progress of the disease; some, because they hesitate to leave the comforts of home, to live alone many miles away; others, because they have not the means to procure such a change. The latter class comprises by far the larger number of tubercular cases.

Now, I firmly believe that, by the construction of immense buildings, covered in part by roofs of glass to admit sunlight in abundance; containing an atmosphere which has been purified, filtered and dried, kept at an equable temperature, and constantly renewed by means of appliances similar to those used for the ventilation of certain factories-an atmosphere that is charged with ozone in definite quantities by using modern electrical contrivances we have a solution of this most important question. These conditions furnish all that changes of climate accomplish; that much must be admitted. There is no specific principle in mountain air that destroys the tubercle bacillus.

By the plan suggested, cases of tuberculosis could be properly isolated, they would not be banished like lepers from their friends, who will never see them alive again, and, being taken in their initial stages, would give some promise of ultimate cure.

It has not been my intention to enter into detail of construction of these mammoth sanitariums, but merely to call the attention of the profession to a question that demands their most earnest attention, and the consummation of which would be hailed with delight, not only by themselves, but by humankind with one accord the world over.

The advantages claimed for this system are: First: Cases would be taken at their inception and hence give greater promise of a cure. Second: A greater number of those afflicted with tuberculosis would be able to avail themselves of the treatment by climate. Third: Isolation would be complete, and the spread of tuberculosis by infection would be reduced to a minimum.

Fourth: Patients would not have to travel

long distances from home and be separated

from their families.

Fifth: Patients would not be subject to the vicissitudes of weather that are invariably

encountered in all climates.

Sixth: The time required for a cure, in favorable cases, would be much less.

SOME AMPUTATIONS PERFORMED DURING THE PAST YEAR.*

BY HOWARD J. WILLIAMS, A. M., M. D.,
MACON, GA.

Since March 26, 1895, I have performed nine major amputations on eight patients, and as many more of minor interest. Five were for traumatisms and four were for disease. The former were railroad injuries; of the latter two were in cases of chronic ulcer; one for tuberculosis of the knee, and one for conical stump. Two were reamputations; one a double amputation, and one a shoulder-joint operation. Recovery followed in all, primary union failing in three.

The first case I present is an amputation of the thumb and two first fingers with all the corresponding metacarpal bones. While not generally considered a major operation, it was more extensive than an amputation in the middle of the forearm, and certainly more difficult.

Henry B., male, 26 years of age, negro coupler, was injured while coupling cars July 26, 1895, near Lumber City, Ga. He was transferred to Macon and placed in the hospital July 27. The wound had not been entirely covered, nor had any antisepticism been used, hence it was infected with maggots when received in the hospital eighteen hours after the accident. The wound was undressed and efforts were made to remove the maggots with chloroform, carbolic acid, etc. On the third day gangrene began, blebs forming on the fingers. The temperature on admission was 102, on the third day it reached 104.4. It then gradually declined and by August 10 was normal.

August 27 the line or demarcation having completely formed, with the assistance of Dr. McHatton I amputated the thumb, first two fingers and corresponding metacarpal bones, served, but no drainage used. A small slough The anesthetic was ether; antisepsis was obformed on the dorsal portion of the wound. Sept. 12, 1895, with the wound granulating The patient was dismissed from the hospital

at the point of sloughing, and the ring and

*Read before the Central of Georgia Railway Surgeons' Association, at Augusta, Ga., April 14, 1896.

little fingers bent and permanently ankylosed. This case illustrates the results that will follow carelessly applied primary dressings. The wound, though extensive, would never have become gangrenous if it had been completely covered with proper antiseptic dressings. One-half of an inch being exposed to the air, it was promptly fly-blown, hence the The bones of the thumb and gangrene. fingers were broken, but had antisepsis been used and the hand placed on a splint, there would have been a good chance of saving the fingers. We thought for a time that the entire hand would have to come off, but by waiting and watching the case, we were able to save a portion of it. The remaining fingers are ankylosed, yet the man gets considerable use out of the stump, carries his dinner basket and uses it in various ways.

CASE II-COMPOUND COMMINUTED FRACTURE OF

THE LEFT HAND.

Wm. H., male, 25 years of age, negro coupler. This man was injured while coupling cars, Oct. 26, 1895, at 3:20 a. m., at the Macon yards. He was admitted to the hospital and the operation was performed at 6 a. m. The hand was amputated two inches above the wrist. The anaesthetic was ether; antiseptics were used but no drainage. The temperature when the operation was performed was 98.6; on the second afternoon it was 102, and rapidly declined, being normal the next day. The dressings were removed on the eighth day, primary union being found, except in one point, from which was discharged an aseptic mucilagenous fluid. On the twelfth day the patient was dicharged, with primary union.

The interest in this case rests upon the fact that no drainage was used, and that on opening the dressings on the eighth day, a thin pinkish mucilagenous discharge escaped from the wound. This was not pus, nor was it septic, simply a change in the consistency of retained exudations. I am never alarmed by this discharge, as it occurs often when no drainage is employed, and it does not interfere with union.

CASE III-COMPOUND COMMINUTED FRACTURE OF LEFT FOREARM AND ARM-LIMB

CRUSHED OFF.

Chas. S., male, 18 years of age, negro, a driver of a baggage wagon, fell from his

no

wagon, his arm being caught under the wheels of a slowly passing engine, on March 26, 1895, at 10 p. m. He was placed in the hospital and an operation performed at midnight. The amputation was two inches below the shoulder-joint. The anæsthetic used was ether. Antiseptics were employed, but drainage. The temperature was normal when the operation was performed. It was 102.4 twelve hours later, and gradually declined by the third day. Dressings were removed on the sixth day and the stitches taken out. The wound was uniting. Patient was discharged on the fifteenth day, primary union being the result.

The point at which this operation was performed is the more interesting feature, viz., near the shoulder-joint, and not in it. If it is possible to avoid an operation in this joint, it is our duty to do so. For by so doing we preserve the symmetry of the shoulder, and add to the comfort of the patient, as the stump aids in holding the clothing in place. Had the engine been moving rapidly, it would have been necessary to go into the joint, as the destruction of the tissues above the point of crushing by the wheels would have reached even up to the axilla. My flaps were very near the crushed tissues.

Wm. H., male, 32 years of age, negro tramp. This man was injured by falling under the car wheels, while stealing a ride near James Station, Ga., on Nov. 13, 1895, at 8:30 p. m. I was telegraphed for next morning and found him lying on a mattress in the agent's office, his foot bound up in old cloths, but no dressings on the arm. The operations were performed in the agent's office. Amputation of the leg was made at the junction of the middle and lower third; the arm was amputated in the lower third. The anesthetic was ether. Antiseptics and drainage tubes were used. The temperature at the time of operation was 100 degrees. The patient was made comfortable for the time in the office, and transferred the next morning to his home at Thomson, Ga., 75 miles further down the road. As the company was not liable for his injury, he was

then turned over to his own physician, Dr. Sterling Gibson. From this gentleman I learned by letter, that he was doing well ten days later; the wound was uniting, he had no fever, and was sitting up in bed. He made an uneventful recovery.

The injury to the foot was simply a complete crushing off through the ankle-joint; the injury to the arm, while there were only a few external signs, was more extensive. The skin was slightly torn near the elbow; the bones of the forearm, from the elbow down to within three inches of the wrist, were badly comminuted, being broken into fifteen or sixteen small pieces; the muscles were pulpified, and the arteries from the elbow down were destroyed. When I arrived, the forearm was cold and pulseless, the skin from the finger tips to one inch above the elbow joint was blacker than that of the rest of his body. This case illustrates how extensively the organs and tissues beneath, the skin may be injured with little or no evidence externally. In such a condition gangrene will inevitably follow, and perhaps death, if an attempt is made to save the limb. Several years ago I saw such a case which ended in death. It was a case of comminuted fracture of the femur, extending into the knee-joint,and injuring the popliteal artery, without laceration of the skin.* A tramp was caught under car wheels. I dressed his limb temporarily. He was then sent to the county poor-house, and an attempt made by the county physician to save the limb. Five days later, when gangrene had advanced extensively, amputation was performed, but the patient died twenty hours later. Had a primary operation been performed, no doubt the man would have recovered.

CASE V-TUBERCULAR ANKYLOSIS OF KNEE-JOINT.

Arthur W., male, 13 years of age, white, school boy. Records of family history showed that a grand aunt had hip-joint disease. Seven years agò this boy had knee-joint disease which left the knee dislocated and ankylosed. His general health since then had been good. The tubercular process had been arrested for six years, but recently he had had pain and some swelling in the joint, which alarmed his family.

Amputation was performed at the junction of the middle and lower thirds of the thigh,

* Reported in a paper for the National Association of Railway Surgeons, and published in the "Railway Surgeon" 1894.

on Jan. 7, 1896. Antiseptic dressings and drainage tubes were used. Anæsthetic was ether. Temperature, morning of operation, 100.2. The next morning it was 101, then gradually declined and on fourth day it was 98.6. The tube was taken out on the third day; dressings and stitches removed on the eighth day; primary union; discharged from treatment on the fifteenth day.

I first saw this lad six years ago in consultation. The tubercular process had about completed its ravages, the joint was destroyed and sinuses had formed, but the joint was not ankylosed. With Dr. McHatton, who also saw the case in consultation, I advised immediate amputation, as the destruction had been. too great to expect any benefit from excision of the joint. Our opinion was rejected and he was placed in charge of a physician, who promised a complete cure with every motion. preserved, with the result above stated-dislocation and ankylosis. When the case came back to me six years later, the limb was destroyed and fearing return of the trouble, amputation was readily accepted. Dissection of the joint after removal of the limb, disclosed a tubercular focus beginning in the tibia.

Operation by the circular flap method is my choice in all amputations. In this case I modified it by making a rather oval flap, beginning lower down on the anterior surface of the thigh, and slanting the incision upwards, so that on the posterior surface it was about two inches higher up. This gave, on recovery, a stump that has a smooth, rounded surface, anteriorly to support the pressure of the thigh against the socket of an artificial limb. The scar, which is slight, is thrown backward, where there is no pressure in using the artificial limb. The cushion over the end of the bone was carefully strengthened by nice adjustment of the subcutaneous tissues by buried catgut

sutures.

CASE VI-CHRONIC ULCER OF LEG AND KNEE, FIBROUS ANKYLOSIS OF THE JOINT.

Benj. L., male, 62 years of age, negro laborer, was scalded in childhood on the right leg and foot, leaving the ankle stiff, the knee

partially ankylosed, and the toes amputated.

Later on an ulcer formed on the outer side of the leg and knee in the cicatrix. This would partially heal and break down for a period of

forty years. As age advanced, his health became undermined. His arteries took on calcareous degeneration, digestion failed; and to save his life he wished the limb amputated. The urine had a specific gravity of 1026; no albumen; no sugar. There was no long complication. He was admitted to the hospital Sept. 19, 1895, and on September 20 I amputated in the middle third of the thigh. The anaesthetic was ether. Antiseptic dressings and drainage tube employed. During the first week his temperature varied daily between 98 and 100.4. During this time he was very much depressed, requiring persistent stimulation. The drainage tube was removed on the third day, and on the eighth day the stitches were taken out; primary union. On the eighteenth day he was discharged, walking out of the hospital on crutches.

The interest in this case rests upon the long history, 40 years duration, without any systematic complication, except atheromatous degeneration of the arteries. The blood vessels were so hard and brittle that I preserved a specimen (exhibited). When ligating the femoral, I did not apply the ligature directly to artery, fearing it would break the walls. With a large needle threaded with catgut, I went one-half to three-quarters of an inch above the end of the vessel, through the muscles and other tissues; with this, as a puckering string, I tied down the tissues, forming a cushion around the artery and so occluded its lumen. I I had no secondary hemorrhage. I encountered this same condition several years ago and had much trouble from the ligature breaking the vessel, and finally only controlled the bleeding by the same method used in this case.

CASE VII-CHRONIC ULCER OF THE RIGHT LEG OF TWENTY-TWO YEARS DURATION.

Ella W., female, aged 37 years, white, single, no occupation; has no specific history but is of scrofulous parentage. When 15 years of age she struck her right leg, outer surface, against a rail in climbing a fence, producing a slight wound, which never healed, but gradually extended until an ulcer, 6x10 inches in dimension, and one-fourth to one-half an inch. deep, had formed. This never grew better, notwithstanding various methods of treatment. Though only 37 years of age she presented the appearance of a woman of 60 years, thin, shrunken, wrinkled, skin yellow and

waxy, evidently a victim of amyloid degeneration.

She was admitted to the hospital Nov. 1, 1895, under Dr. H. McHatton, who was then on surgical duty. The urine had a specific gravity of 1010, contained a trace of albumen and some tube casts; no heart or lung complication. She was placed on tonic and alterative treatment. November 25, under strict antisepticism, Dr. McHatton amputated the limb in the lower third of the thigh. The anæsthetic was ether; drainage used. Coming out of the ether she vomited persistently for four days. The temperature was normal, and there was no pain. The drainage tube was removed on the third day. On the eighth day the dressings were changed and we were surprised to find no union whatever, the wound discharging two or three ounces of thick pus. The flaps gradually melted away, without any apparent inflammatory reaction, each day growing shorter and shorter, until the end of the bone covered with thick, unhealthy granulations protruded an inch and a half beyond the flesh. Nothing would arrest the destruction.

She remained in this condition until Jan. 1, 1896, when I went on duty. She was put on ferri et potassii tartratis, and local applications, under which treatment she began to show general improvement.

January 27 I reamputated, or rather resected the end of the bone, without disturbing the granulating tissues at the end of the stump. Anæsthetic, chloroform; antiseptics and drainage tube used. Cutting down upon the bone I passed a chain saw around it and sawed through. The bone was then peeled out and the incision sewed up with silk. No vomiting followed the use of the chloroform. Primary union took place in the incision and shortly after the granulating end of the stump closed up. She was discharged Feb. 26, 1896, recovered.

This case was an exceedingly interesting one, In case number seven we have a chronic ulcer of forty years duration in a negro, without any constitutional involvement; in this case. we have an ulcer of twenty-two years duration in a white woman, with amyloid degeneration. Thorough antisepticism was used in both amputations, primary union occurred in the first, sloughing following the second. Catgut was used in both operations for ligatures

and sutures.

The negro had fever during the first few days, the white patient had normal temperature throughout the entire time, she had no pain in the stump during the first week and but slight odor before the first dressings were removed on the eighth day. During the amputation both Dr. McHatton and I noticed a peculiar condition of the subcutaneous tissues and muscles; the former was of a bright orange yellow, color unlike healthy subcutaneous fat, while the muscles resembled beef which had been exposed to the air for several hours, bluish and glazed, the fibers. being extremely tough.

On opening the wound on the eighth day, and finding so profuse a suppuration and no effort at union, we were disposed to blame the catgut, but this was negatived by the fact that in a castration I had performed three days previously, I had used some of the same gut without any untoward results. Nor could we find any other circumstance or agent in the operation to cause sloughing and suppuration. We finally decided that, as the woman's system was saturated with bacteria, suppuration must have resulted in the amputation wound from this condition; further that as her system was already accustomed to the suppurative process, her temperature was unaffected by the infection of the new wound.

In the second operation I did not make new flaps, fearing a repetition of the sloughing, but contented myself with a simple incision and resection of the end of the bone. Primary union in the incision I made was quite as great a surprise to us as non-union was in the primary operation.

CASE VIII-CONICAL STUMP OF RIGHT ARM,

May J., female, aged 9 years, white, school girl. Six years ago when she was three years of age, her arm was crushed off by a falling tree. At that time I amputated the arm in the middle third of the humerus; primary union took place with a good rounded stump.

Oct. 1, 1895, her mother brought her back to me for treatment for conical stump. The bone had forced itself through the tissues covering the end of the stump to a distance of an inch and three-quarters, and it was covered with granulations, resembling very much the appearance of an ulcerating sar

23, but as she was suffering also with malaria, operation was deferred. Owing to her age and the probability of recurrence of the conical stump, it was decided in consultation that a shoulder-joint operation should be performed.

October 25 amputation was done through the shoulder-joint with Wyeth's pins to control the circulation. The anaesthetic was ether; antiseptic dressings and drainage tube were used. Not over half an ounce of blood was lost. The temperature when operation was performed was 98; that evening it rose to 101.2; on the second evening it was 103.6, with daily rise and fall for first week. By some misunderstanding the drainage tube was left in the wound for five days, and when it was removed pus flowed from the wound. Union by first intention in part of the wound and by granulation in the remainder. Discharged from the hospital Nov. 15, 1895, recovered.

This last case is interesting, as one of those occasional cases of growth of the bone after amputation in childhood, known as conical stump. The condition is not the fault of the operator, nor is it the result of inflammation, or retraction of the soft parts. The younger the child and the nearer the seat of the upper epiphysis of the humerus or the tibia and fibula, the greater the probability of its occurrence. The only other amputation in the humerus in childhood I have performed, was in a boy aged 9 years, caught under car wheels. Whether he has had the condition develop I cannot say, as he passed out of my hands immediately afterward, and I have not seen him in ten years. It has not occurred in several amputations in the leg which I have performed, and I do not think it is as prone to follow in this region as in the humerus.

The treatment recommended for the condition is reamputation through the continuity of the bone, but in this case, for the reasons given in the report, I decided on the shoulderjoint operation.

After the operation I dissected up the periosteum and found that it was inflamed; no doubt the inflammation had extended up from the inflamed granulating tissue covering the exposed bone beyond the stump. I felt satisfied on finding this condition, that the joint operation and not a lower one had been performed, for disease of the bone, no doubt, would have followed the latter amputation. (Humerus preserved and exhibited.)