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able, except vomiting occasionally. I drove out each night for four nights and slept in the house, returning to office in town for day's business. Trained mother and older daughters so that my nurses were but little inferior to those nurses you find in the best hospitals.

Amputation at the Hip Joint, with Report of a

Case by Wyeth's Method.

BY H. H. VINKE, M, D.,

ST. CHARLES, MO.

A

MPUTATION at the hip has always been considered a very grave and formidable operation. In briefly glancing over the history of this

interesting operation, (see "Ashhurst's International Encyclopedia of Surgery,”) we find that the first removal of the lower extremity at the coxofemoral articulation through living tissues was done during the latter part of the last century, and inasmuch as the patient died, either as a result or in spite of the operation, the operator and the new surgical procedure were denounced by the entire medical profession. For a long time the propriety of this operation was seriously questioned, but this did not deter the bolder and brighter surgeons to resort to this extreme measure in cases where death was inevitable without it, and as a result of these efforts we find the first successful case reported in 1812, This was at a time when the methods of preventing alarming and tatal hemorrhage were unreliable and and only partially effective; when only partial anesthesia could be secured; and when the treatment of wounds was still crude and unscientific. To plan and to successfully execute such a formidable operation under such circumstances, was certainly an evidence of great skill and boldness on the part of the surgeon, and when it is remembered that chloroform, ether and similar anesthetics were unknown at this time, the courage of the patient is deserving of much admiration.

Two factors, principally, contributed to render amputation at the hip so extremely hazardous, namely, shock and hemorrhage. As nearly onefourth of the body is removed at this operation, it will be readily understood that shock will always remain a fruitful cause of death, but owing to improved methods of operating, of comparatively recent date, the dangers from hemorrhage have been reduced to a minimum. In that comprehensive

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and admirable work on surgery, International Encyclopedia of Surgery, the author says: “The most pressing risk in any amputation at the hip joint is that of hemorrhage, for a few jets from the femoral artery will reduce any patient to a state from which he is not liable to rally,” and according to Voelkner 33 per cent of those that succumbed after amputation at the hip, died within the first day and nearly all of these of hemorrhage. It might prove interesting to brietly enumerate the principal methods in vogue up to within recent date, to successfully meet this "pressing risk of hemorrhage," and then to describe the modern bloodless amputations. One of the earliest methods, and one most frequently resorted to, was the formation of a large flap from the anterior and inner side of the thigh by transfixion. As soon as cut, the flap was grasped by an assistant and the large vessels at once compressed. After the vessels had been secured, the head of the femur was exarticulated and the cutting of a small posterior flap completed the operation.

We can not help feeling astonished at the marvelous dexterity of the earlier surgeons when we read that this operation was completed in 1/2 minute. It must be remembered, however, that, at this time, chloroform had not yet come into general use, and every other consideration was sacrificed for the sake of rapidity. Later it was sought to compress the aorta or iliac arteries as a preliminary step to the amputation. The former was compressed a little below and to the left of the umbilicus by means of Lister's, Pancost's and Esmarch's abdominal tourniquets, or by manual or digital pressure; the common iliac artery was compressed by the hand of an assistant introduced into the rectum of the patient, as suggested by Drs. Woodbury and Van Buren, or by a lever devised for this purpose by Davy. Compression of the aorta through the abdominal wall can be done thoroughly and successfully in lean subjects only, and, even then, the hemorrhage must be considerable, so much so as to determine a fatal issue in many cases; besides this, the pressure is likely to do injury to the abdominal organs. As to compression of the common iliac artery, I do not know whether this method has been resorted to successfully in many cases, but even with the common iliac artery compressed, the loss of blood cannot be inconsiderable. The compression of the artery high up not being altogether safe or satisfactory, attempts were made to compress or tie the artery as it escapes from the pelvis. The artery may at this point be successfully compressed by the hand of an assistant, or by placing a firm compress over the external iliac, held in place by rubber tubing surrounding the posterior part of the thigh and the rim of the pelvis, as first suggested by Lloyd; then, too, the femoral artery may first be tied just below Poupart's ligament,

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which is still a favorite method with many surgeons. It is questionable whether the first two methods of compressing the external iliac or common femoral arteries can be relied upon to render the occurrence of hemorrhage impossible, and it has been claimed that the primary tieing of the femoral predisposes to secondary hemorrhage and affords a new avenue for infection. In order to avoid the primary tieing of the femoral, Hewson, Mus. scraft, Spencer, Myles, Dandridge and others either devised or improved needles and skewers, which are passed through the thigh, between the bone and vessels and upon which the artery is compressed by means of elastic tubing which encircles the ends of the needle in the form of the figure 8.

These methods of controlling hemorrhage were greatly improved upon by Trendelenburg, who uses two needles instead of one, in the following manner:

The first is passed through the thigh a little above and parallel to the point where the knife is passed through the soft parts, in order to cut the usual long anterior flap. The blood vessels are compressed by passing rubber tubing around the ends of the needle. After the tlap has been formed, the vessels are tied and the needle and tubing removed. The head is now disarticulated and the second needle passed through the soft parts a short distance above the base of the posterior flap which is to be formed. Again the blood vessels are compressed by passing elastic tubing around the ends of the needle in the form of the figure 8. After this the vessels are tied, and the needle and the tubing having been removed, the operation is completed in the usual manner. Notwithstanding Dr. Koenig's assertion to the contrary, (Lehrbuch der speciellen Chirurgie, 1894,) Senn's new bloodless amputation has apparently marked advantages over the amputation at the upper third of the thigh, and subsequent excision of the head of the femur, for it would seem that the latter operation, can only be considered in cases where the soft parts are in such a healthy condition as to admit of amputation at the upper third, whereas Dr. Senn's method may be safely resorted to in cases where the parts are so extensively injured or diseased that amputation at the hip is imperatively called for. Dr. Senn begins his operation by expelling the blood from the limb by means of Esmarch's bandage. The head of the femur is first excised, dislocation being effected by a long external incision similar to Langenbeck's incision for resection of the hip, but longer. After the head of the bone has been brought out through the external wound, a large dressing forceps, carrying a long rubber tube held in the center, is passed at the point of the cavity of the small trochanter through the soft parts and permitted to emerge on the inner side of the thigh. The tubing is then divided and each half of the tubing is used

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to first tie separately the anterior and posterior parts of the soft thigh, and then the remaining ends are utilized to firmly encircle the soft parts of the entire limb. This will arrest all hemorrhage, and after Esmarch's bandage has been removed, the surgeon proceeds to cut flaps, the long anterior and short posterior preferably. The blood vessels are now tied, drainage tubes are inserted at the most dependent positions, and the acetabulum is packed

with gauze.

But there is probably no method which commends itself for simplicity and effectiveness so much as Wyeth's. The fact that Esmarch's bandage can be applied to the limb up to the very point where the encircling compression tube securely arrests all circulation, renders this an ideal method. In fact, by means of it the circulation is as readily arrested at the hip-joint, and the loss of blood during an amputation at this point is not greater than at any other part of the thigh. The following description of Dr. Wyeth's method is in his own words (Medical News, Vol. LXIII, No. 1091): “With the patient in the usual position for a hip-joint amputation, the limb should be emptied of blood, either by elevation of the foot or by the Esmarch bandage applied from the toes to the trunk. While the member is elevated or before the Esmarch bandage is removed, the rubber tubing constriction is applied. To prevent the possibility of the tubing slipping, I employ two large mattress needles or skewers, about 3-16 of an inch in diameter and 10 inches long, one of which is introduced one inch below the anterior superior spine of the ilium and slightly to the inner side of prominence, and is made to traverse superficially, the muscles and fascia on the outer side of the thigh, emerging on a level with and about 3 inches from the point of entrance. The second needle is made to enter one inch below the level of the crotch internally to the saphenous opening, and, passing squarely through the adductors, comes out an inch below the tuber ischii. A piece of rubber tube, half an inch in diameter and long enough when tightened in position to go five or six times around the thigh, is now wound very tightly around and above the fixation needles and tied.”

In regard to the formation of flaps but little need be said. It appears that flaps have been taken from all portions of the thigh, and the single, oval, modified circular, antero-posterior flaps and other methods have had enthusiastic supporters, and excellent stumps are claimed for all these different methods. It would seem, therefore, that it is of little importance from what particular part of the thigh the flaps are obtained, on the other hand it is of the greatest importance that no diseased or crushed tissues are utilized. In cases where the tissues high up are so crushed or diseased that no healthy flaps can be made, the wound should be permitted to close by

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granulation. This brings me to my report of my case of amputation at the hip-joint by Wyeth's method.

The patient, a young girl, aged 16,- of healthy parentage, 'had never been seriously ill up to a year ago. About this time she was struck by her brother with a ruler on the upper part of the right thigh, and as the pain soon subsided, no attention whatever was paid to this slight injury. A few months afterwards, however, she noticed a swelling at this place, which grew rapidly but caused no pain nor serious inconvenience. When she first consulted a physician, Dr. J. E. Bruere, of this city, five months after the receipt of the injury, the tumor had already assumed large proportions. It occupied the upper third of the thigh and bulged out prominently on the anterior part. There was some doubt as to whether we had to deal with a lipoma, fibro-lipoma or with a sarcoma, although the rapid growth of the tumor pointed to the latter. It was determined to remove the growth, if possible. The incision through the skin and subcutaneous tissues revealed a large fatty cushion, and after this thick fatty layer had been removed, the real tumor came into xiew. This appeared like a large irregular sack, and seemed covered by the sheets of the muscles. Upon being incised a large quantity of a brown, semi-solid substance escaped, not unlike prune preserve. The muscles of the thigh were at this place totally destroyed and disorganized by the neoplasm. After removing the contents of the sac, it became apparent that the femoral vessels formed part of the tumor. In fact, so far as it could be determined, the growth developed from the sheaths of the vessels, probably being what the German authors term, Gefaessscheidensarcoma. Being unable, therefore, to remove the entire growth, we contented ourselves with filling up the sac with gauze and dressing the wound antiseptically. The removed mass was sent to Dr. Blickhahn, of St. Louis, who pronounced it to be a round-cell sarcoma. The wound healed kindly and for four months she had no further trouble, and was able to be around again. At the end of this time she noticed that the tumor grew with unusual vigor and rapidity, and this time the growth of the tumor was accompanied by pain. A sack like projection, the size of an egg, bulged through the upper part of the scar of the incision. In the course of a month this sac burst, giving rise to alarming hemorrhage, which was temporarily controlled by a thick compress. Amputation at the hip-joint now became imperative, in our opinion, and the patient and parents consenting, it was resorted to on the 13th of August.

Though weakened from hemorrhage and much reduced in health by disease, the condition of our patient was still fairly good. Drs. Bruere, C. M. and T. R. Johnson, Geret and Morgner, assisted me during the opera

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