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British Hospitals 41 per cent., the Imperial General Hospital of Vienna 36 per cent., and the hospitals of Paris the enormous deathrate of 60 per cent.
To a certain extent, the reasons of this difference are the same as in the operation of herniotomy, but there is this distinction between them. Patients suffering amputation are much longer in hospital upon the average than herniotomy cases, and if there is the least prevalence of those septic influences grouped under the name of “ Hospitalism,” they are apt to succumb to erysipelas or pyæmia. Now the people of the west, living in a dry climate, and permeated with frontier ideas, are accustomed to expose themselves freely by night or day to fresh air, sleeping with the windows and often the doors open. In such a population, the surgeon has little difficulty in enforcing thorough and constant ventilation, because all the patients, nurses, and interns habitually co-operate with him; bence septic complications are comparatively rare; but as we go east, the air is more moist, and the whole community, medical men, and all, are imbued with the constant dread of taking cold, and the further east we go, the more this fear seems to prevail. In a community possessed with this dread, the surgeon will be a remarkable man if he is not himself influenced by it to lower somewhat his demands for fresh air, and his attendants, brought up with the idea that the chief danger of the wounded man is “ taking cold," will, in spite of all orders, keep the doors and windows too much closed. The result, by a uniform law of nature, is a great increase of mortality. From these considerations, we see why there is but little difference between the results of hospital and of private practice at the west.
The terrible mortality of 60 per cent. after the major amputations of Parisian hospitals is largely explainable on the same principles. The ventilation is fearfully neglected there. Those who ever followed the old veteran Velpeau in his wards will remember the foul smell that pervaded them, yet this surgical hero, with a gravity and innocence that showed that he had no idea of his own responsibility in the matter, announced as a curious scientific fact, that every winter (when the windows are closed) there was an epidemic of erysipelas in his wards, and that the cases originating in his hospital were much more malignant than those entering from without.
Other Parisian surgeons have been seen to go their rounds, examining and probing wounds and ulcers, simply wiping their hands and instruments on an apron, as they passed from bed to bed, and taking no precaution against carrying septic contagion. When such things are seen among the head surgeons, it is easy to conceive what will be done by nurses and dressers.
In combating against hospital infection, the surgeons of the Lake States have had the advantage of smaller hospitals than those of the east, few of them ever having had over three hundred patients at the utmost, and most of the time much smaller numbers.
The opinion advanced by some surgeons, that a large hospital, after a moderate period of occupancy, becomes so contaminated that all its stones and mortar are full of fomites, and cannot be purified except by destruction, is not sustained by facts. St. Bartholomew's Hospital of London is a large one, and has been a long time in existence, and formerly suffered its full share of septic influences. Sir James Paget, however, very early began a reform, and since then Mr. Callender has so revolutionized every branch of the surgical administration, that septic influences are banished, and the results of ainputations are made superior even to the best of private practice. In the St. Bartholomew's Hospital Reports, vol. x., p. 133, he gives the following table as the result of the improved management:
This is a mortality of only about two per cent. Mr. Callender's attention is not confined to rectifying the ventilation. Sponges are banished; every patient has his own dressing brush, kept in his own glass of carbolated water; every bed of an operative patient is baked in an oven, before he is placed on it, and the most minute care is exercised to put the patient in good condition and to operate on him at a favorable stage.
The profession in London endorse Mr. Callender as a man whose truth and honor are above suspicion, and if this is so, it is safe to say that his experiment in St. Bartholomew's will revolutionize the hospitals of the world.
Sir J. Y. Simpson made an effort to ascertain the mortality of the four major amputations in private country practice in Great Britain. To this end he distributed to the profession of the
kingdom an immense number of circulars, asking reports of cases. The responses gave him a collection of over 2000 major amputations in country private practice, with a mortality of only 10 per cent. This would be a valuable result as showing the superiority of private treatment over that in hospitals, and instructive to us as showing that British private practice is twice as successful as that of our Lake States, had the statistics been rightly collected, but unfortunately, Sir James' method of gathering the figures bad a „fault which deprives them of almost all their value. As his erroneous plan is repeated every year by various committees of medical societies, a word or two in exposure of its fallacy may be useful. His plan was simply to prepare a printed blank for reporting the cases, and asking a response. This was mailed in great numbers to all parts of the kingdom; often to persons with whom Sir James was wholly unacquainted, and of whose truth and honor he had no proof. The result of such promiscuous circulars is always something like this
1st. Those surgeons who have happened to have a "a run of bad luck," that is, an accidental succession of fatal cases, feel chagrined at their ill success, and are by no means disposed to blazon it abroad. Generally they will not answer the circular.
2d. Those who, from skill or accident, have had a series of successful cases, are naturally elated, and will respond with alacrity. Hence, the fatal cases are suppressed and the successful ones reported.
3d. Dishonest surgeons (and there are some such in Great Britain as well as elsewhere) will falsify their reports, omitting fatal cases, and stuffing the blanks with fictitious successful ones.
For these reasons the plan of Sir J. Y. Simpson, and of so many surgical committees, of mailing blank reports to a great number of unknown practitioners, must bring in statistics which are utterly delusive, and whose falsification is always on the side of success.
To avoid this error, I collected the above statistics by applying only to surgeons whose integrity and truthfulness were personally known to me, and made the applications in such a way as to obtain a full report in nearly every case. Almost the only persons applied to, from whom I obtain no reports, were certain surgeons in Chicago, whose memoranda were all burned in the great fire, and whose cases were too numerous to be correctly recalled by memory. By this method, I reached fewer persons than Sir J. Y. Simpson, and obtained fewer cases, but the reports which I did secure are
reliable, and represent the true results of surgery in the Lake States. The persons reporting are all educated men, and fully equal in point of skill to the average of those who would receive such a circular as that of Simpson. I think, therefore, that Sir James deceived himself by his method of procedure, and had he secured reports representing the exact truth, the mortality of country practice would have appeared there, as it does here, to be about twenty-one instead of ten per cent., for the average of the four major amputations.