If laceration of soft parts only exist, restore such flaps or pendulous portions as still retain a sufficiently wide attachment to preserve their vitality, and suture them in place with fine needle and catgut. Trim away such parts as are jagged and crushed beyond redemption.

If bone be splintered, exposed and protruding, in other words, if it be a compound fracture, the choice will be (according to the extent and severity of the comminution of bone, and bruising of the soft parts), either amputation or re-adjustment of fragments, or suturing of the soft parts as may be best accomplished, and the adjustment of the injured finger on a splint.

AMPUTATION OF FINGERS.-Methods of finger amputation as laid down in text-books, and as practiced on the cadaver are of little value as guides to amputations of crushed fingers.

General Rules.-First: Save as much as possible, except if the amputation must come very close to a phalangeal articulation it is not considered well to leave so small a portion that it is scarcely more than the base of the phalanx, with its articular cartilage. It is better to sacrifice the whole of the phalanx, and separate at the articulation. Second: It must be borne in mind that it is especially desirable to save enough of the distal phalanx to preserve the insertion of the flexor tendon.

Third. In amputating through the middle phalanx, bear in mind that the tendon of the flexor sublimis digitorum is inserted at about the middle of the shaft of the bone. If its attachment can be saved, power of flexion for the stump is preserved.

Fourth. None of the proximal phalanges are supplied with tendon attachments except that of the little finger (flexor osis minimi digiti).

Fifth. Close the tendon sheath, in making a finger amputation, with the aid of a fine needle and catgut, or a ligature tied about its extremity like a purse string. This may prevent, should suppuration subsequently develop in the word, extension of the same to the rest of the fingers and palm of the nand. This is of special importance in the management of amputations of the thumb and little finger, for the tendon sheaths in these are continuous tubes, leading to the palm of the hand and wrist.

Sixth. In amputation through the index, middle or ring fingers, above the middle point of the middle phalanx, flexion may be preserved by sewing with fine sutures the severed tendon to its sheath, or to the adjacent connective tissue, or to the skin flaps themselves.

Seventh. The smallest fragment of even a stump of one finger, especially if all the others be lost, should be preserved as an aid to the thumb.

Eighth.-Discrimination may be used in the management of finger amputations, between the patient who is in affluent circumstances, and the one who is dependent on the use of his hands for subsistence. In both, usefulness is of the first consideration. In

Remnant of right hand after amputation of index, middle and ring fingers, with heads of corresponding meta-carpal bones. Result, a useful member utilized effectively in all household duties. Patient can hold a pen with ease and write a legible hand.

the former, beauty and symmetry stand first; in the latter, strength and serviceability for performing manual labor are the important desideratum. Obviously, a better looking hand as a whole results from removing the whole of the index finger, with the head of its meta-carpal bone, thus forming a continuous and graceful curve from the base of the thumb to the middle finger, than leaving an ugly stump of the proximal phalanx, or even the angular protrusion resulting from a meta-carpo-phalangeal disarticulation.

The appearance of the whole hand following an amputation of the middle or ring finger, is vastly improved by taking with it at

least half or two-thirds of its meta-carpal bone, thus permitting the remaining fingers to approximate each other, and make the loss less noticeable, The same principles apply also in the management of a little finger amputation.

Ninth. For actual work, however, and manual labor, a stronger and more serviceable hand results from saving every inch possible, both of the meta carpal and phalangeal portions.

Tenth. In amputating at the extreme tips of the fingers, it is better to leave the nail matrix, even though it may be but a small portion that can be saved. A slightly shortened finger, protected by even a distorted nail, is better than a finger with no nail at all.

Eleventh-In fashioning flaps to cover finger stumps, preserve as far as possible integument from the palmar surface. The palmar skin is thicker, better supplied with nerves and blood vessels, hence makes a better stump covering. Antero-posterior flaps are made by preference, although lateral, or any compromise between the two, are permissible, if the mutilation of the soft parts prevent first choice.

Instruments for Finger Amputations are few and simple. Scalpel, mouse-toothed forceps, scissors, artery forceps, fine saw, bone pliers, medium sized needles, needle forceps, sterilized catgut, silk-worm gut.

After crushing accidents of the hand and fingers, it is often difficult to know how much of the contused soft parts may be allowed to remain.

In general terms, all severely lacerated parts, jammed and contused beyond recognition, are best trimmed away, for if left, they are very liable to undergo gangrene. It should be borne in mind, however, that the blood supply to the hand is very abundant, the capillary circulation very active, and preservation of vitality may follow contusions of seeming great severity. Of the bony portions, all comminuted and exposed fragments must be removed, projecting jagged points trimmed away with the cutting pliers, and a smooth section left for covering with the soft parts.

Care should be observed in the use of the cutting pliers, for in seizing upon the shaft of one of the phalanges to sever a piece, a crushing effect may result with comminution. It is better to chip away, little by little, from one side and then the other, until such reduction is effected as is necessary.

The amount of bone removed must sometimes be governed by the amount of soft parts remaining, from which to fashion flaps. There must be enough integument in a fairly good state of vitality

projecting beyond the end of the bone to well cover it. With the scalpel or scissors, or both, trim away and fashion the flaps so that if possible the greater part of the covering of the stump shall be from the palmar aspect of the finger. Do not leave the flaps too long-just enough to cover the end of the bone with accurate coaptation of the edges. Close the opening in the tendon sheath. This may be facilitated by lifting its attachment to the anterior surface of the phalanx. Surround with a catgut, purse string fashion, or suture with the aid of fine needle and catgut. Include the end of the tendon in the sutures, especially if there be no other flexor attachment remaining. Sew the edges of the flap together with several interrupted catgut sutures. It is well also, to insert deeply two or three sutures of silk-worm gut.

It is advisable to leave a small aperture in one angle of the stump for drainage. This is of special importance in case the wound is not quite clean, and subsequent suppuration occur. minute pledget of gauze placed in the aperture serves excellent purpose in maintaining it and acting as capillary drainage.

Dressing.-Apply crumpled gauze abundantly. Plain sterilized absorbent gauze is quite suitable, as is also gauze prepared with iodoform or boracic acid. Imbed the whole hand in gauze applied in this way, and over all this a sheet of absorbent cotton. Outside this apply a roller bandage, preferably of the gauze, two and one-half inches wide, since by reason of its elasticity it can be applied much more smoothly than a bandage of firm cloth. Place the arm in a sling and direct that it be thus carried until healing is complete.

There is an advantage in this abundant dressing, in that it encloses all the fingers, deprives the patient of any use of his hand while healing is taking place, and thus makes it fairly certain that he will not displace the dressing nor do injury to the part.

Simple lacerations of the fingers, involving a moderate area of the soft parts only, may safely be dressed singly, securing the moderate layer of crumpled gauze which is applied to the part by a narrow gauze finger bandage with a layer of collodion applied externally, especially about the edges close to the base of the finger, to prevent it from slipping off. The abundant dressing, however, and securing the whole arm in a sling is invariably the best course to pursue where anything so important as an amputation has been effected.

Patients who have suffered finger injury should be seen by the surgeon or report to him at least every other day. This is of especial importance because, even with the utmost care and antiseptic precautions, suppuration within the wound, or sloughing of the con

tused tissue may occur. Ordinarily such cases, managed as above directed, undergo repair without interruption and without necessitating change of dressing for at least a week, when on examination the wound will be found united by first intention and without pus.

Under favorable progress pain diminishes during the first twentyfour hours, and by the second day the part is comfortable, gives little or no annoyance to the patient; he feels well, sleeps tranquilly, and eats liberally of light nourishing foods. What are the indications of unfavorable progress in the wound and necessity of removal of dressing? At the expiration of the second day, or in the course of the third, increasing discomfort in the wound occurs, with may be throbbing pain, aggravated by holding the hand in a dependent posture. There is likely to be slight elevation of temperature, falling off in the appetite, and difficulty in finding a comfortable position for the hand during sleep. With these symptoms, do not delay in making a change of dressing, pull out the tent of gauze which has been left in the angle of the wound, gently press the tissues about the stump to force out any accumulation of purulent material which may have collected. Enlarge the aperture, if greater opportunity for drainage seems desirable, by taking out one or two of the adjacent catgut sutures. Dress the wound daily thereafter, and if, on the second dressing, suppuration be more threatening, indicated by diffuse reddening and tumefaction of the soft parts in the vicinity of the wound, remove more of the stitches, so as to freely expose the innermost portions, cleanse the wound at each dressing with peroxide of hydrogen solution (one part to two of water), and soak the whole hand for half an hour, at least once a day, in a warm two per cent. carbolic acid solution. Continue to dress abundantly with crumpled gauze, preferably, when suppuration has occurred, iodoformized, sublimated, or borated.

INCISED WOUNDS.-Fingers are liable to be cleanly cut off by the axe, cleaver, hay cutter, circular or band saw. Lesser incised wounds occur in the use of the carving knife, chisel, and even the pocket knife. The possibility of restoring a severed digit which has been cleanly cut off, such as would result from the stroke of a sharp cleaver or axe, may, if carefully readjusted within a short time-half an hour-and accurately sutured, re-unite and be preserved. Adjust it securely upon a finger splint, dress abundantly with crumpled gauze, envelop the whole hand, place the whole arm and hand in at posterior fore-arm splint, and carry in sling. If no attempt be made to restore the lost part through failure to find it, or because it is