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then turned over to his own physician, Dr. Sterling Gibson. From this gentleman 1 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 ago 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
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 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 alunder terative treatment. November 25, strict antisepticism, Dr. McHatton amputated the limb in the lower third of the thigh. The anææsthetic 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 sarcoma. A piece of this bone was removed and examined microscopically.
She was admitted to the hospital October
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 anæsthetic 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.)
Under the above caption Dr. Charles W. Hitchcock of Detroit has written a most timely paper, which he read before the Detroit Academy of Medicine some time since, and which is published in a recent number of the Physician and Surgeon.
This paper, from which we quote freely, gives us an excuse for saying some things which we have wanted to say for a long time. It begins as follows:
"I trust I shall not be thought too commonplace in my choice of a subject if I ask you, for a few moments, to descend from the heights and consider some of the common things of everyday life, to leave for a moment appendicitis, its varieties and necessities, the intricacies of problems gynecological and ophthalmological, while we talk plainly and familiarly about some common points of minor surgery, which observation has shown me are often insufficiently grasped, if not absolutely misunderstood, by general practitioners, to whom the majority of these cases go."
Verily, life and art are made up of small things and nothing should be deemed com
monplace which will add to success in the relief of suffering and the prolongation of useful life.
In modern surgery he is most uniformly successful who is most careful and painstaking in regard to the little things, and as our author further says:
"In this day and age it goes without saying that, if best results are to be secured, we must apply to minor surgery precisely those principles which obtain in more extensive work. While of course no one is so blind to the present position of surgery as to wilfully or utterly ignore all antiseptic or aseptic precautions in his minor work, yet how easy it is to neglect important points, to handle an open wound or a crushed hand or foot with hands not made surgically clean, and how often do we see things, the asepsis of which could be well doubted, applied with the greatest carelessness to surfaces which should be kept as aseptic as possible. Asepsis and antisepsis are the keystone of the surgical arch of to-day, and he who doubts it or neglects all effort to carry out their principles, fails to do himself or patient justice, and fails to give the latter the benefit of that to which he is justly entitled."
If we are truly scientific in our practice we will strive as conscientiously for the attainment of every detail of asepsis in the dressing of a finger or the suturing of an eyelid as in the performance of a laparotomy or the removal of a brain tumor. If we do not do so we are equally disloyal to our patient and to surgery and untrue to ourselves. We are under the same moral and scientific obligation to secure a perfect result in one case as in the other, if we can.
Someone has said that aseptic surgery can be done wherever hot water and soap can be found, and it is true; and if one can get some carbonate of soda or borax he can do without the soap. Most men realize that it is better for instruments if they be sterilized by boiling in a 3 per cent solution of sodium carbonate rather than in steam, but few seem to know how very valuable the same solution( or a solution of borax of equal strength) is for cleansing wounds and the skin in their neighborhood. It may be made to take the place of ether and alcohol in the cleansing of the field of operation and the hands, and is harmless,
even if applied about the eye. Such a solution forms a most excellent bath for a greasy and begrimed crushed hand and "takes the fire out of a burn."
Some can most easily attain asepsis by the use of antiseptics and, indeed, there are some cases in which antiseptics are absolutely essential to success, and we have no quarrel with the surgeon who must have bichloride, nor with him who still clings to carbolic acid, but, as Dr. Hitchcock says:
"The broadest man is he who is not bound to one thing nor two, but is a man of many resources, who keeps ever in his mind's eye the one thing to be accomplished, realizes that this is possible through many agencies, and makes himself the slave of none. Many are the means by which a wound and its surroundings may be made surgically clean, aseptic, and many the methods by which it may be kept so."
It has been amply demonstrated that aseptic wounds heal best if made dry and kept so. We should therefore make no application to a wound which will destroy the superficial cells of the surface or promote oozing, if we desire primary union. Iodoform is certainly not a sine qua non and if any drying powder is needed we have boric acid, aristol, dermatol and many others which are less offensive and equally efficacious.
Relative to ointments our author speaks as follows and we fully endorse his conclusions:
"Have you ever watched the healing of a contused and lacerated wound of the finger under carbolized vaseline, and have you noted the sluggish healing, the mushy appearance of the tissues, the whitened and soggy condition of the skin? Surely there is nothing healthy about this and it is far from simulating any effort of nature to effect a prompt repair. Contrast it, if you please, with the action in a similar case, treated without other application than a bandage over antiseptic gauze, and you will wish to speed the day when such dressings shall no longer be seen. The philosophy of greasy applications to healthy tissues has never been apparent to me; their use is, I am sure (save in burns), unsurgical, and the passing of the ointment from (traumatic) surgery may be a fit theme for congratulation.
"In burns, for excluding air for the first few
days, the ointments may find some excuse for their existence in this field. Even here they will best be early discarded and the separation of the slough be best hastened by a simple water dressing or one of normal saline solution, which dressing I have found to give the greatest comfort in these cases."
We all know that some wounds cannot be made aseptic and others will become infected in spite of all our care. In such cases the indication is obvious. We must dress frequently with a moist absorbent dressing, and cleanse the wound thoroughly at each dressing with an efficient but non-irritating germicide; possibly a 1-2000 solution of the bichloride of mercury is as yet the best we have.
Double Dislocation of the Sternal End of the Clavicle.
At a meeting of the New York Surgical Society, February 12, 1896, Dr. L. W. Hotchkiss presented a man, about twenty-eight years of age, who, on January 28 last, had sustained injuries by the wheels of a heavy truck passing over him. There was a wound of the forehead, a transverse fracture of the right humerus in its middle, a complete forward (presternal) dislocation of the left clavicle on the sternum, and a partial dislocation of the right clavicle upward and backward. The right dislocation had reduced itself, but that on the left side was not reducable by ordinary means, the fracture of the humerus interfering to a considerable degree with manipulation, and it still persisted. It did not particularly impair the functions of the arm, though the deformity was considerable. The case was presented to illustrate a rare dislocation and to show how little impairmen of function had resulted.
Dr. B. F. Curtis said he had never seen a double traumatic dislocation of the clavicle, but he had photographs of a case of double dislocation, apparently of congenital origin, in a girl of thirteen years. There was also some lateral curvature of the spine, and it was for that that she came under his care. The clavicles were not absolutely dislocated, but in certain positions of the arm the sternal end of each of them would slip out almost entirely on the anterior surface of the sternum. There was no pain, apparently no weakness, and the functional disturbance was so slight that nothing was done for the condition.-Annals of Surgery.
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