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shoulder, but he said he was all right; there was nothing the matter with him. I whispered to him and told him it was useless to talk that way, not meaning my friend to hear it, but I judge he did hear it and went and told their lawyer. When it came to cross-examine him he asked: "Did you find anything wrong about the shoulder-joint?" "Well, very little." Then the lawyer said: "You didn't see that very little, did you, until Dr. Marks told you?" He also swore that the man didn't suffer any pain. What is the use of swearing to a thing like that? No man can whether another man is suffering pain or not. We may think he is shamming and not telling the truth, but I would hate very much to swear that a man was not suffering pain who had his shoulder dislocated.
Regarding the treatment of fracture I am often asked: "How do you treat fractures? What is your rule? What splints do you use?" My answer is, I have no particular splints and follow no particular rule. I believe there is but one rule which is applicable to all cases of fracture, and that is to reduce the fragments and place them in their position as soon as possible, and the surgeon's anatomical knowledge and mechanical ingenuity will suggest the appliances to keep them in position. In my younger days, like most of us, I thought it was necessary for a man who pretended to doctor fractures to have a large number of splints, and I thought it necessary to keep them in a place where everybody could see them to show that I was prepared to treat fractures. In the course of time, when I got a fracture, I was much surprised to find there was not one I could use and had to make a splint out of a shingle. Since that time I have had very little to do with patent splints, because there are no two fractures, it seems to me, exactly alike. We have fractures which. are very similar, but if you will examine them closely you will find there is a little difference in them which will need a little change in the treatment in order to hold the bones in position and keep them in the position they ought to be. That is the course I have pursued. I have no rule and I have no splints except those I make myself. I believe the surgeon who follows the books and treats them all alike, and never goes outside of what he finds in the books, will not as a rule have
the best success. It seems to me every fracture is a law unto itself, as far as treatment is concerned. I don't believe I have ever treated two fractures exactly alike, and I have had quite a number during the last forty years. But in spite of all we can do we fail sometimes to get the desired result, especially in fractures close to the body, in the femur, just below the trochanter. I have found that fracture the most difficult I ever treated. I remember one such case where, in spite of all I could do, I could not keep the upper fragment down in position with the lower fragment, with any amount of force I could put on. Then I thought I could follow it up with the lower fragment and I pulled it up so hard it seemed as if it would strike his chin, but I couldn't keep it up there. This was an eyesore to me for several years. The man got well, but the bones overlapped in spite of all I could do. I don't know how I could have changed it. I had counsel, but nobody could help me.
A fracture of the wrist joint is another which does not always result as well as we would desire. As you are aware, there are a great many different splints recommended for this and different methods of treating it. Sometimes it comes out very well, but other times it doesn't. There is a difference of opinion regarding the cause of the deformity. What causes it? Dr. Moore, as you are aware, claims that the extremity of the ulna gets entangled in the extensor carpi ulnaris. It seems to me it is due greatly to the conformation of the joint and the action of the very strong muscles below this joint. The tenacity of the muscles forces it up. How do you treat it? Do you always treat it the same? I have always treated it as Hamilton recommends and have had very good results.
I have made it a rule to keep it in the prone position. This I think is the best position it can be in. I examine it every few days. I never leave fractures as some men do. I should not dare to put it in place and go off and leave it. Generally the hand is badly swollen and I can't tell how it is getting along. When it is swollen I can't tell exactly the position of the fragments, and I want to see it every few days and mold it into shape, and if there is any deformity I can force the ends together and straighten them as they should
be. We may have a comminuted fracture which may produce anchylosis and various deformities. But, as I said, I treat every case by itself; every case is a law unto itself.
INJURIES OF JOINTS.
BY MILTON JAY, M. D., CHICAGO, ILL.
The more complicated the structure of any organ or part, and the greater the variety of tissue entering into its make-up, the more serious will be the result of injuries to such organ or part. In considering joint injuries and their treatment and results, it is well to keep in mind their complicated anatomical construction, as well as their extended physiological action, so as to be the better prepared to combat the various pathological processes that may arise; each and every structure entering into the composition of joints is subject to injuries and consequent pathological conditions. The expanded cancellous structure of the ends of the long bones may be the seat of injuries as well as disease, as well as the incrusting cartilage and the capsular ligament, which is well developed in the ball-and-socket joints, these being attached to the bones, and closely connected with the periosteum. The joint cavity, except over the articulating cartilages, is lined by a synovial membrane, which is either a closed sack or communicates with a bursa; it is lax enough to permit of the free movement of the bones upon each other, and is more or less folded or fringed, holding and covering masses of fat. This stricture is extremely liable to injury. Outside the joint are the muscles moving the joint, and the tendons running in sheaths; these are often injured. The muscles and joint structures are innervated by branches of the same nerves; the same blood vessels supply the periarticular structures and the joint proper. So very intimately are all these structures connected that an injury to any one of them may very soon extend to another, and even all of them, so that it is often not an easy matter to determine which particular structure was primarily and originally the seat of the injury. It is not always an easy matter to make a correct and exact diagnosis of joint injuries, particularly is this the case after much time has passed since the reception of the injury. Much will depend upon the nature and condition of the
Read by title at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May 1, 1896.
joint at the time the injury is received; should the joint be one that has previously been affected with rheumatism or gout, syphilis, or previous injuries, the conditons may be much aggravated, and the result far less satisfactory, and in many of these cases a satisfactory history is very difficult to obtain.
In our railroad practice, where we have so many joint injuries and complications, we are often left very much in the dark as to the true history of the exact condition of the joint and surrounding structure before the injury was received; and yet the railroad surgeon is held responsible and is expected to produce as good results in an injury of an old chronic diseased joint as if the joint had been in a perfectly healthy condition at the time of the last injury. There is certainly no class of injuries with which the railroad surgeon has to deal that will give him more trouble and anxiety than the various and complicated joint injuries. Often the injury may be very extensive, tearing or lacerating all the structures of the joint, even penetrating into and opening the joint in such a destructive manner that it would seem as though there was no hope of saving the limb, yet under proper treatment the joint and limb are saved. Another case may seem to be much more favorable, the injury slight, the laceration and tearing much less extensive, the joint not penetrated, in fact, the case does no present seemingly any very grave symptoms; yet, with the best of care and the most skillful treatment, the case goes from bad to worse and the patient loses both joint and limb, if not his life, and many times the condition of the parts at the time of the injury has had more to do with the result than we imagined.
In the injuries to the special structures of joints, the synovial membrane is most frequently affected; the membrane becomes congested. chiefly around the edges of the cartilage and in the fringes which, because of their undue vascularity and cedema, are elongated; at times the entire membrane is highly injected, the synoval secretion is increased in amount according to the intensity of the inflammation, but as a rule the inflammation, thus lighted up, does not long remain confined to the synovial membrane, but affects the other parts of the joint. In acute attacks due to trauma, these cases are readly diagnosed, and by a proper treatment are generally soon relieved. Rest is an all
important factor in the treatment; this, with equable pressure as firm as can be comfortably borne, will generally accomplish the desired result, placing the limb in the most comfortable position, and applying a plaster of Paris bandage, including not only the joint, but a portion of the limb on either side of the joint, allowing it to remain at rest for days, or until the fluid has been absorbed, and the inflammatory action ended. In some cases of chronic synovitis, with much distension and extravasation of blood into the joint, where there is danger of the joint structures becoming disorganized, the fluid had better be drawn off; if aspiration is done, every precaution must be taken to prevent sepsis. As a rule, cases of arthritis and periarticular inflammation, owing to the complicated structures affected, will require a longer time for recovery; time in many of these cases is an all-important factor in the treatment. Time and rest will often accomplish more than all other treatments. Nature is the great restorer, and to conform our treatment to harmonize with her laws, is one of the great objects to be attained in all surgical treatment.
The classification, of joint injuries and wounds is generally made into penetrating and non-penetrating. Those that are penetrating, opening up the joint structures, are expected to be the more serious in their results, and more difficult of treatment, and yet while this is true as a rule, it is not always the case. Some joint Some joint injuries without an external opening are more dangerous and complicated in their nature, and more fatal in results than others that are penetrating. Simply opening into a joint is of itself not necessarily a fatal procedure under strictly antiseptic precautions; indeed, it is often done as a necessary surgical interference to relieve existing pathological conditions of the joint structures.
The joint injury most to be feared and dreaded is where the joint has been crushed; all the joint structure, bony as well as all other tissues composing the joint, have been injured, and this is often the case without a penetrating wound of the joint. Sometimes, indeed, to successfully treat such cases, it becomes necessary to open the joint. A half century ago all such injuries, and particularly wounds penetrating the joint, were considered as calling for immediate amputation; but not so in this day of surgical knowledge and skill. The point which more than any other should be im
pressed upon every railroad surgeon is this: Never sacrifice a limb until all attempts to save it have failed. I would not underestimate the gravity and anger of penetrating wounds of joints, they are always serious, but only more grave than the non-penetrating in this, there is the additional danger of infection, to which every open wound is subjected. The fate of most of these open wounds depends upon the treatment received at the first dressing. If there has been no septic infection at the time the wound was received, and none at the first dressing, the danger is more than half passed, unless there be laxity or carelessness in the after treatment. The war-cry in the treatment of all wounds now, is prevent sepsis and the battle is won.
By far the most common joint-injury is sprain. This is produced by a sudden wrench or twist of the articulation, and occurs most frequently in the ankle, knee, wrist and elbow. Its degree may vary from that which is so slight that is effects quickly subside, to that which is associated with luxation, or fracture, or both. The line of displacement may pass through any section of the investing capsule, but it most often is through that part in which motion is least. By this abnormal movement the synovial membrane is unfolded on one side and compressed on the other, and when the normal limit of such change is reached, the membrane is torn and crushed. The ligaments, though their fibers cannot stretch do elongate somewhat, but the limit is quickly reached, and further extension produces laceration. Rupture of the vessels and slight or extensive hemorrhage into the joint cavity may occur, as well as injury of the articular structures. Intraarticular extravasation to any considerable amount is indicative of severe injury and adds greatly to the gravity of the case. The symptoms are well marked, the only question, as a rule, being whether or not the case is a simple sprain, or whether there is an existing luxation, or, more often, fracture. Pain is instantly produced and is always severe; should there be much hemorrhage into the periarticular struc tures, movement of the joint is arrested. Color changes in the skin take place in a short time. Should there be fracture extending into the joint, this may very seriously complicate matters, and greatly add to the liability of ankylosis of the joint.
The prognosis varies with the joint affected,
the extent of damage done and the promptness and efficiency of treatment. The treatment consists in the prevention or the limitation of the inflammation in and about the joint. Should there be extensive hemorrhage into the joint, it should be withdrawn through an aseptic aspirator needle before the dressing is applied. By far the best treatment, as a rule, is immobilization of the joint, by the application of a plaster of Paris bandage. This will give comfort, prevent swelling and rest the joint. In persons suffering from constitutional tuberculosis, syphilis or rheumatism, these favorable results must not be expected.
I have seen two cases during the past year that were peculiar; the tendons overlying the joint were the seat of the injury. One of the men had been subject to rheumatism, though he had not had it for two years. The other had had syphilis some years ago. The first, a robust-looking young man twenty-four years of age, received a severe sprain of the right ankle. Pain was very severe, but there was very little swelling and no effusion into the joint. A plaster of Paris bandage was applied and kept on for a week. The pain was not relieved. The bandage was taken off for a day, and then reapplied, remaining for another week, still there was no relief from pain. There was very little swelling, some rigors, not well marked, but a temperature, two days after the injury, of IOI degrees, and from that to 103 all the time for the two weeks, occasionally reaching 104 degrees, and at one time 105. There was pain and some tenderness on the inner side of the ankle joint, extending up the tendons; not much pain on moving the joint. After twenty days of unsatisfactory treatment, an anæsthetic was administered, and an incision made, extending some two inches below the joint on the inner side to six inches above the joint parallel with the tendons. This incision was carried down to the joint and the joint examined. The joint structures were normal, but the tendon sheaths were discolored, and thickened with granulation tissues; this was scraped or curetted off from the tendons wherever found; the wound was thoroughly cleansed and antiseptically dressed, and placed in a plaster of Paris cast. Not a drop of pus was found in or about the ankle and the wound healed without suppuration. An examination of the scrapings from the tendon sheaths, both by the micro
scope and by culture, was made, but no bacteria were found. The man made a speedy recovery and now, one year after, has had no trouble.
The other, the syphilitic case, was very similar as to the nature and extent of the injury and the progress and treatment of this case was almost identical with the first, except the temperature, which was at no time more than 103 degrees, and never below 101 degrees for three weeks. The operation was made in the same way and the tendon sheaths were found disorganized. About one dram of pus was obtained; the wound was dressed and treated in the same manner as the case first mentioned and it healed without suppuration. It is now six months since the operation and there has been no trouble. An examination of the pus obtained revealed simply the pus microbe.
Here were two cases of similar injuries, both in location and extent; one in a rheumatic and the other in a syphilitic subject; the progress and treatment was the same, the condition of the parts the same, except that one had progressed farther than the other.
In considering joint injuries, it is well for us to remember, as railroad surgeons, who have so much to do with injuries, how many joint diseases simulate, and in all respects resemble joint injuries. It is an easy matter to class all joint troubles as injuries when often the supposed injury has had but little or nothing to do with the condition of the joint, which depends upon a pre-existing constitutional or local joint affection. Neuralgic pain in a joint may be due to constitutional or to local causes, i. e., to disease of the brain or spinal cord; to neurasthenia, to malaria, to syphilis, to nerve injury, to pressure upon a nerve by a tumor, to affection of organs more or less remote. Like similar pain elsewhere, it is intermittent and variable in intensity, and is unassociated with any apparent permanent change in the articular, or periarticular structures, and yet in every essential particular resembles a joint injury. Hysterical joints may be mistaken for disease of joint injury. More than half a century ago Brodie directed attention to cases of seeming articular disease or injury, in which no joint lesion was present, and which were only manifestations of hysteria. Since then such cases have been found to be of frequent occurrence. The patient imagines he has seri
ous disease, which causes great local distress and entirely prevents passive motion, except at the cost of much suffering. There is not in these cases much swelling, but great hyperæsthesia of the skin, the least touch causing pain. There may be apparent rigidity of the muscles about the articulation, but this disappears when the patient is anæsthetized.
It is of the highest importance that the true nature of the affection should be determined. These cases are often misunderstood, and the patient is treated for actual articular disease or injury, and in consequence becomes a permanent cripple.
In this connection may be mentioned gonorrheal arthritis or what is frequently called gonorrheal rheumatism. The joint affection, whether characterized by intra-articular effusion, by articular and periarticular exudamatic. Though a patient with gonorrhea may have rheumatism and a rheumatic joint because of such antecedent disease may be more susceptible to the toxic action of the gonococcus, or of the mixed gonorrheal and pyogenic infection, the symptoms vary according to the stage of the disease. In the acute form the suffering is intense, worse at night, and aggravated by movements. The parts are swollen and hot; the skin is red, there is decided elevation of temperature and acceleration of pulse. The accumulation in the joints, in spite of any treatment will often remain unchanged for weeks, or even months. In the treatment of this, as in other forms of arthritis, rest is of great importance. As long as there is any inflammation the joint should be kept immoboltions, or by the presence of us, is not rheuized. Any existing hydrarthrosis may be aspirated and the joint the joint injected. In rheumatic arthritis the symptoms those of acute synovitis. Pain, extreme sensitiveness to pressure, and heat and swelling, due in part to effusion into the pariarticular structures, but chiefly into the cavity. Suppuration never occurs unless there has been a mixed infection.
A peculiar osteo-arthritis, known as Charcot's disease, has been frequently observed in patients affected with locomotor ataxia. The joint changes are, in the main, those of osteoarthritis in general, but there are certain differences of importance. The disease is much more acute and without any injury having been
received, the joint suddenly swells, and soon a large intra-articular effusion occurs. There is extensive, and at times very rapid, ulceration, and wearing down of cartilage and bone; new formations are as a rule limited, though an hypertrophic variety is sometimes met with. The lesion often extends along the shaft of the bone and pieces of bone are separated as though there had been a comminuted fracture.
The ligaments quickly break down with resulting great mobility. Dislocation, or characteristic deformity without complete luxation may occur. Everything seems to indicate that the disease is primarily neurotic, depending upon changes that have taken place in the spinal cord.
While these last mentioned diseases are not joint injuries, I have referred to them to show how striking the similarity between many joint diseases and joint injuries is, and how very important it is, in all cases of injury, to know the pre-existing constitutional, as well as local conditions of the individual.