A566m 1877 f... '■'■■ t\r.... m m&* S. , iVS NLH D05bl76E 3 NLM005617823 V LS. THE / MORTALITY ' / ^7 '" X',- SURGICAL OPERATIONS UPPER LAKE STATES. COMPARED WITH THAT OF OTHER REGIONS. By EDMUND ANDREWS, A. M., M. D., PROFESSOR OF PRINCIPLES AND PRACTICE OF SURGERY IN CHICAQO MEDICAL COLLEGE, ASSISTANT SURGEON IN THE NATIONAL SOLDIERS- HOME^^-r^im r pTrt* By THOMAS B. LACEY, M. D., __r^o CV- CHICAGO : HAZLITT & REED, PRINTERS, 172 AND 174 CLARK STREET. I877. wo ft5'(st1.-tY\ /27? PREFACE. The preparation of this paper, which is reprinted from the Chicago Medical Journal and Examiner, has been a work of immense labor. My plan has been to compare the results of each surgical operation in the Lake States with the same in other regions. To obtain the statistics of the latter a wide array N of surgical literature had to be consulted, in several languages, and at a great expenditure of time. After comparing the statistical results of any given opera- tion, both at home and abroad, I have collected and appended the opinions of the chief surgical authorities of both continents as to the cases suited to its per- formance, and added my own reasons and conclusions to theirs. The surgeon therefore can obtain at a o-lance the results of any operation, both here and elsewhere, and with them the opinions of the principal authors respecting it. All surgeons have felt the need of such a condensed view of operative surgery, yet there is not in the English language a single work supplying the want. IV PREFACE. I trust that this humble beginning, imperfect as it is, ma)7 furnish the means of settling many questions for the practitioner who is debating with deep anxiety the propriety of a proposed operation, and can find no decisive information in his standard text books. No. 6 Sixteenth St., Chicago, 111. e. a. The Mortality of Surgical Operations IN THF UPPER LAKE STATES, COMPARED WITH THAT OF OTHER REGIONS By EDMUND ANDREWS. A.M., M.D., PrO'Fbbkoi; or Principles and Practice of Surgkrt in Chicago Medical Collkuk. Assisted by Thob. B. Lacey, M.D., Assistant Subbeon in the National Soldiers' Home. Operative Surgery in the Lake States of America has results widely different from those of the Atlantic region, and of Europe. Many operations are much less fatal here than there, so that to the most important of all questions about a proposed operation, viz., What is its danger * the Western practitioner can find no book to furnish him a correct answer. Full proof of this will be given as we proceed. The object of the present essay is to assist the Western surgeon in ascertaining with regard to the principal operations : 1. What is their risk in the Lake States \ 2. What has it been in other regions'( 3. What are the opinions and precepts of the principal surgeons of the world regarding each? 4. What conclusions are we to draw for our own guidance t Before entering upon details, we may illustrate the wide difference between the results of our surgery and that of other regions by studying the following condensed table : 2 The first thing which strikes the Western surgeon in this table, is the prodigious excess of mortality reported almost everywhere. With us the average mortality of all the four major amputations combined, is only 20 pel- cent., while in the hospitals of the Atlantic States it is 30 per cent. ; in the great Imperial General Hospital (k. k. allg. Krankenhaus) of Vienna, 36 per cent., in the British hospitals, 41 per cent., and in the famous hospitals of Paris, it attains the astounding figure of 60 per cent. 3 Yet these rates of mortality are not inevitable results in each region, for if we examine more closely, we find that the British country hospitals have a mortality but little greater than those of Chicago. I pass over, for the present, the strange figures of Sir J. Y. Simpson about British private practice, which show an apparent mortality for the four major amputations, of only 10 per cent. The error of these figures has been exposed by Callender and others, and the curious way in which it occurred will be hereafter explained. Again, if we take the important operation of herni- otomy, we find a perfectly similar result, as we may see from the following figures : TABLE II. Showing the Mortality of Herniotomy, in the Lake States, compared with that of other Regions. Lake States...........--------........--------- Vienna General Hospital-------....... -....... London Hospitals.....-------.................. British larger Provincial Hospitals______________ " smaller " " -- ......_____ Paris Hospitals........._______________________ Combined Hospital and Private Practice in Boston, Cheever------..............--------------- It thus appears that the very hospitals and great masters to which we have resorted most for instruction in surgery have the least success in curing their patients. It follows also, that as operative risks with us thus differ greatly from the rates generally given at the East, we shall be compelled to revise all the estimates, and deduce new rules adapted to the facts of our own region. It is in the hope to contribute something to this great end, that the following facts and figures have been laboriously collected. It will be remarked by referring to Table I, that there is but little difference in the Lake States between the results of private and of hospital practice, and, I may also add, between country and city practice. Here an- t-he figures, fractions being omitted : DEATHS. MORT. 34 8 24 254) 114 44 326 i:-56 42 177 72 1 41 118 53 45 361 244 68 27 14 4 Mirt. of the 4 maj. amp's in Lake States Hospitals-----........19 per ct. " " " private practice in the Lake States. .19 " country " " -.20 " In contrast to this approximate uniformity, Sir J. Y. Simpson represents the mortality of hospital major amputations in Great Britain to be four times as great as in private country practice, viz. : British civil hospital mortality............................ 41 per cent. " private country practice mortality...............____11 " Two things here surprise the Western American surgeon : 1. That the difference between the hospital and private practice is so enormous— 2. That country amputations in Great Britain should be twice as successful as among the vigorous, well-fed population around our great lakes. This last point requires consideration, and certainly looks like an error, for our country people are robust, well fed, and well housed, probably more so than the British peasantry. It cannot be the difference in skill, for though the average American grade of professional education is lamentably low, yet the country surgeons, from whom I collected these cases were picked men, all known to me to be men of education, and generally of -superior capacity. Taking them together, I pronounce fthem, without hesitation, to be fully equal to country surgeons in Great Britain. After eareful reflection, I think that Sir J. Y. Simpson's country statistics are grossly delusive, and that he in all honesty has fallen into a fatal error in the manner of collecting his cases. I wish to dwell upon this a little, 'because the same identical blunder is repeated every year i by vcojuamittees of medical societies, desirous of collecting ^surgical statistics for their reports. Sir J. V. Simpson printed a quantity of blank reports of amputations to be filled out with the operations and jtheir results, and mailed these to an immense number of country surgeons, most of whom must have been personally unknown to him. Now, in the replies thus 5 obtained, there will be three sources of error, all tending to understate the deaths and exaggerate the proportion of recoveries. 1. Those surgeons who are honest, but have chanced to have a "run of bad luck," that is, an accidental series of incurable cases, will not be likely to answer the circular. They are chagrined at the results of their efforts, and indisposed to court publicity for them. To a large extent these men will neglect to reply, and their fatal cases will be lost to the collector. 2. For analogous reasons the honest surgeon, who has had accidentally a "run" of favorable cases, feels ex- hilarated, and quite desirous to have them brought to notice. Such men will all respond, and thus give a preponderance of successful cases. 3. The dishonest men, (and there are perhaps some liars in Great Britain, as well as elsewhere) look upon the circular as a favorable opportunity to bring them- selves into the notice, at least of Sir James, and perhaps of the rest of the world, if he should chance to publish names. They will therefore fill up the paper with falser cases, or true cases with false results, or deceive more gracefully by omitting their fatal cases. It is inevitable that statistics gathered by promiscuous circulars must be grossly delusive, and they always falsify on the successful side. Impressed with the necessity of avoiding this error, I only applied to men of known and high-toned honesty, and almost always made my application in such a way as to secure a positive response. In this way the number of cases collected was much smaller than that obtained by Simpson, but they are truthful, and, I believe, repre- sent correctly the results of operative surgery in this region. If this correction could be made in Sir James' tables, I think the results of British private practice would not differ greatly from the American. There is another mode of collecting statistics equally albsurd which it may be worth while to mention here. 6 This consists in searching the files of medical journals and picking up and tabulating the operations there re- corded. The notorious fact that men for the most part go into print with only successful cases, is sufficient to show the utter worthlessness of such figures. I have not entered upon the old dispute whether statistics are of any use. Fifteen years ago the principal English surgeons were accustomed either to scout them openly, or, when they employed them, entered a protest that they attached little weight to them. At the present time, the whole surgical world is agreed, that properly collected, they are important aids in arriving at truth. The fact is, statistics are simply recorded experience, and cannot be ignored, any more than experience in any other form. They have the same liability to error as other methods of investigation, viz., that they may be unskillfully or dishonestly managed, and fail to reach the truth ; but the same must be said of all other modes of recording experience. No sane man will pin his faith to statistics alone, but all surgeons at the present day recognize them as important aids, in our methods of research. The cases in this essay are derived— 1. From the surgical records of Mercy Hospital, which have been carefully preserved under my own supervision since June. 1859. 2. From records of my private practice. 3. From such partial records of operations in the Marine, the County, St. Luke's and the two Women's Hospitals, as survived the great fire. 4. Notes of the operations of surgeons in Chicago and in the surrounding country, who are personally known to me, and whose statements I believe can be relied on for candor and truth. As I desire that these statistics shadl be worthy of the highest confidence, I have carefully rejected from the Lake States lists all matter furnished by persons not [known to be trustworthy, as well as all tables of f' A. J. Baxter..... • K. W. Lee....... •' E W. Lee....... ' S. Marks......... 30 yrs. 32 " 24 " KBASON FOR OPERATION. Comp. fract. humerus from R. R. cars..... Gunshot fracture at joint................. R. R. fracture humerus.................. Caries of humerus after ampt. at mid. 3d.. Disease of parts.......................... N ecrosis after fract. humerus............. Compound fract. humerus................ Compound fract. shoulder................. Necrosis of humerus after ampt. of arm.. Compound fract. of humerus............. Compound fract. of humerus.,........... Compound fracture of humerus.......... Traiunat. aneurism of subclavian artery.. Complications. Tissues of chest torn None. None. None. None. None. None. H 2 Flap. Flap. w io Medium. Good. Bad. Primary, 7 days. Bad. Good. Medium 6 weeks Primary 6 mouths " Primary. Bad. j......... " I Primary. Medium. 8 weeks Resttlt. Recovered. Died.t Recovered. Died. HO 43 days 36 hrs. Recovered, 4 weeks 5 ' 4 ' Hospital or Prit. Practice. Hospital. Priv. Prac. Hospital Priv.Pr:..-. Or Hospital. * Surgeon's name not recorded. t Cause of death, pyremia. Total, 13 cases. Recapitulation—'Recovered. 10, of which 5 were primary, 2 secondary, 1 pathological, and 1 not stated. Died, 3, of which 2 were secondary, and 1 pathological. General mortality, 23 pei out Hospital practice, 5 cases, of which 2 died. Private practice, 8 cases, of which 1 diet! 9 DISARTICULATIONS OF THE SHOULDER ABROAD. , I find the following records of this operation in various- countries : TRAUMATIC PRIMARY CASKS. AUTHORITIES. CASES. DEATHS. Med. Hist. War of Rebellion, Pa.i 11, Surg. Vol., p. 614. New York Hospital, Boston Med. Jour., 1872.......___ Boston City Hosp. Kept., Dr. Cheever............ 485 7 9 15 11 1 2 3 3 8 1 9 19 5 2 172 12 6 6 2 19 117 4 7 Mass. Gen. Hosp., 1871..................-.......-..... 8 Penn. Hosp., Dr. Norris......................______ 2 U. S. Marine Hosp. Repts., Dr. Woodworth___........ St. Thomas Hosp. Rept., London.............-......... 1 1 8t. Bartholomew's Hosp., London, Mr. Callender........ St. George's Hosp., London_________............. K. k. allg. Krankenhaus, Wien. .... 3 4 Leeds Gen. Infirmary, Mr. Nunnely.................... Glasgow Infirmary, Glasgow Med. Jour., 1854.......... Siege of Antwerp, Schmidt's .Tahrbiicher, vol. 156, p. 249. Paris, 1830—32—48, " " " " . Crimean War, " " " " . Italian " •' " " " . British Mil. Hosp., Brussels, 1815, Guthrie's Com......._ SchleswigHolstein War, Schmidt's Jahrbucher, vol. 156.. War of 1866, " " " __ Battles of Vittoria, Pyrenees and St. Sebastian, Guthrie, quoted in Diet, des Sci. Med., Art. Amputations____ 1 4 8 0 1 105 5 1 3 o l Totals......................._ ............ 796 276 Mortality, 35 per cen' TRAUMATIC SECONDARY CASKS. CASBC. DKATHS. Med Hist. War of Rebellion, Part II, Surg. Vol. ,p. 614.. 223 91 New York Hosp., Boston Med Boston City Hosp. Rept., Dr. Billroth's Letters ....... . Jour., 1872 ___ 4 2 Cheever _____ 2 1 1 0 Dr. Herrgalt, Strasburg..... .... . 1 1 Battles of Vittoria, Pyrenees, and St. Sebastian, Guthrie, quoted in Diet, des Sci. Med., Art. Amputations ... 19 15> Glasgow Infirmary, Glasgow Med. Jour., 1854. . 7 4 Siege of Antwerp, Schmidt's lahrbucher, vol. 156...... 3 2 Paris, 1830—32—48, 11 j shoulder I Middle 3d. Flap, upper 3d. Re-ampt. mid. 3d. Upper 3d. Circ, upper 3d. Upper 3d. Circ. middle 3d. Flap, upper 3d. Great shock. Tetanus. Upper 3d. Lower 3d. Upper 3d. Middle 3d. Upper 3d. Flap, upper 3d. Upper 3d. Lower 3d. Upper 3d. Good. Med. Had. Good. Bad. (100(1. Med. Bad. Good. Notsta'd Primary. ! 15 mos. 2 years. i Primary. IPrimary.| jPrimary.j Second'y i Primary.' Second'y 3 days. Primary. 2 weeks. 11 mos. Second'y Primary. 10 days. 20 hours. Primary. Died. 48 hrs. Recovered 50 days " + \'i week? Died. § I 3 days. Recovered!4 weeks " 3 weeks A " 4 " Died. ...... Recoveredlfi week hHdavs Hospital. Priv. Prar, Hospital. Priv. Prae. Hospital. Priv. Pra<\ Hospital. Priv. Prai ♦ No in Andrews' Surgical Record, 8,390. t No. in Andrews' Surgical Record, 8.421 t Had tetanus 2n days. $ Cause of death, gangrene. 14 RECAPITULATION. Total Number.....- -........ Traumatic, primary........ " secondary______ Time of operation not stated. Pathological .. -............. Hospital Cases............... Private Practice__________ kSEB. DEATHS 27 3 15 3 8 o 1 1 0 3 0 10 1 16 1 PER CENT. ■MORTALITY. 11 20 0 0 0 10 AMPUTATION OF THE AEM ABROAD. The following figures give a fair view of the world's experience in this operation : TRAUMATIC PRIMARY. AUTHORITIES. Med. Hist. War of Rebellion, Surg. Vol, Part II, p. 697. British Mil. Hosp. in Brussels, 1815, Guthrie's Com'ntaries American War of Secession,Confed. Army,Warren, of N.C New York Hosp., Bost, Med. Jour.T May 1, 1872______ Pennsylvania Hosp., " vt " " ______ Boston City " " " lt " ______ Mass. Gen. " " " "• " ...___'. Guy's Hosp. Reports, London___................____ St. Thomas'Hosp., " ___........___________ St. Bartholomew's Hosp., " 1853—71-......-....... St. George's " "■____________ ______ Mr. Richardson, at Birmingham, England, 1853—64____ Varieus German Surgeons, Franco-German War_______ Mr. Nunnely, Leeds Gen. Infirmary, England_________ Crimean War, Schmidt's Jahrbucher, Bd. 156y S. 249____ Dr. Loffler, Danish War with Prussia___________...... Dr. Beck, at Tauberbischofsheim.............___ ; Siege of Antwerp, Schmidt's Jahrbiicher, Bd. 156, S. 249. Franco-German War, " " " " Schleswig-Holstein War, " " " " War of 186fi, Totals.................____________77777" 3,259 21 92 14 58 14 36 15 2 45 3 32 22 62 849 19 7 9 40 19 7 ___L. 4,625 602 4 16 0 ."> 4 7 6 1 4 2 12 10 22 489 9 2 1 19 1,226 Mortality, 2? per cent. 15 TKAUMATH SECONDARY. AUTHORITIES. Med. Hist. War of Rebellion, Surg. Vol..Part II., p.697.. New York Hospital, Bost. Med. Jour., May, 1872______ Pennsylvania " " " " " ------- Boston City " " " " " _______ Mass. Gen. " " " " " ------- Guy's '' London____.............._______ St. Thomas' " " -----......____......... St. Bartholomew's Hosp., London, 1858—71............. St. George's " -----.....".------- Mr. Richardson, Birmingham, 1853—-64------......... Various German Surgeons, Franco-German War....... British Army in the Crimea...................-.-.----- Schleswig-Holstein War, Dr. Loftier-................... Dr. Beck, at Tauberbischofsheim.......... 1.......___ Maas and Billroth, each a case_________......------- Siege of Antwerp, Schmidt's Jahrbiicher, Bd. 156, S. 249 _. Crimean War, " " " " Franco-German War, " " " " Schleswig-Holstein War" " " War of 1866, " " " " .. American War of Secession, Confed. Army, Warren____ British Mil. Hosp.,Brussels, 1815, Guthrie's Commentaries Totals___________________________________1,820 1,313 4 9 s 8 12 29 3 15 16 16 12 14 146 31 12 15 100 51 Mortality, 36 per cent. FOR PATHOLOGICAL CAUSES. 416 1 0 9 3 2 9 6 8 3 2 1 86 21 K 4 38 13 64K AUTHORITIES. New York Hospital, Bost. Med. Jour., May 1, 1872 Pennsylvania " " " Boston City " " " " " " Mass. Gen. Guy's " London, 1861—68........... St. George's " " 1864—68........... St. Thomas' " " ......--........... St. Bartholmew's " " 1853—71......---- London " " 1862—68........... Middlesex " " 1867-68-------- Kings College " " 1863—68........... Royal Free " ' " 1862—68........... Westminster " " 1861—67........... St. Mary's " " 1868............... Edinburg Infirmary, 1859—68..............---- Glasgow " 1847—68........_______..... Statist, des Hopitaux de Paris, 1861—63........--- Med. Reports, British Army--------......---- Archiv. Klin. Chirurg., Bd. VIII, S. 926, 928, 1088 . Deutsche Zeit. fur Chir., Bd. II, S. 380.....------ Leeds Gen. Infirmary, Mr. Nunnely..........-..... Totals...................................--- Mortality, 20 per cent. 3 4 5 32 42 T> 1 4 1 3 1 r.i 19 19 3 4 3 20 "204 41 ]« GENERAL SUMMARY OF AMPUTATIONS OF THE ARM. Traumatic primary______ " secondary____ Pathological............. Time and cause not slated Totals, .. LAKK STATES. ABROAD. CASES. DEATHS. pkb i:k\t. MORT. CASES, ■™- i r, 3 1 | 0 20 li 0 I) 4,625 1,820 204 6,445 1,226 648 41 ... 27 »") 11 1,874 27 36 20 30 It appears, therefore, that amputations of the arm abroad have a mortality of 30 per cent., which is nearly three times that of the Lake States. Civil cases abroad have also a much greater mortality than military ones, owing to the fact that soldiers are mostly young and vigorous men, and military amputations of the arm are largely done at once on the field of battle, before the patient has been subjected to the deadly miasm of the average military hospital. OPINIONS OF AUTHORS AND CONCLUSIONS. The great authorities on surgery, give us almost no advice about the particular indications for amputation of the arm, but fall back on the established general principles, which are these : 1. The superior extremity is of more value than the inferior, and should be sacrificed with more reluctance. 2. Gangrene and diseases of its joints are less dan- gerous than in the inferior extremity ; hence in certain cases it is less perilous to delay the operation, until its necessity is full}7 proved. 3. The principal causes requiring amputation of the arm are : first, injuries, where the part of the limb below is pulseless and dead; secondly, where gangrene from disease has destroyed the limb ; thirdly, where cancer of the member is so situated as to be incapable of full extirpation without nmputation. 17 Severe compound and comminuted fractures of the shaft of the humerus and even of the elbow or the shoul- der, do not require amputation, if there is circulation in the part below. Extensive laceration of the soft parts with comminution of the bone makes no difference. Modern surgeons are not appalled by the ghastly looks of the wound. The bone and all the skin and muscles may be severed, but if the artery, and some of the nerves and veins are left, the limb may usually be saved. In like manner, no one now thinks of amputating the arm for caries of the joints, nor for necrosis of the shaft of the humerus, unless some special circumstances ren- der it necessary to disregard the usual principles. « In short, the conservative surgeons have largely won the day, so far as the superior extremity is concerned. At the same time the amputations, if required, are far less dangerous than those of the lower extremity. The primary operations are a little less fatal than the second- ary, and the pathological ones (amputations of com- plaisance excepted) are less than half as dangerous as the traumatic. The mortality of all amputations of the arm in the Lake States is, taking all kinds together, only 11 per cent., which is about one-third the mortality abroad. Demme, Stromeyer, and Max Schmidt (Schmidt's Jahr- biicher, 1872,) agree that in gunshot wounds of the elbow joint, conservative treatment is four times more dangerous than resection, while amputation of the arm is interme- diate between them. They recommend the conservative treatment, therefore, for mild cases only, and amputation only for cases not admitting of resection. Legouest, (Traite de Chirurgie d' Armee, p. 530,) says, speaking of military surgery, "When the elbow has received a com- minuted fracture, and the brachial artery is opened, it is necessary to amputate the arm immediately." In my opinion this should depend on whether the collateral circulation keeps up the supply of blood. If it does, 2 18 and if some of the large nerves are also intact, resection should be preferred. AMPUTATIONS AT THE ELBOW JOINT. Of these I find only two Lake State cases, both of which recovered. TABLE V. AMPUTATION AT THE ELBOW JOINT. OPERATOR. REASON FOR OPERATION. Compli-cations Time. Result. Prac-tice. Dr. E. Andrews Cook Co. Hosp. opr. not stated Mortification forearm after wound None... Not stat. Second'y Primary . Recover. Priv. pr. Hosp... No conclusions can be drawn from so small a number. The operation abroad seems equally rare, so that the entire literature of surgery does not furnish us the means of comparing primary, secondary and pathological cases. I find only the following records : AUTHORITIES. ^Pennsylvania Hospital____________________......... Dr. Herrgalt, Siege of Strasburg, 1870-71____________ Other reports in Franco-German War, Deutsch. Zeit. fur Chirurgie, B. II, S. 105_________________........ Circular No. 6, Surg. Gen. U. S. Army_______.....___ Statist, des Hop. de Paris, 1861-2-3________________ Guy's Hosp. Reports______________....._________ Leeds' Gen. Infirmary, Mr. Nunneley_______ Zurich Hosp., 1860-67, Arch. Klin. Chir., Bd. X., S. 891 Deutsch. Zeit. fur Chir., Bd. II., S.380______________ Totals.......-............................ CASES. DEATHS. 1 0 o ~ 11 6 19 0 4 2 1 0 20 1 2 1 1 1 61 13 Mortality, 21 per cent. This gives fifteen per cent, better results than amputa- tion of the arm, so that it would seem it should be preferred to the latter whenever the choice of location is offered. 19 OPINIONS OF AUTHORS AND CONCLUSIONS. Expectant treatment of gunshot wounds of the elbow is to be advised only in the slightest cases. The statistics of the Med. and Surg. History of the War of the Rebellion, p. 829, part II, Surg. Vol., give 938 cases treated conservatively, with only 10 per cent, of deaths ; but a great number of these were trivial wounds, and not at all to be classed with those where a bullet had gone through the interior of the joint. I think that in the latter class expectant treatment would be the most dangerous of all procedures. Amputation at the elbow was first done by Pare, and improved by Brasdor. It gave rise to great differ- ences of opinion among eminent men. Those opposing or discouraging it are Boyer, Rich- erand, J. Cloquet, T. J. Roux, (the latter very bitterly,) Chelius (Chelius' Surg., vol. Ill, p.. 718), and Henry H. Smith (Smith's Surg., vol. II, p. 689). On the other hand, we have in favor of it, Brasdor, Velpeau, Dupuytren, Malgaigne, Legouest, Hamilton, Gross, and Bryant. Gross speaks of the operation in very high terms, both as to safety and excellence of the stump. (Gross' Syst. of Surg., vol. II, p. 1110.) Bryant of England, also praises it in the highest terms. (Bryant's Surg., p. 953.) It is evident that the weight of authority among living surgeons is decidedly in favor of the operation. It should not be substituted for excision, but when an amputation is inevitable, and there is room for a choice of location, the elbow is to be preferred to any point above it. AMPUTATION OF THE FOREARM. Owing to the success and safety of conservative treat- ment of the forearm, amputations of this segment are comparatively rare. I have obtained records of only 20 cases in the Lake States, which are here subjoined : TABLE VI. AMPUTATION OF THE FOREARM. OPERATOR. > a 70 19 20 REASON FOR OPERATION. t COMPLICATIONS. Operati'n, Con-diti'n Time. Result. Time to d'h or r'y Practice. Dr. J.H.Hollister Primary ... Secondary . Primary ... 10 years___ Primary ... Recovered Died ..... Hosp, ... "• , u n y. «■ A nf („,.„™ Good «' " E. Andrews .. Circular . 2 mos. .. 6 weeks. 32 days.. 70 " .. " Gangrene of crushed hand............-'--- Priv. pra. 11 u Hosp. ... H 11 11 Wound of forearm by saw.................. Bad.. Good " J. H. Hollister Priv. pra. n n l n Tl Hosp. ... 33 30 52 5fi 8 20 45 28 50 " Dr. H. Wardner Considerable shock..... " " intern. Scirrhus of lip removed 3 Low. 3 .. Mid. 3 ... Low. 3... Flap. .... Low. 3... Cir. low.3 Lower 3d Upper 3d Med.. Bad.. Good Bad.. Primary ... 18 hours ... 2 years..... Primary... Secondary 4 weekf___ Recovered Died..... 31/* wks. 3 mos... Priv. pra. " " " E. D. Kittoe.. Hand and forearm crushed in thresh, mach. n u n u " E. W. Lee.."." 3 weeks. 4 " 11 u 11 n " S. S. Bedal... " S. Marks..... 11 11 3 weeks. 12 days . Hosp. ... Priv. pra. 21 RECAPITULATION. CASES. DEATHS. 20 2 14 0 2 0 4 2 9 1 11 1 PER CT. MORT. Total number_____ Traumatic Primary.. " Secondary Pathological........ Hospital Cases...... Private Practice..... 10 0 0 50 11 9 AMPUTATION OF THE FOREARM ABROAD. The following are the principal published records of this operation : TRAUMATIC PRIMARY. AUTHORITIES. Med.& Surg. Hist. War of Rebel., Surg.Vol., Part II., p. 967 New York Ho«p , reported by Sir J. Y Simpson----- Pennsylvania Hosp., " " " " _____ Boston City Hosp., Dr. Cheever.........__________ Mass. Gen. Hosp., reported by Sir J. Y. Simpson____ Guy's Hosp., London______........------------- St. Bartholomew's Hosp., London, 1853 to 1871........ St. George's " " ______........... U. S. Marine Hosp.........___..............______ Dr. Herrgalt, Strasburg, Frencha<~d German War--- Dr. Beck, Austrian and PrussianWar____________.. Leeds Gen. Infirmary, Mr. Nunneley_________....... Siege of Antwerp, Schmidt's Jahrbiicher, B. 136....... Crimean War, " " "....... German-French War, " " "....... Dr. E. Warren's Surg., p. 396, Confederate Army____ British Mil. Hosp. in Brussels, 1815, Guthrie_______'. Totals, Mortality, 11 per cent. TRAUMATIC INTERMEDIARY. AUTHOHTIES. CASES. DEATHS. Med. & Surg. Hist. War of Rebel., Surg. Vol., Part II., p. 967, 450 106 Mortality, 23 per cent. 22 INTERMEDIARY AND SECONDARY CASES COMBINED. AUTHORITIES. CASES. DEATHS. 2 0 3 1 11 4 12 2 1 0 1 0 14 2 1 0 1 0 5 0 5 1 96 S6 2 2 22 4 17 5 193 77 Boston City Hosp., Dr. Cheever......---------- New York " Works of Sir J. Y. Simpson... Pennsylvania " " " " " Mass. Gen. Gay's " London----------......... St. "Thomas' " " _____________...... St. Bartholomew's Hosp., London, 1853—71........ St. George's "............--- Chinese Missionary " ---.................... Geissel in French and German War................ Beck in Austrian and Prussian War................ Crimean War, Schmidt's Jahrbiicher, B. 136___ German-French War, " " " ___ Dr. E. Warren's Surgery, p. 396, Confederate Army British Mil. Hosp. in Brussels, 1815, Guthrie_____ Totals,___..................______________ Mortality, 40 per cent. PURELY SECONDARY (AFTER INTERMEDIARY PERIOD). AUTHORITY. CASES. DEATHS. Med. & Surg. Hist.War of Rebel., Surg. Vol., Part II, p. 967, 184 29 Mortality, 16 per cent. PATHOLOGICAL CASES. AUTHORITIES. Boston City Hospital, Statement of Sir. J. Y. Sinmson. New York Hospital, " " " Pennsylvania " " " " Mass. Gen. " " " " Edinburg Infirmary, 1859—68___.......... Glasgow " 1847—68...................".."."."." St. George's Hospital, London, 1864—68___ Guy's " " 1861—68..... Loudon " " 1862—68___ Middlesex " " 1867—68___ King's College " " 1863—68___ Royal Free " " 1862—68____________ Westminister " " ......... St. Thomas " " ____..... St. Bartholmew's" " 1853—71____ Leeds Gen. Infirmary, Statem't of Mr. Nunneley Billroth's Practice..........................___ Other European Cases....................____ Totals______________..........___ 6 7 6 27 23 a 6 8 4 13 5 5 0 1 1 1 1 1 1 4 1 2 0 18 1 21 3 4 2 8 0 162 36 Mortality, 22 per cent. 23 GENERAL SUMMARY OF AMPUTATION OF THE FOREARM ABROAD. Traumatic, primary.................. " intermediary ____________ Intermediary and secondary combined Purely secondary____....._________ Pathological___.__________________ Totals..................______ CASES. DEATHS. 1,507 159 450 106 193 77 184 29 iea 36 2,496 407 PER CENT. MORT. 11 23 40 16 22 16 Mortality in the Lake States, 10 per cent. It appears, therefore, that the mortality of this opera- tion among us is less than two-thirds that of the pub- lished statistics. OPINIONS OF AUTHORS AND CONCLUSIONS. Authors have very little to say on the indications for amputation of the forearm, except to apply the follow- ing principles : 1. Conservative treatment is very safe. 2. The arteries and nerves pass down in several trunks, so that they are seldom all destroyed at once. 3. Artificial hands are of very little practical use. Acting on these truths, surgeons rarely amputate the forearm, except for some injury which has already de- stroyed the life of the member, or some disease like can- cer, which cannot be otherwise gotten rid of. In all severe compound fractures, gunshot wounds, etc., in which there is the least ground of hope that the circula- tion may recover itself, the effort is made to save the limb. Conservative treatment in the forearm and hand is carried to its fullest extent. Legouest (Chirurg. cV Armee, p 350,) says, that when a bullet traverses the wrist in its greatest diameter, with great shattering, amputation of the forearm will be required. 24 AMPUTATIONS OF THE WRIST AND HAND IN THE LAKE STATES. Of these, I find records of only eight cases, all of which recovered. AMPUTATIONS AT THE WRIST JOINT—ABROAD. TRAUMATIC PRIMARY. AUTHORITIES. Med. & Surg. Hist. War of Rebel., Surg. Vol , Part II, p. 1018 Pennsylvania Hospital___....._________________ Dr. Herrgalt, in Strasburg__....... ______________ Leeds General Infirmary, Mr. Nunnelpy_____....... Siege of Antwerp, Schmidt's Jahrbiicher, p. 156_____ Totals 54 8 2 102 1 167 14 Mortality, 8 per cent. TRAUMATIC INTERMEDIARY. AUTHOBITY. CASES. DEATHS. Med. & Surg. Hist. War of Rebel., Surg. Vol., Part II, p. 1018, 7 1 Mortality, 14 per cent. PURELY SECONDARY (AFTER INTERMEDIARY PERIOD). AUTHORITY. CASES. DEATHS. Med. &Surg. Hist.Warof Rebel., Surg. Vol., Partll, p. 1018, 5 1 Mortality, 20 per cent. TRAUMATIC, TIME NOT STATED. AUTHORITIES. CASES. DEATHS. German Authors_________.......__ 2 1 67 13 8 1 0 27 6 0 U. S. Marine Hospital____________ Crimean War, Schmidt's Jahrbiicher, p. 156 Italian War, German-French War, Schmidt's " " Totals..........______ . 91 34 ---------^-———.----------------. Mortality, 37 per cent. This increased mortality, as compared with that of the cases known to be primary, may be due to the fact that 25 the second list is mainly made up of military cases, many of which had other injuries to determine a fatal result, yet it seems impossible to make any satisfactory solution of such palpable discrepancies. PATHOLOGICAL CASES. Cases, 14. Deaths, 1. Mortality, 7 per cent. GENERAL SUMMARY OF AMPUTATIONS OF THE WRIST. LAKE STATES. Eight cases. No deaths. ABROAD. Primary........ Intermediary___ Purely secondary Time not stated.. Pathological ___ Totals,____ CASES. DEATHS. 167 14 7 1 5 1 91 34 14 284 1 51 PER CENT. MORT. 14 20 37 7 18 OPINIONS OF AUTHORS. Legouest and Albert Malinas, in a work entitled "Conservation," etc., advise conservative treatment in gunshot fractures of the wrist, and, in support of their opinion, give the following facts, on gunshot wounds of this articulation : MORTALITY OF CONSERVA-TIVE TREATMENT. MORTALITY OF AMPUTATION. 11 18 28 Italian War_____....._______ 2o to 46 Legouest says {Cliirurgied)' Arruce, p. 530) that ampu- tation at the wrist is only required when the injury to the hand is such as to destroy the hope of any future use of it. 26 Joseph Lister, in Holmes' System of Surgery, vol. V., p. 655, rather discourages the operation, and thinks it no better than amputation of the forearm. Gross, on the other hand, in his System of Surgery, vol. II., p. 1108, thinks it preferable by far to amputation of the forearm. » Erichsen says it is not often required. Ashurst's Surgery, p. 115, says if it is done, the disarticula- tion should be at the radio-carpal junction. Vidal (Pathologie Externe, Tome Y., p. 64:6) approves the operation in suitable cases. It appears, therefore, that authors conflict somewhat in their opinions of the operation, without any decisive scientific proof on either side. The statistics too are in hopeless contradiction. The Crimean war is said to have given a mortality of 28 per cent.; the Italian war is stated variously from 13 to 46 per cent., and the late American war at only 5 per cent. ^No results can be deduced from such utterly irreconcilable statements. Science must wait for a better collection of facts.' AMPUTATIONS THROUGH THE METACARPUS. No records for the Lake States. Abroad, seventy-six cases are recorded without a death. AMPUTATION AT THE HIP JOINT. Of this important operation I obtain records of the follow- ing seven cases in the Lake States: TABLE VII. AMPUTATION OF THE HIP JOINT. E. Powell. Ammmnan D. Brainard M.Watcrhouse Sauk Co.Wis REASON OF TIIE OPERATION. COMPLICATIONS Pthisis pulmonalis Caries of hip and iiiflamation of knee Recurrence of cancer in stump of thigh ... Comp. and cominin. fract. entire lemur (Jreat shock .. Hi Necrosis of entire femur......... jEnchondroma of femur........ Recurrence cancer removed from thigh 4(~)|Both thighs crushed by R. R.--- Emaciation, hectic None. Opera- tion. Flap Flap .. lliph.3 & op. th Bad. Med. Bad. Time. 12 hour! 3 mos. .. Primary Result. Died .. Recove. Died .. Time to d'h 4days 12'h. Prac- tice. Hosp. Hosp. Priv.p Causes of death—remarks. Died 10 m. after of phthisis Exhaustion Exhaustion Shock ..... 28 RECAPITULATION. Total number of cases..................................7 Died---3 Traumatic.............................................2 " ---1 Pathological...........................................5 " ---2 AMPUTATION OF THE HIP JOINT ABROAD. The Surgeon-General of the U. S. Army, in Circular No. 2, publishes a report of Asst. Surg. Geo. A. Otis, M. D., which carefully collects the published cases of the world up to 1869 (Cir. No. 2, S. G. O.), so far as performed for gunshot wounds. Of these, 115 were in the Crimean and other foreign wars; 62 were in the American war, and 6 were later cases. Asst. Surg. Otis gives in Circular ]STo. 2, p. 112, the following con- densation of the whole: AMPUTATIONS AT THE HIP JOINT FOR GUNSHOT WOUNDS ABROAD. Primary (finished cases)...... Intermediary................ Secondary (after intermediary) Re-amputations............... Totals..........._____ CASES. DIED. 76 75 76 70 20 13 8 4 180 162 PER CENT. MORTALITY. 99 92 65 50 90 The New York, Boston and Mass. general hospitals give five traumatic primary cases, all fatal. AMPUTATION AT THE HIP JOINT FOR PATHOLOGICAL CAUSES. AUTHORITIES. Lake State Surgeons (see table No. VII. above)..... Guy's Hosp. Reports.............................. St. Thomas' Hosp. Reports......................... St. Bartholomew's Hosp., 1853 to 1863, Mr. Callender Statist des Hopit. de Paris, 1861-2-3............... Mass. Gen Hosp.................................. Leed's Gen. Infirmary, Mr. Nunneley___....._..... Ashurst's Surgery, p. 131...........____.......... Totals______...........................___ 5 1 2 1 3 2 2 42 58 2 1 0 0 3 2 1 18 27 Mortality in pathological cases, 47 per cent. 29 OPINIONS OF AUTHORS AND CONCLUSIONS. Opinions on this amputation have formerly been widely conflicting, but as statistics have accumulated and thrown light on its results, a greater degree of unanimity has been attained. In 1740, the Academy of Surgery in Paris opposed the operation, when one of its members wished to perform it. In 1848 they approved it. In 1859 they again discussed it, and of forty-four opinions, thirty-four justified it. (Pathologie Externe par Vidal, Tome V., p. 703.) Chelius, vol. III., p. 689, justifies it when a crushing or mortification extends so high as to prohibit amputation below the trochanter. Stromeyer (Maximen der Krlegshellkunsi) declared in 1861 that it was not yet proved justifiable in military surgery. Loeffler {Grundsdtze und Regehr fur die Behandlung der Schussivuiiden im Kriege) took similar ground. Roehard, in Saurel's Trade de (Jhlrurgle Navale, pronounced it improper in the primary stage, and Sedillot maintained for years that the primary amputation was never successful. Baron II. Larrey and M. Legouest (Memoires de la Societe de (Jldrurgie, Tome V.) obtained a definite opinion from the Society of Surgery, that the operation was unjustifiable unless the thigh was almost torn away from the trunk. Erichsen's Surgery, vol. II., p. 301, seems to speak ralher flippantly and without consideration of the terrible danger of the operation. It advocates it, not only where the disease of the femur is too extensive for excision, but even for limbs rendered simply useless by atrophy, deformity, etc. Curiously enough, in disregard of the fact that amputation is more dan- gerous than excision, the author recommends it as a choice, where the health is supposed to be too low to bear the excision. Joseph Lister, in Holmes' System of Surgery, vol. V.. p. 651, says it is justifiable in some desperate circumstances. Henry II. Smith (Prin. and Pract. of Surg., vol. II., p. 694,) assumes that it may be required, arid forbids the circular operation as specially objectionable. Gross (System of Surgery, vol. II., p. 1127,) says, amputa- 30 tion at the hip is never to be undertaken except where there is no other chance of life. Asst. Surg. Geo. A. Otis, M. IX, the author of Circular No. 2, S. G. O., after a careful survey of the war records, and of European opinions and military experience, arrives for gun- shot cases at the following conclusions (Cir. No. 2, pp. 122, 123): "Amputation at the hip joint, for gunshot injury, notwith- standing its great fatality, cannot be altogether discarded, and should be performed under the following circumstances: 1. When the thigh is torn off, or the upper extremity of the femur comminuted with great laceration of the soft parts, in such proximity to the trunk that amputation in the conte- nuity is impracticable. 2. When a fracture of the head, neck or trochanter of the femur is complicated with wound of the femoral vessels. 3. When a gunshot fracture, involving the hip joint, is complicated by a severe compound fracture of.the limb lower down, or by a wound of the knee joint. " There are two other possible contingencies under which primary or early intermediate coxofemoral amputations for injury may be admissible: 1. When, without fracture, a ball divides the femoral artery and vein near the crural arch. 2. When a gunshot fracture in the trochanteric region is compli- cated by such extensive longitudinal Assuring as to preclude excision. Experience has yet determined nothing on these points. Secondary amputations and re-amputations at the hip, in military surgery, should be performed when, from caries, or necrosis, or chronic osteomyelitis following gunshot wounds, or amputations in the continuity, the patient's life is in jeopardy. " Restricted to the classes of cases above enumerated, coxo- femoral amputation will occasionally save lives that would otherwise be inevitably lost. " Primary excisions of the head or upper extremity of the femur, should be performed in all uncomplicated cases of gunshot fracture of the head or neck. Intermediate excisions are indicated in similar cases where the diagnosis is not made out till late, and also in cases of gunshot fracture of the tro- chanters with consecutive arthritis. Secondary excisions are 31 demanded by caries of the head of the femur, or secondary involvment of the joints, resulting from fractures in the tro- chanteric region or wounds of the soft parts in the immediate vicinity of the joint. " Expectant treatment is to be condemned in all cases in which the diagnosis of direct injury to the articulation can be clearly established. u Although the great majority of cases complicated by lesions of the pelvis terminate fatally, the successful operation of Dr. Schonborn proves that a slight injury of the margin of the acetabulum does not contra-indicate the operation of excision. " Experience teaches that considerable portions of the shaft may be with propriety removed with the head, neck and tro- chanters, in cases in which splintering extends below the trochanter minor." In the light of all the known facts, I think that these remarks of Dr. Otis are the best considered, and most care- fully stated conclusions ever made, up to the time they were penned, and that to a certain extent they are applicable to other traumatic cases. Since they were written, however, the whole system of treat- ing wounded joints by antiseptic methods has been developed, and the question has arisen whether a certain number of shat- tered hips heretofore deemed to require amputation or excision would be better treated by laying open the joint freely, remov- ing dead fragments, and treating by Lister's antiseptic meth- ods. Probably they would, but science has not yet given the means of a positive answer, so that a painful darkness still hangs over some portions of the subject of hip joint injuries. The antiseptic consideration, however, would affect the ques- tion of excision more than that of amputation, as at the pres- ent time few would think of amputating at the hip for recent injuries, unless the limb were destroyed, or gangrene inevita- able, and therefor antiseptic treatment out of the question. There is yet one other condition in which antiseptic method might possibly come in to postpone or supersede amputation in a few rare cases. ' If the limb is carried away by a shot, too high for amputation below the trochanter, it has been deemed 32 unavoidable that the patient must take the added terrible shock of a primary amputation at the hip, though his chance of surviving it is not over one in a hundred. The antiseptic method enables us in most cases to promptly subdue the local inflammation, and to completely suppress the exhausting drainage of suppuration, so that some of these cases might probably be better treated by this plan, and thus either heal- ing the parts by granulation without operation, or else postpon- ing the amputation to a late secondary period, when it is much safer. This principle has proved abundantly successful in some .parts of the body, but there is no recorded experience of its application to hip joint wounds. The principal pathological indication for this amputation has hitherto been cancer of the thigh, so situated as to admit of complete removal in no other way. Some instances are on record where it has been successfully done and the patient lived in comfort for years, though perhaps there may be doubt about the correctness of the diagnosis in a part of them. The whole thing lies in a nutshell. If the tumor is really malignant, there is no reasonable expectation of a permanent cure, and as pathological amputations have a mortality of 47 per cent., they have about one chance in two of killing the patient at once. The question therefore is this: Granted that there is no rational expectation of a permanent cure, and only a moderate hope of prolonging the life, is an operation, which kills immediately one-half the patients, desirable? It is evident that the prospect is greater for shortening than for lengthening the life by the operation, in such circumstances. It would seem to be justified, therefore, only in those cases where the terrible pains of the disease call for operative relief at almost any risk. Caries extending far down the femur, can hardly be called an indication for amputation at the hip, now that wTe under- stand the value of subperiosteal excision of bony shafts. AMPUTATION OF THE THIGH. This important operation furnishes us the following list of cases in the Lake States: - TABLE VIII. AMPUTATION OF THE THIGH. No. An- drew's Sur.Rec OPERATOR. 5471 8880 77-J(i itsu 1653 5488 "l36«V 6397 Dr E. Andrews E. W. Lee... E. Andrews . Not stated .. S. S. BedaL. Thos. Lacy.. E. Andrews. J. S. Sherman E. Andrews. M. Gnnn .. R. Isharn.. La Count.. II. A. Johnson B. Andrews.. J. W. Freer .. G.Ammerman A. Fisher. Hyde ........ J. *H.Hollister E. Owens___ REASON FOR OPERATION. COMPLICATIONS. Protrusion.of bone after prev.amput Comp. fract. of leg................. Leg crushed by cars. Carious knee........ Comp. fract. thigh_____ Disease of knee.......... Gangrene from injur}7___ Comp. Jraet. of knee..... Knee crushed by timber. Caries of knee........... Great shock........ Much exhausted___ None............... Suspected phthisis. Gangrene_____..... None.................... n temperate............. None___................ Had been previous exsec R. R. accident, drunk............ Comp. fract. leg.................. Senile gangrene.................. Comp. fract. of femur............. " " knee.............. Chronic inflam. of knee.......... Crushed knee and hemorrhage... Cancer of knee................... Comp. and commin. fract. of leg. Cancer of tibia................... Caries of knee and morti. of leg. Freezing of leg___............ Chronic inflam. of knee with caries Knee joint nearly severed with ax. Gunshot wound of knee joint...... Comp. and commin. fract. leg..... Knee crushed by car wheel........ Crushed thigh and op.leg Opposite knee bruised .. Iu temperate............. None............. Great shock...... Wounds op. limb,g.shock Operati'n Re-a. m.3 Flap low3 Lower 3d Flap. m. 3 Lower 3d Mid. 3cir. Cond. at opr Good Med.. Good Bad.. Good Med.. Good Flap.low3 Good Am. " Flap.lowS Lower 3d Inflamed—suppurating None.................. Bad. Med" Bad.. Good Bad.. Med.. Bad.. Good Time to operation. Secondary Primary ... ■V-A years... fi " ... 8 " ... 10 days ___ 13 years___ li days___ Primary .. Recover'd Died..... Recover'd Died ..... Primary .. Secondary li days___ Primary .. 3ii hour's .. Some mos. Primary .. Primary .. 1 year...... !) months .. i years..... li months .. •il/2 years... 3 " ... 6 hours___ 3 weeks___ Primary ... Result. Recovered Died ..... Recover'd Died ____ Recover'd Died ..... Recover'd Died ..... Recover'd Time death or Practice. recovi !) davs . 3 weeks 6 days .. 6 mos. .. 5 weeks 1 hour .. 10 weeks 7 weeks 48 hours 7 weeks. 6 5 7 10 " 6 8 2 mos. .. Hospital. Private .. Hospital! Private .. Private .. Hospital. Private .. Hospital. Private .. Hospital. Private.. Hospital. Private . to Hospital. Table YIII.— Continued. H. Wardner..'14 M.Waterhouse 2." 141 E. D. Kittoe.. J. Andrews .. E. Andrews.. J. H. Hollister 22 E. Andrews.. .. 34 S. Marks.....31 in 38 24 1 28 !l 58 24 45 l!l 32 2'J 30 40 J. II. nollister Disease of parts................... Necrosis of entire tibia............ Diseased knee (chronic)........... Chronic suppuration of knee...... Both knees and legs crushed...... Crushed ankle and split tibia...... Necrosis of tibia and fibula........ Crushed knee and part of thigh ... Scrofulous knee................... Fract. leg and thigh............... Caries of knee after fracture....... Caries femur after amp. lower 3d.. Above case relapsed 4 months after Round-celled sarcoma of femur___ Caries of knee..................... Colloid—head tibia and femur..... Dog bite followed by gangrene___ Tetanus from injury of the thigh.. Traumatic Gangrene___.......... Anchylosis knee, disease of tibia . Knee crushed by R. R. accident... Leg crushed between cars......... Osteo-sareoma of tibia............. Leg and lower thigh crushed...... Leg crushed by R. R. accident..... Anchylosis knee—disea. bones___ Disease of tibia and femur......... \nchyl. knee, caries tibia......... Knee joint opened with ax........ Leg and knee crushed by rock___ ltiLeg crushed with K. R. accident.. 5111Osteo-sareoma, tibia.....___...... 22 Knee crushed by car wheel........ Cook Co. Hosp... Dr. E. D. Kittoe. A.Fisher.....10 " .....26 J. H.IIollister'2-J Knee and part thigh crushed...... Comp. and'commin. fract. of femur Caries of femur. " H. Wardner..'2D Thigh crushed on R. R. Scrofulous............... Great exhaustion........ Amcmia _................ Haemorrhage and shock. Great shock............. Debilitated ............. Great shock___......... Other injuries—heart dis. None.................... Debility................. Femur fract. in walking Abscess in the bone.... Not stated.............. Great shock. Great shock. Great shock. Great shock. Both 1. 3d Lower 3d Flap. m. 3 Re-a. m. 3 Cir. up. 3 Flap. 1.3d Cir. low.3 Flap. " Flap, up 3 1 low. 3 up. low. mid up. low. mid low. mid " low.3 Middle 3d Upper " Bad. Med. Bad. med.. Bad- Good Med.. Good Bad.. Good Bad.. Med".! Bad.. Good Bad.. Med.. Bad.. Good Bad.. Good Bad.. Good Bad.. 2 years. 3 years..... 2 hours___ 1 hour..... 3 years..... Primary ... 2 years..... Secondary 6 years..... Many mos. li months .. 3 10 days___ 8 " .... 9 years..... 4 hours___ 8 hours___ li months .. 12 hours ... Primary ... 6 years..... 3 " ..... 21 " ____ 20 days .... Primary ... About 1 yr Primary ... 24 hours 6 Died..... Recover'd Died ..... Recover'd Died ..... Recover'd Died ..... Recover'd Primary ... Died..... Recover'd Died ..... 2 mos. 15days.. 4 hours . 16 hours 3 days 2 mos. 3 3 days mos. .. 6 weeks 4 8 mos. .. 6 weeks 4 mos. .. 5 " 2 " 6 " 4 weeks I weeks Hospital. Private.. Hospital. Private.. 03 Hospital. Private .. Hospital. Private.. Hospital. 10 hours Private.. Recover 'd:5 weeks. Died .....|(> hours . Recover'd _______ Died .....'12 hours 35 RECAPITULATION. CASES. DIED. 76 18 5 2 1 1 2 0 4 3 5 1 7 2 18 5 9 3 22 0 20 6 54 11 PER CENT. MORTALITY. Total of all kinds.............................. Traumatic, primary, upper 3d..............---- " intermediary or secondary upper 3d ... Pathological, upper 3d......................... Traumatic, primary, middle 3d................. " intermediary and secondary combined, middle 3d................................... Pathological, middle 3d........................ Traumatic, primary, lower 3d................... " intermediary and secondary combined, lower 3d____........•_...............------- Pathological, lower 3d.......................... Hospital cases................................. Private practice.....................---------- 24 40 28 33 0 30 20 'There is on record in the literature of surgery a prodigious mass of cases of amputation of the thigh, but, unfortunately, most of them are so destitute of details that they cannot be properly classified. Generally there is no statement in what portion of the thigh the operation took place, and often the essential distinction into primary, secondary and pathological cases is ignored. The statistics of the upper two-thirds are especially meagre. AMPUTATION UPPER 3d OF THIGH ABROAD, TRAUMATIC PRIMARY. AUTHORITIES. Rept. Boston City Hosp., Dr. Cheever....... Mass. Gen. Hosp. Rept., 1871---........... Dr. Herrgolt, Siege of Strassburg, 1870-71 .. Dr. Nunneley, Leeds Gen. Infirmary...... Dr. E. Warren's Surg., p. 395, Confecl. Army Totals.......................------ 40 11 11 13 i 2 1 9 2 5 3 24 Mortality abroad, 60 per cent. 36 AMPUTATION UPPER 3d OF THIGH ABROAD, INTERMEDIARY AND SECONDARY COMBINED. AUTHORITIES. CASES. DIED. Circular No. 3 Surg. Gen. U. S. A....................... 7 6 5 2 Dr. Herrgolt, Siege of Strassburg, 1870-71................. Dr E Warren's Surg., p. 395, Confederate Army........__ 5 1 Totals...................._________........ 18 8 Mortality abroad, 44 per cent. AMPUTATION UPPER 3d OF THIGH ABROAD, PATHOLOGICAL. AUTHORITIES. Circular No. 3, Surg. Gen. TJ. S. A....... Rept. Bost, City Hosp., Dr. Cheever _........ " Mass. Gen. Hosp., 1871.............. " TJ. S. Marine Hosps., Dr. Wood worth. Leeds Gen. Infirmary, Mr. Nunneley....... CASES. DIED. 3 1 2 1 15 4 1 0 9 2 30 8 Totals............___.................___........ 30 Mortality abroad, 27 per cent. AMPUTATION MIDDLE 3d OF THIGH ABROAD, TRAUMATIC PRIMARY. AUTHORITIES. Circular No. 3, Surg. Gen. TJ. S. A................... Rept. Boston City Hosp., Dr. Cheever.............. " Mass. Gen. Hosp., 1871 _...................... Dr. Herrgolt, Siege of Strassburg, 1870-71........... Dr. E. Warren's Surg., p. 395, Confederate Army TJ. S. 2 4 13 1 13 Totals____................._________............I 33 16 Mortality abroad, 48 per cent. AMPUTATION MIDDLE 3d OF THIGH ABROAD, TRAUMATIC, INTERME- DIARY AND SECONDARY COMBINED. AUTHORITIES. CASES. DIED. Circular No. 3, Surg. Gen. U. S. A......................... Rept. Boston City Hosp., Dr. Cheever .. .. 4 4 7 9 15 1 1 3 8 10 " Mass. Gen. Hosp, 1871........... Dr. Herrgolt, Siecje of Strassburg. 1870-71 Dr. E. Warren's Surg., p. 395, Confederate Army U. S Totals____..................... 39 23 Mortality abroad, 59 per cent, 37 AMPUTATION MIDDLE 3d OF THIGH ABROAD, PATHOLOGICAL. AUTHORITIES. CASES. DIED. Circular No. 3, Surg. Gen. U. S. A___.................... Rept. Boston City Hosp., Dr. Cheever____........ " Mass. Gen. " 1871............................ " Rostoch "........................... 4 4 47 1 1 1 10 0 Totals____.............................____..... 56 12 Mortality abroad, 22 per cent, AMPUTATION LOWER 3d OF THIGH ABROAD, TRAUMATIC, PRIMARY. AUTHORITIES. Circular No. 3, Surg. Gen. U.S.A.......... Rept. Boston City Hosp., Dr. Cheever..... " Mass. Gen. Hosp., 1871____...... Dr. Herrgolt, Siege of Strassburg, 1870-71. Dr. E. Warren's Surg. Confederate Army.. Totals......_______........_______•............. 83 6 3 13 10 35 12 2 2 27 10 37 Mortal ity abroad, 45 per cent. AMPUTATION LOWER 3d OF THIGH ABROAD, INTERMEDIARY AND SECONDARY COMBINED. AUTHORITIES. Circular No. 3, Surg. Gen. TJ. S. A........ Rept. Boston City Hosp., Dr. Cheever____ " Mass. Gen. Hosp., 1871............ " TJ. S. Marine Hosp.................. Dr. Herrgolt, Siege of Strassbugh, 1870-71 Totals____....................... 60 3 0 4 1 8 6 1 0 1 1 43 28 36 Mortality abroad, 60 per cent. 3S AMPUTATION LOWER 3d OF THIGH ABROAD, PATHGLOGICAL. AUTHORITIES. Circular No. 3, Surg. Gen. TJ, S. A................. Rept. Boston City Hosp., Dr. Cheever........____ " Mass. Gen. " 1871.................... " Rostoch " .......________........ " British Army.............................. * Glasgow Infirmary___......................... ♦St. Thomas Hosp., 1835-40...................... *Univ. College Hosp., 1843....................... * Hussey_______........___________........... * James at Exeter................______________ * Cases in Med. Times and Gazette, 1851-57........ * Addenbrooke's Hosp., Cambridge................ *St. George's Hosp., 1866____.................... *London Hosp., 1854-57......................... * Provincial Hosps..........................____ Totals_________......_______.....______ Mortality Abroad, 20 per cent, 909 CASES. DIED. 2 0 7 2 101 19 3 0 2 1 92 19 13 4 54 10 55 10 119 10 54 9 92 77 12 6 169 38 134 33 178 AMPUTATION THIGH ABROAD, TRAUMATIC, PRIMARY, STATED. PLACE NOT AUTHORITIES. Dr. E. Warren's surg., p. 395, Confederate Army Guy's Hosp. Repts............................ St. Thomas' Hosp._____...................... St. Bartholomew's Hosp., 1853-71.............. Penn. Hosp.__..................----......... Mass. Gen. Hosp-----------................. Malgaigne, quoted in Gant's.Surg., p. 689....... Other cases " " " " ------ Birmingham Gen. Hosp., 1853-64____________ Deutsches Zeitschrift f. Chir. B. 1, S. 187, \ German-French War, )..... Same work, B. V., S. 26________.............. Bech's Kriegschir............................ Circular No. 6, Surg. Gen. TJ. S. A.............. New York Hosp.___......................... Boston City Hosp..-........-------.......... Siege of Antwerp, Schmidt's Jahrbiicher, B. 156. " " Paris, 1830-32 " German-French War " Crimean War " Italian " " German " 1866 Totals....................---.-------......------- 2490 Mortality, 78 per cent. 25 9 12 5 5 2 26 9 24 10 60 25 46 34 24 24 19 13 23 15 5 4 10 4 423 229 16 12 21 15 12 2 3 0 27 17 1589 1424 109 85 11 5 194; * Archiv. Klin. Chir. B. VIIL S. 910. These are all amputations for disease of tho knee; they must therefore have been, with few exceptions, in the lower 3d, and are con sequently classed as such. 39 AMPUTATION OF THIGH ABROAD, INTERMEDIARY AND SECONDARY COMBINED, TIME NOT STATED. AUTHORITIES. Guy's Hosp. Repts....................... St. Thomas' Hosp. Repts.....___________ St. Bartholomew's Hosp., 1853-71_______ Birmingham Gen. Hosp., 1853-64.....___ Gant's Surg., p. 689, Military cases_______ Billroth and others, in German-French War Bech's Kriegschirurgie________........ Circular No. 6, Surg. Gen. TJ. S. A_______ Mass. Gen. Hosp....................._.. New York " ............_________ Boston City • "............_________ Pennsylvania "..............-------- Siege of Antwerp, Schmidt's Jahrbiicher, B. 156 Paris, 1830-32 German-French War " Crimean " " Italian German War, 1866 Dr. E. Warren's Surg., Confederate Army Totals___................................________ 1690 11 2 53 67 300 34 15 14 4 15 3 6 52 221 128 47 39 1 29 15 270 22 22 477 9 6 3 6 1 4 39 197 107 28 34 1279 Mortality abroad, 76 per cent. AMPUTATION OF THIGH ABROAD, PATHOLOGICAL, PLACE NOT STATED. AUTHOUITIES. Guy's Hosp. Repts., 1861-68_________ St. Thomas Hosp. Repts......_______ St. Bartholomew's Hosp. Repts., 1853- St. George Hosp., 1864-68............ London Hosp., 1862-68............... King's College Hosp., 1863-68______ Royal Free " 1862-68........ Westminster " 1861-67______ St. Mary's " ........ Brit. Army Med. Rep................. Mr. H. D. Cardin, of Worcester______ New York Hosp..................... Pennsylv. ".................... Boston City ".................... Mass. Gen. " .......----........ Totals........................_____..........---- 768 229 DIED, j 83 27 9 1 278 89 54 25 68 23 14 5 6 1 0 4 6 1 3 0 6 0 21 6 37 9 16 4 162 34 Mortality abroad, 30 per cent. 4.0 The following are figures from various authorities, in which the particulars of time, place, etc., are more imperfectly given than the above: AMPUTATION OF THIGH, DETAILS, TIME, PLACE AND CAUSE IMPER- FECTLY STATED. AUTHORITIES. CASES. DIED. PER CENT. MORTALITY. Military cases from American and various Europ-ean Wars, after deducting figures previously quoted............... _____............... 2156 1243 1444 713 1 67 Civil Cases from various Sources____.....____ 57 Totals................................... 3399 2157 63 GENERAL SUMMARY OF AMPUTATIONS OF THE THIGH. Upper 3d, primary....................____ " intermediary and secondary_____ " pathological..................... Middle 3d, primary........................ " intermediary and secondary..... " pathological.................... Lower 3d, primary......................... " intermediary and secondary...... " pathological..................__ Place not stated, primary.......____...... " " " intermediary and secondary " " " pathological.............. Conditions not stated at all................ Totals............................... 76 18 LAKE STATES. PER CASE DIED CT. MORT 5 2 1 1 2 0 4 3 5 1 7 2 18 5 28 9 3 33 22 0 00 3 1 76 18 24 PER CASE DIED CT. MORT 40 24 60 18 8 44 30 8 27 33 16 50 39 23 59 56 12 22 83 b'( 45 60 36 60 909 178 20 2490 1943 78 1690 1279 76 768 229 30 3399 2157 63 --- --- --- 9615 5950 62 It appears, therefore, that the average mortality of amputa- tion of the thigh, in the Lake States, is considerably less than half that given in the published statistics elsewhere. OPINIONS OF AUTHORS. Authors contradict each other somewhat as to the conditions requiring amputation of the thigh. Erichsen, vol. II., pp. 200 and 237, advises immediate 41 amputation of all compound gun shot fractures of the femur, except in the upper third. On the other hand the Archives Generates de Medicine (tome xiii., serie 5e) says that in the Crimean War conserva- tive treatment of gun slu>t fractures of the femur, or of any other part of the inferior member, was five times more suc- cessful than amputation. Yet Macleod, discussing the same war, says, we ought to use conservative treatment in the upper third, and amputation in the middle and lower thirds. Hamilton says, in gun shot fractures of the middle third conservative treatment and amputation have equal success, while conservative treatment is the most fatal in the lower third. This is doubtless because gun shot fractures in the lower third are apt to split into the knee joint, thus opposing a very dangerous complication to conservative success. In contradiction to this difference of the upper and lower thirds, Max Schmidt (Schmidt's da/irbucher, 1872) says all the war statistics of 1830 show that conservative treatment of gun shot fractures of the thigh is more successful than ampu- tation, in every portion of the member. Demme and Legouest give statistics to the same end (see same article), showing that in all parts of the thigh, treated for gun shot fractures, the mortality of amputation exceeded that of conservative treatment by the following amounts: DEMME. LEGOUEST. Mort. of amp. in upper 3d exceeds conser. treat, by 29 pr. ct. 27 pr. ct. middle 3d " " 11 " 26 " lower 3d " " 18 " 32 " Legouest elsewhere states (Chiruryie d'Arm/e, p. 537), that in the battle of Langensalza, 1866, and in the French army in the Crimea, and in Italy, conservative treatment of the thigh was most successful by about nineteen per cent.; while in the English army in the Crimea, in the American war of secession, in the Schleswig-Holstein war and in Stromeyer's figures from the battle of Langensalza, amputations of the thigh were more successful than conservative treatment by about fourteen per cent. Dr. Albert Malinas (Conservation, Paris, 1872, p. 51) gives 42 a table showing that gun shot fractures in the thigh, in the Crimea and in the Italian war, according to the experience of the French army, were better treated conservatively than by amputation. He says the results were these: Crimean War. Italian War .. MORTALITY OF CONSERVATIVE TREATMENT OF THIGH. 35 per cent. 58 per cent. MORTALITT OF AMPUTATION OF THIGH. Upper 3d, Middle 3d. Lower 3d, 94 per cent. 94 per cent. 90 per cent. 64 per cent. Dr. S. AY. Gross, in the October number of the Am. Jour. Med. Sci., 1867, carefully collated the statistics on this sub- ject, from which essay I condense the following points respecting gun shot fractures of the thigh, treated some by amputation and some by conservative treatment: TREATMENT OF GUN SHOT FRACTURES OF THE THIGH. AMPUTATIONS. CASES. DIED. 4123 3146 695 381 753 572 225 177 268 175 236 130 PER CENT. MORTALITT. All kinds Combined___........................ Primary..............._____.................. Secondary (and Intermediary).................. Franco-Sardinian Army in Italy, and \ iv??^ o i British Army in Crimea. *' j Swer^d 76 55 76 79 65 55 CONSERVATIVE TREATMENT. Franco-Sardinian Army in f All kinds combined Italy, in 1859, French J Upper 3d.......... Army in Crimea and Am. 1 Middle 3d......... War of Secession. [ Lower 3d......... 1450 445 327 295 923 306 181 150 PER CENT. MORTALITT. 64 69 55 51 He concludes that in gun shot fractures of the thi^h con- servative treatment is better than amputation by twelve per cent., the lower third being no exception, and better than exsection of the femur by twenty-four per cent. 43 Billroth, of Vienna, in his letters from the late German - French war, collates figures from various wars, which foot up as follows: CONSERVATIVE TREATMENT OF GUN SHOT FRACTURE OF THIGH. MILITART AMPUTATION OF THIGH. Cases........................1339 Died................___.....949 71 per cent, mortality. Cases........................3721 Died.........................2826 76 per cent, mortality. As already stated, the Archives Generates de Med., 1859, has an article claiming that, in the Crimean war, conservative treatment for gun shot fracutre of the leg and thigh was five times more successful than amputation. It is evident that the opinions of the most eminent men are in utter contradiction on this subject; and b}7 some inexcusable blundering the fig- ures are in the same situation. The truth is that military statistics are often extremely delusive, in consequence of the improper manner in which they are collected. AVe will dis- cuss this matter further under the head of " Conclusions." Formerly all gun shot fractures of the femur were supposed to demand amputation, but Malgaigue defended, before the French Academy, the opinion that conservative treatment should be tried wherever the circumstances [did not compel amputation. Yelpeau and Jobert (de Lamballe) sustained him. Hamilton {Military Surgery, p. 399) advises to amputate the thigh for gun shot fracture: 1. AYhen the patient must be carried far, over rough roads without adequate support to limb. 2. AYhen the bones are greatly comminuted. 3. AYhen there are uncontrollable pains and spasms. 4. AYhen there is great contusion or laceration of soft parts. 5. AYhen the principal arteries or nerves are destroyed. 6. AYhen the fracture is at or near the knee. He advises not to amputate: 1. AYhen the bullet fractures the head, neck—trochanter—or shaft just below the trochan- ter. 2. AYhen the wound is from a pistol, a spent ball, or any projectile which makes but little comminution. u Longmore, in his article in Holmes' System of Surgery, vol. ii, p. 227, quotes the statistics of the American war as showing that conservative treatment of gun shot fractures of the upper third of the thigh was three per cent, more successful than amputation, and hence recommends conservatism in uncom- plicated cases. In the middle and lower thirds he recommends amputation, as shown by statistics to be slightly safer in the middle, and decidedly safer in the lower third than conserva- tive treatment. His figures from Circular No. 6, S. G. 0.,are so erroneously quoted that I am obliged to correct them from the original document: Upper third. Middle third Lower third. CONSERV. TREAT. 330 238 173 I PER DIED CT. MOliT AMPUTATIONS. CASE DIED PER CT. MORT 237 i 72 32! 24 ;o 132 55 ; 931 511 55 tOll 58 ! 243| 112 46 Circular No. 6, of the U. S. Surg. Gen., compares conser- vative treatment of gun shot fractures of the knee, with treatment by amputation just above, with the following results: Gun Shot Fracture of Knee, treated by Amp. Lower Third of Thigh...................... Same Injury Conservatively Treated........... 452 308 331 258 PER CENT. MORTALITT. 73 84 Dr. E. AYarren, of the Confederate army, and Surg. Gen. of North Carolina, gives, in his " Surgery of the Field and Hospi- tal," two hundred and one cases of fractured knee joint from the Richmond hospitals, with one hundred and twenty-one deaths, a mortality of sixty per cent. He remarks judiciously that these figures do not represent the whole truth, as many bad cases died before reaching the hospitals. AYere these added the mortality would doubtless be greater. The Deutsch Zeitschrift fur Chir., Bd. 2, S. 106 gives 45 from the German-French war, thirty-four cases of penetrating gunshot wounds of the knee joint, with twenty-four deaths; a mortality of seventy per cent. Max Schmidt {Jahrbiicher, 1872) advocates conservative treatment—not only in wounds about the knee, not penetrat- ing the capsule, but also in the simpler intracapsular wounds. Surgeon J. M. AVoodworth, formerly Med. Director of the Army of the Tennessee, and now Supervising Surgeon of Marine Hosps., claims, on the contrary, that almost all gun shot openings of the knee joint, even if the bones are not fractured, should, in military practice, be amputated. Guthrie (Commentaries on the Crim. AYar) says gun shot fractures of the knee joint imperatively require primary ampu- tation; but that if the patella alone be broken, and that only moderately, delay may be allowed. At page 151 he maintains that when gun shot fractures of the lower half of the femur do not communicate with the knee joint, conserva- tive treatment should always be preferred. CONCLUSIONS. From this somewhat contradictory mass of opinions on one of the plainest operations in surgery we see how far from being settled many precepts of our art still are. AYe will try to evolve partial order out of the chaos, and where this is im- possible we will at least ascertain what points are still unknown, and must wait the further growth of science for light upon them. 1. It is settled forever, as every one knows, that the nearer the operation comes to the body the greater the risk, other things beino- equal. There is an apparent exception in the traumatic secondary cases, for in these the mortality of secon- dary cases increases as we approach the knee. This is probably due to the inclusion of many cases in which compound frac- tures opened that joint, producing supperation, etc., in which accident the earlier secondary amputations are excessively fatal. Amputations in the height of an active suppurating inflammation of the knee are considered almost necessarily fatal. Did the published records admit of our sifting out 46 these knee cases, we should probably find that the remaining secondary cases followed the usual rule of increasing danger as we approach the body. Our average Lake State mortality for all amputations of the thigh is only 24 per cent, against 62 per cent, elsewhere. Our number in the upper two-thirds are too small to establish reliable averages, but if we distribute the 24 per cent, risk according to the experiences elsewhere, we shall have the fol- lowing as our probable rates: PROBABLE RISK OF AMPUTATIONS OF THIGH IN THE LAKE STATES. Upper 3d Primary....................about 30 per cent. " 3d Intermediary................ " 45 '' " " 3d Purely secondary............ " 20 '' " " 3d Pathological................ " 18 *' u Middle 3d Primary................... " 24 " " "' 3d Intermediary............... " 36 " " " 3d Purely secondary............ " 25 " " " 3d Pathological................ " 15 " " Lower 3d Primary.................... " 22 u " " 3d Intermediary............... " 45 u " " 3d Purely secondary............ " 25 u >< 3d Pathological................ " 10 " '■ These figures can only be approximate, of course. Massive as are the published statistics of amputations of the thigh abroad, most of them are in such a wretchedly crude and even contradictory condition, that their usefulness is in a great measure lost, and proportions taken from them and applied to our cases must be received with many allowances. I ought to say here that in the division into traumatic and pathological, experience shows that amputations of " expedi- ency," or " complaisance," that is, amputations performed to remove deformities, on limbs otherwise healthy, have a mor- tality much greater than other pathological cases, and rank nearly the same as traumatic primary operations. The above averages will do as a starting point, but in each case we must consider the individual modifying circumstan- 47 ces. If the patient's condition and surroundings are better than usual, his risk will be much less; and if the reverse, it will, of course, be greater than the above average. Injuries which, like bullet wounds, comminute the bones in the interior of the knee, require primary amputation, but if the period for this has already passed, the patient is in a very dano-erous situation, as amputations of these cases are desper- ately perilous during the acute portion of the suppurative stao-e, and excisions are the same, while delay is not much better. Perhaps the best way would be to open the joint, pick out the fragments, apply Lister's carbolic acid treatment thoroughly every day , and keep up extension of the leg by adhesive plasters, weight and pulley, and thus carry the case over the period of acute activity, when the risk of an amputa- tion will be greatly diminished. This is only a suggestion, for which there is no accumula- tion of experimental proof as yet adduced. Ordinary compound fractures, not comminuted, but yet extendinc into the knee joint, were often best treated in former times by a primary amputation; but at present, he that is master of the antiseptic methods, and bold enough to apply them thoroughly, will find them more useful than amputation for such cases, if seen immediately. Military fractures of the thigh, not implicating the knee joint, and' not accompanied with such injuries to vessels or other parts as will produce mortification of the member, are best treated conservatively, and especially so in the upper half of the thigh. AMPUTATION AT THE KNEE JOINT. This operation has evidently not been a favorite in the Lake States, as I have no cases of it reported to me. Abroad the following statisctics are found: 48 PRIMARY. AUTHORITIES. CASES. 1 2 49 39 1 109 DIED. Boston City Hosp. Rep. Dr. Cheever...............____ St. Bartholomew's Hosp., 1863-71.................______ Mass Gen. Hosp.___...........______ 0 0 3 Circular No. 6, Surg. Gen. U. S. A------ Crimean War, Schmidt's Jahrbiicher, Vol. German-French War, " " " American Jour. Med. Sci., 1868, pp. 333, 5, 15G~p 55. Dr. "250"..... Brinton.. 16 31 1 47 Totals..............____........ 206 98 Mortality, 48 per cent. INTERMEDIARY AND SECONDARY COMBINED. AUTHORITIES. Dr. D. Cheever, Boston................................. St. Bartholomew's Hosp., 1863-71....................... Seige of Strassburg, 1870-71. Dr. Herrgolt.............. Crimean War, Schmidt's Jahrbiicher, Vol. 156, p. 250____ German-French War, " " " " " " ____ American Jour. Med. Sci., 1868, pp. 333, 555. Dr. Brinton. Totals_____________..........___........____ Mortality, 49 per cent. PATHOLOGICAL. 68 86 CASES. DIED. 1 1 1 0 3 3 AUTHORITIES. Guy's Hospital Reports................____........... St. Bartholomew's Hosp., 1863-71........____......... Mass. Gen. Hosp---...............----------....... American Jour. Med. Sci., 1868, pp. 333, 555. Dr. Brinton British Army Med. Rep.........________________ Prof. Billroth, Arch. Klin. Chir., B. x._.................. Liicke, Deutsch Zeitschrift fur Chir., B. ii................ Totals___......_________.......____________ Mortality, 26 per cent. TIME OR CAUSES IMPERFECTLY STATED, AUTHORITIES. St. George's Hospital, London____ Circular No. 3, -Surg. Gen. U. S. Army, Traumatic " 6, " Bericht,k. k. allg. Krankenhaus, Wien Statist des Hop. de Paris, 1861-2-3 Liicke. Deut. Zeitschrift, B. 2..... Zurich Hosp., 1860-67............ Arch. klin. Chir., Bd 17, S. 510.... Totals_________________ Mortality, 54 per cent. 1 0 6 2 11 4 92 l!i 1 0 7 6 1 0 119 31 CASES. DIED. , Traumatic___ 1........ 7 3 73 3 2 2 1 38 129 3 0 51 2 1 1 1 11 70 40 SUMMARY OF AMPUTATIONS AT THE KNEE JOINT ABROAD. Primary........__________________________ Intermediary and Secondary combined............. Pathological...................................... Conditions imperfectly stated", but cases nearly all military....................______........... 206 86 119 129 98 42 31 70 PER CT. MORT. 48 49 26 54 The pathological cases here are nearly all those called by Brinton " secondary pathological; " that is, cases which are more or less chronic. The importance of the distinction is that amputations in the acute inflammatory stage of the knee joint are very fatal, whether performed -at the knee or just above it, and should be avoided if possible. ■ OPINIONS OF AUTHORS. Amputation at the knee joint, instead of at the lower third of the thigh, was first performed by Fabricius Hildanus, in 1581, and re-introduced to the profession mainly by the efforts of Yelpeau, Markoe and Brinton. It was first performed in America by Prof. Nathan Smith. The operation was at first mainly performed by leaving the condyles in the stump. Mr. Carden, of Great Britain, intro- duced as an improvement the plan of sawing off the articular portion of the condyles, and the statistics of that country apparently showed about six per cent, more safety by that method, but Dr. Brinton, (Am. Jour. Med. Sci., 1868,) adds the American statistics, which change the result, and render the two methods almost exactly equal, as may be seen in the following figures: CONDYLES LEFT. cases, died, pr.ct.mort. American Cases.................................45 \% 27 Foreign Cases.........._________................34 jq * 29 Totals..................................79 22 28 CONDYLES REMOVED. cases, died, pr.ct.mort. American Cases...................................19 6 32 Foreign Cases...........................________13' 3 23 Totals 4 32 9 28 50 Dr. Brinton compares the mortality of amputation at the knee joint with that of amputations of the thigh, in order to show that the knee joint is much the safer location. In doing so, however, he commits the mistake of making his compari- son with amputations in all parts of the thigh together. This is not fair. Cases which require amputation at the mid- dle and upper thirds of the thigh, do not admit of the knee joint as a substitute. The only thigh amputations which allow the choice are those at the lower third. If now we take our summary of amputations in the lower third abroad, and place them beside the corresponding knee amputations, we get the following result: MORTALITY OP AMPUTATIONS. At Lower 3d of Thigh. At Knee Joint. Traumatic Primary_________________.....45 per cent. 48 per cent. Traumatic Secondary............._________60 " " 49 " " Pathological______.................T......20 " " 26 " " Averages........._____..........42 " " 41 " " The superiority of the knee joint amputation over that at lower third of the thigh averages only one per cent., a differ- ence too small to be trusted, especially as part of the cases are picked up from scattering operations reported in journals, a method of collection which always gives too large a propor- tion of successful results. Mr. Liston, in Holmes' System of Surgery, p. 606, praises the operation exceedingly for the small amount of tissue divided, the excellence of the flap, the absence of exfoliation of bone and great length and usefulness of the stump. T. Holmes (Surgery, its Principles and Practice, p. .923,) says he is " rather fond " of the operation. Gant's Surgery, p. 706, says the " results with regard to the stump are advantageous." Gross' System of Surgery, Yol. II., p. 1122, praises the operation because of its length of stump, the fact that it avoids some dangers by not opening the medullary canal, has no exfoliation of bone, and has a low mortality; but he opposes its performance when any point lower down is admis- sible. 51 Parker, of New York, in the New York Journal of Med- icine, Yol. IX., JSi. S., p. 80S, advocates it as tljustifiable," and giving a good stump. Dr. Henry Smith, in his Operative Surgery, at first opposed it, but later, in his Principles and Practice of Surgery, Yol. II., p. 704, retracted his first opinion, and though still in doubt, inclftied to favor it. Markoe of Xew York, Brinton of Philadelphia, Erichsen of London, and Yon Langenbeck of Berlin, all favor the operation. Of the older surgeons, Yelpeau, Textor, Kern, Yolpi, Bras- dor, J. L. Petit, Hoin and Blandin advocate the operation; while Dupuytren, Larrey and Zang unconditionally opposed it. • CONCLUSIONS. It is evident that the mass of the best writers now favor the amputation at the knee joint whenever the condition admits of its being substituted for that of the lower third of the thigh. Its danger is perhaps a little less, and the stump is better. It is therefore to be preferred in such cases. As to the question whether simple disarticulation, or sawing through the condyles is the best, the statistics show the danger to be the same, when the American and Foreign cases are added together. It has been thought that the presence of the carti- lage and synovial surface would have some of the same evils which result from opening a knee joint to the air, but experi- ence apparently shows otherwise, or if the presence of those tissues is somewhat objectionable, that danger is balanced by the increased risk of pyaemia induced when the cancellous tissue of the condyles is sawn through. AMPUTATION OF THE LEG. Of this very common operation I find the following cases recorded in the Lake States: TABLE IX. AMPUTATION OF THE LEG IN THE LAKE STATES. No. An- drew's Sur.Rec till 1553 ItiOl 1857 1943 5390 5392 5508 55(17 5(itil 519(5 HOI 7 tm-i l»300 imnu 5975 7012 OPERATOR. Dr. E. Andrews La Count. E. Andrews.. D. Brainard. Ammerman . A. Fisher.... E. Owens .. Cook Co. Hosp. REASON FOR OPERATION. Both feet crushed. H. Wardner.. Leg crushed by cars................ Neuralgic stump of leg............ Leg and arm crushed by cars...... Large ulcer from burn............. Fractured leg by cars.............. Fractured leg by cars---.......... Foot crushed off................... Leg crushed by cars............... Leg crushed by cars..........--- Comp. tract, foot&leg. Caries of tibia Caries of tibia...........-......... Caries of ankle.................... Comp. fract. of ankle..........--- Foot and ankle torn badly......... Wound of ant. tibial art. Gangrene Comp. fract. tibia and fibula....... Diseased foot from injury.......... Comp. and commin. fract. of leg.. Senile gangrene................... Both feet crushed.................. Caries of ankle.................... Comp. fract. of ankle.............. Necrosis of tibia and fibula........ ('omp. and commin. fract. leg & arm Comp. and commin. fract. leg, R.R. R. R. fracture...................... Disease of parts................... Leg crushed by falling tree........ Leg crushed on R.R.and fract.elbow Foot and ankle crushed by boats.. COMPLICATIONS. Mortification. Kept in close, foul room. None.................... Great shock—amp.of arm None.................... None.......-............ Severe hemorrhage...... Mortification of foot..... None.................... None.................... Calcified arteries, exhaus None.................... None.................... Hemorrhage............. None.................... None.................... Weak with age Great shock___ Great shock, ampt.of arm Shock and contusion of ? pelvis,thigh&abdomei) Shock................... Shock and hemorrhage.- Operati'n Dbl. Amp Middle 3d Re-a.up. 3 Middle 3d Lower 3d Middle 3d Circ.m.3d Upper 3d Middle 3d Upper*3d Middle 3d Cir. low.3 " mid.3 " low.3 Flap lo\v3 Circ. Flap up 3 " low. 3 Lower 3d Cond. at opr Good Bad.. Good Med.. Bad. Bad. Med. Flap up. 3 Upper 3d Middle 3d Lower 3d Bad.. Bad. Med. Upper 3d Bad. Middle 3d Med. Lower 3d I " . Time to operation. Primary ... 4 years___ Primary ... 2 years___ Primary ... 3 days___ Secondary Several yrs " week Primary .. Secondary Primary .. Secondary Primary ... 1 month .. Primary .. Primary 4 hours__ 12 " .. Primary .. Secondary Primary .. Secondary Primary .. Recover'd Died..... Recover'd Died..... Recover'd Died ..... Recover'd Died ..... Recover'd Died ..... Recover'd Died ___ Recover'd Died ..... Recover'd Time to death or recovery 8 mos. . 30~days ti weeks 10 " 8 8 mos. . 5 weeks 6 days . 3 days 6 weeks 5 davs .. 1 '■" ... Practice. Private.. Hospital. Private.. Hospital. Private. _______ Hospital . 3tidays..i ti hoiirs _i Private .. 4 days .. 2 mos... 6 weeks Hospital. Private . Ox Table IX.—Continued. Dr. N. Senn......|10|Ankle cut by reaper............... "" " ......28 Caries of ankle and tarsus fr. injury "" " ____|2l|Leg crushed by runaway........... " II. Wardner.. 25;Ankle cut by axe.................. 11 " " ..[35iCaries of ankle.................... M.Waterhouse|12;Leg crushed by car wheels----- " " i75!Leg crushed by wagon wheels. E. D. Kittoe.. lf> Leg torn by threshing machine 40 Leg torn bv threshing machine Shock and hemorrhage.. Shock and hemorrhage.. Tuberculous diathesis... None _................... Ana'inia......-.......... . Great shock...... None E. Kittoe, Jr.. 42|Bad comp.'and commin. fract.of legjlntempcrate J. Andrews _Jl5;Comp. fract. of leg........ E. W. Lee___klOVomp. fract. of leg.....-.. " " ___i 8JComp. fract. of leg.....--- " " ___22 Comp. fract. of leg------ " il ___I 9j('omp. fract. of leg........ 25|Comp. fract. of leg........ 45;Comp. tract, of leg........ 22jFeet crushed by cars...... E. Andrews S. Marks ... 27:Amurismal varix of anterior tibial j vessels, caused by scythe when 13.. liok'aries of the taisus.......-.......I- 8 Gangrene of foot after K. R. acci- | dent, fracture of the other leg ... 58iCaries of the tibia.........--...... 19 Disease of ends of bones, following S primary amputation of leg...... 9lRoth ankles crushed by locomotive ..lliBoth feet frozen. Drunk.......... J30'■ Foot and ankle crushed by locomo . i23JFoot crushed by cars ...,.......... 28'Caries of tarsus.................... 20;Leg cut off with steamboat cable I immediately above ankle---- 32!Foot and low. port, of tibia crushed 58[Caries of tarsus.--.............. 55lCaries of tarsus and lower end tibia 19|Caries of tibia.................. 43|Caries of tarsus............---- 42 Caries of tarsus................. ... iNone................. ... None................. ... iNone.....-.....-..... ... iNone.................... ... J None.........---_-...... ... icon cuss ion of brain---- ...!Great shock. Pirogoff's ampu. of opposite foot eight days after........ Lower 3d I...... •' iBad.. Circ.m.3d ...... Upper 3d IBad.. Middle 3d; u .. Upper 3d Good " IBad.. 11 " Good " Bad.. ..........Good Flapup.3Bad.. " |Med.. li hours___ 1 year...... 8 hours__ 3 days .... 1 year..... Primary .. 8 hours ... (i " ... 3 months . Secondary Primary .. .Both lee Bad. Lower 3d Bad.. Upper 3d Good Low.3flapMed.. " Bad.. Upper 3d IGood Mid.3nap' " Low.3ilap Med.. Mid.3Hap;Bad_. Low.Sttap'Good Mid.3 flap Low.3tlap!Med. Mid.Stlap " . Upi>er3d Bad. Lo\v.311ap, " . " IBad. 14 years — About 0 yn 15 days ... 6 years--- 9 months . 2 hours ... 8 days___ Primary .. Secondary 3 years--- Primary .. 21 years... 9 years___ 3 years--- 1 year..... 2V2 years.. Recover'd Died..... Recover'd Died , .. Recover'd Died..... 6 weeks. 4 4 4 li " 21 days . 3 " - 15 days . 24 hours 4 weeks 14 " 10 days . " ....- 48 hours Recover'd Died Recover'd i Died Private.. 3 mos. .. 4 weeks li mos. 3 mos. Hospital. Hospital. Private.. Hospital. Private .. Hospital. Private .. Hospital. Private -- Hospital. Private .. Hospital. 7 davs ..|Private 54 RECAPITULATION. CASES. DIED. 70 16 00 8 16 4 23 3 32 9 16 3 13 3 13 6 4 1 5 1 7 2 6 1 3 1 12 1 6 1 5 1 9 1 28 5 41 11 PER CENT. MORTALITT. Total of all locations___......_.............. " upper 3d............................... •' middle 3d...............______________ " lower 3d___________...............___ Primary, all locations___................__ Intermediary and secondary, all locations_____ Pathological, all locations.................... Upper 3d, primary_________________________ " intermediary and secondary combined, " pathological___.............._____ Middle 3d, traumatic and primary____________ " intermediary and secondary combined. " pathological______________________ Lower 3d, traumatic, primary.................. " intermediate and secondary combined. " pathological......__________........ Conditions imperfectly stated..........._______ Hospital practice.........____________________ Private practice_________........______________ 23 36 25 13 28 19 23 18 These cases are not sufficiently numerous to settle all points, but they show that, like amputations of the thigh, those nearest the body are most dangerous. The upper 3d has a mortality of 36 per cent., the middle of 25 per cent., and the lower 3d of 13 per cent. Hospital cases, by some accidental coincidence show better than those in private practice. .^AMPUTATIONS OF THE LEG ABROAD. Of these the literature of surgery furnishes a prodigious list, and, were they properly classified, they would settle nearly all questions capable of statistical solution. Unfortunately they are very imperfect in detail, and only a portion of them can be classified. AMPUTATION OF THE LEG ABROAD; UPPER 3d, PRIMARY. AUTHORITIES. Rept. Boston City Hosp., Dr. Cheever.. Mass. Gen. Hosp. Rept., 1871_________ Dr. Herrgolt, Siege of Strassburg, 1870- Warren's Surgery, Confed. Army Rept. Totals___________.........-----------------..... 85 4 26 14 41 7 5 17 31 Mortality, 36 per cent. 55 AMPUTATION OF THE LKG ABROAD; UPPER 3d, INTERMEDIARY AND SECONDARY COMBINED. AUTHORITIES. Rept. Boston City Hosp., Dr. Cheever---.....----- " Mass. Gen. Hosp, 1871.........____________ Dr. Herrgolt, Siege of Strassburg. 1870-71........... Dr. E. Warren's Surg., p. 394, Confederate Army IT. S. Totals. CASES. DIED. $ 1 0 13 4 6 3 33 18 53 25 Mortality, 47 per cent. AMPUTATION OF THE LEG ABROAD; UPPER 3d, PATHOLOGICAL. AUTHORITIES. Rept. Bost. City Hosp., Dr. Cheever........ " Mass. Gen. Hosp.,________......... " Rostock Hosp. Rep........------- Statist, des Hopitaux de Paris, 1861-62-63.. Totals. 62 1 1 42 7 4 2 15 9 19 Mortality, 31 per cent. AMPUTATION OF THE LEG ABROAD; MIDDLE 3d, PRIMARY. AUTHORITIES. Rept. Boston City Hosp., Dr. Cheever............... " Mass. Gen. Hosp., 1871........_____________ " U. S. Marine Hosps., Dr. Woodworth........ Dr. Herrgolt, Siege of Strassburg, 1870-71__........ Dr. E. Warren's Surg., p. 394, Confederate Army U. S. Totals...................___________....... CASES. DIED. 67 0 19 1 0 5 30 Mortality, 45 per cent. AMPUTATION OF THE LEG ABROAD; MIDDLE 3d, INTERMEDIARY AND SECONDARY COMBINED. AUTHORITIES. CASES. DIED. Rept. Boston City Hosp., Dr. Cheever_________.......... " Mass. Gen. Hosp., 1871_____________............. 3 20 1 3 1 8 Dr. Herrgolt, Sie^c of Strassbugh, 1870-71_______ _______ Dr. E. Warren's Surg., p. 394, Confed. Army_________..... 1 2 Totals___...........________............. 27 12 Mortality, 44 per cent. 56 AMPUTATION MIDDLE 3d"OF LEG ABROAD, PATHOLOGICAL. AUTHORITIES. CASES. DIED. t Rei 3 46 0 ti Mass Gen " 1871 ................... 3 49 3 Mortality, 6 per cent. AMPUTATION LOWER 3d OF LEG ABROAD, PRIMARY. AUTHORITIES. Rept. Boston City Hosp., Dr. Cheever.....---- " Mass. Gen. Hosp., 1871................... Dr. Herrgolt, Siege of Strassburg, 1870-71_____ Leeds Gen. Infirmary, Dr. Nunneley-----..... Dr. E. Warren's Surg. Confederate Army, p. 394. Totals.....___.................................... 99 3 0 20 7 2 1 69 28 5 1 37 Mortality, 37 per cent. AMPUTATION OF LOWER Sd OF LEG ABROAD, INTERMEDIARY AND SECONDARY COMBINED. AUTHORITIES. Rept. Boston City Hospt...............—...... " Mass. Gen. Hosp. 1871......._____...... " U. S. Marine Hosp___..........._______ Dr. Herrgolt, Siege of Strassburg, 1870-71_____ Dr. E. Warren's Surg., p. 394, Confederate Army Totals.........___...................__________ 31 6 15 •2 Mortality, 29 per cent. AMPUTATION OF THE LOWER 3d OF LEG ABROAD, PATHOLOGICAL. AUTHORITIES. CASES. DIED. Boston City Hospt. Rep___............._............ 1 2 28 o o Mass. Gen. Hospt. Rept. 1871........._________ 5 Totals___......._________ 31 5 Mortality 16 per cent. 57 AMPUTATION OF THE LEG ABROAD, IMPERFECTLY CLASSIFIED. AUTHORITIES. Circular No. 6, Surg. Gen. U. S. A....... Statistics of Crimean War.............. Italian War___........... " German-French War....... British Country Hospitals_____________ St. Bartholomew's Hosp., 1869____..... K. k. allg. Krankenhaus Bericht, Wien .. Leeds General Infirmary............... Parisian Hospitals_______________..... Edinburg Infirmary, 1859 to 1868....... Glasgow " 1844 to 1868....... Guy's Hospital, 1861 to 1868....... London " 1862 to 1868....... Combined Reports from various authors 2348 611 1361 940 475 326 141 70 838 177 193 61 241 71 99 15 266 160 86 38 180 77 102 36 67 39 558 212 Totals............................................. 6955 2833 Mortality, 40 per cent. GENERAL SUMMARY OF AMPUTATIONS OF THE LEG. Total of all kinds....._______....... " private practice... ___......... " hospital "................. " upper 3d....................... " middle 3d___.................. " lower 3d____......____'______ Upper 3d, primary........___........ " intermediary and secondary. " pathological_______........ Middle 3d, primary--------.......... " intermediary and secondary " pathological..........____ Lower 3d, prim'ary.......____________ " intermediary and secondary. " pathological................ LAKE STATES. ABROAD PER CASE DIED CT. MORT CASE DIED I 70 16 23 7459 3004 41 11 27 28 5 18 22 8 36 200 75 16 4 25 ' 143 45 23 3 13 161 51 13 6 85 31 4 1 53 25 5 1 62 19 7 2 67 30 6 1 27 12 3 1 49 3 12 1 99 37 6 1 31 9 5 1 31 5 40 38 31 32 36 47 31 45 44 6 37 29 16 The small proportion of perfectly classified statistics ren- ders this summary a little irregular, but still it shows the general decrease of danger as we recede from the body, and the superior safety of pathological amputations (those of " expediency " always excepted) over traumatic cases. 5 s OPINIONS OF AUTHORS AND CONCLUSIONS. Authors say very little about the special indications demand- ing amputation of the leg. In general terms they are such as demand amputation in any other part of the body. The sur- geon must not be swayed, as is too often the case, by the ghastly appearance of a bad compound fracture, but consider the intrinsic condition of the limb as to circulation and inner- vation. If these functions are fairly preserved, a great amount of bony injury can be successfully overcome. In war a bullet traversing from before backward may shatter the tibia, bury a hundred of its fragments in the tissues of the calf, and destroy the posterior tibial artery and nerve, and yet the wound make no great external display. On the other hand, if the ball traverse from behind forward, the artery and nerve may escape, and the fragments of bone be driven out into the external air in front. The wound is large, ragged, and terrible to the eye, but much less dangerous than the for- mer. Yet many a surgeon, in looking over his patients, has been moved by mere external appearances to amputate the .better limb and try to save the worse one. Analogous errors are common in civil practice. A mere bad compound fracture does not necessarily require amputation. Compound dislocations of the ankle often require resection, but rarely amputation. It is much disputed whether it is best to amputate anywhere for senile o-anorene in the foot. If, however, it is decided to be best, the amputa- tion should be at least as high as the upper third of the leu- and not in the foot. Some advise the lower third of the thio-h. "Where the injury or disease requiring amputation of the leg admits of a choice of location, all authors aoree that it should be as low down as possible, in order to reduce the risk to the lowest attainable figure. In the leg, as well as else- where, amputations of " expediency," i. e., for deformities etc., have the general risk of traumatic, and not the slio-liter one of pathological cases. In compound fractures and dislocations of the ankle joint amputation should not be performed unless mortification of 59 the foot or other imperatiye reasons demand it. liesection has the best results in those cases, conservative treatment next, and amputation the worst. SYME'S AMPUTATION AT THE ANKLE. I have not obtained a single recorded case of this operation in the Lake States, but the literature of the profession gives us many cases from abroad, though generally not classified. They are as follows: AUTHORITIES. Deutsch Zeitschrift, fur Chir. Bd. I. und II..... Dr. Herrgolt, Seige of Strassburg, 18-70-71____ Dr. E. Warren's Surg., Confederate Army______ Hancock______............................. Birmingham Hospt. 1858-64, Richardson______ Rostock Hospt. Rept. 1868..................... Brit. Army Med. Rep__________............. Archiv. Klin. Chir. Bd. X, Billroth............ li N, XIII and XVII____ Totals_______________................ Mortality, 9 per cent. We will discuss the merits and opinions on this operation at the same time with the next one. PIROGOFF'S AMPUTATION. Of this we find in the Lake States quite a number of cases which are given below: CASES. DIED. 3 0 2 1 o 1 219 17 45 7 6 1 2 0 o 0 44 3 325 30 TABLE X. PIKOGOFFS AMPUPATION IN THE LAKE STATES. j OPERATOR No.j OR REPORTER. 18()6Dr. E.Andrews 22 20(13' 5128 5684! " " 14 5259 " " 19(17 8430 8518 CAUSE OF OPERATION. Both foot frozen. Foot crushed___ " and mortified. II.A.Johnson ..; " "............... E. Andrews 18 Caries of tarsus............ '• 39 Foot crushed............... J.S.Sherman 25 ■' " ............... COMPLICATIONS. Both feet amp. at once. Intemperate............ None None.................... Op. leg cr. and amp. 10 d Opera- tion. PirogofTs Con- ditio Good Med. Good Med . Time j of Result. operation Second'y. Primary . 13 days .. Primary . 18 ms.... Primary . 10 days .. Died..... Recov'r'd Time to death or recovery 1(1 days .. 51 days .. 5 months -l'a ins... 2li ms... 12"ins.-_. Practice. Hosp 35 61 RECAPITULATION. Total (all Hospital patients). Primary_________________ Secondary and intermediary. Pathological......._______ 9 2 5 1 3 1 1 0 Total mortality in the Lake States, 22 per cent. The cases are not numerous enough to furnish by them- selves any special conclusions. Abroad the literature furnishes us a moderate number, mostly unclassified. PIROGOFF'S AMPUTATION- ABROAD. AUTHOBITIES. Penn. Hosp......................______.....____ St. George's Hosp.__............................ Rostock Hospt. Rept............................. Dr. E. Warren's surg., p. 394, Confederate Army ... Bericht k. k. allg. Krankenhaus, Wien........___ Braithwaite's Retrospect, Jan. 1867_____________ Archiv. klin. Chir. Bd. X, Billroth_____________ " " VIII_______........____ Deutsch. Zeit. f. Chir. B. I, S. 187; B. II., S. 380.... Totals............________......_____.......____ 112 2 0 2 1 4 1 i 0 26 9 58 5 11 4 1 0 7 0 20 Mortality, 18 per cent. OPINIONS OF AUTHORS. Syme's and Pirogoff's amputations are rivals of each other, being applied to the same class of cases. The American Surgeon General's Circular, No. 6, says that Pirogoff's operation is regarded with little favor. Baron von Horrowitz, the Surgeon-in-Chief of the Russian Marine, says that Pirogoff himself has abandoned it on account of the frequent occurrence of necrosis of the os calcis. Dr. Stephen Smith says the stump of Syme's operation is better than that of Pirogoff. Ilewson, on the contrary, (quoted in Ashurst's Surgery, p. 122,) says that Pirogoff's stump has some decided advantages over Syme's, in that the patient can walk and run upon it. 62 Liston, in Holmes' System of Surgery, Vol. V., p. 644, pre- fers Syme's amputation as simpler, easier, and less liable to caries. Grant's Surgery, p. 701, says this liability to caries is not present in traumatic cases. Erichsen's Surgery, Vol. I., pp. 78, 79, speaks favorably of Pirogoff's operation, and thinks the objections to it not very well grounded in experience. Gross' Surgery, Yol. II, p. 1119, prefers amputation of the lower 3d of the leg to either Pirogoff's or Syme's operation. Dr. Stephen Smith, on the contrary, in his contribution to the papers of the United States Sanitary Commission, con- cludes that Syme's amputation is 50 per cent, safer than that at the lower 3d of the leg. Hamilton's Surgery, p. 368, says that the stump in both Pirogoff's and Syme's operation is often most excellent. Bryant's Surgery, p. 964, speaks in the highest terms both of Pirogoff's and Syme's amputations. CONCLUSIONS As usual, the opinions of surgeons are a little contradictory of each other, yet the majority favor Syme's rather than Piro- goff's method. The statistics, though less perfect than could be desired, still point to the same conclusion, for we have as follows: MORTALITY. Syme's amputation. Pirogoff's " 325 112 30 20 9 per ct. 18 " It would appear, therefore^ that thus far Pirogoff's opera- tion has had double the mortality of Syme's, an important fact scarcely referred to by our best authors. It is evident, therefore, that as facts and opinions now appear, they compel us to consider Syme's operation as much the best. The military statistics of Demme, Stromeyer and Leo-ouest give for compound fractures of the foot much better results 63 for conservative treatment than for any kind of amputation. The superiority of their conservative figures varies from 28 to 59 per cent. It would seem, therefore, that an amputation of the foot is not demanded for ordinary bad compound fractures, but only for that portion of them where there is such an amount of mortification as compels it. OTHER AMPUTATIONS OF THE FOOT. I have included these all in a single table, whicli is here subjoined: TABLE XL AMPUTATIONS THROUGH TARSUS AND METATARSUS IN LAKE STATES, (EXCLUDING PIROGOFF'S AND SYME's.) No. 6654 5129 Dr. E.Andrews OPERATOR OR REPORTER. Hyde..... E. Owens H. Wardner E. D. Kittoe J.Andrews. E. W. Lee.. S. Marks ... CAUSE OP OPERATION. Crushed toes___ Both feet frozen. Fracture of both feet. Feet frozen........... Frost bite Foot crushed. on R. R. Feet frost bitten and mortified. Foot cut off by axe............. Foot crushed by stone.......... Wound of dorsal artery of foot. Foot crushed by R. R........... COMPLICATIONS. None. Drunk......... None........... Consider'ble shock Great shock....... Up. &lo. jaws fract Caries of foot...... None.............. OPERATION. In metatarsus............ At juncture of tarsus and metatarsus of both feet.. At juncture of tarsus and m tatarsus of both feet.. Junct. tarsus & metatarsus Chopart's in one foot and Hey's in the other....... Both feet through metatar. Chopart's................. Metatarsus of one foot and all the toes of the other Chopart's................ Metatarso-phalangeal arti- culation ............. Chopart's.............. Con- diti'n Time of operation Good Med. Bad . Good Med. Bad . Good Med. Bad . Good 12 days .. Second'y. Primary 8 days ... 3 days ... 6 hours .. Second'y. 4 hours .. 3 hours .. Primary - Recov'r'd Result. Time to death or recovery 6 weeks 3 mos. .. Died.. Recov'r'd 1 month 3 mos. .. 4 " .. 5 " .. 6 " .. 3 days .. 4 weeks. 5 " 2 mos. .. 3 " .. Practice. Hospital. Private. Hospital. Private. 65 RECAPITULATION. CASES. DIED. 17 1 10 0 7 0 3 0 3 0 PER CENT. MORTALITT. Total of all kinds............._____....... Total Chopart's amputation..................... 10 0 0 Chopart's primary.................______--- 7 0 0 " intermediary and secondary_________ 3 0 0 Junction of tarsus and metatarsus_____........ 3 0 0 CHOPART'S AMPUTATION ABROAD. The few published statistics of this operation are imper- fectly classified. Of 101 cases of all kinds, sixteen died, which is about sixteen per cent., while of our ten cases recorded in the Lake States none died. OPINIONS OF AUTHORS. As above stated, Demme, Stromeyer and Legouest show military statistics to the effect that in compound gunshot frac- tures of the foot, conservative treatment is better by a large figure than any amputation. Holmes' System of Surgery, Yol. Y., p. 642, says Chopart's amputation is " undesirable," on account of the tendency of the stump to point its extremity too much downward. Erichsen, Yol. I., p. 73, thinks that Hey's amputation at the tarso-metatarsal articulation is often not desirable, and prefers if possible to saw through the metatarsals in front of the joint. In respect to Chopart's amputation he, contrary to Holmes' opinion, says that the stump is excellent, and that if it points too much downward it should be remedied by divis- ion of the tendon of Achilles. He advises to saw off the head of the astragalus, and the articular surface of the os calcis. GENERAL EFFECTS OF AGE, SEX, TIME OF OPERATION, AND PATH- OLOGICAL CONDITION ON THE MORTALITY OF AMPUTATIONS. These topics are as yet very imperfectly investigated, owing to the present rude condition of the science of statistics. Some dim light, however, has been thrown on them. A ge.—Malgaigne's statistics of the Hospitals of Paris give the following conclusions: 5 66 1. Under five years of age the mortality of amputations is more than between five and fifteen years. 2. From five to fifteen years is the most favorable age. 3. From fifteen to twenty years the risk increases. 4. From twenty to fifty years it remains nearly stationary, but increases again after fifty. (Dictionnaire des Sciences Medicales.) Mr. Callender, of St. Bartholomew's Hospital, London, says that in that institution the death of a child or of a patient under the age of forty is an exception, and that age increases the tendency to death. » From 1853 to 1863 the mortality of primary amputations all ages was less than ten per cent., while of ten cases over sixty- five years of age, sixty per cent. died. The experience of St. Bartholomew's Hospital is very valuable, because it is of all the hospitals in the world perhaps the most free from septic hos- pital contamination. (Med. and Surg. Trans., Yol. XLYIL, p. 75, 1864.) It is probable that amputation at the hip joint, and at the upper part of the thigh, will be found to undergo a great increase of danger at the age of puberty, when the pelvic organs assume their adult development. This rule probably applies to all operations and injuries to the pelvis and the parts immediately adjacent. Sex.—The opinions and figures on the influence of sex are in utter contradiction to each other, showing the present unfin- ished state of our knowledge on plain points which ought long ago to have been well settled. The Dictionnaire des Sciences Medicales, in the article on amputations, says that women bear amputations better than men, and cites in proof, the statistics of Newcastle, Glasgow, Edinburg and Paris, summed up as follows: CASES. DIED. PER CENT. MORTALITT. Amputations in males........._________ 1244 284 441 83 35 29 " in females................... On the opposite side, Mr. Callender (Med. and Surg. Trans., 67 1864,) says that the mortality of the operation among women is worse by fifty per cent, or more than among men. Schmidt's Jahrbiicher says that at Jenna the mortality of certain amputations was 2 If per cent, worse among the women than among the men. There is no reconciling such absolute contradictions. All we can say is that at present the influence of sex on the mor- tality has not been properly determined. Time of Operation.—Here we are met again with irrecon- cilable contradiction. Dr. Ashurst, of Philadelphia, has tab- ulated in his Surgery, p. 110, 2,201 cases from the civil hos- pitals of both continents, showing primary amputations of all kinds as having a mortality of 32 per cent., and secondary ones of 50 per cent. The statistics of military amputations in the Crimean and American wars show a similar result. On the other hand, the Dictionnaire des Sciences Medicales, tome III., p. 770, gives figures which foot up as follows: CASES. DIED. PER CENT. MORTALITT. Primary amputations of all kinds....._........ Secondary " " " -------------- 5599 2265 3164 1290 56.51 56.95 These statistics show the primary and secondary cases to have almost exactly the same mortality. The usual assertion of authors is that, in general, primary amputations are safer than secondary, but that at the hip and in the upper half of the thigh secondary ones are the safest. The greater danger of primary than of secondary amputa- tions at the hip and upper part of the thigh, is established, at least in adults. It is not proved, nor provable in children, who bear operations about the hips much better than adults; but the vast mass of figures above quoted show that, taking all kinds together, primary amputations have scarcely a shade of superiority over the secondary, a result in bold contradic- tion to the opinions taught by nearly all authors. Intermediary Amputations.—Military surgeons divide the cases ordinarily called secondary into two parts, those per- »;s formed after the first 24 hours, and before the establishment of free suppuration, being separated from the remoter second- ary, and termed intermediary. These are considerably more fatal than either primary or secondary operations, except in the case of the hip joint. At that articulation every stage is safer than the primary. The underlying principle appears to be that the presence of acute inflammation is a source of greatly increased danger, and large operations should be avoided if possible during its existence. Pathological Condition.—Here is a wide field of investi- gation, which has been only imperfectly explored. Traumatic amputations on the average are much more fatal than those performed for disease. Ashurst's table (Surgery, p. 109,) col- lates over 4,000 cases of all kinds, and gives Mortality of traumatic amputations,. .. .41 per cent. " " pathological " ___30 " But all traumatic cases are not alike. Those which have pro- duced a chronic trouble of many months' duration, often become to all intents and purposes like pathological cases. In suppurating knee joints, both traumatic and patholog- ical, the acute stage of the inflammation is an excessively dan- gerous time for amputation, and is to be avoided by all possible means. Amputations of " complaisance," or " expediency," so-called, that is, amputation of members otherwise healthy, but simply deformed, though technically classed as pathological, have not the safety of other pathological cases. Their rates of mortal- ity are almost the same as those of traumatic cases. Cancer, necrosis, caries of joints, etc., are pathological con- ditions often demanding amputation, and the danger of one perhaps differs from that of another, but the literature of the profession gives only an obscure light respecting it. At pres- ent we know little of the difference, but only the o-eneral fact that taken together, amputations for these causes are much safer than those performed for traumatic causes. Flap or Circular Operations.—Efforts were formerly made to show statistically an advantage of one or the other 69 methods, but the results were contradictory, and with the multiplication of new plans the old discussion between the advocates of flap and circular amputations died out, without any decided superiority being shown for either. At the pres- ent day surgeons selecting one or the other method, do it on other grounds than any supposed general difference of mortal- ity between them. Indications for Amputation.-The Dictionnaire des Sciences Medicales (Article Amputation,) sums up the indications with excellent judgment, and substantially as follows: Pathological Causes.—1, irremovable cancer; 2, diseases of bones not otherwise removable; 3, caries of joints after white swelling (this does not always require it); 4, diffuse aneurism, threatening gangrene, not amenable to ligation; 5, other aneurisms disorganizing parts too seriously to admit of cure by ligature, etc. Traumatic Causes.—6, tearing off of limbs; 7, crushing of both bones and soft parts to disorganization; 8, comminuted fractures, with destruction of the great nerves at the root of the limb; 9, wounds of large joints not admitting of resection and extensive injury of coverings; 10, compound dislocations with great destruction of soft parts and principal vessels; 11, very destructive burns: 12, traumatic gangrene. Surgeons should carefully avoid the vulgar error of being influenced by the external appearance of the wound, instead of the condition of the parts, and the state of the innervation and circulation. RESECTIONS. Of these important operations I find a considerable number of records,- several of which are derived from a valuable report of Dr. Henry Lyster to the Michigan State Medical Society: TABLE XII. EXSCISIONS OF LARGE JOINTS AND BONES IN THE LAKE STATES. OPERATOR. Dr. E.Andrews. Dr. J. S. Sherman. " Bogue,..... " D. Brainard REASON TOR OPERATION. Caries of ankle............ Deformity of ankle fr.inj'ry Comp. fracture of elbow... Caries of, ankle............ Caries of knee (recent)--- " shoulder........ " knee............ " shoulder........ " knee ............ " tarsal bones..... Talipes varus............. Hip dis. and caries Of ankle Caries of ankle after fract. Hip disease and caries. None, COMPLICATIONS. Abscess at ankle. None............. Tuberculous family None.............. Hip disease, carious. Hip disease, carious. 25jHip disease, carious. 18 " " " 26 " 8| " OPERATION, Cond. at opr Excision of ankle " elbow ... " ankle... " knee___ " shoulder " knee___ Bxc. up. 3V2in.humerus " of knee......... " of ant. tarsals..- " of ankle......... " head of femur... " of ankle......... Good Bad.. Med . Good Bad.. None.............. Cachexy following diphtheria......- None.............. None.............. " head of femur___ " hd.&troe.lianterfem " head and (part tro- chanter of femur--- Exc. head of femur--- " " " and part of trochanter. Exc. head of femur___ " '■ " and 2 in. of trochanter. Exc. head of femur.. Exc.hd.fem.& trochant. Exc. head of femur. Time to Operation. Result. several yrs. primary ... S.years..... 2 weeks___ some mos. 2 years..... recovered died.. recovered some mos. congenital. 6 years..... secondary . some mos.. 7 years..... 2 years..... Good Bad.. Med. Bad.. 2 years.. 2 years.. 1 year .. 6 mos... several mos 3 years.. 9 mos... Time to death or recovery. 10 days.. failed. recovered some ms. died..... recovered died. recovered died .. recovered died. recovered 4 weeks. 8 mos... 2 years. 10 mos. mos— 4 mos___ 4 weeks.. 7 mos--- 4 mos___ 4 mos___ Practice. Hospital . Private .. Hospital. Private .. Hospital. Private .. Hospital. Private ... Hospital. Private.. ' Table XII, 1532 Dr. E. Andrews... 7543 60 20 " D. Brainard___ 50 " A. Fisher...... " J. E. Owens... Cook Co. Hospital. iOiDr. N. Senn....... •26 Dr. II. Wardner___ 17 Dr. E. D.Kittoe.... 12 '• " " _ 11 Dr. E.I). Kittoe... 25 " M. (illllll....... " J. II. Beech.-.. 8 " T. A. McGraw. 5 " H. F. Lystor... 7 '• " " _ 11 " J. F. Miner___ 9 Dr. D. O. Farrand. 8448 Dr. E. Andrews... 8598 20 " " " 7794 40 " " l> _ 7823 40 " " " Caries of knee............ Car.head humerus,gunshot Diseased knee............. None . Tumor of upper jaw. Caries of elbow....... Hip disease.......... Disease of lower jaw. Hip disease.......... Osteo-sareoma lft sup. max Necrosis of tibia....... " of lower jaw.. Necrosis of lower jaw..... Caries of head of humerus Caries ofhip joint........ Caries of hip joint....... Caries of ankle joint..... " of shoulder,stabbed Comp. fract. ankle..... Commin. sup'g fract. ankle Syphilitic None. None. None. Contus. intern. None.......... ■Continued. Exc. of knee......... head of humerus knee............ Med . entire jaw. elbow joint...... hip joint......... nearly entire jaw hip joint and Ay2 in. of femur....... left sup. maxilla. shaft of tibia--- half the body of lower jaw.......... head &3 in hum's hd. & troch. femur " head and part of trochanter of femur Exc. femur, head and trochanter of femur Exc. ankle joint....... " shoulder joint... " ankle joint...... Good Bad.. Good Bad.. Med . Bad.. Good Bad.. Med . Good Good Bad. Med 1 year.. 18 mos. 4 years___ 16 mos. 18 mos. 3 years 2years--- 18 mos___ many mos some years Bad.. 20 hours... died.. Good 4 weeks___recovered died..... recovered 5 weeks.. died..... recovered died recovered died .. recovered died.. recovered 3 mos--- 5 weeks .. 10 days. Private Private . Hospital Private Hospital. Hospital . Private .. 72 RECAPITULATION. CASES. DIED. PER CENT. MORTALITT " Resection of the shoulder joint___________..... 5 2 19 8 9 8 0 0 8 3 1 1 " " elbow " __ -.....___.. " " hip " ____............ 42 " " knee " ________________ 37 " " ankle " ____............ 11 " of other parts ______________ 12 Totals...............________......____ 51 13 25 PRIMARY RESECTIONS OF THE SHOULDER JOINT ABROAD. AUTHORITIES. Med. and Surg. Hist. War of Reb'n, part II., vol. II. p. 599. St. George's Hosp., London___.................___..... Circular No. 6, Surg. Gen. U. S. A........____....._____ Gant's Surgery, p. 672..................._______....... Chisholm's Mil. Surg., Confed. Amer. Array.....________ Deutsch. Zeit. Chir. Bd. 1, 2 und 5......_______________ Jahresbericht gesammt, Med. Bd. 2, p. 874____........ Warren's Surg., Confed. Amer Army___________________ Totals____...............____.....______......__ 845 CASES. DIED. 515 160 1 1 210 50 59 18 41 13 15 8 1 1 3 1 252 Mortality of primary cases, 30 per cent. INTERMEDIARY RESECTION OF THE SHOULDER ABROAD. AUTHORITIES. CASES. DIED. Med. Surg., Hist. Rebellion, part II., vol. II., p. 599___ 120 104 Mortality of intermediary cases, 46 per cent. r INTERMEDIARY AND SECONDARV CASES COMBINED; ABROAD. AUTHORITIES. Med.'ancl Surg. Hist. War of Reb'n, part II.,vol. II., p. 599. Gant's Surgery, p. 672_______.....-----_........_____ Chisholm's Mil. Surg. Amer. Confed. Army.............. Warren's Surgery, •' " " ___...... Arch. klin. Chir., Bd., 10 und 13....._____.....____ Deutsch. Zeit. Chir., Bd. 1, 2 und 5_____________________ Billroth's Briefe_______...........____.....__________ Dr. Herrgolt, Seige of Strassburg______________________ Totals. Mortality, 37 per cent. CASES. DIED. 316 131 34 6 29 7 2 1 4 1 49 13 6 2 3 1 443 162 73 PATHOLOGICAL RESECTION OF THE SHOULDER; ABROAD. Mortality, 19 per cent. CONDITIONS LMPERFECTLY STATED: ABROAD. AUTHORITIES. # CASES. DIED. Gant's Surgery, p. 657___.....__........................ 80 9 6 1 15 Archiv. klin. Chir. Bd. VIIL, S. 106, Bd. X., S.892, 1893.... Deutsch. Zeit. Chir. Liicke, Bd. II., S. 380................ 2 1 Statist, des Hop. de Paris,___................___________ 0 Totals.......... ___..........._______......... 96 18 AUTHORITIES. Otis' collection of foreign military cases, Med. and Surg. Hist. War of Rebellion, part II., vol. II:, p. 607________ London Hosps.,......................................... Trans. 111. State Med. Society, 1863......_____:.......... Bericht k. k. allg. Krankenhaus, Wien_____............. Archiv. klin. Chir. Bd. VIIL, Bd. X., Bd. XI_____________ Heyfelder Lehrbuch Resectionen, p. 210, being cases of Jagers, Paulo, Baudens, Esmarch, Ritter, Beith, Black- man and G. Meyer.............................------ Totals.....______________........................ 595 CASES. DIED. 378 156 8 2 6 1 6 4 28 9 169 30 595 202 Mortality, 34 per cent. SUMMARY. CASES. DIED. PER CENT. MORTALITY Total resections of shoulder abroad____________ 197!) 5 634 0 32 " " " in Lake States...... 0 OPINIONS OF AUTHORS. Gant's Surgery, p. 656, advocates resection of the shoulder in destructive diseases of the articulation. T. Holmes, Syst. of Surgery, Yol. Y., p. 664:, says this operation is to be preferred to amputation in gunshot fracture and componnd dislocation of the joint, when the injury is not too extensive, and is the only operation admissable in chronic disease of the joint, except perhaps rapidly growing tumor of the head of the bone, when he prefers amputation. Billroth in his Surgical Pathology, p. 472, says it is safer than amputation. 74 Dr. Hodges, of Boston, in his excellent monograph says \he results are excellent, but that the limb resulting being no better than that after natural anchylosis, the operation is not to be performed when there is good chance of natural recovery. T. Holmes,, of England, repeats the same opinion. Bryant, of London, and Woodward, of Washington, (Cir. No. 6, S. G. O.) praise the operation, but Bryant's quotations of Cir. No. 6 are very inaccurate as to this point. Ashurst says it ought not to be done for malignant disease. The other authors for the most part accept it as an estab- lished and valuable operation, without special discussion. Loftier (General-Bericht, 1867, S. 288,) favors it in military cases, but condemns it in the intermediary period. Stromeyer, Schwartz, McLeod and Demme all favor the operation in military surgery. CONCLUSIONS. ■ The five shoulder resections in the Lake States were all suc- cessful. In other regions the operation is fully recognized as far safer than amputation at the same point. The foregoing table of the operation abroad give as follows: Average mortality of resection of shoulder joint, 32 per cent. " " amputation at " " 39 " Every motive, both of safety and of usefulness of the mem- ber requires resection to be preferred to amputation, whenever the conditions admit of the choice. Destruction of the head of the humerus and of considerable portions of the soft parts do not necessitate the loss of the limb. The decision rests mainly on the condition of the axillary nerves and vessels. Generally if, after an injury, there is a pulse at the wrist and some innervation in the hand, the resection is to be preferred. In old irreducable dislocations with the head of the bone pressing on the axillary plexus, resection has been practiced but in the present state of surgery a subcutaneous division of the ligaments to any extent necessary to allow of reduction would usually be preferred. 75 The diseased conditions requiring the operation are for the most part so plain as to require no discussion. The primary- stage has the least mortality, the secondary the next, and the intermediary period is decidedly the worst, and should be avoided whenever it is possible. The classified results foot up as follows: Mortality of primary cases................30 per cent. " of intermediary cases............46 " " of interm. and second, cases comb.. 37 " " of pure secondary cases..........29 " " of pathological cases.............19 " RESECTION OF THE ELBOW JOINT. Of this operation my Lake State tables furnish me only two cases, both of which were successful. Abroad the figures were as follows: PRIMARY RESECTION OF THE ELBOW ABROAD. AUTHORITIES. Med. and Surg. Hist. War of Rebel'n, pt. II., vol. II., p. 845 Rept. Boston City Hosp., Dr. Cheever..................... Warren, Confed. Amer. Army............................ Esmarch, quoted in Gant's Surgery, p. 675................ St. George's Hospital, London______.................___ Chisholm's Mil. Surg., Amer. Confed. Army.............. Arch. klin. Chir., Billroth's collection, Bd. X., S. 892_____ " Bd. XIII., S. 576...................... Deutsch Zeit. Chir., German-French War, Bd. I.,S. 187, und Bd. II., S. 105____________________..........._____ Siege of Strassburg, 1870-71. Dr. Herrgolt............... Totals. 318 68 2 2 1 1 11 1 • 1 1 25 3 4 2 1 0 12 3 4 1 379 82 Mortality, 22 per cent. INTERMEDIARY RESECTIONS OF THE ELBOW ABROAD. AUTHORITIES. Med. and Surg. Hist. War of Rebellion, pt. II., vol. II., p. 845 CASES. DIED. 196 69 Mortality, 35 per cent. 76 INTERMEDIARY AND SECONDARY RESECTIONS OF THE ELBOW ABROAD, COMBINED. AUTHORITIES. Med. and Surg. His. War of Rebellion, pt. II., vol. 11., p.845 Warren's Surgery, Amer. Confed. Army, p. 399.....______ Esmarch, quoted in Gant's Surgery, p. 675........_______ Prof. Billroth, Arch. klin. Chir., Bd. X., S. 892......_____ Billroth's Briefe____................-------............ Chisholm's Mil. Surg., Amer. Confed. Army.....-------- Deutsch Zeit. Chir., Bd. I., S. 187 and Bd. II., S. 105______ Dr. Koch, Arch. klin. Chir. Bd. XIII., S. 575-6__________ Dr. Herrgolt, Seige of Strassburg, 1870-71___________..... Total................._____.....-.-............. 397 Mortality, 28 per cent. PURELY SECONDARY RESECTIONS OF THE ELBOW ABROAD, (LATER THAN INTERMEDIARY.) CASES. DIED. 250 74 3 2 29 5 3 2 1 1 36 6 64 16 4 1 7 5 397 112 AUTHORITIES. Medical and Surgical History of the War of the Rebellion, part II., vol. II., p. 845......---------------------- 54 Mortality, 9 per cent. PATHOLOGICAL RESECTIONS OF THE ELBOW ABROAD. AUTHORITIES. Boston City Hosp. Rep. Dr. Cheever---- Dr. R. Hodges______........--------... Rostock Hospt. Rept., 1868_____________ British Army Med. Repts.---------...... Gant's collection from British Hospitals... Heyfelder Lehrbuch der Resectionen, S. 216 Statist, des Hop. de Paris---.....------- Archiv. klin. Chir. Bd. VIIL and X------ Totals. 3 119 1 5 218 188 ."> 16 0 15 0 1 22 23 64 Mortality, 12 per cent. RESECTIONS OF THE ELBOW, WITH CONDITIONS IMPER- FECTLY STATED. The following cases have been collected by various authors, whose sources of information are partly the same, so that a portion of the cases are duplicated, but as it is impossible to 77 get access to all the original documents quoted, the duplica- tions cannot be eliminated. The totals, therefore, are too large, but as the duplications affect the cases and the deaths to the same extent, they do not materially vitiate the ratio of mortality: AUTHORITIES. Deutsch. Zeit. fiir Chir. Bd. II., III. and IV_______....... Archiv. klin. Chir. Bd. III., IV., VIIL, IX., XIII., XV. and XIX.........._............____.........._____ Jahresbericht gesammt. Med. 1871, S. 403..........______ Dr. Billroth, Archiv. klin. Chir., Bd. X........____...... Zurich Hosp., 1860-67....................________...... Dutrelepont's table........................____......... Heyfelder's Lehrbuch der Resectionen, S. 246-7__________ Bericht k. k. allg. Krankenhaus Wien.................... Stromeyer at battles of Langensalza and Kirchheingen..... Statist, des Hop. de Paris_____.......................... Gant's collection from British Hosps., Surgery, p. 675_____ London Lancet, 1862.........__.....................___ Circular No. 6, Surg. Gen. U. S. A_______......._______ U. S. Marine Hospt. Reports........____________........ Trans. 111. State Medical Society, 1863................... Totals___........................................ 140 428 1217 30 25 333 286 23 25 2 19 149 286 2 4 25 56 223 4 3 40 32 11 4 1 1 33 16 0 1 2969 450 Mortality, 15 per cent. GENERAL SUMMARY OF ELBOW JOINT RESECTIONS ABROAD. Primary..............................22 per cent. mort. Intermediary..........................35 " " Intermediary and secondary combined.....28 " " Pure secondary (later than intermediary). . . 9 " " Pathological...........................12 " " Unclassified...........................15 " OPINIONS OF AUTHORS. As usual there has been some conflict among writers over this operation, but' in the main they are pretty well agreed in its favor. Circular No. 6, S. G. O., says that the mortality of it in the United States army was a little greater than that of amputa- tion of the arm, but'attributes it to the fact that many of the cases were partial resections which the author, Dr. Woodward, 78 considers more dangerous] than complete ones in traumatic cases. The Medical and Surgical History of the War of the Re- bellion (prepared by Dr. Otis,) shows that in the American war the secondary cases were far safer than the primary, but recommends the primary because many cases not operated on are supposed to die before reaching the secondary stage.—Part II., Yol. II., p. 905. Yet on page 829 it gives the total mor- tality of non-operative cases at only ten per cent., which is less than half that of primary excision. As the non-operative cases are generally military, we cannot infer that operation is to be rejected in bad cases, yet the success of the non-opera- tive treatment suggests a doubt whether many would die while waiting for the advantages of the secondary period. The writer of the work thinks that in our army the substi- tution of resection of the elbow for amputation above effected no saving of life. The French armies, according to Chenu's statistics, had a fearful mortality in resections of the elbow, so that Prof. Sedillot declares it ought to be rejected from the service; but the German surgeons in the Schleswig-Holstein war had bril- liant success with it. Hugelshofer, Deutsches Zeitschrift fur Chirurgie, Bd. III., S. 8, gives the same opinion, viz.: that partial resections are dangerous, and ought not to be performed. At page 6 of the same article he assumes it as certain that complete resection is safer than amputation above the elbow, and remarks, " be the functional results good or bad, as you will, the preservation of a certain number of human lives, which would have fallen a sacrifice to amputation of the arm, or to conservative treat- ment, must give the operation the first place in the treatment of wounds of the elbow joint." Heyfelder, in his Lehrbuch der Resectionen, pp. 246-7 gives statistics showing that partial resections are rather more dangerous than complete ones. In an essay elsewhere pub- lished, he says the results are brilliant. Stromeyer recommends it in gunshot wounds. Demme and Saltzman give the mortality of conservative 79 treatment for gunshot wounds of the elbow as over sixty per cent., which is nearly three times the danger of resection for similar wounds. Hanover (Deutsches Zeit. Chir., Bd. III., S. 7,) opposes the operation bitterly, declaring that of sixteen army cases only one succeeded in getting anchylosis, and that when anchylosis was not obtained the limb was useless and burdensome, and the patient prone to desire it amputated. On the other hand, Hugelshofer says that in most cases a sufficient stiffening of the false joint is obtained to give a use- ful limb. Liicke, of Berne, admits that absolutely firm anchylosis is not usually obtained, but says that a loose arm is better than none. Neudorfer gives the operation a high rank. Billroth says that of sixteen movable joints in his observa- tion, all were more or less useful. Bickersteth, of Liverpool, says that of forty cases, thirty- eight survived, and all had very useful limbs, Gant's Surgery, p. 650, recommends the operation. Holmes' System of Surgery considers the operation prob- ably more dangerous than amputation of the arm. Erichsen favors it in proper cases. Gross' System of Surgery, Yol. II., p. 1085, considers it an established operation. Bryant, Hamilton and Ashurst all recommend the operation in proper cases. CONCLUSIONS. The opinion of several of the above authors that excision of the elbow is more dangerous than amputation of the arm, is wildly erroneous. The foregoing summaries show that the mortality of the excision varies between nine and thirty-five per cent., while that of amputation of the arm is from twenty to thirty-six per cent. It is evident, therefore, that the con- sideration of safety is decidedly on the side of excision, if the condition of adjacent parts admits of the choice. In regard to conservative, as compared with operative treatment, there 80 are no figures properly arranged for a decision because the non-operative cases are generally the mildest. The conserva- tive figures are very contradictory. Demme and Saltzman put the conservative treatment in gunshot wounds at sixty per cent., while Billroth observed it in twenty-four cases to be eight per cent. The Medical and Surgical History of the War of the Rebellion, part 11.,] Yol. II., p. 829, has by far the largest mass of conservative figures, viz.: Cases, 924; deaths, 96; mortality, 10 per cent. This seems at first glance a fine result, but when we consider that they were mostly slight wounds, we see that we have no true basis of comparison. When the bones are pulverized by the passage of a bullet, it would be folly to talk of conservatism. Slight compound fractures of the joint, and mild cases of caries do best without operation, under Lister's antiseptic in- jections and dressings, but bad comminution of the bone or extensive necrosis require excision. Amputation only comes in when the destruction of the circulation, or the presence of cancer, or other incurable conditions render the loss of the limb unavoidable. EXCISIONS OF THE WRIST JOINT. I have occasionally performed this operation, but have pre- served no records of the cases, nor obtained any from other Lake State surgeons. Abroad the statistics are very meager, and of doubtful value. I have gleaned from various works three hundred and five cases, with fifty-seven deaths, which is a mortality of nineteen per cent. Many of the cases were only partial, leaving the complex articulations of the remaining bones to suppurate and breed pyaemia in very unfavorable circumstances. It ap- pears to me that complete resections would be far safer. The utter poverty of the literature on this subject compels us to lay it aside as not yet properly investigated. Probably a complete resection would be advisable whenever it offers a fair opportunity to save a hand, whose innervation and circulation is in fair condition. 81 RESECTIONS AT THE HIP JOINT. Of these I have nineteen cases from the Lake States, with eight deaths, which is a mortality of forty-two per cent. They were all cases of caries of the joint. The literature of the pro- fession furnishes us the following figures for other regions: TRAUMATIC PRIMARY RESECTIONS OF THE HIP ABROAD. AUTHORITY. CASES. DIED. Circular No.*2, S. G. 0., p. 137, collected by Otis.......... 39 36 Mortality, 92 per cent. TRAUMATIC INTERMEDIARY RESECTIONS OF THE HIP ABROAD. AUTHORITY. CASES. DIED. Circular No. 2, S. G. 0., p. 137, collected by Otis........... 33 30 Mortality, 91 per cent. PURELY SECONDARY RESECTIONS OF THE HIP ABROAD. AUTHORITY. CASES. DIED. Circular No. 6, S. G. 0., p. 137............................ 13 11 Mortality, 85 per cent. COMBINED INTERMEDIARY AND SECONDARY RESECTIONS OF THE HIP ABROAD. AUTHORITIES, Warren, American Confed. Army .. Chisholm, " " " Billroth's Briefe................ Deutsch. Zeit. f. Chir. Bd. I., S. 187 Archiv. Klin. Chir., B. 13, S. 575... 1 0 2 1 2 2 1 1 1 1 Totals. Mortality, 71 per cent. Extensive statistics have been gathered on the Pathological Resections of the Hip Joint, by Hodges, Ashurst, R. Good, Heyfelder, Sayre, Fock, Leisrink and H. Lyster. These have been carefully collated by Ashurst, in the Pennsylvania Hos- pital Report, 1869, and in his Surgery, 1871. Gant, in his Surgery, published the same year, gives a collection of late 6 82 cases from British hospitals, which appear to be mostly or en- tirely additional to those collated by Ashurst. Tho two col- lections taken together give a tolerable summary of what is known on the subject, and are here subjoined: PATHOLOGICAL RESECTIONS OF THE HIP JOINT ABROAD. AUTHORITIES. CASES. DIED. Ashurst's Surgery, p. 605; terminated cases................ 327 79 163 Gant's " p. 638; " " ___............ 22 Totals_______________......___............____ 406 185 Mortality, 46 per cent. The cases of Sayre and other American surgeons are in- cluded in Ashurst's collection, with many from Germany, France, etc. Gant's cases are all British, and show decidedly better results than Ashurst's figures, which are gathered from all nations. The French and German cases especially are very fatal. GENERAL SUMMARY. Primary------j----........---..... Intermediary......................... Purely secondary............T------- Combined intermediary and secondary. Pathological........................ LAKE STATES. 19 PER CT. MORT 421 39 33 13 7 406 36 30 11 5 185 92 91 85 71 46 It appears, therefore, that in the Lake States we have no recorded experience of traumatic cases, but in pathological ones our results are somewhat better than the average o-iven in surgical literature, and immensely better than in France, where Leisrink gives a mortality of eighty-six per cent. The seventy-nine late cases from British hospitals, however, give only twenty-eight per cent., which is better than the Lake States by eighteen per cent, OPINIONS OF AUTHORS. Only a few years ago excisions of the hip joint for disease 83 were generally condemned, but of late this opinion has been reversed. Ashurst, (Penn. Hosp. Rept., 1869,) thinks it a serious operation, only to be undertaken when there is no reasonable prospect of recovery without it. He concludes: 1. That the sex of the patient is immaterial. 2. That the age is important, the success before puberty being much greater than after. 3. That total excisions are as successful as partial. 4. That in fatal cases only one-fourth of the deaths are due to the operation. 5. That in gunshot wounds (p. 211, Ashurst's Surgery,) fracturing the joint, excision, though very fatal, is the safest course. Gant's Surgery, p. 632, claims that destruction of the artic- ular cartilages of the hip without anchylosis always justifies the excision, (Mr. Hancock advocates the same practice,) but that the operation should not be performed for mere anchy- losis. Mr. Gant says that disease of the acetabulum does not prohibit the operation, but that the effect of spontaneous dis- location is rather to be reckoned as opposed to excision. For gunshot fractures of the joint he seems to favor the excision, as being excessively fatal, yet about the only hope left the patient. Prof. Sayre, of New York, says {Orthopedic Surgery, page 284), that in hip disease, with vitiated constitution and bones diseased beyond the operator's reach, the patient is probably hopeless; but when the disease is chiefly local, the constitution not undermined, the bones not affected beyond the possiblity of removal, and the circumstances of air, food, etc., favorable, the operation offers the best possible chances of recovery. Holmes, of England, in direct contradiction to Sayre, thinks that the poor patients, located in bad air and under bad nurs- ing, are the ones that ought to be operated on to relieve them, as quickly as possible, from the irritating diseased bone, while patients in good circumstances will have a better chance without operation. Hamilton favors the operation in a suitable selection ofj 84 carious cases, but doubts its applicability to gunshot wounds. Gross, Erichsen, Druitt, Bryant, Holmes and Johnstone favor it in a proper selection of cases of hip disease. Dr. J. S. Sherman, late Professor of Orthopedic Surgery and Diseases of the Joints in Chicago Medical College, says that in determining the question of excision for hip disease, " the general condition of the patient should be considered as much as the condition of the joint itself. Cases in which the gen- eral condition is bad, and which do not yield readily to treat- ment, should be operated on early, independent of the amount of caries; but where the general condition is good, and endur- ance can be expected, the operation should be postponed. The majority of such cases recover excellently without opera tion. Hence, it is justifiable to give them a chance and not exsect early, but if exhaustion occurs exsection is necessary." Surgeon Otis, of the U.S. Army (Circular No. 2, S. G. O. P. 123), after the most elaborate view ever made of the subject of gunshot wounds of the hip, says: " Primary excisions of the head and upper extremity of the femur should be performed in all uncomplicated cases of gun- shot fractures of the head or neck. Intermediate excisions are indicated if the diagnosis is not made out till late, and also in gunshot fracture of the trochanter with consecutive arthritis. Secondary excisions are demanded by caries or secondary involvement of the joint from fractures or wounds in the immediate vicinity." " Expectant treatment is to be condemned in all cases in which direct injury to the articulation can be clearly estab- lished." Hamilton, as we have already mentioned, doubts the sound- ness of Otis' conclusion. CONCLUSIONS. In caries of the hip joint, below the age of puberty, excision is not a very dangerous operation; and, although the mortality is from twenty-five to forty per cent., yet only one- twelfth of the deaths are due to the operation. Almost always the patient is relieved, and if he dies it is in spite of the 85 operation. Above the age of puberty the danger of the oper- ation is much greater, and the majority of the patients die. If this excision is contemplated, therefore, in a child approaching the age of puberty, it should be done as early as possible, and after that age should not be done at all if it can be avoided. Formerly excision of the hip for caries was generally con- demned, but some twenty years ago the old prohibitions were broken over, and numerous cases were operated on. As experience accumulated, however, it was found that though the operation rarely killed the patient, yet the wounds were very slow in healing, so that in many instances those that were not operated on recovered fully as early as those subjected to excision. This damped the ardor of the operators somewhat, and at the present time We seem to be forced to about the following conclusions: 1. Cases of morbus coxarius which do not suppurate, of course do not suggest any operation. 2. Suppurative cases, which do well under tonics, antiseptic injections, etc., should have a full and prolonged trial of expectant treatment, and only be operated on if their progress seems to be obstinately slow. 3. Cases below puberty, which gradually get worse, the fistulas ■ refusing to heal, and the patient steadily losing ground, should be operated on reasonably early, without waiting for extreme exhaustion. 4. Cases above puberty may be operated on if no other hope exists, but not until the minor operation of opening the joint and using antiseptic injections and dressings has been thoroughly tried on Lister's plan. 5. Sex exerts little influence on the results. 6. Disease of the ilium, to a moderate extent, is no obstacle to excision. 7. When spontaneous luxation occurs it usually relieves the patient of a great irritation, and favors spontaneous recovery, but if otherwise it constitutes no objection to excision. 86 8. The great majority of cases of suppurating hip disease will recover without operation. 9. In uncomplicated gunshot fractures of the hip joint, the present state of science indicates that excision should be per- formed as soon as possible, yet nine-tenth of the patients are reported as dying; and if all the cases were known, which the chagrin of the surgeons caused them to suppress, the mortality would show still worse. It is greatly to be desired that more light should be had on this terrible subject. Surgeon Otis could scarcely find a single clear case of recovery from gunshot fracture of the hip without operation (Cir. No. 2, p. 121), yet the depth of the parts caused the diagnosis to be very doubtful in many cases; and we may well stagger at an opera- tion whose deaths are an unknown quantity, ranging some- where between ninety and one hundred per cent, of the whole. Perhaps the antiseptic plan would give better results. RESECTIONS OF THE KNEE JOINT, t This operation has received-little favor in the Lake States. I have records of only eight cases, of which three died. All the eight cases were pathological. In other regions we have the following list. (The numbers being too few, and the records too imperfect, the traumatic cases cannot be classified into primary, intermediary and secondary. They are all for gunshot wounds and display a fearful mortality): TRAUMATIC RESECTIONS OF THE KNEE JOINT, ABROAD. AUTHORITIES. Circular No. 6, American Cases____....... " No. 6, Foreign " _______.___ Chisholm, Confederate Army, Unifjd States Warren " " " " Billroth, Arch. klin. Chir. B. X. und Briefe. Billroth's Briefe, p. 267................... Geissel, German-French War.............. Herrgolt, " " ------------- Totals___.......................... Mortality, 85 per cent. 87 PATHOLOGICAL RESECTIONS OF THE KNEE JOINT, ABROAD AUTHORITIES. Boston City Hospt. Rept___............................ Cases Collected by Dr. R. Hodges, Boston............... " M. L. Peniere, 1762 to 1869......... " " Gant from British Hosps. Gants' Surgery p. 621_____________.............. Sundry German Operators........................_____ Totals............................................. 901 208 431 241 15 1 60 131 64 265 Mortality, 29 per cent. Some of these figures of different authors include, partly, the same cases as others, and their analysis does not enable me to separate them completely; but as the repetitions affect both columns alike, they do not materially change the ratio of mortality. GENERAL SUMMARY OF RESECTIONS OF THE KNEE. Lake States, Pathological. Traumatic, Abroad....... Pathological, " ______ 53 901 3 45 265 PER CT. MORT. 37 85 29 It appears, therefore, that, contrary to our experience in amputations, pathological resections of the knee have been less successful here than abroad. However, the number of our cases is so small that this may he an accidental occurrence. OPINIONS OF AUTHORS. Hodges shows that excision of the knee has a higher mortality than amputation above it, and that out of 208 case 102 failed or died. "-Bryant, of London, shows that of 431 cases of disease of the knee which were amputated, the mortality was only twenty-two per cent., while of 178 similar cases resected, thirty-nine per cent. died. After a careful reivew of the subject, he opposes the operation. T. Holmes speaks discouragingly of the operation, but 88 allows that it may, perhaps, be done in chronic disease of the knee, in patients below the middle age. Gant favors excision cautiously in caries, provided the disease does not occupy too much of the bones. He endeavors to show that the mortality of excision -of the knee is no greater than that of amputation of the thigh, and conse- quently preferable, because it saves the limb with no greater risk than is incurred in amputation. In this argument he commits the singular error of comparing the mortality of the excision with that of amputation of all parts of the thigh, high and low, alike. Now, the choice lies only between excision and amputation at the lower third of the thio-h, where the mortality of amputation is much less than that of excision. Pirogoff' disapproves the operation in war surgery. Hamilton discourages the operation, especially in gunshot wounds. McLeod and Longmore oppose it in military practice. Ashurst opposes it in gunshot cases, but allows it in dis- ease. He says it is not very successful below five years of age, and very fatal in persons past the prime of life;" but the safest period is from five years to puberty. Recent cases of disease should generally not be operated on; but only those which have either actually proceeded to caries and suppura- tion, or else show the characters of gelatinous arthritis (white swelling of old writers), in the doughy, semi-elastic swelling. In a suitable selection of such cases he recommends excision but in those who are too old, or too young, or who have vis- ceral complications, or too extensive disease of the bone to leave a useful limb after its excision, or who cannot afford the long time of recovery which excision requires, amputation is to be preferred. (Med. Record, Yol. 2, p. 443.) Erichsen allows it doubtfully in extensive disease or faulty anchylosis. Sir Geo. Ballingall favored it in civil, but opposed it in military practice. Guthrie favored it in military practice, provided all the circumstances were favorable. 89 Gross approves it for disease, if the latter is not too extensive. Butcher, Swain, Ferguson and P. H. Watson approve it strongly, and Druitt says it is one of the greatest triumphs of modern surgery. CONCLUSIONS. The above opinions are contradictory enough to satisfy the genius of discord. In such a confusion of precepts of the masters, we must appeal to the facts, which give us the following results: PER CENT. Mortality of Traumatic Amputations of the Lower Third of the Thigh, Abroad..............................................45 to 60 Mortality of the Traumatic Excisions of the Knee Joint, Abroad.. 85 Mortality of Pathological Amputation of Lower Third of Thigh, Abroad___........................________________....... 20 Mortality of Pathological Excision of the Knee, Abroad________ 29 The figures of the Lake States, so far as they go, confirm the showing of a much greater mortality for the excision than for the amputation. Eighty-five per cent, is a terrible death rate, and is sufficient to condemn the traumatic excision to final oblivion. The pathological excisions are only nine per cent, worse than the amputations, and this difference is not so great but it may be properly overruled in some cases where the importance of saving a natural limb is very great. The drawbacks, however, must be considered, and they are these: 1. Owing to the inflamed condition of the bones the time of healing is often ten or fifteen months. 2. There is always considerable doubt about such an anchy- losis of the bones as will enable the patient to step on the limb. 3. A large per centage of cases fail so completely as to necessitate a subsequent amputation. 4. In ohildren, if the operator removes the entire epiphysis of the femur, the growth of the limb in length is, in a great measure, arrested. A candid consideration of all these facts renders it impossi- 90 ble for the conscientious surgeon to recommend excision of the knee joint in more than a very few unusual cases. The eight pathological excisions of the knee in the Lake States are too small a number to yield any special conclusions, yet the three deaths in the eight cases are a dismal recom- mendation when compared with our twenty-two pathological amputations of the lower third of the thigh, without a single death. RESECTIONS OF THE ANKLE JOINT. Of these the Lake States furnish us nine cases with one death, which is eleven per cent. Abroad the literature is scanty, so that the subdivision of traumatic cases is impossible. Taken together they are as follows: TRAUMATIC RESECTIONS OF THE ANKLE, ABROAD. AUTHORITIES. Deutsch. Zeit. B. V., S. 26......... " B. I., S. 187........ " B. II..S. 106r_____ Stromeyer, Battle of Langensalza. Heyfelder, Resectionen, p. 162___ Circular No. 6, S. G. O........... Jaeger's Tables_____............ Sir Astley Cooper.........p...... Josse......___________......... Taylor........... Gants' Collection. Totals............................................. 147 CASES. DJED. 1 0 2 2 5 3 1 0 67 6 18 6 29 1 9 0 6 0 5 0 4 1 19 Mortality, 13 per cent. PATHOLOGICAL RESECTIONS OF THE ANKLE, ABROAD. AUTHORITIES. Hancock's Collection of British Cases.................... Heyfelder's Collection, deducting British Cases, Resectionen p. 162............................_________ Archiv. klin. Chir. B. 8 und 10__________ Deutsch Zeit. B. II., S. 380, Liicke.......... 25 1% 3 Totals............................................. 72 Mortality, 12 per cent. 91 OPINIONS OF AUTHORS. Hueter thinks resection of the ankle is indicated in suppur- ative inflammation of the joint. Langenbeck had a ''run of bad luck" with it, all his eight cases performed for caries being failures; however, he recom- mends it for many cases of gunshot wounds. He and the German surgeons generally favor the sub-periosteal method. Mayer opposes partial resections, but A. Rose and Frank Hamilton favor them when circumstances demand. Ashurst, p. 612, brings statistics to show that excision of the external malleolus has the same mortality as that of the entire ankle, viz.: twenty per cent. Pirogoff believes resection of the ankle to be safer than amputation in compound fractures, and that the risk of con- servative treatment is intermediate between the two. Kade disapproves the operation in most cases. Gant, p. 644, favors the operation for disease, provided the affected portions of the bones do not extend too far from the joint. In gunshot wounds of the ankle, he generally prefers excision to amputation, p. 289. Ashurst, pp. 211 and 612, favors both traumatic and patho- logical excisions. Holmes, in the first edition of his System of Surgery, opposed the operation, but in the second edition retracts his opinion, and cautiously favors excision. Gross advocates it where the caries is not too extensive. Erichsen and Druitt both oppose it. CONCLUSIONS. As compared with amputation of the leg in the lower third, excision of the ankle is much the safest. The following figures show the difference: Mort. of Exc. of Mort. of Amp. of low- Ankle, Abroad. er 3d of Leg, Abroad. Traumatic............................13 per cent. 33 per cent. Pathological..........................12 " 16 " In the Lake States the operation has proved a little safer than abroad, viz.: 92 Average Mortality of all Excisions of Ankle, Abroad........12*^ per ct. " Lake States....11 As between excision and amputation there is only one con- clusion possible. Excision is far the safest, and also preserves a useful foot for walking. It is therefore to be preferred to amputation whenever the choice is possible; that is, when the foot is not mortified, nor the parts above and below the joint too much diseased or disorganized to allow their serv- ing a future useful purpose. It is here to be remembered that Lister's antiseptic treatment has revolutionized some of our precepts. I have, by this method, healed an ankle proved by the probe to be completely carious, though I am sure that one could not always succeed in that way. It would be well in many cases to give it a trial before proceed- ing to excision. In the same antiseptic way, many compound dislocations and fractures of the joint can be readily cured without operation. On the whole the following statement probably gives pretty nearly the truth: CASES FOR AMPUTATION. 1. Death of the foot from any cause. 2. Cancer or incurable disease of the foot, rendering its presence pernicious. 3. Caries and necrosis, so destroying the parts above and below the joint as to render it impossible to remove the disease and have the end of the tibia rest on the foot, or to preserve periosteum enough to reproduce the bones. 4. Compound fractures effecting similar destruction of parts. CASES FOR EXCISION. 1. All ordinary cases of caries, which resist antiseptic treatment. 2. Certain cases of talipes, and displacement from old accidents, which resist orthopedic treatment. 3. Compound fractures and dislocations which have resisted antiseptic measures, and have not destroyed the circulation in the foot. 93 4. Dislocations of the astragalus, and compound dislocation of the tibia forward which will not remain in position after being reduced. CASES FOR ANTISEPTIC TREATMENT. 1. Caries in its earlier suppurative period. 2. Simple suppuration of the joint. 3. Compound fractures and dislocations which will stay reduced, which have not destroyed the circulation in the foot, nor hopelessly disorganized too much of the adjacent parts. OPERATIONS UPON THE LARNYX AND TRACHEA. Of these I have obtained trustworthy records of thirty-five cases, some of which are of decided interest: TABLE XIII. Operations on the Larynx and Trachea. No. An-drew's Sur.Rec OPERATOR. < 2 6 4 1 1 12 ':} REASON FOR OPERATION. COMPLICA-TIONS. OPERATION. Cond. at opr Time to operation. Result. Time, to death or recovery Practice. Dr. H.A. Johnson " E. Andrews.. '' H.A.Johnson '• E. Andrews.. " II. A. Johnson " E. Andrews.. Memb. croup...................... None...... None...... None...... None...... None...... None...... None...... None...... None...... None...... None...... None...... Phthisis... None...... Trache.abv.thyroid gld. Bad.. 3 days 4 or 5 days. Died 1 hour .. 1 " .. Private.. Diphtheria........................ Memb. croup............________ Hospital. Private .. 11(5 it n Recover'd Died Successful Recover'd Died Recover'd Died Recover'd Died Died Lived..... Died ..... Lived..... 6 weeks 24 hours 138 n n 674 Oedema glotidis................... u Good Bad.. Med. ;l 7593 Foreign body in trachea........... Trache. below thyroid. " in haste....... " above thyroid . 1 or 2 days. some hours n 7592 i. i. 1 hour .. 10 min.. 4 days . 3 " .. 3 " .. t. 7594 ii ii " 7595 " 7598 Bad u 7599 Stricture of glottis with asphyxia. Oedema "................ 11 8003 " " " .. 4;'' " Herrick......j 4 " D. Brainard .. 1 Trache. above thyroid. ii Hospital. Abscess at root of tongue......... " " II. A. Johnson 3 " •• " | 3 Foreign body in trachea 3 months " None...... None..... None...... None...... None___.. Oedema of lungs___ " above thyroid. Bad.. Good Bad.. 4 days..... 8 " 6 '• 7 " 48 hours ... 16 days___ 2 weeks___ 10 days ... Private .. Memb. croup ..................... 24 hours 5 120 " 12 " 10 •' 20 " 14 days . " H. Wardner.. " II. A. Johnson " E. Powell .... " J. W. Freer... '• J. Andrews... " Onnn........ " J{. G. Bogue.. " II. A. Johnson 1 1 30 o 3 ,, it n n " above thyroid. Laryngo-tracheotomy . Trache. below thyroid. u n "■ Hospital- ForeiSnbodv in trachea::::;:::::: Private .. Diphtheria........................ None____ None___.. None...... None...... None...... None...... Art. mortis None...... None...... Ulc. larynx "• 28 days.. High trache. Tumor re-moved twice, 2d sucesfl Med.. 1 year...... 4 days ..... 8 " 5 months .. 7 days..... 5 " 7 " Not stated. „ ........ 3 10J iO; 5 li; 4 101 Trache. above thyroid. Bad.. Bad.. " iMed.. IBad.. Fair. 1 hour .. 10 hours 3 mos. .. few hrs. 23 hours 22 " ;; -- Cancer in larynx.................. Diphtheria....................... " :: •■ n ' ■■ ........ Swelling of laryngeal muc. memb. >t " :: 95 RECAPITULATION. CASES. DIED. 35 20 21 17 6 2 4 1 4 0 PER CENT. MORTALITY. Total for all causes........... For meinb. croup or diphtheria. For foreign bodies in trachea.. For Oedema glottidis......... For other causes_____........ 57 81 33 25 0 The diphtheritic portion of the cases, arranged by age, are as follows: Under 1 year. 1 to 2 years. . 2 to 3 " ... 3 to 4 4 to 5 5 to 6 6 to 7 7 to 8 8 to 9 9 to 10 CASES. DIED. 3 2 3 3 4 3 3 2 1 1 2 2 2 2 1 1 0 0 1 1 The case of epithelioma of the larynx was a remarkable one. The growth obstructed respiration, so that asphyxia was im- minent. Prof. H. A. Johnson then performed tracheotomy. The tumor continued to grow until it encroached downward upon the lower part of the larynx; the patient still wear- ing the tracheotomy tube. Prof. Johnson then divided the thyroid cartilage in the middle line, and removed the growth, which had its seat just below the vocal chords. The wound healed nicely, the patient still wearing the tracheotomy tube. After a considerable period the growth returned, and Prof. Johnson repeated the thyrotomy, removed the tumor more thoroughly, and cauterized the seat of it with nitric acid. The recovery was good, and the surpising part is that after two operations of thyrotomy, the patient has a good and con- stantly improving use of the vocal chords in speaking. The last operation was many months ago. The tumor has not returned. Its character as an epithelioma was thoroughly demonstrated by the microscope. 96 LARYNGOTOMY AND TRACHEOTOMY, ABROAD; FOR DIPHTHERIA OR CROUP. AUTHORITIES. Boston City Hosp. Rept....... Prof. Wilms, of Berlin......... Arch. klin. Chir. Dr. Kiihn, B. 8 K. k. allg, Krankenhaus, Wien.. St. Bartholomew's Hosp. Repts.. Totals..........................____.............. 641 CASES. DIED. 9 5 335 232 277 152 10 7 10 6 402 Mortality, 63 per cent. LARYNGOTOMY AND TRACHEOTOMY FOR DIPHTHERIA OR CROUP, ABROAD. Arranged by Ages, from Prof. Wilms, of Berlin. Under 2 years..... From 2 to 3 years. From 3 to 4 years. From 4 to 5 years. From 5 to 6 years. From 6 to 7 years. From 7 to 8 years. From 8 to 14 years CASES. DIED. 6 6 56 41 69 47 74 56 57 37 33 18 21 16 19 11 PER CENT. MORTALITT. 100 73 68 76 65 55 76 58 LARYNGOTOMY AND TRACHEOTOMY ABROAD, FOR 03DEMA GLOTTIDIS. AUTHORITIES. CASES. DIED. Archiv. klin. Chir., B. 8, S. 559.................. 73 19 Mortality, 26 per cent, LARYNGOTOMY AND TRACHEOTOMY, ABROAD; FOR REMOVAL OF FOREIGN BODIES. AUTHORITIES. Archiv. klin. Chir., B. 8, S. 559.................... Dr. Durham, Holmes' Syst. Surg., Vol. II., p. 496... Prof. Hamilton, of Columbus Med. Col., O......... Mortality 25 per cent. Totals............................................. 3g2 149 167 46 40 37 12 89 97 LARYNGOTOMY AND TRACHEOTOMY FOR ALL CAUSES, ABROAD. AUTHORITIES. Boston City Hosp........................................ A. E. Durham's collection of cases operated on for foreign bodies, Holmes' Syst. Surg........................... Med. and Surg. Hist. War of Rebel'n, Vol. I., Pt. I......... K. k. allg. Krankenhaus, Wien........................... Statist, des Hopit. de Paris, 1861-3.....................,_ Hopit. des Enfants Malades, Paris, 1851-63, quoted by Fischer & Bricheteau, Traiteraent du Croup, etc......*. Hopit. St. Eugenie, Paris, 1854-61, same authority......... Same Hospt., 18G2-3. Statist, des Hopit., Paris........... Other Hosp of Paris. " " " ____...... Dr. J. Kuhn, Arch. klin. Chir., B. 8, S. 559................ Totals..........__________....................... Mortality, 62 per cent. OPINIONS OF AUTHORS. Dr. H. A. Johnson, Prof, of Diseases of the Respiratory and Circulatory Organs in the Chicago Medical College, has had more experience in tracheotom}', probably, than any one in the Lake States. He gives the following Opinion: " Tracheotomy or laryngotomy should be performed in all cases of threatened asphyxia from causes which cannot be speedily removed by other methods, as for instance in cases of " 1. Foreign bodies in the larynx not easily reached and removed through the natural passages. " 2. (Edema of the glottis, threatening death from asphyxia. "; 3. Tumors, malignant or non-malignant, in the larynx. threatening asphyxia, and not easily removed through the natural passages. "4. Acute inflammation, simple or diphtheritic, producing so much obstruction to respiration as to materially diminish oxygenation of the blood. " The danger in aH these cases is not so much from the operation as from the disease for which it is performed, hence the earlier it is done the better. " The operation is seldom successful in children under two years of age. 7 CASES. DIED. 15 6 167 37 20 ,13 46 22 513 354 1013 749 396 329 225 153 17 11 707 269 3119 1943 98 " In young subjects especially high tracheotomy is prefera- ble to the low operation. "Ether may be given when there is not much asphyxia,but in the asphyxiated condition there is already anaesthesia. The exhibition of ether in such condition probably adds to the danger." A. E. Durham, of Great Britain, (Holmes' System of Sur- gery,) says laryngotomy should not be performed in early childhood, on account of the small size of the crico-thyroid membrane; nor in acute or extensive disease or injury of the larynx, but is adapted for adults, and especially for males. It is the best operation for foreign bodies impacted in the larynx, and for polypus, stricture and limited chronic disease of the organ. He recommends laryngo-tracheotomy when the pa- tient is too young for laryngotomy, and the surgeon fears to go below, but not for adults, lest the voice be injured. Tracheotomy he advises for adults, and generally the lower operation in dyspnoea from acute laryngitis, polypi, syphilitic diseases, etc. A. W. Barclay, of Great Britain, (Holmes' System of Sur- gery, Vol. IV., p. 513,) says in respect to membranous croup, " Our chief resource for prompt relief to breathing is tracheo- tomy." He distinguishes membranous croup from diphtheria, and is dubuous about the operation in the latter disease, but concludes that it is justifiable where the dyspnoea is so uro-ent as to throw other symptoms into the shade. Erichsen says that tracheotomy and laryngotomy are re- quired in croup and diphtheria when the laryngeal obstruction to respiration is great, and pulmonary and bronchical disease relatively slight. Many cases of dyspnoea from other diseases and from accidents also require it. Gross advises tracheotomy in urgent dyspnoea in oedema glottidis, diphtheria, etc., and also for foreign bodies in the air passages. Hamilton prefers crico-thyroid laryngotomy in apncea from hanging, drowning, and other causes requiring haste, thyro- tomy for laryngeal growths, and high tracheotomy for most cases of diphtheria and croup requiring operative relief. Low 99 tracheotomy he admits only for cases complicated with bron- chocele, or for impaction of foreign bodies in the bronchi. Druitt advises tracheotomy or laryngotomy for threatened asphyxia from croup, diphtheria, or from any other disease. CONCLUSIONS. The opinions of Prof. H. A. Johnson, quoted above, express the results of the best investigations on this subject so cor- rectly that it seems unnecessary to do more than refer to them as in my opinion giving the proper indications for this opera- tion. As between the Lake States and other regions the figures show to our disadvantage, thus: Mort. of laryngotomy and tracheotomy, 54 per cent. Ditto in Lake States,...... 81 " " I think this inferiority in the results of our surgery is due to two causes: 1. Operating on too many patients below the age of two years. 2. Delaying the operation until the patient' was too far exhausted to recover. The operation ought to be performed earlier. LITHOTOMY. Calculous diseases of the urinary organs in the Lake States seem to be less frequent than in Missouri, Kentucky and Tennessee. This is probably due to the fact that the water of the Great Lakes, which furnish the drink of all the towns on its shores is almost destitute of any mineral constituents, and differs but little from rain-water. Hence there is probably no surgeon on these shores who can show a list of cases so nu- merous as some of the operators elsewhere have done. TABLE XIV. LITHOTOMY. NO. IN MY bec'd OPERATOR. CJ CO F M M M M F M M M M M M M M M M M M M M M M M M M 6 < 12 7 38 11 5 55 65 35 6 35 5 7 12 2 3 35 52 40 4 2 5 53 11 DESCRIPTION OP CALCULUS. COMPLICATIONS. OPERATION. Cond. at opr Time to Operation. .Result. Time to death or recovery. Practice. Dr. Z. Pitcher.. Dr. E. Andrews. Large calculus............. recovered died . recovered died..... recovered died . ., recovered 54 Calculus fusible, 1 xl* in. '• 1 xl% " " aysx % " " l xiy2 " " 1 xl& " ii» " l&xia* " " 114x1% u " I&x2 " " 1 x2 " 9i " y2 " % " 2 Calculi.................. Dribbling of "urine. Chronic cystitis ... Lateral___."........... Good Bad.. Med. Good Bad.. Med. Good Med. ii Good 4 weeks.. Hospital. 20 some years 271 11 30 days.. 6 weeks.. 1294 11 u 1720 ii Forward to pubis * left n 1746 Severe hemorrhage fr. bladder be. op. None.............. 4 years..... some years 1V4 years... IK years... 2 days... 1755 1, 1766 u 1783 u u 25 days.. u 1785 « « « 1789 " •1 several yrs. 4 vears..... since birth. H 5700 Incontinence of ur. None.............. 11 11 weeks. Hospital. 5176 u 6060 « 6151 " " some years 6550 ti 3 weeks.. 3 " .. 4 " .. 4 " .. Hospital . 6836 Calculus mulberry, 3V4 dr.. " fusible, lxlJ4in.. 2 " 3 " small............. " i}4, in- long....... Phosphatic calulus, 1x154. 9 " " comb. 5l/20Z Calculus in memb. portion of uretha, 2l/t in. long... u 6930 " u lt 7017 n 11 !, 7526 « •1 7799 " n 1 mos___ 3 weeks.. 6 " .. 7693 n 11 " :: 1 year ..... Unknown . u 8497 11 11 Hospital. 8515 1. 11 © © Table XIV.—Continued. Dr. E. Andrews. Dr. J.S.Sherman Cook Dr. E Co. Hospit . Owens... Dr. H Dr.E . Wardner. D. Kittoe. Dr. J. Dr. E Dr. S Dr. J. Andrews. Powell... . S. Bedal . S.Sherman M 23 Calculus. " mxWi in......... Mulbenv calculus, 1 in___ Phosphalic " l%xl% in. Oxalate of lime calculus .. Small, soft phos. " Phospbatic " 5 drs. Dark-colored " 4 " Phosphatic " 3J4 " Large calculus, 2% oz...... Calculus. 1 large.several small calculi Calculi both in uretha and bladder.................. Calculus, wt. 6 dr.;........ 2x1 y, in. wt. 3 dr. Vixljn.. None. Delirium and exha. None.............. Ulcers and thick- ening of bladder. Ulcer of rectum. None. Urinary fistula. None.......... None... Cystitis. Rone ... Lateral Bilateral... Lithotomy. Lateral .... Supra-pubic. Lateral...... Bilateral... Lithotomy. LITHOTRITY. 6366 IDr. E.Andrews.|M|._I " concreted around a roll of chewing gum... Good Bad.. Good Med . Bad.. Good Bad. Bad.. Med '. Bad.. Good Good Med . Med . 5 years ___ 2 years..... some years 2 mos."..... 6 mos. 4 years . 20 years. 3 years.. lSyears.. some years 12 mos..... 14 years___ 8 years. 4 years. 10 years... died..... recovered died..... recovered 8 days. 4 hours .. died..... recovered died..... recovered died..... recovered died..... recovered 65 days. 6 weeks. 4 » 3 " 2 ' " Hospital. Private.. Hospital. Private.. I..............|10 sittings in 19 days.. |Good| 1 month .jHospital. 102 KEC A PITU LATION. CASES. DIED. 48 11 21 8 26 3 21 8 28 3 1 0 TER CENT. MORTALITY. Total Lithotomy.......... Lithot. over age of puberty " under " " Hospital.................. Private practice........... Lithotrity.............. 23 38 12 38 11 0 LITHOTOMY ABROAD. AUTHORITIES. Gross' cases—Gross on Ur. Org., p. 276. p. 270. p. 276. p. 276. p. 276. p. 276. Mott's Mettauer's " Kissam's " Goldsmith's " N. R. Smith's " Dudley's cases, Ky., given by Eve, Trans. Am. Med. As. 1871 Eve's cases, Tenn., adults................................ " " " children............................. Pope's cases, St. Louis, Mo., adults....................... " " '' " children..................... Boston City Hospital Report.........____............... Pennsylvania Hospital..........................._______ United States Marine Hospital Report................... Circular No. 3, S. G. O............................_____ Sir Henry Thompson's British Collection minus, the Noi wich cases........................___.........____ Mr. Chas. William's table of Norfolk and Norwich cases for 97 years..............._____......___.......... St. Bartholomew's Hospital.............................. St. George's " ....................._____»__ British Army Reports.................................... Luneville's Hosp.—Gross on Ur. Org., p. 276_______...... Hotel Dieu, La Charite and H6p. des Enfants—Gross on Ur. Org., p. 276______________.......................... St. Mary's Hosp., Moscow—Gross on Ur. Org., p. 276....... Loretto Hosp., Naples— " " " p. 276....... Saharunpore Disp, India— " " " p. 276....... K. k. allg. krank. Wien................................. Mission Hosp., Canton, China, Dr. Kerr................... Totals.....----......----.................. 5758 140 162 91 65 58 45 225 51 45 35 32 5 111 1 9 1034 1015 73 17 6 365 133 411 553 824 65 187 12 7 4 3 3 3 3 2 2 0 18 0 1 123 132 13 1 0 33 42 82 108 25 19 674, Mortality, 12per cent. The effect of age is shown by the following figures of Sir Henry Thompson: 103 MORTALITY OF LITHOTOMY AT DIFFERENT AGES. DURING THE YEARS. 1 to 5, inclusive. 6 to 11, 12 to 16, 17 to 20, 21 to 29, 30 to 38, 39 to 48, 49 to 58, " 59 to 70, 71 to 81, CASES. DIED. PER CENT. MORTALITY. 473 33 7 377 16 4 178 19 11 76 11 14 86 11 13 75 7 9 100 17 17 191 40 21 233 63 27 38 12 32 The following figures are token from Mr. Keith's table, British Medical Journal, March 20, 1869, and show the mor- tality in groups of twenty years: Under 21 years. 21 to 40 years .. 41 to 60 " .. Over 60 " .. CASES. DIED. 1530 151 356 66 477 108 479 156 PER CENT. MORTALITY. 10 19 23 33 Dr. Dulles, of Philadelphia, in the Am. Jour. Med. Sci., July, 1875, gives a table showing how the dangers of lith- otomy increase with the weight of the stone, as follows: Under one ounce................Mortality, 9 per cent. One to two " ................ " 16 " " Two to three" ................ " 41 " " Three to four" ................ " 43 " " Mr. Crosse and Dr. Gardner calculate the mortality accord- ing to size as follows for the Norfolk and Norwich Hospital and the Saharupnore Dispcnsar}-: One ounce and under One to two ounces ... Two to three ounces . Three to four ounces. Four to five ounces .. Five to six ounces ... Six to seven ounces .. Totals..... 1327 CASES. DIED. 969 88 249 38 68 25 21 12 11 6 7 2 2 2 173 104 MEDIAN OPERATION. Prof. Gross (Urin. Org., 1876,) gives the following collec- tions : CASES. DIED. American Surgeons................................... 205 56 64 25 9 Rever, of Cairo.......__................................ 9 Norfolk and Norwalk Hosp.............................. 13 Pemberton, of Birmingham._............................. 1 Totals......................................... 350 32 Mortality, 9 per cent. BILATERAL OPERATION. Cases, 536. Died, 41. Mortality, 8 per cent. RECTO-VESICAL OPERATION. Cases, 83. Died, 16. Mortality, 19 per cent. SUPRAPUBIC OPERATION. Dr. Dulles, of Philadelphia, gives the following comparison between the lateral and suprapubic operrtion, whicli seems to indicate that tne latter is safest for stones of very large size, but not for those of less than two ounces weight: WEIGHT OP STONE. Under one ounce... One to two ounces.. Two to three ounces Three to four ounces Four to five ounces . Five to six ounces.. Six to seven ounces. LATERAL OPER. CASES. DIED 529 119 35 11 5 2 2 47 18 16 7 3 0 2 SUPRAPUBIC OPER. CASES. DIED. 14 3 21 4 14 4 19 6 16 7 11 4 2 1 LITHOTRITY. This operation has been inexcusably neglected in the Lake States. I have record of only one case, which was however successful. 105 LITHOTBITY ABROAD. AUTHORITIES. Brodie.............................................. Fergusson........................................... Keith of Aberdeen..........____________........... Thompson.......................................... Crichton_____...................................... Boston City Hospital____............................ Pennsylvania "................................. Trans. Am. Med. As., 1871, Prof. Eve.................. Trans. N. Y. Med. Soc_____......................... Statist. Hop. de Paris, 1861-2-3....................... Civiale, Paris....._......................................I 591 K. k. allg. Krank, Wien.............................. Liicke, Berne....................................... Dr. J. G. Kerr, Mission Hosp., Canton, China.......... Totals____.......________.................... 1455 115 9 109 12 116 7 204 13 122 8 1 0 14 2 4 0 49 9 56 9 591 14 42 16 2 0 30 3 102 Mortality, 7 per cent. The large figures of Civiale, in the above list, showing a mortality only one-third that of the best surgeons elsewhere, have been received with much incredulity,, and even gave rise to direct charges of falsehood; especially as the official statis- tics of the hospitals of his own city show a mortality six times as great. It would be, perhaps, safer to exclude the Parisian statistics from the list entirely, which would leave the results of the operation elsewhere, as follows: Cases, 808; deaths, 79; mortality, 10 per cent. Probably this is not far from the truth. OPINIONS OF AUTHORS. Civiale was almost the inventor of lithotrity, or, at least, he was the first to give it a practical form, and to establish it in the profession. He advocated it warmly as a matter of course. Sir Henry Thompson says that lithotomy should not be performed in adults, for stones, unless they are above the middle size, say larger than an almond; but lithotrity be sub- stituted for it. Above the middle size he would be guided by the condition of the patient, as to his probable ability to 106 bear the number of sittings requisite to pulverize such large calculi. Most authors prefer lithotomy for children, both because the risk is slight and because the uretha is inconveniently small for lithotrity, and the child will not readily remain quiet during the sittings of the latter operation; yet Fergus- son and others have performed it on children, and Coulsen claims that it will prove safer for them than lithotomy. Mr. Hawkins (Holmes, Syst. Surg., Vol. IV, p. 1112) opposes lithotrity in children, but that in adults irritable bladders and diseased kidneys do not, as was formerly thought, necessarily forbid it. Erichsen, Bryant, Morland, Gross, Ashurst and Hamilton agree for the most part as follows. Lithotomy is generally to be preferred: 1. In children. 2. In very narrow and irritable urethras, with the calculus large. 3., In cases with badly diseased, irritable, sacculated or very atonic bladders. 4. In very hard stones over an inch in diameter, or softer ones over an inch and a half in diameter. Lithotrit y is preferred by these authors in nearly all other cases, but the rules must be subject to exceptions in cases where spec'il combinations of circumstances require it. CONCLUSIONS. Lithotomy is a rather rare operation in the Lake States. Its success here is also less than abroad, a fact in striking con- trast with most other operations. Of our forty-eight cases on record eleven died, which is twenty-three per cent., while the rest of the world gives us in over five thousand cases a death rate of only ttwelvei per cent. If we compare the Lake States with Missouri, Kentucky and Tennessee the contrast is still greater. In the latter States three hundred and eighty-eight cases give only twenty- two deaths, which is less than six per cent. The only reason 107 which I can offer for our inferior results is, that the disease being rare in the Lake States, the people, though so alert in business affairs, "are unaccustomed to'think of this disease, and in its earlier stages rarely suspect its existence. On this account they generally neglect it until it is so far advanced that the safest period for operation has passed by. One of my worst cases was that of a highly educated man who had a calculus for many years, and yet obstinately refused to entertain the idea of its existence, and rejected all the advice of his physician to submit to an examination. The remarkable results of lithotomy in Missouri, Kentucky and Tennessee are due to several causes: 1. The frequency of the disease keeps the populace alert on the subject, and prompt to seek aid if it is suspected. 2. Owing to the mildness of the climate the houses are extremely open to ventilation, even in many cases to the actual absence of doors and to the leaving out of all " chink- ing " from the intersticies of the numerous log cabins. Houses are built, not for tightness and warmth as in our cold climate, but for coolness and ventilation. The patients, therefore, are exempt, from many causes of pyaemia and other septic complications. 3. The population is thoroughly well fed and magnificently developed, averaging considerable taller and larger than in most other States. They are, therefore, better subjects for operation than the denizens of northern States, who are largely immigrants from Europe. 4. Dr. Dudley, of Kentucky, selected his cases. Prof. Eve says that in addition to his two hundred and twenty-five operations there were about eighteen patients, or seven per cent, of all whom Dudley rejected on account of their bad condition. If any surgeon rejects seven per cent, of his most .unpromising cases it will make a great difference in the per cent, of mortality, yet few conscientious men will feel justi- fied in refusing to give a man a chance for his life simply because that chance is not as good as the average. Dr. Dudley, I believe, generally used a gorget, and the bilateral incision. If I am correct in this, his large number 108 of selected cases is probably the reason why our figures show only eight per cent, of mortality for the bilateral method. The old rule is probably true which reserves the bilateral in- cision for the larger stones. The results of the median operation seem to show very favorably, giving a mortality of only nine per cent, but it must be remembered that these are selected cases, only small stones being operated on by that method, and hence'the figures give no true basis of comparison. Mr. A. Poland, in Holmes' System of Surgery, compares sixty-four cases of median with sixty-four cases of lateral lithotomy, and finds that the lateral proved the safest. On the whole it seems doubtful whether the median method possesses any decided advantage, and in future we shall hear less of it except in children, because it is now conceded that the majority of adult cases adapted to that plan are better treated by lithotrity. Suprapubic lithotomy seems, if the small number of tabu- lated cases can be trusted, to be the safest plan in stones weighing over two ounces. LITHOTRITY. This operation has been greatly and improperly neglected among us. We have not cases enough to determine its risk. Abroad the average mortality has been seven per cent., or if we exclude the enormous and disputed list of Civiale, it will be ten per cent. The later operations seem more successful than the earlier. Perhaps sevan per cent, may approximately represent the present average. There is no doubt that in almost all adult cases lithotrity is the safest operation, and that it should be preferred whenever special conditions of the patient do not render it inelioible. The present drift of science favors extending the application of the operation as much as possible. OPERATIONS FOR MECHANICAL OBSTRUCTIONS OF THE INTESTINES. Of these I find record of fifty cases, which are here sub- joined: TABLE XV. OPERATIONS FOR MECHANICAL OBSTRUCTION OF INTESTINES. No. in Rec OPERATOR OR REPORTER. 14 HO 40 58 45 38 50 80 4 35 30 27 60 65 20 36 60 65 50 52 62 38 51 84 48 34 55 55 CAUSE OF OPERATIOls COMPLICATIONS. OPERATION. Con-diti'n Duration belore operation Result. Practice. 22 21 695 1562 7694 7516 7722 Dr. E. Andrews.. Dr. A. Fisher__ Dr. F.W.Mercer.. Cook Co. Hoepit. Dr.H. A. Johnson. Dr. N. Senn...... Dr. J. Andrews.. Dr. E. W. Luc Dr. F.W.Mercer.. Strangulated congenital her " scrotal ' " femoral " umbilical ' " femoral ' " inguinal ' None Good Med. Good Bad.. Good Med.. Bad.. Good Bad . Recov'r'd Died Recov'r'd Died .... RecovVd Died___ Recov'r'd Died ___ Recov'r'd Died .... Recov'r'd Private.. k ..... ,i " n tt ". ' Mortified intestine tt " tt 36 hours . " t n n " i tt " opened 6ac....... 3 days ... 50 hours . 30 hours . 6 days ... 5 days ... 48 hours . 3 day8 ... 20 hours . 36 " 40 " 10 " " 8770 t it Hospital. 7725 7756 7754 t tt Private.. ' .....Gut mortified...... " artificial anus..... " artificial anus..... !! 8770 Hospital. 1 .....Mortified intestine tt " i tt tt 11 tt » it " tt Private.. -- " inguinal ' " femoral ' " inguinal ' " femoral ' " scrotal ' " inguinal ' ........Peritonitis........ " opened sac....... Bad.. Med'. I 4 days ... 6 " ... 6 " ... 5 " ... 4 " ... 2 " ... 2 " ... 15 hours . 10 " .. 2 days ... 2 or 3 day 5 hours .. -- ........Gut mortified...... » :: ........Gut mortified...... ........Cartilaginous tum-or on protud. int. n tt it u tt tt .... u u "(la Bad . I' n it tt tt tt 7787 " inguinal her nia ........None.............. " opened sac....... Good 4 hours .. Private. Table XV.— Continued. Dr. E. Andrews.. Cancerous stricture of rectum Stricture of rectum............ L'anceriius stricture of rectum Stricture of rectum............. Intnssucccption. None. None.......... None,.......... Lupus of anus. None.......... Gut mortified. None......... Lumbar colotomy___ Forced dilatation___ Gradual " ___ Forced " ___ Cut the stricture...... Forced dilatation...... Gradual " • ..... Pneumatic aspiration . Forced injections.__ Med.. Bad.. Good 'Bad.. Good Med.. Good Bad. Med. 2 years.. 2 years.. 3 days .. 1 day--- 8 hours . 24 hours iday---- Recov'r'd Hospital. Improved Private.. Cured ... Improved Died .... Improved Died .... Cured ... Died .... Hospital. Private.. Hospital. Private.. nospitai. Private.. Ill RECAPITULATION. CASES. DIED. 34 8 1 0 5 3 1 1 6 1 2 0 1 0 PER CENT. MORTALITT Herniotomy................................ Pneumatic aspiration of strangulated hernia . Forced injections for intussusception......... Pneumatic aspiration for intussusception..... Forced dilatation of stricture of rectum...... Gradual dilatation of stricture of rectum..... Incision of stricture of rectum............... 24 0 60 100 17 0 0 HERNIOTOMY ABROAD. The literature of the profession furnish the following sta- tistics: AUTHORITIES. Bellevue and Charity Hosp., New York, Hamilton___ Boston City Hosp.................................... Boston Private Practice of Dr. Cheever............... United States Marine Hosp. Repts.................... London Hosps.: quoted Arch, klin Chir., Bd. 8, S. 30. Larae British Prov. Hosps. " " " " " Small " " " " ". " " " . Dutrepont's personal observations____............... Paris Hosps., Old statistics of Malgaigne............. Statist, des Hop. de Paris, 1861-2-3..... Textor's Cases. Wurtzburg........................... K. k. allg. Krankenhaus, Wien.................... Deutsch, Zeitschrift, Bd. 2, S. 381.................. Arch. klin. Chir, Bd. 11, S. 320, 341.................. Totals........................................ 1475 31 10 17 5 326 177 118 12 220 172 56 259 27 45 15 7 7 1 136 72 53 1 133 136 24 114 16 15 730 Mortality abroad, 49 per cent. Mortality in the Lake States, 24 per cent. It thus appears' that the danger of this operation in the Lake States is less than half that of the published statistics abroad. I can only account for this by the fact that the alert, wide awake western man when he has a strangulated hernia which he cannot reduce himself, comprehends the urgency of his case, and promptly sends for professional help. The operations are therefore performed early, and are consequently successful. The slowness of the same people to apply for help in cases of calculus is because the latter disease being rare here, and coming on insiduously, is not understood nor suspected until a late period of its progress. 112 OPINIONS OF AUTHORS. There is no controversy, of course, as to the frequent neces- sity of this operation, and still further, all surgeons are agreed that when necessary it should be performed at the earliest practicable moment, as every hour increases its danger. Almost the only point of controversy has been whether the peritoneal sac should be opened, or the stricture divided outside the sac. Erichsen, Hey, Ashton, Key, Luke, Druitt, Bryant and Holmes prefer division of the stricture outside the sac except where fear of mortified intestine or other special reasons for- bid. Sir Astley Cooper preferred the extraperitoneal division in large old hernias, operated on early. Ashurst favors it in all cases where the taxis is justifiable. Gross and Birkett favor it in mild and recent cases, while Gant, Lawrence, J. F. Smith, Hamilton and Pirrie think that the sac should usually be opened, and the extraperitoneal division be reserved for exceptionally favorable cases. Statistics have been gathered to decide the question, but I have not inserted them, because they are worthless. At first glance the extraperitoneal shows much less mortality than the other method; but the fact that the early cases only are selected for extraperitoneal division, shows that this operation is performed on much the safest class of patients, while the later cases, where there is risk that the gut may be mortified, com- pel the opening of the sac. Late cases are always dangerous, whether there is mortifi- cation or not; hence, there is no proper basis of comparison. There are no reliable statistics of the two operations per- formed on patients of the same quality. CONCLUSIONS. Herniotomy is indicated whenever other means of relief fail, and should not be delayed a single hour unnecessarily. When there is strong reason to fear that the gut may be already mortified the taxis should be omitted for fear of returning a mortified intestine, and herniotomy should be 113 resorted to at once. Every hour of delay increases the danger. If the strangulation is so recent and mild that it is morally certain that no mortification has yet occurred, the extraperi- toneal division is the best, unless special circumstances forbid, for it diminishes the risk of peritonitis. The aspirator, of course, should never be used in a case deemed to be too far advanced toward mortification for prudent taxis, but it seems probable that in early stages it may be a valuable assistant to successful reduction, and experience has not yet developed any special dangers in its use. OVARIOTOMY. My records of this operation are mostly from Prof. Byford, and Dr. Dunlap, of Springfield, Ohio. 8 TABLE XVI. CASES OF OVARIOTOMY PEKFORMKD BY PROF. W. II. BYFORD. My first twenty-five operations were performed before the Great Fire, and the notes of them were burned up; the most I can say of them was that the proportion of recoveries was 66% per cent. One of these cases was in the Hospital for Women and Children, and recovered without any bad symptoms. My next thirteen cases are as follows: DURATION < OP TUMOR 30]3 years___ 31114 months. 32jG years___ 42 7 months .. 31 9 months .. 33 1 year...... 23 1 year...... 3fi 7 years..... 18(18 months. 24 0 years .... 24 17 months. 43 11 months. 2713 years..... SIZE AND DESCRIPTION OF TUMOR. Wt. 37 lbs. Multilocular. Right ovary. tents of main sac thick as jelly....... MAURI D GENERAL CONDI- TION BEFORE OPERATION. Married Married Single. . Sin MODE OR PECULIARITY OF OPERATION. Muitilocnlar. 28 lbs.......................... Both ovaries diseased alike. Two ovarian tn mors weighing 20 lbs........................ Two large tumors, one springing from each; ovarv. ~ Weight, 28 lbs....................... Dermoid tumor, weighing 23 lbs. Lett ovary. Married. .Health poor--- Multilocular ol right ovary. Left so diseased .,'„,, , as to require removal. Weight, 37 lbs.......Married. Health good..... Multilocular. 34 lbs........................... Single. .IV ry much l in par Multilocular. 28 lbs...........................|Married.j\ cry rnuch nnpar Dermoid cyst, 27 lbs .........................Singe. .[Health good. ... Multilocular. 30 lbs...........................ISingle. .!\ cry much impar Multilocular. 15 lbs...........................Married.) erv much impar Dermoid 30 lbs ................!Marned.,(>ood condition.. Multilocular. 45 lbs...........................^Married.1 Emaciated....... Greatly impairedjSecured pedicle with liga- | ature lelt in wound...... Recovered. Greatly impairediRighf ovary seat of tumor: lelt diseased and remov'd Recovered. Greatly impairediBoth ovaries removed.....iRceovered. TIME TO | DEATU OR PRAC- RECOVERY. 3 weeks___ (i weeks.. 2 months Greatly impaired Both ovaries removed. iDicd.......|21 days ... Recovered. (3 weeks... Recovered. Recovered. Died....... Recovered. Recovered. Recovered. Recovered. Recovered. 5 weeks... 3 weeks... 14 davs ... 2 weeks... 2 months . 2 weeks... 4 wesUs... ti weeks... Private Ilospit. Private Private ^ 115 In addition to the above I have accounts of 118 cases, of which 3i died, operated on by the following surgeons, viz.: Dr. Dunlap, of Springfield, Ohio, and Drs. E. Andrews, J. Andrews, D. Brainard, Brauns, A. Fisher, J. M. Hutchinson, A. K. Jackson and E. O. F. Holer. RECAPITULATION. AUTHORITIES. Byford's operations before the great fire (notes burned up). By ford's operations since................................ Dunlap's operations.................................... Other Lake State operators.............................. Total Lake States cases....................... 156 25 8 13 2 107 26 11 8 Mortality in the Lake States, 28 per cent. OVARIOTOMY ABROAD. AUTHORITIES. W. L Atlee, Philadelphia................................ Prof. Peaslee, N. Y...:................................... Dr. G. Kimball, of Lowell, Mass.......................... Spencer Wells, of England, 1876.......................... Dr Clay, of Ens;;., quoted in Peaslee on Ov. Turn., p. 248... Dr. Keith of Scotland, " " " " ... Thomas " " " " ... Bradford " " " " ... Dr. Cheever, of Boston.................................... Bryant (Trans. Obst. Soc, London, 1865)................... Tyler Smith, " " "................... St. Thomas' Hosp......................................... St. Bartholomew's Hosp.................................. St. George's Hosp........................................ Grimsdale, quoted Arch. klin. Chir. Bd. 8, S 813........... Cases in Germany, Russia, Switzerland, Italy, Spain, Australia and India, Arch. klin. Chir. Bd. 8..................... K k allg Krankenhaus, Wien_____.............------- Roosevelt Hosp.......................................... Totals....................................... 1660 350 28 203 500 250 136 27 30 4 10 20 3 23 5 10 35 Mortality, 29 per cent. 116 GENERAL SUMMARY. CASES. DIED. PER CENT. mortli'y. Lake States___........____________________ 156 1660 44 484 28 Abroad___________________......_________ 29 OPINIONS OF AUTHORS. In the treatment of ovarian cysts two operations have to be considered, viz.: Tapping and ovariotomy. On these points Prof. "W. H. Byford, of Chicago, has favored me with the following opinions: TAPPING. " Tapping an ovarian tumor is always attended with danger, and ought not to be resorted to without important reasons. This operation is especially hazardous in the polycystic variety. " It is allowable in monocysts, when the diagnosis is doubt- ful, for the purpose of deciding the nature of the fluctuating mass. " When the collection of fluid is very great and the patient in an exhausted condition, by evacuating it the patient will generally recruit under proper treatment. She will then bear ovariotomy better. " If for any reason ovariotomy is impracticable, we may often palliate the suffering and prolong the life of the patient by tapping one or more times, as the case may require. " Again, there is another condition, not very rare, in which tapping may be relied upon as curative, i. e., when the vitality of the tumor is decreasing. This condition is more frequently observed in patients somewhat advanced in years, and is recognizable by what I would denominate tentative tapping, or the history of the case connected with this operation. If after several evacuations the length of time in which the tumor fills up is increasing, we may expect by repetition of the operations the vitality of the growth will be exhausted and eventually will not till again. I have seen two remark- 117 able instances of this kind, in which the patients recovered after they had been tapped a number of times." "indications for ovariotomy." " We are justified in the performance of ovariotomy only when the patient's health is becoming impaired in consequence of the presence of the tumor. This will occur when it is large enough to press mischievously upon the vital organs. Of course other indications, under special circumstances, may determine the propriety of the operation, but it would not be expedient here to enter upon the consideration of them, as it would require too much space. " Ovariotomy should not be thought of until the diagnosis is so clearly demonstrated as to leave no doubt in the mind of the operator." Mr. Bryant, surgeon to Guy's hospital, thinks that tapping should be omitted in the majority of cases, unless needed for the purpose of diagnosis. Spencer Wells, however, whose vast experience gives weight to his opinion, thinks that previous tapping does not materially affect the safety of a subsequent ovariotomy. Mr. Bryant thinks that ovariotomy should be performed in almost all cases of benign polycystic ovarian tumor, except when the patient's health is so broken down as to render it nearly certain that she will not bear the operation. As to the time to be selected he thinks ovariotomy should not be thought of until the health of the patient begins to suffer seriously from the growth of the tumor. Jonathan Hutchinson discourages mere tapping, but speaks favorably of injections of iodine in the few unilocular cases. He favors ovariotomy strongly in proper cases, and reckons the risk at about 33 per cent. Spencer Wells, and all the other great ovariotomists, of course favor the operation in proper cases, and it is scarcely worth while to quote against their decisive authority the crude objections of less experienced men in the earlier years of the discussion of this subject. 118 CONCLUSIONS. The mortality of this operation, in the Lake States, has been 28 per cent, for all cases collected by me, but only 26 per cent, in the hands of Prof. Byford. Abroad the mortality has been 29 per cent, but grows somewhat less as skill and exper- ience accumulate. The operation has been safer in Great Britain than on the continent of Europe. It is a grave operation and never to be undertaken except after full investigation of each case, but there is no doubt that it is firmly established as one of the great operations of surgery. As remarked by Prof. Byford, it- ought not to be performed until the patient's health begins to suffer from the pressure of the tumor, and a very careful investigation of all the conditions of the case should be made before decision; and then, if it is found that no insuperable obstacle exists, the operation is to be positively recommended, for after the tumor begins to interfere with the functions of vital organs, the short and miserable remnant of a life, without an operation, may rationally bt risked for two chances out of three for a perma- nent cure. With regard to tapping the tumor, nothing better can be said than the judicious words of Prof. Byford, quoted above under the head of " Opinions of Authors." TRANSFUSION. This operation has been performed in the Lake States but few times, so far as I can learn. The records are very imper- fect, but some interesting observations have been made. Prof. Freer and Prof. E. Andrews have transfused for haemor- rhage in eight or ten cases. Prof. Freer's cases were the most numerous of the two, and one of them was so greatly improved as to give the highest hopes of recovery, when the patient suddenly died with symptoms of embolism. None of the cases of either operator finally recovered. Dr. Hotz trans- fused one case of haemorrhage with lamb's blood, with the result of saving the patient. Dr. Hotz, together with Dr. Prcegler and Dr. Wild, transfused, with lamb's blood, in eight cases of phthisis and anaemia. One was temporarily improved 119 and one died of the effects of the operation. Dr. Hotz is of the opinion that the operation should be limited to cases of recent haemorrhage, but Prof. Freer is disposed to think that if Dr. II. had repeated the transfusion some of the failures might have been transformed into successes. Prof. Freer has experimented largely on dogs, and from his observations concludes that the transfusion of defibrinated blood is the most successful plan. Abroad the operation, if honestly quoted, has been more successful. Laudois gives 96 finished cases, of which only 31 died, being a mortality of 32 per cent. The opinions of authors on this operation are generally expressed in rather vague terms, but for the most part they favor it for desperate haemorrhage. Gross, Freer, Ashurst, Moore, of England, Blnndell and others favor it decidedly. Freer and Ashurst prefer defibri- nated blood. CONCLUSIONS. The literature of transfusion is still in a very crude condi- tion. My opinion is, however, that in cases of dangerous haemorrhage it is an important resource, and that it is best performed with defibrinated blood. I think the ill success which has attended it in the Lake States is due to the reluc- tance of surgeons to undertake it promptly, and to the consequent fact that the patients were generally too far gone for recovery. MISCELLANEOUS OPERATIONS IN THE LAKE STATES. The following list contains a number of scattered cases recorded by myself and others worthy, perhaps, of notice, but not numerous enough to be tabulated in detail: 120 OPERATIONS. Trephining for frac of skull..................... " for insanity after fracture____.......... " for idiopathic insanity............____ " for epilepsy (permanancy of successes not known).............................. Ligation of common carotid artery for traumatic haemorrhage..................................... Ligation com. carotid for vascular tumor of orbit___ Ligation of brachial art. for traumatic aneurism..... Ligation of common iliac art. for aneurism of aorta.. Ligation ext. iliac for traumatic aneurism........... Ligation of ext. iliac for aneurism of femeral........ Ligation of femeral for wounds..................... " " " aneurism......_............ Compression of arteries for aneurism*.............. Stricture of uretha treated by internal section*...... " " " divulsion*............ " external perin sect.*__ " " " gradual dilatation*... Operations for haemorrhoids*....................... Forcible rupture of anchylosisf.................... Operations for ununited fracture*................... Stretching sciatic nerve for neuralgia (Nussbaum's operation)....................................... Neurotomy..............................._....... 10 2 2 1 1 1 1 1 1 3 2 6 24 15 2 50 45 8 24 * Records very imperfect. t Three of the successes were imperfect. For convenience of reference to those who wish to see at a glance what the experience of the world has been with regard to the principal operations, the following table is prepared: TABLE XVII. MORTALITY OF THE PRINCIPAL OPERATIONS. CASES. PER CENT. LAKE STATES PER CT. ABROAD. Amputation at shoulder ioint. orimarv...... 35 tt " " second, and inter, comb. " " pathological... 48 29 u " average of all cases .. ___ 30 39 u arm, primary____.......... 27 " " intermediary and second, combin. " pathological.............. 36 " 20 IC " average of all cases__ 11 35 II elbow joint, average of all cases .. 21 " forearm, primary.......... H II " intermediary........ 23 " " secondary ......... 16 121 TABLE XVII. —Continued. Amputation at forearm, pathological........._____ " average of all cases________ " wrist, primary.................____ intermediary___.............. " secondary.................... " pathological________......... " average of all cases........... " hip joint, primary............._____ " " " intermediary_______'_____ " " " secondary................ " " " pathological............... " " " average of all cases*...... upper 3d of thigh, primary........... " " " " inter, and sec. comb'd " " " " pathological_____ " middle" " primary___...... " " " " inter, and sec. comb'd " " " pathological...... " lower " " primary........... " " " " inter, and sec. comb'd " " '' ,l pathological...... " average of all thigh cases............. knee joint, primary.................. " " " intermediary and sec. comb'd " " " pathological__........... " details not stated.......... upper 3d, primary............... " " intermed. and sec'y comb'd let middle pathological average of all cases. lower primary_____......... intermed. and secondary pathologicalf........... average of all cases..... primary................ " " " intermed. and sec'y comb'd " " " " pathological_____...... " " average of all cases.........____ " " average of all times and locations " ankle, Syme's........................ " " Pirogoff's..................... " foot, Chopart's....................... Resection, shoulder, primary..................... " " intermedia^................. " intermed and second, together " " pathological____............ " average of all cases____..... elbow, primary........-------........ " intermediary................... " intermed. and second, combined . " " secondary, alone................ " " pathological................--- " wrist, average of all cases.............. hip, primary.......................--- " " intermediarv...................... 10 43 40 28 24 36 25 13 'V! * This per cent, in the Lake States was derived from only seven cases. expected to continue so low in the future. t Derived from forty-nine cases. Mortality accidentally low 9 It cannot be 122 TABLE XVII. — Continued Resection, hip, intermed. and second, combined--- " " secondary__..................... " " pathological..................... " knee, all traumatic combined.......... " " pathological.................... " ankle, all traumatic combined......... •' " pathological................... Herniotomy.............---------............. Hernia, radical cure operations.................. Lithotomy, 1 to 5 years........................ " 5 to 11 years........................ " 11 to 16 years........................ 16 to 20 years........................ 20 to 30 years......................... " 30 to 38 years........................ " 38 to 48 years........................ " 48 to 58 years........................ " 58 to 70 years........................ " 70 to 80 years........................ " average under puberty............... " " over " ............... " " all ages combined........... Lithotrity...................................... Tracheotomy and laryngotomy for diphtheria & croup, Under 2 years...........................---- 2 to 3 years................................. 3 to 4 years____............................ 4 to 5 years................................. 5 to 6 years................................. 6 to 7 years................................. 7 to 8 years______.......................... 8 to 14 years................................ All ages together........._.................. Tracheotomy and laryngotomy for cedema glottidis " " for foreign bodies . QSsophagotomy..........________............_. Ovariotomy.................................... Transfusion for haemorrhage..................... Ligation of the aorta........................... " common iliac artery................. " internal " " .........'........ " external " " ................. femoral " " ................ " profun. femoris " ................. popliteal "................. " arteries of leg and foot.............. •' innominata artery................. " common carotid " internal " " subclavian " axilla^ " brachial " radial and ulnar Trephining for fracture of cranium........ " for epilepsy................... Colotomy.................i............... Gastrotomy for stricture, foreign bodies, etc. Extraction of loose cartilages from the knee 42 37 11 24 38 23 81 25 28 123 I have in this unusually prolonged article endeavored to give a condensed view of the statistics and opinions of the world, on every principal operation in surgery. It has been a work of immense labor, but yet a very necessary one, for the contradictions of authors and the very frequent hastiness and superficiality displayed in writings of recognized authority render it almost impossible for the practical surgeon to dis- tinguish truth from error. I return my thanks to those gentlemen who have contributed their cases for the Lake States lists, and their names will be found in the tables. I regret that the great Chicago fire swept out of existence the records of several excellent surgeons, thus depriving me of the benefit of their extensive experience; but the cases which I did obtain have been carefully sifted and fairly represent the results of surgery in this region. Chicago, No. 6 Sixteenth St., Dec. 1, 1876. /%Usi^aJuq.&s-*- COMPLIMENTS OF THE AOTHOR. *i THE MORTALITY^ 3^ SURGICAL OPERATIONS UPPER LAKE STATES, COMPARED WITH THAT OF OTHER REGIONS. By EDMUND ANDREWS,. A. M., M. D., PROFESSOR OF PRINCIPLES AND PRACTICE OF SURGERY IN CHICAGO MEDICAL COLLEGK, ASSISTED By THOMAS B. LACEY, M. D., ASSISTANT SURGEON IN THE NATIONAL SOLDIERS1 HOME. CHICAGO: HAZLITT & REED, PRINTERS, 172 AND 174 CLARK STREET. I877. -J V JS k_z.r-i^\ NLM005617823