O N 
Railroad Injuries 
- OF THE - 
Extremities of the Human Body 
- WITH - 
OBSERVATIONS ON THE SITE OF AMPUTATION 
AND 
Subsequent Treatment of the Stump. 
By THEODORE R. VARICK, M. D., 
Medical Director of and Surgeon to St. Francis’ Hospital, and Surgeon to 
Jersey City Charity Hospital, Jersey City, N. J. 
Read before the American Medical Association, at its meeting in 
Washington, D. C., May 7th, 1884. O N 
Railroad Injuries 
OF THE 
Extremities of the Human Body 
WITH 
OBSERVATIONS ON THE SITE OF IMPUTATION 
AND 
Subsequent Treatment of the Stump. 
By THEODORE R. VARICK, M. D., 
Medical Director of and Surgeon to St. Francis' Hospital\ and Surgeon to 
Jersey City Charity Hospital, Jersey City, N. ./■ Gf* 
Read before the American Medical Association, at its meeting in 
Washington, D. C., May 7th, 1884. The consideration of severe injuries of the extremities 
of the human body the result of rail road accidents, and 
indeed of all crushing blows inflicted by great momen- 
tum, is the topic which I have selected for discussion on 
this occasion. 
I shall consider their proximate traumatisms, also their 
effect on the heart and great vessels. 
For their effect on the nervous system, I refer you to 
the antagonistic works of Erichsen and Page. 
Lastly, I shall offer a few observations on the subject 
of amputations and the after treatment of the stump, also 
the reports of a few cases bearing on the subject under 
discussion: 
In the good old days of stage coaching, when travel as 
a rule was limited to nine inside and three outside, in- 
cluding the driver, and the speed of twelve miles an hour 
was considered a marvel, an occasional upset seldom re- 
sulted in more than a simple fracture, or when compound, 
scarcely ever comminuted, the offices of the surgeon were 
rarely called in for any other purpose than to apply 
splints, to reduce a dislocation, or to administer to sundry 
contusions. 
In this progressive age, the increase of speed and mul- 
tiplication of travelers are accompanied by increased fre- 
quency of accidents, and greater gravity of the trauma- 
tisms resulting from derailment, collisions, the coupling 
of cars, and the running down of unfortunate pedestrians 
who may not be able to get out of the way. 4 
Owing to the great weight, and high rate of speed, in- 
juries inflicted by trains in transit are of the most de- 
structive character, producing comminution of bone, and 
laceration and purification of soft parts. 
The traumatism is not confined to the immediate part 
struck, but extends far beyond. 
The appearance of the integument is not always a cri- 
terion of the condition of the subjacent parts, as there 
may not be the slightest abrasion or mark of contusion 
thereon ; yet the underlying muscular and vascular sys- 
tems may be hopelessly destroyed. 
It is a common observation that, concealed under the 
tegumentary condition above stated, we And rupture of 
the muscles, the bellies of which are full of eocliymotic 
patches, and at points, so pulpified as to be easily broken 
down by the fingers. 
The inquiry naturally arises as to the “modus operan- 
di” by which such results are produced. 
It is difficult to imagine a force sufficiently powerful by 
direct impact, to produce such a disintegration of the 
subcutaneous parts, without leaving its impress on the 
surface, and we are compelled to look elsewhere for the 
cause. 
It is a well recognized fact, that a muscle may be rup- 
tured by its own contractile force especially when taken 
by surprise, or unprepared for the call made upon it, or 
when in an unnatural or awkward position when struck. 
A case in point has recently come under my observation. 
I. L. C., aet 54, a strong heavy muscular man, while 
wheeling a bale of liay on-a truck, on making a sudden 
effort for the purpose of ascending an incline, felt as he 
supposed, a smart blow on the calf of the left leg, followed 
by lameness. I saw the case six hours after the occur- 
rence and found a subcutaneous depression about two 
inches in extent in its transverse diameter, in the exter- 
nal belly of the gastrocnemius, into which on pressure 
the finger readily sank. 
There followed in a few hours extreme ecchymosis of 
the part. 5 
At the present time (two months after the injury) the 
lameness has not entirely subsided, and the depression 
is well marked. So also the “lawn tennis” leg serves 
as an illustration of the pathological condition under 
consideration. 
The effect of blows in producing muscular contraction 
is well illustrated by the tendon patellar reflex contrac- 
tion of the quadriceps extensor. 
A very firm amount of pressure on the ligamentum 
patellae, or the tendon immediately above, gradually ap- 
plied, produces scarcely any action on the part of the 
extensors of the leg ; but let the same amount of force 
be applied in a sudden manner, and “ up goes your foot.” 
The condition of ankle clonus is thus described : “If 
the foot is firmly flexed by pressure on the sole, and the 
tendo-achillis is tapped briskly, the foot at once under- 
goes flexion and extension in rapid succession for a con- 
siderable number of times. Gowers found the average 
number of contractions to be a little more than six in a 
second. By the aid of the myograph, Gowers has ascer- 
tained that the commencement of the ankle clonus occurs 
too soon after the blow upon the tendo-achillis, for the 
impression to travel up to the spinal cord and back to 
the muscles of the leg. 
It is therefore concluded that unlike the knee phe- 
nomenon, the foot clonus is produced by the direct stim- 
ulation of the muscles both on the front and back of the 
leg through suddenly increased tension.”* 
In these instances although the mechanism is different, 
the effect on the muscular fibres is the same. 
A blow upon a muscle held in extreme tension causes 
violent and repeated contraction, and as in the case where 
great momentum inflicts the blow, it is fair to assume 
that rupture of the contracting muscle or of its tendon 
to a greater or less extent may ensue. 
In the tendon-reflex and ankle clonus, the joints are 
left free (except in the latter case when motion is only 
* Reynold’s System of Medicine, Vol. 1, page 987, Am. Ed. 6 
restricted by manual pressure) to move as the muscles 
contract; but in the case of rail road injuries, one end of 
the limb is often held immovable between the rail and 
car wheel, while the other is fixed by the weight of the 
body, so that the force of muscular contraction is ex- 
pended on the muscle itself. 
This involuntary contraction in conjunction with the 
efforts of the victim to free himself, would produce some 
of the lesions which come under our observation. 
Again, The liquids of the human body are confined 
within strong tegumentary and fascial coverings. Blows 
of many tons momentum rupture these envelopes in many 
places, pulpify and comminute the tissues beneath, and 
eject the liquids they contain with great force, and to 
great distances. These ejected liquids are sometimes 
thrown into other tissues, and the blood and lymph are 
driven back through the larger vessels with the same 
momentum as that of the blow struck. 
The whole vascular system being a series of tubes, hav- 
ing a common centre at the heart, this organ, on its right 
side at the time of the blow, receives the impulse of 
venous blood, and should there exist any organic cardiac 
imperfection, a fatal paralysis, commonly known as 
shock, may result, paralysis from over-distension. 
It is fair to assume that the rupture of the vessels of 
the part when struck a heavy blow, is in reality a fortu- 
nate circumstance so far as the life of the individual is 
concerned, as in this way a certain portion of the force 
is expended; for should the whole momentum of the 
projected current be thrown on the heart, instant death 
might result. 
On the arterial side the blood flowing toward the part 
struck, is suddenly and forcibly arrested. 
This sudden arrest of the circulation, is felt by the 
heart at its systole, producing heart strain, synchronous 
with the augmented propulsion thither on the venous 
side. 
These forces together produce the results above de- 
scribed. 7 
These results are in proportion to the size of the ves- 
sels involved in the injury, or, in other words, to the 
proximity to the heart. 
After death from direct or primary shock, the heart is 
found gorged with blood, distended to its utmost capa- 
city, together with general engorgement of the whole 
venous system. 
In view of the tremendous power of the impinging 
force, is not this a reasonable, or at least a plausible, ex- 
planation of the conditions described l 
This injected and pulpified condition of the muscular 
tissue may exist in any part, as high up as the point of 
origin of the muscle. 
Even though the soft parts may not present the typical 
appearance described, and seem healthy, yet their vitality 
may be so far injured at the time, as to render their repa- 
ration impossible; or the gradual supervention of sub- 
fascial hemorrhage, higher up in the limb, may, by grad- 
ually increasing pressure, destroy the already weakened 
circulation of the part. Sloughing not unfrequently fol- 
lows when least expected. 
The subject of treatment of those cases requiring am- 
putation, has to a certain extent been foreshadowed in 
the preceding remarks. 
In statistics of amputations performed at St. Francis’ 
Hospital, Jersey City, published in “The American 
Journal of the Medical Sciences,” April, 1881, I use the 
following language, referring to the damaged condition of 
the parts above the seat of injury, “ a recognition of these 
facts has led to the jiractice of giving the seat of injury a 
4 wide berth, ’ especially as relates to the lower extremity. 
“In those cases where the injury extends above the 
lower third of the leg, the rule is to amputate above the 
knee, or in other words, put a joint between the seat of 
injury and the point of amputation, as under these cir- 
cumstances alone can we be assured of sound tissues at 
the point of the operation. It has occurred in several 
cases which have come under my observation where this 8 
rule lias not been followed, that the operation although 
most skillfully performed, has resulted in sloughing of 
.the stump, involving re-amputation, re-section of the 
bone, or death of the patient. 
The sloughing involves oftentimes not only the integu- 
ments, but also the connective and muscular tissues. 
In some cases it has been observed that the muscles 
slough to a much greater extent than the skin, giving the 
stump a cupped appearance, with the bone projecting 
from the centre ; the whole resembling an old fashioned 
candlestick. 
Since the introduction of anaesthetics, shock from ope- 
ration has been reduced to a minimum, and therefore the 
removal of a few more inches of the limb, is of very little 
consequence so far as the safety of the individual is con- 
cerned ; and the perfection reached in the adaptation of 
artificial limbs amply compensates for the increased 
shortening. 
All these considerations should outweigh the risks of 
amputation in the immediate proximity of the injury. 
It matters very little as to the method of amputating ; 
each giving practically, equally good results. 
The subsequent treatment of the patient, and manner 
of dressing the stump, is often the determining cause of 
the favorable or fatal termination of the case. 
It has been my practice for many years, after the ves- 
sels have been tied, to sponge the surface of the stump 
with water a little below the boiling point, not only for 
the purpose of dislodging any coagula that may have 
fawned in the interstices of the tissue, but to stop further 
oozmg. The Haps should not be brought together until 
every particle of oozing has ceased, as it is a recog- 
nized fact that any extravasation in the cavity of the 
stump allowed to remain, is one of the most potent fac- 
tors of sepsis, which frequently occurs where this precau- 
tion is not observed. A drainage tube of sufficient size 
having been placed in position, the flaps are to be 
brought together and retained by sutures alone. 
A stream of some antiseptic fluid (I have as a rule used 9 
Volkman’s solution of Thymol) is run through the tube 
until every trace of color is lost, and the liquid is abso- 
lutely clear. 
Over all is applied a wad of oakum which is confined 
with a roller of sufficient tightness, to counteract any 
spasmodic action of the muscles and give the limb firm 
support. 
The stump is washed out, through the drainage tube, 
twice or thrice a day. The tube is allowed to remain un- 
til all colored discharge has disappeared. The ends of 
the tube are left free, in order that the syringing may be 
done without disturbing the dressing. 
The fenestrm in the drainage tube should be large 
enough to prevent clogging by the discharges, and the 
tube itself should be occasionally rotated, so as to bring 
the fenestrm in co-aptation with different parts of the 
wound. 
Reliance should not be wholly placed on the tube, as 
there may be interstices in the stump, which may serve 
as receptacles for the accumulation of the discharges. In 
order to obviate any possibility of such a contingency, it 
is my practice, after washing out the tube, to insert the 
nozzle of the syringe into the wound alongside of the 
tube, and thoroughly wash out the wound externally to 
the tube. 
One great source of ill-success is using too small a tube. 
It is better to have one too large than one too small. 
In cases where the injury is received above the knee, 
and the part requires immediate amputation, file stump 
should invariably be left open, and treated after the 
method recommended by the late Prof. Jas. R. Wood, of 
New York. 
In open stumps there sometimes exists, especially in 
muscular subjects, a strong tendency to retraction of the 
flaps. 
This is to be counteracted by the application of exten- 
sion, after Buck’s method in cases of fracture of the thigh. 
The straps are to be applied on the anterior and posterior 
aspects of the limb, and they are further utilized, as gran- 10 
illation progresses, by pinning the two together, thereby 
approximating the flaps. By this, method the dressing 
may be renewed, and the wound thoroughly cleansed, 
without any inconvenience to the patient. 
Injuries of the hand and arm occur most frequently 
from coupling cars. 
These injuries vary in degree, from the crushing of a 
few phalanges to that of the whole upper extremity. 
Owing to the greater reparative powers possessed by 
this part of the economy, we are justified in operating 
nearer the seat of injury than in the lower extremity. In 
injuries to the hand, especially, should conservative sur- 
gery be carried to its extreme limit. 
Injuries to the dorsum of the hand and fingers, are less 
serious than those involving the palm or palmar aspect 
of the fingers. 
It is my rule, provided the palmar arches are intact, 
and even one digital artery remains to a finger, to avoid 
amputation; allowing those hopelessly damaged to slough, 
and the line of demarcation to form before removing the 
part affected. 
After removing portions manifestly destroyed, such as 
lifeless parts of fingers attached solely by tendinous and 
tegumentary connections (and the same remark applies 
to the toes and feet), the part is immersed in water as 
hot as can be borne with comfort, and allowed to remain 
in the bath about half an hour. It is then wrapped in 
oakum wrung out of warm water, or a hot flax seed poul- 
tice, and the whole enveloped in oil silk. 
These baths are repeated at intervals of three hours, 
until the sloughing ceases, and the line of demarcation 
is formed. The part is then dressed with Bals. Fir, and 
any portion of bone remaining uncovered by soft parts 
is removed and the whole allowed to heal by granu- 
lation. 
By following this plan of treatment it has been my 
good fortune to save many a hand and foot which had 
been condemned as irreparable. In conclusion I beg leave to offer the reports of a few 
cases illustrative of the preceding remarks. 
Case I.—B. received a c. c. c. fracture of the leg at the 
junction of the lower and middle third, the result of hav- 
ing been run over by a locomotive and train of cars. 
Above the immediate seat of injury, there was not the 
slightest mark to indicate that there was any damage to 
the subcutaneous soft parts. 
Notwithstanding the opposition of two other surgeons, 
I amputated at the loAver third of the thigh. 
On dissecting the amputated part, the gastrocnemii 
were found lacerated and pulpified at several points, at 
which were found extensive extravasations of blood. 
Underlying the whole was found a string of coagula, ex- 
tending from the seat of injury to the popliteal space. 
The patient made a rapid recovery. 
Case II.—Pat Gilligan, aet 27 years, was admitted to 
St. Francis’ Hospital, Jersey City, Sept. 5th, 1875, on 
account of a c. c. c. fracture of the right leg, at the lower 
portion of the lower third, having been run over by a 
train of cars. Amputation was performed at the junction 
of the lower and middle thirds. The soft parts at this 
point were apparently sound. 
In a few days sloughing of the stump set in to a greater 
extent in the subcutaneous tissues than in the skin. 
The stump ultimately assumed the cup shaped appear- 
ance heretofore described. The patient linally recovered 
and was discharged from the hospital May 27th, 1876. 
Case III.—Reported by Dr. F. D. Gray, interne to 
“The Jersey City Charity Hospital.” 
“ On the morning of August 2d, 1883, Mark Setor, aet 
35, laborer, was admitted to the Charity Hospital, Jersey 
City, suffering from the effects of a railroad accident 
which occurred several hours previous. 
Examination showed that he had sustained a c. c. 
fracture of the right tibia and fibula about the middle 
third, also a crushing injury of the right foot. ‘ ‘ The patient was however suffering severely from 
shock, and the operation (amputation) was postponed 
till the next day, hoping that his condition would im- 
prove. Under the influence of stimulants and nourish- 
ment the patient rallied sufficiently so that the operation 
was deemed expedient. 
The point selected for the operation was about two 
inches below the knee joint. The external wound being 
quite extensive and reaching pretty well up toward the 
knee. It was barely possible to secure sufficient sound tis- 
sue to make the flaps, (antero posterior.) In fact the 
inner border of the anterior flap was made up in part of the 
edge of the wound. A drainage tube was introduced, the 
flaps united throughout by sutures, and wrapped in tow- 
els wrung out of hot water, then again surrounded by a 
layer of cotton. The dressing was repeated often enough 
to keep up the warmth of the stump. The stump washed 
out three times daily with a two per cent, solution of 
carbolic acid. 
The patient rallied quite satisfactorily from the imme- 
diate effects of the operation, and for eight or ten hours 
did as well as coidd be expected. After this he began to 
grow restless, and slightly delirious. On the morning of 
August 4th (day following the operation) the stump pre- 
sented a swollen and discolored appearance. Its tempe- 
rature was lowered, and on pressure it gave the (hackling 
of emphysematous tissue. In short, it had all the ap- 
pearance of beginning decomposition. 
Stimulants and nourishment, together with anodynes, 
were freely administered, but with no effect, as the pa- 
tient grew rapidly worse, delirium and restlessness in- 
creasing, while at the same time he became exceedingly 
weak. Death occured about two o’clock on the morning 
of Aug. 5th—about thirty-six hours after the operation. 
Before death the cellular tissue of the stump had be- 
come emphysematous from generation of gases up to the 
middle of the thigh. 13 
I am indebted to Dr. John D. McGill, surgeon to St. 
Francis’ Hospital, for the reports of the three following 
cases: 
Case I.—Patrick Nicholson, aged 19, brakeman by 
occupation, was admitted to St. Francis’ Hospital, Nov. 
9tli, 1881, having sustained a c. c. fracture of the bones 
of the foot. 
The soft parts about the seat of injury, and extending 
as far as the malleoli, were more or less contused and 
lacerated. Above the malleoli the tissues appeared to 
have escaped serious injury, and were apparently 
healthy. 
Amputation was performed at the lower third of the 
leg, with long anterior and short posterior flaps. The 
open method of treatment was adopted. The patient 
rallied well from the operation. 
Forty-eight hours after the operation the anterior flap 
presented a bluish yellow tinge at its lower border, and 
some eccliymosis was observed on the leg above the 
stump. Twenty-four hours later the stump presented a 
swollen, unhealthy appearance. A well defined slough 
extended about an inch and a-half from the lower border 
of the anterior flap. A solution of permanganate of pot- 
ash was applied locally, quinine and opium internally; 
quinia gr. v. every three hours. 
Poul tices were subsequently applied to the stump and 
within eight days about one-lialf of the anterior flap had 
sloughed. Two abscesses were opened in the leg above 
the stump, and several troublesome sinuses slit up. 
After this the patient did well, and was discharged 
cured January 28th, 1882. 
In this case although the tissues at the site of opera- 
tion were apparently healthy, at the time of amputation, 
subsequent events proved that the limit of injury to the 
soft parts was considerably higher in the leg. 14 
Case II.—William Size, aet 27 years, railroad em- 
ployee, July 20tli, 1882, sustained a compound fracture 
below the knee joint. 
From the seat of injury to the knee joint, the integu- 
ment was intact, but the underlying tissues crepitated 
upon digital pressure. Amputation being decided upon, 
in view of the doubtful condition of the tissues below 
the knee, it was determined to operate at the lower third 
of the thigh. 
An examination of the amputated leg disclosed the 
following: 
Seat of injury about the middle of the leg; c. c. frac- 
ture caused by the wheel of a rail road car. Skin above 
the injury intact, but somewhat contused in places. 
Muscles were of a bluish red color. Small clots of 
blood were entangled in the meshes of the muscular 
iibres which had a frayed look. That the nerves, arter- 
ies and veins, had shared injury with the muscles, was 
plainly evident. This condition of soft tissues extended 
from the point of direct injury (some six inches below 
the joint) almost to the knee. 
In this case it was apparent, that had the operation 
been performed below the knee, owing to the fact that 
the soft tissues were injured beyond reparation, a disas- 
trous result would have been certain. 
As it was, the patient made a somewhat tedious but 
very satisfactory recovery, and was discharged cured 
September 8th, 1882. 
Case III.—Timothy Daly, aet 20 years, was admitted 
to St. Francis’ Hospital November 3d, 1882, having sus- 
tained a c. c. fracture of the leg two or three inches 
above the ankle. The patient was employed as a brake- 
man on a coal car, had missed his footing, and fallen be- 
tween the cars. Before he could be extricated two or three 
cars had passed over his leg, completely severing the foot. 
When admitted Daly was suffering severely from 
shock ; skin pale, cold and clammy; pulse feeble and 
rapid ; lips bluish in color. Owing to the mangled and 15 
lacerated condition of the blood vessels at the site of in- 
jury, there was but a small loss of blood. The condition 
of the patient was such that all operative interference 
was negatived until reaction should take place. Under 
the use of stimulants, with artificial heat applied to the 
extremities, the patient slowly reacted so as to be in 
condition to permit amputation in about 12 hours after 
the injury was received. In this case as in case II, owing 
to the nature of the accident and irreparable injury to 
subcutaneous tissues and blood vessels, it was deemed 
expedient to operate above the knee. An examination 
of the amputated leg revealed about the same condition 
of the muscles and blood-vessels that was noticed in 
case II. The degree of injuries to the tissues being per- 
haps a little greater. Without the occurrence of other 
incidents worthy of note, Daly made a satisfactory re- 
covery and was discharged cured January 11th, 1883. 
Many more cases might be quoted did time and space 
permit. 
That the method of treatment advocated, has not been 
barren of results, I report that since August 12th, 1879, 
during my various periods of service at St. Francis Hos- 
pital I have performed 21 major amputations, without 
a death. All with the exception of two were for c. c. 
fractures the results of rail road accidents. Of these, 15 
were primary and 6 secondary, which are classified as 
follows: 
Thigh, primary, 6. Secondary, 4 10 
Leg, primary 3 
Hip joint, secondary 1 
Shoulder joint, primary 1 
Arm, primary 2. Secondary, 1 3 
Fore arm, primary 3 
Total 21 
In the Jersey City Charity Hospital during the same 
period, I performed 7 major amputations with one death. 16 
All these cases were for c. c. fractures the result of 
rail road injuries, viz.: 
Thigh, primary 5 
Leg, primary 1 
Fore arm 1 
Total 7 
The fatal result in one case was due to secondary hem- 
orrhage occurring on the fourth day after the operation. 
The patient was a broken-down tramp, and the hemorr- 
hage due to sloughing of the stump, opening the femoral 
artery above the ligature. In private practice I report 
three cases, all successful, viz : 
Thigh, secondary 1 
Leg, secondary 1 
Arm, primary 1 
Total 3 
This gives a total of 31 cases, with 1 death. 
Finally, the treatment may be epitomized in one sen- 
tence, viz: 
/ 
Amputate through sound tissues, and keep the stump 
clean.