surgery to the hand and foot without approximation or attachment of the severed tendons would be unsuccessful so far as ultimate practical results are concerned, while piastic operations might bring about perfect healing to a crushed toe or finger, yet if the tendons were neglected and left to care for themselves, the result may be worse than useless, as is seen in those straight, stiff fingers an incumbrance especially to the railroad employe. In dealing with all wounds to the foot or hand, but more particularly the latter, it is very essential that we investigate to what extent, if any, the tendons may have suffered, and if it shows that they have been implicated, it will be necessary for us to devise means that will return them to their normal relations for proper healing, to relieve any functional disturbance of the parts.

Railroad injuries are so often of a tearing nature that these tendons are found too short for approximation. Where this exists the deficiency may be substituted by filling in with a mattress suture of silk, or if not too much, catgut or kangaroo may be used. The Czerny method or splitting for the necessary distance, with the detached half turned down and sutured to the other part

of the tendon, forms a tendon sufficiently strong to perform its physiologic functions.

When only one end can be found, as is sometimes seen in wounds where the attachment has been torn out, it may with advantage be united to an adjoining uninjured tendon having the same general anatomic relations.

Periosteal attachment offers a very favorable method. A case of this kind came under my attention during the summer in which a passenger in a wreck received an ugly gouged wound on the wrist, lacerating the flexor tendon attachment to the carpal bones. The free ends of the tendons were caught, and with the hand flexed on the wrist the tendons were sutured into the periosteum and fascia of the carpal bones, and at the end of two weeks the hand had healed and patient was discharged from care without functional disturbance.

When a portion of the fingers, hand, toes or feet is sacrificed the flexor and extensor tendons should, whenever it is possible, be brought over the stump and sutured. This will prevent retraction of the flap and afford a much stronger and useful stump.

Not much can be said in conservative treatment of the bones of the hand and foot, except to save as much of the framework as possible, for a great deal can be accomplished by these plastic operations, as has already been said. As a rule nerves below the wrist or ankle do not require special attention. The amount of destruction to large vessels will materially affect our action in the propriety of practicing conservative treatment. When the main vessels have been injured our wounds will invariably be followed by gangrene and nothing short of amputation will do, but in cases of possible doubt give them the benefit and try to save all possible.

DISCUSSION.

Dr. W. J. Williams, Adel, Ia.: I wish to compliment the gentlemen for the thorough manner in which they have covered the subject. Dr. Fairchild said that the object of the surgeon should be to save as much of the framework of the hand as possible. I do not agree with him. The aim of good surgery should be to preserve the functional utility of the foot or hand; its prehensile function; the function that normally belongs to these members.

I had a little experience early in my career that I will relate. A boy shot off his finger; I had been taught to save all I could, and I did. But the result was that he had a bad finger, it did not look well nor was it useful to the boy. Another surgeon had his hand bitten off by a horse and he took a great deal of pains to try and cover up these large knuckles, only to get them where he did. not want them at all. Shortly afterward a man had his hand torn in a threshing machine. I got his consent to take off the fingers and in two weeks he was out chopping wood. Later a buzz saw cut directly through the thumb and first two fingers of an old gentleman. The bones stuck out so far that I told him I might have to take it all off; but he did not agree to that. He wanted them covered up because he wanted all the thumb he could get. He insisted on my trying to do what I could to save as much as possible, and I did. I made an extra flap and peeled off the tissues of the thumb, turned it around and slipped it back and got it all covered nicely. He got a good hand and it was useful to him.

Whenever two or three fingers are cut off, my position is to get them as much out of the way as possible so that you can retain the prehensile power of the hand as much as possible. We cannot lay down any hard and fast rule in this respect.

Dr. D. C. Brockman, Ottumwa, Ia.: I think a good rule is to save all of the hand which will be of use to the patient. Take off all that is not useful, but do not always take it off at the first dressing. Volkmann has well said that the fate of a compound fracture lies with the first

dressing. That is a good rule, but it has its exceptions. The fate of a compound fracture, or a laceration of the hand very often lies with the old dirty blanket or the waste wrapped around it before the surgeon sees it. The hand is then so septic that it is impossible to clean it.

In

These papers are just what we want, they are practical. Every shop, every yard office and every factory should have a "First Aid" dressing that can be readily gotten out and applied as soon as the accident occurs. the first dressing lies the fate of the injured hand or foot, therefore, that dressing should be clean. Do not be in a hurry to amputate fingers, because it is possible that they can be saved and be useful. I see feet and hands amputated every year that might have been saved. You can amputate the day after to-morrow just as well as you can to-day. You can tell in a few days just what is to be done. If you take off the hand to-day, you can never put it back again. Save all you can, and if a secondary operation becomes necessary you can do it later on. Dress the wound, elevate the limb and keep it quiet. No matter how much the bone is denuded, save it if you can, unless the blood supply to that part has been shut off. By doing this you often will get results that will surprise you and that will win for you the everlasting gratitude of the patient. Do not be in a hurry to amputate, because nature often will do wonders in these lacerating wounds of the hands and feet.

Dr. C. F. Larsen, Crystal Falls, Mich. : A few years ago I had an experience which has led me to the same conclusion with regard to the treatment of these cases as Dr. Brockman. I would not remove anything from an injured foot or hand until I see exactly what will be useless to the patient later on. About six years ago a woodsman came to my office with an injured toe, the result of his ax slipping while he was chopping. After undoing a dressing of tobacco and flour I found that the toe had almost been severed from the foot. The toe hung by a narrow strip of skin and I wanted to snip it. off, but the man would not consent to it. He felt that I could save it if I would try. After considerable pleading on his part I consented to try to do what I could toward saving that toe. I cleaned up the foot, put on a moist dressing, packed the foot in hot bottles and put the man to bed. I found no reason on the following day to interfere, nor on the second or third day. In fact, the case progressed very nicely and the man still has his toe and it is a useful part of his foot.

Dr. G. W. Johnson, Savanna, Ill.: An incised wound is one thing and a crushed wound another. To let a hand dangle in wet dressings for two or three days looks like bad surgery. It seems strange that we have to wait two days before we can tell whether or not that hand should be amputated, when nothing but the flexor tendons are there. There are times when a member is almost hopelessly injured and yet there is every reason to try and save it. If I had my index finger mangled and it is devitalized, of what good is it to me? I would rather have it off. I think there is too much stress laid on the saving of little patches and fragments that may be sticking out and really are in the way of perfect and speedy healing.

use.

Dr. A. W. Law, Madison, Wis.: Two years ago I read a paper on traumatism of the foot. The foot I alluded to looked as though it never would be of the least An engine and train ran over the foot and smashed it. But to-day, by following an expectant plan, that foot is as good as ever. I think expectant treatment is the proper treatment nine times out of ten. Often when a hand or foot looks as though it could not possibly be saved, by simply waiting and watching developments, the foot is not only saved but it retains its usefulness.

Dr. N. C. Loose, Maquoketa, Ia.: One statement made by Dr. Crawford ought to be emphasized very strongly and that is the advisability of saving tissue. I have hear men in this association say that the best dress

factory results, thereby relieving further sacrifice of tis

sues.

A case of this kind is under my attention at the present time, where all the superficial tissue was completely burned off the palmar surface of the hand, with the loss of the distal end of phalanges of middle and ring fingers, leaving a one-sided but comparatively healthy tegumentary flap on the dorsal surface. As soon as sloughing was at an end and granulation under way, a mattress suture was introduced into these flaps, bringing them over onto the palmar surface, anchoring them to the palm. Skin grafts were then slid under these anchoring sutures covering the remaining raw surfaces, which extended nearly around the fingers, including all the webs. Within less than two weeks' time all grafts, as well as the flaps had united, resulting in a very useful hand, the fingers regaining their freedom of motion, crippled only to the extent of loss of the first joint of the two fingers.

Another case in the same class came to my attention where all the palmar surface of the hand and fingers was destroyed, involving destruction of the phalanges as well. In this instance, the remaining portion or the dorsum of the fingers was brought down on to the palm and anchored, and by filling the exposed spaces with a few grafts, the hand healed without delay, giving us a free, smooth and sound healthy skin surface, avoiding the undesirable and ill effects of contracted and painful scar tissue.

An interesting case of this kind is one of a trainman. who received an accident which caused stripping of the greater part of the integument and fascia from the dorsum of foot, and the crushing off of all the toes with exception of the outer surface of the great toe; this was carried over on to the arch of the foot and anchored, and by the implantation of skin grafts the foot healed. without further loss. The foot can now be used in ordinary shoes with the end filled with hair, and he walks without hindrance, only a slight limp or halt is noticeable. when running.

On May 24 of this year I was called to see a boy of 18 who while alighting from a moving train fell with one foot under the wheels, crushing the great toe and adjoining one off at the metatarsal articulations; the soft parts extending back on the foot were also torn into irregular flaps. The fragments of the crushed toes were disarticulated and the irregular flaps brought up to cover as much as possible, and anchored to await nature's decision. As was anticipated, some sloughing took place; as soon as this was at an end skin grafts were substituted, with complete recovery July 4, with absolutely no impairment in the use of the foot, and he goes about walking or running without a limp. He wears an ordinary shoe, but keeps the toes filled with hair.

The most interesting case coming under my attention was one of a brakeman who had been standing on the pilot of an engine, and his foot was caught either under the pilot or the truck wheels, it was impossible to learn which. The 4th and 5th toes were crushed near metatarsal joints; 3d toe through second phalanx; a deep laceration in foot between big toe and second toe; a deep laceration on dorsum of foot extending from toes to ankle. Deep laceration on inner surface of foot, which was practically separated from the deep plantar tissues, enough so to admit free exploration of all the bones with the finger, but attached at the two ends, and on outer surface. No bones broken except the phalanges, and no very important vessels injured, but the laceration had opened different planes in the soft tissue. In the treatment gauze drains were used and the various planes anchored with a single silkworm gut for each laceration, and dressed in moist antiseptic dressings and left to await results. Considerable labor was spent in bringing about reaction and hastening granulation, but as was to be expected, more or less sloughing was present. The foot

was carefully nursed, and every possible effort used to maintain vitality of the tissues; after the line of demarcation had been established and sloughing ceased, healthy skin flaps were then made, and shifted about over the foot to divide the covering up of the raw granulating surfaces as much as possible. This operation was repeated at intervals with the aid of grafting until the foot was entirely covered by healthy skin tissue, and at the end of nine months' treatment, he was returned to his regular duty as a freight brakeman, suffering no inconvenience.

This case demonstrates forcibly what can be done in the treatment of crushed wounds with anchorage, and the establishment of avenues for drainage. Otherwise, if closed with approximation it would probably have resulted sooner or later in an amputation.

Many conditions may be encountered where pedicled flaps may be utilized with great advantage. This privilege will not only afford us the benefit of the prevention of scar tissue and its contraction, deformities, pain, etc., but will be a means to hasten recovery.

Instances are also met quite often where it is possible to divide flaps, and slide them out on raw surfaces, saving important structures, and material loss of function.

Considerable experience in the past few years in emergency surgery has convinced me it is the duty of every railway surgeon to give more consideration to this conservative plan of treatment. If the result in a few cases has not been ideal, we cannot, under our present aseptic precautions, consider our labors lost, only as a matter of time.

The loss of function to the hand or foot is in proportion to the absence or deformity of their parts; the more that can be saved and the lesser the deformity, the more is the injured and company benefited, as well as the services of the surgeon appreciated. It is the surgeon who knows when and where to amputate that the railroad company more particularly desires, than the one who knows how to perform the most brilliant amputation disregarding conservatism.

With these crushed and lacerated wounds we have in addition many complications existing to which our attention is necessarily demanded for complete success. Among these the severing of tendons is of extreme importance. The extent of tendon involvemnt cannot be definitely determined by the outward appearance of a wound. An injury to the skin is often very deceptive in estimating the size and gravity of the injury, owing to its great elasticity. Large portions may be crushed and torn, and yet the tendons escape, while in the smaller ones the injury may have been received in such a manner as to completely sever any number.

Conservative surgery to the hand and foot without approximation or attachment of the severed tendons would be unsuccessful so far as ultimate practical results are concerned, while piastic operations might bring about perfect healing to a crushed toe or finger, yet if the tendons were neglected and left to care for themselves, the result may be worse than useless, as is seen in those straight, stiff fingers-an incumbrance especially to the railroad employe. In dealing with all wounds to the foot or hand, but more particularly the latter, it is very essential that we investigate to what extent, if any, the tendons may have suffered, and if it shows that they have been implicated, it will be necessary for us to devise means that will return them to their normal relations for proper healing, to relieve any functional disturbance of the parts.

Railroad injuries are so often of a tearing nature that these tendons are found too short for approximation. Where this exists the deficiency may be substituted by filling in with a mattress suture of silk, or if not too much, catgut or kangaroo may be used. The Czerny method or splitting for the necessary distance, with the detached half turned down and sutured to the other part