Ferguson, of removing the projection of the astragalus in performing Chopart's operation, is an undoubted improvement. The upper extremity has been removed at the shoulder joint, between the 1st of April, 1855, and the end of the war, 39 with a fatal issue 13 times, or 33'3 per cent. Of these operations 33 were primary, and 9 deaths followed, giving thus a mortality of 27'2 per cent.; while of 6 secondary operations died, or per cent. During the previous period of the war at least 21 other cases of amputation at this joint were performed, beyond id ot'tliat numlior ("> died thus t"tal of r.:id 19 deaths, or a ratio of mortality of -r o-nt. It is impossible fairly to contrast the results of amputation at the shoulder and that in the shaft of the humerus; The mortality following this operation is shown in the fullowin-r ivr had upwards of 90 recoveries from about 100 cases on which he operated, and this success he attributes to his method of operating.:n military practice particularly, it very much oftonor happens that the trunk has suffered severely in those injuries which necessitate exarticulation, than those in which amputation of the upper arm alone is required.
Not a few illustrations of this occurred in the Crimea. Thus, in at least two of the cases returned as shoulderjoint amputations, "besides the injury to the arm, the scapula was carried away or destroyed, and the muscles of the chest torn. In no operation is the advantage of primary over secondary so evident as in that at the shoulder-joint; early operation at this part being an exceedingly successful undertaking, while late interference generally affords a considerable mortality. Thus, if we take Guthrie's experience in Spain, and Dr. Thomson's observation after Waterloo alone, this point is well illustrated: of 19 cases of secondary amputation mentioned by Guthrie as having been performed between June and December, 1813, 15 died, while, of an equal number who were operated on in the field, only 1 died.
Dr. Thomson again says, " In Belgium almost all of those recovered who had undergone primary amputation at the shoulderjoint, while fully one-half died of those on whom it became necessary to operate at a late period." The same point is illustrated to some extent by our Crimean results, less than a third of the primary, and two-thirds of the secondary perishing. Deputy-inspector Gordon had one case of recovery, in which both the arm and the greater part of the scapula were removed. Mr. Howard of the 20th regiment successfully removed the right arm of one man and the left of another, in close succession, at the joint, for injury occasioned l>y the.same cannon ball which had struck upper arm was performed in the i'rom April 1st to the end of the war, 1<>2 in 25 cases, the mortality per cent. I thus 24'5. Of the total number, 96, and 22 deaths were primary operations. The ratio of the mortality was thus 221) for the primary, and 50'0 for the secondary operations. tore-arm was amputated during the same period primarily, and the hand at wrist once, with one death; while of 7 secondary operations in the; arts, 2 died. These returns do not speak of a considerable number of secondary amputations of the arm, which were performed early in tin- war, and the success of which was certainly such as to warrant us in trying t the, most cases of wounds of the almost impossible to say what wound of the arm by a ball will not recover; so that it is a well-recogd rule to wait, in all but M-S, and only amputate if unavoidable at a subsequent illegible in the scan of the first
The edges of the flaps wnv usually united by suture. The observation of this iiu-thod in the Crimea did not certainly appear to be satisfactory. To wait, as Liston so strongly advocates, till all oozing has ceased from the cut surfaces, is unquestionably a most useful precaution, and one of great moment to their successful and early union. The irritation which the stitching of the edges occasions, the want of sufficient room for subsequent swelling, the confinement of pus which is thereby favoured, all appear reasons against sutures. Stripes of wet lint applied like adhesive plaster, always appeared preferable. I never saw one case among our most numerous amputations in which primary adhesion took place throughout the whole surface of the flaps.