generation with almost infallible precision; yet notwithstanding we believe that the day for such instructions is past, and that this time-honored practice should only apply to the exception now as rigidly as the exception applied to this ancient rule in the past.

We have had no doubt of the advisability of delay until after reaction was established, prior to the discovery and use of anesthetics, or even now when chloroform or bromide of ethyl is used for obtunding the senses; but when ether is the anesthetic used, we do question the propriety of delay as a rule, under the circumstances.

What are the claims for delay, and the objections to prompt operative interference?

They are, chiefly, that the additional injury sustained by the operation will increase the shock and general depression, and thus hazard the potient's life.

Does practical experience in surgery warrant these claims as surgery is practiced to day?

Whilst it may have warranted these claims when operations were performed without the aid afforded by the use of ether, nitrite of amyl, the hypodermic and antiseptics, it certainly does not warrant them when they are judiciously used.

Instances are by no means uncommon where a mangled arm or leg, which has had the life actually crushed out of it by massive machinery, will prolong the shock, which a prompt amputation even without any anesthetic will greatly mitigate.

It is a notable fact that when ether is used under such circumstances, the pulse will even improve and the temperature of the extremities rise, in the very midst of an operation, as I have witnessed time and again on the operating table, which changes are most marked after the mangled member has been removed.

That large masses of partially or wholly devitalized tissue have a depressing effect on the economy, and thus retard reaction, has long since been recognized by surgeons, and is readily demonstrated in the experimental laboratory.

Erichsen, speaking of shock, says on page 107: "In some cases, however, the presence of a crushed limb appears to prolong the shock, and thus prevents the patient rallying, notwithstanding the administration of stimulants. Under these circumstances, the surgeon would be justifiable in operating before reaction came on."

Ashhurst, on page 137, says: "In some instances, however, especially in the cases of compound fracture produced by railroad or machinery, the mangled limb seems by its presence to act as a continual source of depression, and in such cases prompt amputation, even during the existence of a certain amount of shock, will give the patient a better chance than delay. Particularly is this the case when the injured part is very painful, and when the bleeding is going on from small vessels that connot be controlled."

Agnew, in Vol. II, page 383, says: "There can be no objection to adjusting a broken limb, the malposition of which must, by causing pain, add to the severity of the shock. Nor would it be wrong to control the hemorrhage of a wound, even if in doing so it became necessary to cut down upon and expose a large arterial trunk. The collapse which sometimes follows incipient strangulation of an intestine can be no bar to performing an operation for the relief of hernia, as only by doing so can we hope to remove the shock. The same may be affirmed with regard to a compound depressed fracture of the skull with shock; the bone should be elevated as an essential part of the removal of collapse."

Again he says: "There are some who think that in prolonged shock, rather than allow the case to pass beyond the limits of the primary period, it is better to operate, even during imperfect reaction. There can be little doubt of the correctness of this opinion."

"A great deal has been said about the choice of time for performing an operation." "No doubt," says so conservative a surgeon as Mansell Moullin," each case must be judged on its merits-the main guide, of course, is the severity of the shock sustained, as evinced by the patient's pulse and general condition. If it is not severe it need scarcely be regarded; if so grave that it is questionable whether reaction can set in, every means should be tried to bring the patient around before operation is attempted."

Thns from high authority we learn of two conditions at least, in which early operations in surgical injuries are generally agreed upon and advised, viz.: those in which the shock is but slight, and those in which the shock is grave and prolonged.

As to the former there can be no question, and as to the latter, experience has long since demonstrated the advisability of such practice, which time after time has proven successful; then why should we be

* International Encyclopedia of Surgery, by Ashhurst, Vol. I, page 374.

inclined to stick to the old "time honored" custom of waiting for reaction to set in before we operate?

If patients not only live but do well, who are operated on while under the influence of shock, who are so mangled as to prevent reaction altogether, without any operation for their relief, as well as those who suffer but little from shock,then why not operate upon those who are between the two extremes, without waiting for reaction to be established?

For my part I can see no practical, reason for delay, but on the contrary can see several practical reasons in favor of early operations, when an operation is necessary at all.

The presence of a mass of crushed flesh or shattered bones, which is rapidly becoming moribund, in which the circulation has been largely interrupted, the nerves pulpified, and the flesh mangled, is a decided factor in prolonging shock and depressing the vital powers of the system, which prompt removal will as promptly relieve.

Indeed, I have seen patients who were almost pulseless, with cold extremities and labored respirations, when an operation was begun, revive, as it were, almost as soon as the mangled limb was removed; the pulse becoming decidedly stronger, a return of heat to the extremities, with improved respiration, which condition would continue, with scarcely a perceptible interruption after the withdrawal of the ether, after the operation.

Even in double amputations, which are to be much more dreaded than the single, I have operated during shock, and witnessed the same gratifying results.

The use of ether quiets the nervous system and supports circulation as well as deadens the patient's sensibilities, and thus acts as a decided factor in establishing the desired reaction.

It must be remembered, however, this is not the case when chloroform or bromide of ethyl is used; whilst they quiet the nervous system, and benumb all the sensory nerves, they at the same time reduce the heart's tension, which has already been reduced much below normal by shock, which now needs just the support ether furnishes it in its embarrassment, and not the depression produced by the former, which should be strenuously avoided, or if given at all, not used until after complete reaction has been established.

The natural dread of a pending operation has a marked depressing effect on those who, from a sudden and unexpected force of circumstances, are compelled to submit to such a procedure, who cannot help from

worrying more or less about it, and thus retard reaction, and fatigue themselves mentally, which of itself alone will favor the very depression we are seeking to avoid.

They wont, and must see their friends, and bid them good-bye, who through excitement and sympathy will gather around them in spite of the surgeon's advice, and add another factor to increase the already overbrudened nervous system.

Whilst we are waiting for nature to react, the pain, hemorrhage and mental excitement are busy at work, reducing the general powers of the economy, which soon must bear a second shock under much less favorable circumstances than the first.

On the other hand, if an early operation is resorted to, you cut short the hemorrhagic oozing so common in many injuries attending railroad and machinery accidents; you relieve the mental strain and irritation, deaden the excruciating pain so prostrating to the general economy, by the use of ether, and at the same time support the heart and establish the depressed circulation, and hasten the separation of the dying mass of mangled flesh from the living, thus removing the prime cause of that which you are seeking to relieve; after which your patient will awaken, in one sense feeling refreshed as it were, and often the first rational word they say will be, "is the operation all over?" to which an affirmative answer alone, from the surgeon, will add a stimulant to the depressed nervous system that bears no comparison with the most flattering promises of a successful operation before it is performed.

It cannot be denied that impressions have a decided influence in stimulating or depressing patients under any circumstances, and especially those suffering from severe injuries, and the sooner we can bring cheer and encouragement to our patients, the sooner we will get rid of one depressing factor in their case.

What reasons are there for delay at all, when our best authorities not only admit of, but advise early operations in severe head injuries involving the brain, to save life, and do save it by prompt action, regardless of shock ; or where there is marked hemorrhage, or a shattered bone, or a strangulated bowel, or a crushed extremity, which is prolonging the shock, which we all must admit is relieved, if relieved at all, as a rule, by prompt and early operative interference?

If early operations are advisable and have proved successful in these hazardous cases, why are they not advisable, and not only advisable, but

the best practice under milder injuries, or that class of surgical injuries which come in between the two extremes?

For my part I can neither see a theoretical or practical reason for delay at the present day, with ether and nitrite of amyl at our command on the one hand, and antiseptics awaiting our bidding on the other, with the supplemental aid afforded by the hypodermic, when absorption through either the stomach, rectum or skin is so obtunded as to make delay based on their action fatal.

By early operations in surgical injuries I do not mean rash carelessness or indiscriminate operations without regard to the patient's condition or prospects of recovery; but I do mean that the sooner a mangled limb is removed after it has become evident that such is necessary, the better it is for the patient, and that by doing so it will relieve him of unnecessary and prolonged pain, increased hemorrhage, greater mental depression and general shock, and in its place will give comparative comfort, relieve the mental agony, give support to the vital powers, lessen and cut short the shock by hastening reaction, and thereby increase, instead of diminish, the patient's chances for life.

SYNOPSIS OF THE DISCUSSION OF DR. REED'S PAPER.

Dr. A. Dunlap, of Springfield, opened the discussion by saying he only arose to indorse the paper just sent, and thank the author for it. He said he had seen many cases in which early operation was the only means of saving life, and that it, as a rule, was good surgery.

Dr. Weaver, of Dayton, said he was in favor of taking the middle ground, and doubted that either extreme was good surgery. He was in favor of waiting until he had some evidence of reaction setting in ; that in his opinion an early operation would serve to increase, rather than diminish the shock. Whilst he thought it might be good surgery to operate early in depressed injuries of the skull, he considered them entirely different from other surgical injuries.

Dr. Hyatt, of Delaware, said he would be governed in operating by the degree of shock. That owing to vaso-motor paralysis, the blood is drawn away from the heart, and he would advise waiting until that was sufficiently overcome to at least partially re-establish the circulation. would favor reaction by the use of internal remedies, and warmth to the surface and the extremities. He did not think it best to operate until

He