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an apology for not informing you long ago about my case of ununited fracture, insomuch as you took such an interest in the case and furnished such valuable suggestions. I am happy to say that the patient is now well and at work. I send you a history of the case. I shall surely be in St. Louis and shall be pleased to confer with you further. Yours respectfully,
A. O. Williams. The following is Dr. William's report: "Wm. McKinney, aged 30, habits good, no constitutional or hereditary ailments and in good health, was struck, February 8, 1895, by an iron which was half of a hook used by the wrecking crew to pull cars out of the ditch. An engine was pulling on the rope, the hook broke, flew back, struck McKinney on the tibia at the union of the middle with the lower third, producing a compound comminuted fracture of the tibia and fibula. The fragments were adjusted two hours after the accident. Temporary splints were used for seven days, when the leg was encased in a plaster of Paris bandage. Seven weeks from the day of the fracture there was no union. The external wounds healed without supurattion. At the end of 60 days there was union. The limb was again encased in plaster and the patient allowed to go around on crutches. The fracture was examined every few days. There was little progress toward union from one examination to another. Four months after fracture the leg was bandaged with a rubber band just below the knee joint, in order to obstruct return circulation. The ligation was kept up continuously for four weeks. Six months after the accident the patient was sent to D. E. R. Lewis of Kansas City, Mo., who recommended massage, which was followed persistently. The union rapidly became firmer, until nine months after the accident no motion was perceptible."
From the above it will be seen that Dr. Williams' patient was nine months without complete bony union. Taking the three cases, we have the earliest union in the eighth month, and the latest union after the twelfth month. In my patient there was no constitutional condition, such as tuberculosis or syphilis, to delay union, and so far as I have been able to judge, neither of these conditions complicated either of the other cases. I will not now enter
into a discussion of the development and repair of bone, for in my Chicago paper I covered that ground so far as possible from my study and personal experience. For the most. approved methods of operating upon ununited fractures, I refer to an exhaustive article by one of our members, Prof. N. Senn of Chicago in the Annals of Surgery for August, 1893.
DISGUSSION OF DR LEWIS' PAPER.
President Murphy: This is one of the most interesting topics that can come before the as-. sociation, and I would like to have every member take an active part in the discussion.
Dr. Milton Jay, Chicago: The subject of ununited fractures is certainly one of great importance to railway surgeons. What is generally meant by ununited fracture is not that we have no deposit between the fractured fragments, or that we have no plastic lymph or fibrinous deposit in the periosteum. Notwithstanding the very interesting paper of Dr. Lewis, it is yet a question, if at the end of six months no bony lymph or fibrous deposit has taken place in the periosteum, whether we get bony union without boring the ends of the bone. We sometimes see delayed union where the periosteum, which makes the provisional callus, or which forms a band around. the ends of the fragments of the bone, will admit of considerable motion between the fractured fragments. The definitive callus, by the circulation from the bony structures, performs a slight function in the union of bone anyhow. If Dr. Lewis could have seen between the ends of the bone, if he could have seen the condition of the periosteum, which lines the bone, and could have seen no deposit or any intention on part of nature to perform any kind of union, then I still doubt whether at the end of six months he would have union. This provisional callus on the outside is slow, particularly where there has been a compound fracture. However slow it may be, it continues where the plastic lymph is thrown out, so that slight pressure may cause constant irritation, increase the deposit of lymph, and the union of the fragments does not take place, but at the end of six months there was a deposit in the periosteum of provisional callus, which was afterwards absorved, yet it permitted of some kind of motion. If the motion was lateral, the entire thickness of the bones, he never would have had union unless he had sawed off or laid
bare the ends of the bone. The point I wish to make is that if at the end of six months there was no intention of nature towards bony union, I still doubt whether he would have bony union.
Dr. Crook: My excuse for trespassing upon the time of the Association is merely to report a case along the line of Dr. Lewis' paper. When I was an assistant surgeon to the Sacramento (California) Hospital, early in the spring of 1895, an Italian, 34 years old, presented himself with severe ankylosis of the knee-joint. After he had been in the hospital for a week or two and was properly prepared, I operated on him and broke up the ankylosis. In addition there was malposition of the femur, overlapping of the bone, and a shortening of the leg of three inches. He could not bear any weight on the leg. With Dr. White, superintendent of the institution, and assisted by the physicians in the hospital, I operated and removed two and a half inches of the femur. The ends were brought together and sutured with silver wire. The leg was then invested with plaster of Paris with a window on one side for drainage. The plaster cast was allowed to remain nine weeks, at the end of which time it was removed, but union had not taken place. We were very much discouraged. We waited for a week and the man complained of severe pain in the right side. An analysis of the urine was made and it was found to contain pus. A diagnosis of pyonephrosis was made, and a nephrectomy performed. The old wound in the leg was afterwards reopened, the wires taken out, the ends of the bone put together again, and the man was well at the end of five months.
Dr. S. S. Thorn, Toledo: I have had some experience with cases of delayed union. My observation is, that the most fruitful cause of delayed union is malnutrition. I took this ground once before in this Association. It is starvation. A little over a year ago I was in favor of anchoring such bones, but I have seen failures from efforts at wiring the fragments and have suggested to surgeons trying the plan advocated by Mr. Owen, of Liverpool, that is, to maintain fixation of the joints beyond the seat of fracture. In these cases, the ankle and the knee. This fixation is maintained by a trough of plaster of Paris, and the method was presented at our meeting in Chi
cago last year. Let your dressings be loose. That is another important point. After all the necessary preparations are made, turn as far as you can the ends of the bones, in this way make flexion, and pummel them well with the hammer, just as a man does when he is percussing, then put your thumb back into the cast loosely, maintain fixation of the joint, then let it alone. I did this in one case, and at the end of twenty-one days the patient came back and did not like it, at which time I removed the dressing, told the patient that he had better try this treatment for twenty-one days longer, which he did, and there were evidences of successful union. This process of pounding the tissues over the ends of the bones in this way has served me very successfully five or six times within the past five years. I have not wired bones for at least five years. Unless the most perfect precautions are taken, the operation is apt to be followed by unpleasant conditions. In one case an amputation was the only successful termination.
Dr. W. S. Hoy: I regret that I did not get here earlier so as to hear the excellent paper of Dr. Lewis. I understand the subject for discussion is ununited fractures. Dr. Thorn has forcibly struck the keynote of the causes of ununited fractures, and that is anemia of the parts. Very frequently the surgeon, when called to treat a fracture, places a bandage around the limb so tightly that the circulation is partially cut off, and as a result he has nonunion of bone. But the question is, how are we to obtain union in ununited fractures? Dr. Thorn does not believe in wiring the fragments. I do not believe in it. I believe friction does a great deal more than wiring will do. I have in three cases obtained good union, and a useful limb without any marked shortening. My method of treatment of compound fracture is simply to put on a light dressing. I believe the surgeon to-day makes a mistake when he puts on any fracture a cumbersome dressing. I think the more light, the more airy and sim-. ple the dressing is in all cases of fracture, the better will be the results in the end. It is a good rule, in the treatment of fractures, to confine the joints above and below the seat of fracture. I believe in immobility of the parts, and believe that rest is the great principle underlying the treatment of fractures in which there is delayed union. Perhaps some of you have
never tried decalcified bone, taken either from the bone of the ox or cow, slipping it over the fragments. I recall a case in which eight months had elapsed, and yet there was nonunion. The physician in charge suggested that we cut down upon the bone and wire the fragments. He went to a dentist, who drilled six holes, three in each end of the bone. This was a fracture of the tibia. He then applied a plate made from a battered silver watch case, This patient, after eleven months, made a perfect recovery, union of the fragments being perfect. After the screws had become loose in their sockets in this case, the plate was removed and we found perfect union of the fragments, with healing of the external wound.
Dr. P. Daugherty: A few questions have occurred to me since this discussion has been going on. First, as to the causes of delayed union in ununited fractures. One cause has not been spoken of, and that is muscular tissue getting between the ends of the fractured bone. So long as that remains there we are not going to have union. There is a possibility that in the course of time this muscular tissue may become absorbed or disappear and that we will get union without any further trouble. There is one way by which we can nearly always tell whether we have a condition of that kind or not. If we take hold of the bone, force the ends of the fragments together, and we get crepitation we may be sure that there is nothing interposed between the fragments. If we get no crepitation we may be certain that something is interposed between them. Syphilitic, tubercular and anemic subjects from any cauşe are liable to delay union in cases of fracture.
As to the dressing of fractures, we have had suggested and recommended various dressings from time to time. Some thirty years ago I devised a method which I have used ever since. I was called to the southeastern part of Illinois, fifteen miles in the country, to see a man who had a fracture of the leg. This was in the days of the fracture box. There was no lumber, no saw. There did not seem to be anything about the place, not even a hammer. I looked around, saw a piece of board box on a shelf. I had the woman tear up a sheet and make some starch, as though she were going to starch clothes. I took the old board box, out of which I made a splint reaching from the knee to a little below the bottom
of the foot, enveloping it on each side of the leg, leaving a space in the back and in front. I ran it into my starch until it was perfectly stiff. I then took my cotton batting, made a roller bandage, starching each layer as I went When the strach was dry I had a perfectly firm, very light, light, yet perfectly fitting splint. Three days thereafter the man was up on crutches. The swelling in the leg had materially diminished and the bandage became loose. I split it down in front and opened it, and just as often as it became loose I would tighten it. From that day I have never used any other splint. other splint. Plaster of Paris is good, and a great many use it-in fact, nearly everybody uses it now, but I would caution you to look out for one thing, and that is, not to get your bandage too tight. If it is too tight you will have an anemic limb, and that of itself will delay union.
Dr. McCrae: It seems to me a great deal of valuable time is being wasted in discussing the treatment of fractures, when further down on the program we have the subject of treatment of compound fractures. Dr. Lewis' paper does not treat of compound fractures, but ununited fractures. That is the idea which he wishes to convey. The members who have so far discussed the paper have been speaking on the treatment of compound fractures. We are not on that subject.
In the case Dr. Lewis mentioned, I hardly think it was one of non-union. It was not bony union, but he did have, as the first speaker said, the presence of a provisional callus. It is only cases where there is absolutely no provisional callus that we may call ununited fractures, and after six months, if union has not taken place, I doubt, with the first speaker, whether it ever will take place.
Dr. Howard: I would like to ask a question. I have a case of three years' standing in which the radius was thoroughly ossified for some time, but in trying to use friction eight months after the injury, I snapped off an inch and a half of the radius. There never has been provisional callus from the beginning, and I told the man there never would be union. I wish to know if it would not be good policy to remove as much of the bone as is diseased and try to treat it anew?
Dr. G. A. Nash-I think we are pretty well agreed as to the changes which take place in
this condition, yet so far I have not heard anything in regard to the application of the wire gauze splint. While the plaster of Paris cast is very efficient, and in some cases it would not be well to dispense with it, yet in the majority of cases a galvanized wire gauze splint will be found to be strong and very efficient in cases of fracture. It is applicable to most cases. It is light and airy, and it is a form of splint that should be used more frequently than it is. It is admirably suited for injuries of the ankle joint. An angular splint can be made out of this material. The galvanized wire can be soldered and the margins can be cut with scissors and hemmed over with pieces of plaster, which make it a comfortable, light and strong splint.
Dr. E. R. Lewis (closing): The first speaker, Dr. Jay of Chicago, compels me to say, from what I have found out with regard to ununited fractures, that many of us are yet clinging to December, while the earth is in her June. The pathology of this affection has been revolutionized since we studied medicine. We all know to-day that the periosteum is not the osteogenetic factor in the repair of bone. It has been proven conclusively that it is not. The experiments of Mr. Macewan of Glasgow established that beyond the possibility of doubt, and no longer do we talk of repair of bone through periosteal tissue. If you remove a bone for one inch or two inches and preserve the entire periosteum throughout, it collapses and forms a fibrous tube and does not develop a single osteoblast. That has been proven, and we must recognize it because it is a fact. What is it that produces and repairs bone? It is the soft tissue which resides within the bone itself. There is where the osteoblast is developed; there is where the bone receives its repair. The periosteum is The periosteum is not only a protection, but it is the nidus through which the circulation reaches the bone tissue proper. It is aboslutely necessary to the protection of the bone and allows vessels. to reach the bone, but it does not enter in as an osteoblastic factor, and we must recognize that point before we can intelligently discuss delayed union, non-union, or whatever other term you may wish to apply to those cases which do not unite within a certain length of time. We must discard the old idea.
Dr. Crook's case of ununited femur, that he
speaks of as having occurred in California, is interesting. I reported cases at the Chicago meeting where I had wired the humerus, the ulna and three months after the wires had been applied with soft parts uniting perfectly throughout, the bone was not repaired, due to specific influences which we have not discussed in this paper to-day, but which were dwelt upon at length in the paper I presented in Chicago.
Dr. Thorn has made a very happy suggestion relative to the starvation of these tissues and speaks of loose dressings and also calls attention to the fixation of joints. There is one point that we must understand more thoroughly and that is, to fix a leg from the sole of the foot to the hip. We can no longer hold to those ideas, which we believed were as sacred as the Holy Writ itself, because experience has taught us to the contrary. We are advancing, and we must not be clinging to wrong ideas.
I am sorry that Dr. Hoy did not hear my paper. He spoke entirely of the treatment of ununited fractures and illustrated it with six holes bored by a jeweler into the bone, and it served a good purpose. Why did the boring of these holes produce repair? I remember twenty-five years ago when the late Professor Pancoast of Philadelphia exhibited a woman from the far West, as he called it at that time— Wisconsin-who had an ununited fracture of the tibia. The bones were fixed together by means of screws. How did they act? He opened up the bone tissue through which the osteoblasts were formed, and from which the genuine bone structure began. The six holes drilled by the jeweler opened up the cancellous structure of the bone, where the soft tissues in the bone itself produced osteoblasts, without producing bony union. Had he not used a plate at all, the bone would have been more rapidly repaired and better.
Dr. P. Daugherty: Speaking of treatment, I do not care to enter into the subject after Dr. Lewis has practically closed the discussion, except to say that from my own personal experience I reported more than half a dozen cases at the Chicago meeting. I prefer the ivory pegs to the wire because they are absorbed. The ivory enters into the formation of bone by absorption.
A word in regard to Dr. Howard's case of
united radius, after three years. If we break loose the fibrous tissue at the ends of these bones and open up the cancellous structure, union will take place. You expose the boneproducing membrane by so doing. And if I know that I have a case of delayed union, I chloroform my patient and violently rub the ends together in order to knock off the fibrous tissue which has formed a false joint, as we term it.
By D. EMMETT WELSH, M. D., GRAND RAPIDS, MICH.
The object of this paper is not to enter into a theoretical consideration of color blindness, but to present for your consideration the importance of examinations for its detection in the train service of the railroads. Last year you listened to an able discussion of this subject by Dr. Wescott of Chicago, and also witnessed the practical tests as presented by Dr. Williams, now of Boston, formerly connected with the C. B. & Q. Incidentally I might mention that to Dr. B. Joy Jeffries of Boston, Mass., belongs the credit of first bringing before the railway managements of this country the importance of these examinations, not only from a theoretical standpoint, but its practical utility.
Various roads have adopted different forms of examination for the color sense, yet in the main they vary only slightly in the methods. employed.
I will consider the subject of color blindness only in connection with normal eyes. In the adoption of these examinations by a railway a great difficulty confronting both the employer and employe is skepticism, and this is a feature that must be overcome. The employe imagines it is a good device to get rid of him when his record is good. The management, considering the welfare of the traveling public, does not appreciate its importance, and therefore considers that to distinguish between red and green is all that is necessary, until brought to witness an examination in which the defect is prominent. The only satisfactory manner, both to the employer and employe,
*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May, 1896.
in which these examinations can be made is by the ophthalmologist. He is unbiased in his views, and will render a report in accordance with what is found, whereas a foreman or assistant superintendent, having an enmity, can easily, by the examination he makes, cause the applicant to commit error and thus relieve him from the service without good cause.
Two conditions should always be borne in mind in making these examinations, viz.: Mental capability and real defect of color sense. Many men have a feeble color sense, and colors similar in character fail to impress the applicant as really different; in other words, hesitancy is displayed where positiveness should exist.
If a true defect is found, further examination is not necessary. Man, in the various walks of life, selects that which is pleasing and enjoyable to him, and profitable, but after a time so many things bearing upon the same subject present themselves that unconsciously he falls into a certain "rut" and becomes automatic. This is nowhere better illustrated than in the mechanic or engineer. In the latter, from years of trial as a fireman, the location of signal tower and station is known, and even on the darkest night something either marked or vague tells him "where he is at."
A few years of experience teaches the engineer where to apply the air to stop at station or water plug; the condition of the track tells him his location, and if the sense in this direction is quickened, then his perceptive sense must be quickened. A comparison as to intensity of light informs him its character, and though the judgment may be defective, he judges unconsciously, and is always on the alert for the slightest variation.
We, as surgeons, are all familiar with the fact that the engineer can very readily detect the slightest variation of sound while running, and can easily locate a defect in his machinery and readily perceive locations and light. Yet withal it is by comparison, and the slightest variation from the usual position of a signal might produce terrible destruction of life if the engineer was unable to detect differences in color.
I make examinations for visual defects and color blindness for the following roads: Grand Rapids & Indiana, Chicago & West