Bone Diseases.—Diseases of the bones, as inflammation, caries, and necrosis, are now dealt with very differently from of old. The diseased structures are now thoroughly removed; and the inflammation which at one time kept the patient in misery and danger for a long time is subdued from the start.
Osteotomy.—This term, which means the division of a bone, is generally applied to the correction of deformities, such as bow-legs. This operation fifty years ago was not frequently resorted to, and then only in severe cases, the milder ones being left alone or treated with braces, which at best could do little more than prevent increase in deformity. When the operation was performed on the bone, it was then divided, usually with a saw. The operation nowadays for this condition is what is called subcutaneous osteotomy; that is, the wound made is only as large as the chisel used for severing the bone, about one half inch, and owing to our knowledge of microbes and our means of destroying them and preventing their ravages, hundreds of legs are made straight every year which a generation ago could not have been safely touched.
CLINICAL AMPHITHEATRE. GARRETT MEMORIAL BUILDING, PENNSYLVANIA HOSPITAL, PHILADELPHIA, PA.
Amputations.—The first successful amputation at the hip joint, for either injury or disease, in the United States, was done in 1806 by Dr. Brasheur; the next was not accomplished until 1824. As late as 1882, the great American surgeon, Gross, wrote in his “System of Surgery:” “To no operation that can be performed on the human body is the oft-repeated maxim, ‘Ad extremos morbus extrema remedia,’ more justly applicable than to amputation at the hip joint. The operation may become necessary both on account of disease and accident; but it is of so formidable a nature and so fraught with danger, that it should never be undertaken unless the patient has no other chance of escape. The great risk which attends it is chiefly due to shock, loss of blood, suppuration, erysipelas, and pyaemia.... Under highly favorable circumstances, much of the enormous wound may unite by the first intention; but, in general, more or less suppuration takes place, and in some instances the discharge is so copious as to lead to fatal exhaustion. The greatest danger of all, however, is the occurrence of pyaemia, or secondary abscess, especially in amputations at the hip joint in consequence of injury, as a compound fracture or a gunshot wound.” This gives the attitude of the profession toward this operation a little more than fifteen years ago, and the dangers which attended its performance. Let us add that the mortality at this time may be expressed in the following figures. (Dr. F. C. Sheppard prepared these statistics for Dr. Ashhurst.) Of 613 cases in which the results are known, “237 occurred in army practice, of which 30 recovered and 207, or 87.3 per cent died; 71 were performed in civil life for injury, with the result of 47 deaths, or a mortality of 66.1 per cent; 261 were practiced for disease, with 105 deaths, or a mortality rate of 40.2 per cent; and of 44 amputations for unknown causes 34, or 77.2 per cent were fatal.”
In 1890, Dr. John A. Wyeth of New York introduced his “bloodless method” of amputation at the hip joint, and he recently reports 69 operations performed after this manner by himself and others, in which there were 11 deaths, 5 of which occurred in cases of extreme injury, where the patients had lost a large amount of blood and vigor before operation. In 40 cases the operation was done for malignant growth, and 4 deaths occurred, 10 per cent. In 22 the amputation was made for inflammatory disease of the bone, and 3 died, 13.6 per cent. One has but to contrast these statistics to understand what antiseptic methods and recent improvements in the control of hemorrhage have done to lessen the mortality of amputations. The still more recent use of salt solution injected into the circulation of patients suffering from profuse hemorrhage has lately been the means of saving many lives which would have otherwise succumbed to the loss of blood and the shock subsequent to injury and operation. As illustrating the contrast between the septic and antiseptic methods, let us consider the surgery of our Civil War and compare with that of to-day, and we shall see the enormous differences in methods, and particularly in economy of limbs and organs as well as mortality.
PENNSYLVANIA HOSPITAL, PHILADELPHIA.
Hemorrhage.—The arrest and control of hemorrhage has greatly improved within the past twenty-five years. The making of an aseptic wound does away largely with the much dreaded secondary hemorrhage of a generation ago, by preventing suppuration, which is usually the cause of secondary hemorrhage. The clumsy and complicated apparatus of former days for controlling hemorrhage has been superseded by the use of the Esmarch rubber tourniquet, the neat hemostatic forceps, and the sterile animal ligature. No surgeon thinks to-day of applying a silk ligature to a blood vessel and allowing it to hang out of the wound until it separates, so that in case of secondary bleeding he could readily find the vessel; but he applies an absorbable ligature, usually of catgut, which is sterile, and which is entirely absorbed by the tissues after it has done its work. Much suffering has been saved patients by the introduction of absorbable materials for ligation of vessels and sewing of wounds. Formerly one of the great dreads of wounds was the “taking out of the stitches.” To-day where the wounds are not inflamed this is little complained of, and where the animal suture is used there is no discomfort whatever. Many means have, during the past century, been employed for the resuscitation of patients suffering from profuse hemorrhage and shock. The idea of injecting into the veins of the patient thus affected blood from another person or from an animal is not new, and has at times been quite successful. The most generally used method was to draw the blood from a healthy person or animal and inject it into the vein of the patient with a syringe: however, so-called “direct transfusion” was also employed, and consisted in pumping the blood direct from the vein of the healthy individual into that of the patient. Other materials than blood have been injected into the blood vessels of persons suffering from great loss of blood, notably milk. All of these methods have been put upon the shelf, never to be called into use again. The ingenuity of the nineteenth century suggested the substitution of a solution of common salt for blood and, to-day, the intra-venous injection of normal salt solution saves hundreds of lives. The solution is made to resemble as closely as possible the liquid portion of the human blood (the liquor sanguinis), especially as to specific gravity; and as it is always sterilized by boiling before being used, it is free from all the dangers which accompany the transfusion of one person’s blood into another. No well-appointed operating room is without its transfusion apparatus and its salt solution ready for use.
Wounds.—Reference to the remarks on asepsis and antisepsis will show the reader that the treatment of wounds has undergone a complete change in the past quarter of a century; but probably the modern treatment of gunshot wounds illustrates this better than anything else. Until 1885, only six cases were recorded where the abdominal cavity was opened for gunshot wounds, but since that time hundreds of cases have been treated in this way every year. The injuries were formerly considered almost certainly fatal, and if the intestine was injured the patient assuredly died. Now the abdomen is opened, hemorrhage controlled, wounds—often to the number of six or eight or even thirty or more—of the intestines closed, or an injured section of the intestines removed and the abdominal cavity cleansed and closed, with many favorable terminations to make the operation not only a justifiable one, but one of necessity and safety. There is no comparison with the present-day results of gunshot wounds of either abdomen or chest and those of a generation ago. It is the duty of the surgeon, in case of gunshot wound of abdomen, to open, explore, and repair, whereas formerly it was considered the part of wisdom to leave the patient without radical treatment and only to make him comfortable with opiates. Thus cases of damage to the intestines and viscera did occasionally recover in pre-antiseptic days, but it was the rarest occurrence.