« ForrigeFortsæt »
Extracts and Abstracts. for careful maintenance of the coaptation will
usually produce good results. Practitioners who have comparatively few cases are, however, less liable than surgeons to appreciate the probability of a 'gunstock' deformity. In the flexed position of the elbow, moreover, the deviation of the axes of the arm and forearm does not exist; hence, in this position a slight displacement of the plane of the articular surface of the humerus is easily overlooked. For these reasons the extended position is the better for general adoption, since the angularity of the unbroken arm is then noticeable, and any interference with the normal deviation is very apparent." I fully agree with Dr. Roberts in thinking that the surgeon who sees many of these fractures will obtain satisfactory results under any form of treatment which his experience and judgment may lead him to adopt, but for the general practitioner, who sees these cases but seldom, to treat them in extension seems to me unwise, and I am led to this thought by the recollection of the following
The Question of Position in the Treatment of
The following paper, by Charles A. Powers, M. D., of Denver, Colo., surgeon to the Arapahoe County Hospital and consulting surgeon to St. Luke's Hospital, was read at a meeting. of the Denver and Arapahoe Medical Society, March 10, 1896. It is such an important clinical contribution that we reproduce it entire:
Until recent years there was but little difference of opinion regarding the position in which the elbow should be placed in fractures at the lower end of the humerus; the right angle was unanimously advised and employed, and this for the reason that the arm was in the most useful condition possible in case ankylosis ensued. The position was classic, and the injunction to begin passive motion at an early date in order to prevent ankylosis was faithfully followed. In 1880, however, Dr. Oscar H. Allis of Philadelphia, in a most careful and scientific essay, called attention to the change in the axes of the arm and forearm which may take place when the outer condyle slips down or the internal condyle is displaced upward, resulting in a deformity to which the term "gunstock" is applied. For the avoidance of this Dr. Allis recommended that the forearm be placed in a position of extension. He also strongly emphasized the important principle that no passive motion be made at the elbow until union should be complete. This latter proposition, I believe, admits of no debate in the average case; passive motion before consolidation of the fragments leads to rather than avoids ankylosis. But to the contention that the position of complete or nearly complete extension should be employed in fractures entering the joint, I shall ask your attention, and I shall endeavor to demonstrate to you that the position of safety is that of flexion and that this position is attended with sufficiently satisfactory results to warrant its being retained by the average practitioner of medicine.
In order to bring before you the arguments of those who favor complete or nearly complete extension I quote from a valuable paper read by Dr. John B. Roberts of Philadelphia before the American Surgical Association in 1892. Dr. Roberts said: "A surgeon who fully realizes the probability of impairment of the carrying-function in these fractures can, without doubt, treat them equally well in either the flexed or the extended position. Accurate readjustment of the fragments and provision
In a recent communication Dr. Allis writes that the success attained in treating these features with plastic dressings convinces him that manufactured splints held in place by roller bandages are largely responsible for this deformity.
3 Annals of Surgery, July, 1892.
Case I. In July, 1893, a boy of nine years was admitted to my service at St. Luke's Hospital, New York, with the following history: Some six weeks previously he had fallen, injuring the left elbow. Immediately thereafter he was seen by a physician, who told the parents that the elbow was broken. He put the limb up in complete extension, and applied splints, which were changed from time to time and which were finally removed at the expiration of five weeks. At this time there was little or no motion at the elbow and despite vigorous measures, the range did not increase. Six weeks after the injury, as I have said, the lad came under my care. Examination revealed the folsiderably thickened, especially in the region of The elbow-joint was conthe external condyle; the forearm was completely extended upon the arm, and could be fixed but 10°. Under an anæsthetic attempts to flex the elbow proved unsuccessful, whereupon a four-inch incision was made over the external condyle and the joint entered. The coronoid process of the ulna was found to be broken off and displaced upward and backward, lying posterior to the articular surface of The fragment was removed. The external the humerus, thus completely locking the joint. condyle was the seat of a fracture running downward and inward through the articular surface, the fragment being displaced anteriorly. The anterior surface of this fragment was chiselled away, whereupon the elbow could be completely flexed. The wound was sewn up without drainage, the elbow put up at a little more than a right angle, and an ordinary aseptic dressing applied. Complete primary union resulting, motion was begun at the end of four weeks. The arc rapidly increased and
three months later the use of the elbow was very nearly normal.
Case II. One month after the foregoing case came under my observation, I was asked to see a boy of twelve years whose physician told me that some four months previously the patient had sustained an injury to the lower end of the humerus, the exact nature of which he was unable to make out, because of the swelling. He had applied splints in the extended position, removing them from time to time for the purpose of making gentle passive motion. The straight splints were not discarded until union was thought to be complete. At this time, however, the range of motion was very slight and could not be increased. When I saw the lad there was fibrous ankylosis, the forearm being extended upon the arm. Under ether the adhesions were broken up, the forearm brought up to 135°, and a plaster-ofParis splint applied. Ten days later ether was again administered and the remaining adhesions were so far ruptured as to admit of nearly complete flexion. Plaster of Paris was applied with the elbow at a little less than a right angle, and two weeks later active motion begun. A useful limb resulted.
Case III. In March or April of 1891 a young man of twenty years was admitted to my service in the out-patient department of the New York Hospital. He said that he had broken his elbow four months or so before and that it had been treated in one of the metropolitan hospitals in the position of extension. Complete ankylosis resulted. When he came under my observation there was no motion at the elbow, the forearm being completely extended upon the arm. Operation was advised but refused, and I did not see him again.
Cases IV and V are similar to Case III. Each came under my observation in the New York Hospital. In each there was complete ankylosis in the extended position. In both instances the elbow-joint was excised in narrow limits by the attending surgeon on duty-in one case by Dr. R. F. Weir, in the other by Dr. W. T. Bull. Both patients returned to the out-patient department for after-treatment. Each regained good use of the limb; the functions were excellent, considering that the joint had been excised.
These are cases which have been under my own observation, and I am sure that other surgeons can cite additional instances. I am far from saying that the ankylosis was due to the method of treatment; it might have occurred under other forms of management. In the first case the fractured coronoid would have prevented flexion and an operation at the time of injury was demanded; but if ankylosis were inevitable in either case extension was the worst possible position for it. We cannot say in any individual case of fracture entering the elbow
joint that a greater or less degree of ankylosis. will not ensue, especially in people at or beyond middle life and in the gouty or rheumatic, and it is precisely for this reason that we should place the limb in the position best suited to its use in case of stiffening, provided that we do not hazard a deformity which will be of greater moment than can be compensated for by this position of election. I have myself long been convinced that the results are sufficiently good when the elbow is treated at or nearly at a right angle. In 1888 I read a paper' before the New York Academy of Medicine based on the analysis of fifty cases which had been under my own care. The position adopted was that of 90° or thereabouts. Each case was carefully followed to the end and the result is noted as satisfactory in forty-eight cases out of the fifty. Since the publication of this paper I have treated some seventy additional cases, and while the management has been varied in some details, its principle remains-that of immobilization at or near a right angle and the results are sufficiently good to warrant its continuance.
As I have said, the advocates of the position of extension argue that better coaptation of the fragments is thereby obtained, and experiments on the cadaver seem to support their views. But it is interesting to note that a series of very careful experiments on the dead body recently conducted by Dr. H. L. Smith of Boston, tends to prove the exact opposite, and that better coaptation is made by complete flexion. Obviously, both of these views cannot be right, and, further, I do not think that this is a matter in which we can reason definitely from experiments made after death. These tests cannot take into account muscular action, which is a most important factor in the production of the deformity accompanying fracture, and we cannot transmit on the cadaver the exact violence which produces these fractures in the living. In view of these conflicting conclusions, and in the absence of any considerable number of cases supporting either, I have felt that it might be of interest to bring forward clinical evidence in substantiation of the claim that the position of safety, viz., at or nearly at a right angle, yields sufficiently good results to warrant its employment by the general practitioner.
In our largest cities the out-patient surgeons see the greatest number of these cases, and in order to supplement my own views I have communicated with three of my former colleagues in the city of New York, Drs. Frank Hartley, B. Farquhar Curtis, and W. W. Van Arsdale, each of whom is in charge of large dispensary and hospital services, and the name of each of whom is a sufficient guarantee for the sound
1 Medical Record, December 22, 1888.
2 Berthomier: These de Paris, 1875.
Boston Medical and Surgical Journal, October 18, 1894.
The question which I asked each of the gentlemen was as follows: "What position do you consider best adapted to the treatment of fractures of either condyle of the humerus, or of the transverse fracture above the condyles, or of the so-called T-shaped fracture?" Their answers are as follows:
Hartley and Woodbury: (a) Internal condyle-gypsum splints from fingers to shoulder, forearm semiprone, elbow at right angle. (b) External condyle-the same as the internal, except that the forearm is supinated. (c) Transverse or T-shaped-gypsum splint from fingers to shoulder or with shoulder spica, forearm supine, elbow at less than a right angle.
Curtis: Plaster-of-Paris bandage from fingers to axilla in most cases; occasionally when the superficial soft parts are impaired and need watching, a removable dressing with a wooden or tin splint. In the great majority of cases the limb is put up with the elbow inside of a right angle, but not actually flexed, as the latter position would be less comfortable. The hand is in semipronation. When the "carrying-point" is lost and it is difficult to restore it owing to the slipping of the fragments, as usually occurs in fractures of the internal condyle, the limb is put up in full extension and supination with particular attention to the "carryingpoint" for about two weeks, by which time the liability to lateral angular deformity has disappeared and yet union is not so solid as to render it impossible to correct any outer displacement which might interfere with flexion. Then ether is again given, the elbow flexed inside of 90°, and a plaster splint applied with careful attention to the position of the fragments. This splint is left in place until consolidation is complete.
Van Arsdale: In all cases flexion to 90° or to 80°; starch or pasteboard dressing until the swelling abates; then the same or plaster-ofParis for three or four weeks, according to age (until union is complete).
In my own recent cases I have put the limb up in plaster-of-Paris at about 90° when first seen, except in those cases in which a tendency to "gunstock" deformity was apparent. In
In each instance the number represents the surgeon's approximate estimate of his own cases.
Dr. Hartley having charge of the service, the immediate treatment being carried out in all cases by Dr. J. McG. Woodbury.
these latter instances I have made the angle 135° for ten days or two weeks, reduction being made under an anesthetic with careful attention to the "carrying-point," and then changing the angle to 90° or to 80°. I am convinced that the extended position is not necessary to the obtaining of suitable coaptation of the fragments, and I am by no means sure that a moderate degree of cubitus varus is prejudicial to the usefulness of the limb; though I do not know that I am prepared to go quite so far as does Mr. Robert Jones of Liverpool, who says that neither it nor cubitus valgus is of any consequence from either an æsthetic or a functional aspect.
Of my last seventy cases the result has been satisfactory in all but one. This was a young lady of twenty-four years, who came to me one week after an elbow-joint injury. Examination under ether revealed a V-shaped fracture, each condyle being separated and the lines running to a common point at the trochlear surface. Despite all care the arc of motion was limited to between 90° and 135°.
With forced flexion as advised by. Smith' of Boston, and Jones of Liverpool, I have had but little experience, not enough to warrant an expression as to its real value.
I have not presented in detail the cases of the men whose opinions I cite, nor my own. What I want to say is simply this: That after having actively managed this number of cases, six hundred and fifty, it is our opinion that the best results are obtained by treating the limb in the flexed position, and that the general practitioner will find the greatest degree of satisfaction in following this form of management.-Medical Record.
W. G. Laws, M. B. Edin., F. R. C. S. Eng., surgeon to the Nottingham and Midland Eye Infirmary, in a paper read before the Nottingham Medico-Chirurgical Society on April 15, 1896, pointed out that the subject lay in the debatable region between mental states and physical processes, where so many interesting problems remained unsolved. The eye was the end organ which brought us into direct relation with the ether, that ultimate form of matter as to which it became possible to doubt whether it was material at all, and which probably entered closely into the processes of thought itself. Before speaking of the theories of color vision it might be asked what was there in color vision that so many scientific minds had felt required explanation. It would be noticed that every theory contained the same fundamental idea that there must be a certain number of colors, varying with different ob
1 Boston Medical and Surgical Journal, January 4, 1895. * Provincial Medical Journal, December 1894.
servers, but always few, which were to be regarded as pure or simple colors, all others being considered as compounds or mixtures of these. On looking at the perfectly continuous series of colors which we see in the spectrum there seemed to be no obvious physical reason for this distinction. It was, indeed, a psychological rather than a physical one. We had an innate disinclination to conceive of an infinite number of different causes for the infinite number of different sensations of which we were conscious; it was a principle deeply rooted in our reason, expressed long ago by William of Occam, whose famous Razor, "Entia non sunt multiplicanda," was employed by us nowadays as constantly in the solution of physical problems as it was by the Invincible Doctor in the division of the sophistries of Rationalism. Mr. Laws hoped to show, however, in relation to one, at least, of the theories that it was possible to cut too close with it. Many theories of color vision had been proposed during the last 200 years, some of them interesting and original, but two only had gained any general acceptance and to these the discussion would be confined. He then described the theory of Young as it was published in 1801, its modification by Helmholtz more than half a century later, with his proof of the mathematical possibility of reducing all our color sensations to three. Hering's theory was next described, mainly in extracts from his original papers, Mr. Laws considering that none of the published accounts of it in this country did justice to the simple conception, the logical development, and lucid expression of the theory as stated by Hering himself. What we might fairly demand of a theory of color vision was that it should give a reasonable explanation of our everyday experience with regard to our sensations, and also should furnish us with a trustworthy guide when the conditions were modified by pathological processes. As it was impossible for him to discuss all the phenomena in the light of these theories he would make the appeal only to an experiment made for us by nature, namely, the condition of congenital colorblindness. Of this Mr. Laws considered that practically only one type existed, admirably described in Dr. Pole's account of his own case; that other types had been described was due to the attempt to make the facts of observation fit with an erroneous theory; the rare cases of monocular color-blindness were quoted as highly conclusive on this point; finally, the verification was at the hand of each one in the color-blind zone of his own retina. He summed up the evidence from color-blindness as showing that whenever there is a diminution of the number of our color perceptions it is not one that disappears, but always a pair of complementary colors. Here was the reason that the trichromic theory of Young failed-it was not
in harmony with the essentially paired character of our color sensations. Further examples of this character were given in the phenomena of successive and simultaneous contrast, and it was pointed out that we have only to look at a color in order to call up the sensation of another as definite and (under proper conditions) as brilliant as the former, and having the constant psychical character that it is the greatest possible contrast to the former that our minds can conceive. The physical relationship of the two was such that if the spectrum be divided into two halves, and the more refrangible be superposed on the less refrangible half, then color by color and shade by shade the one will neutralize the other and a colorless band result. The dividing line between the two halves corresponds to the neutral point of the spectrum of the color-blind, and thus the same relation holds for their spectrum as for ours. This very remarkable relationship had, he thought, had less importance attached to it than it deserved. The three pairs of antagonistic chemical processes of Hering seemed to him but crudely to account for the facts. Might there not be a deeper cause for it? Much light had been thrown of late years on the relations of light and electricity originally by Clerk Maxwell's mathematical development of the relations of certain physical constants into an electro-magnetic theory of light and, perhaps more strikingly, by Hertz's demonstration of the possibility of producing electromagnetic waves which had all the essential characters of those of light. We know as little of the real nature of electricity as of that of the ether; perhaps, indeed, they were one and the same thing; but one of the most characteristic properties of the former was its power of producing a condition of polarity, or the separation of equal and opposite energies, in matter under its influence. Might not this furnish a clue to the intimate nature of the action of light on the retina and so lead to a completer theory of color vision that we yet possess?-Lancet. Hæmostatics in Hæmophilics.
Dr. H. C. Howard Champaign, Ill. (Amer. Jour. of Surg. and Gyn.), has for twenty years used hypodermic injection of a saturated solution of tannic acid around the seat of the bleeding. Dissolve the acid by aid of heat. Make from three to six injections around the seat of the injury, using a saturated solution as hot as can be stood. Also inject hypodermically onetwentieth of a grain of strychnine and repeat every two hours if needed. Strychnine by the its influence upon vasomoter nerves usually checks bleeding in a short time, but when the amount of blood lost is considerable it is best to adopt the above method of local
Notices and Reviews.
The Principles of Surgery, by N. Senn, Ph. D., LL.D., second edition, thoroughly revised; illustrated with 178 wood-engravings and colored plates. Philadelphia. The F. A. Davis Company.
We have often thought that books, like men, were interesting in proportion as they were free from egoism. The unselfish devotion to merit, the appreciation of work done by others, along with rare selective power and breadth of view, yet with splendid condensation of existing literature, certainly makes this work of Dr. Senn's a masterpiece. The principles of surgery can be made very dull and uninteresting reading and in our earlier life in medicine we keenly appreciated this fact, until we became acquainted with Van Buren's Principles of Surgery. The work under review is certainly a splendid effort, and its worth and charm come through the fact of common-sense arrangement, keen devotion and appreciation of the masters, impartial yet enthusiastic views, and a capacity in the direction of generalization. It is pre-eminently a student's book, and it must be a dull man, indeed, who can take Senn's Principles and not become interested. The chapters on regeneration are now classical and we will never forget our first pleasure in reading them. They contain almost the entire basis or ground work of surgical pathology. Generalizers are born, not made; individualizers are in the nature of a fungous growth. Time is their fate; they bloom and gush for a day, but the masterful generalizer, the establisher or enunciator of principles, is a master endowed from the beginning, and Senn is one. The chapters on regeneration are followed by one on inflammation, wherein is treated the plain and easily understood difference between regeneration and inflammation. Then comes a chapter upon pathogenic bacteria, which includes classification and multiplication of bacteria, along with an extensive life history of bacteria forms. The chapters upon septicemia, pyæmia, tetanus and surgical tuberculosis are especially fine and will bear repeated reading. We may be prejudiced in favor of this book, but certainly think it is by far the best book of this character which we have read, and this second edition, with its many valuable addi
tions, makes it of still greater value. It has been of rare educational value, and we believe that it will continue so.
The International Encyclopedia of Surgery. A Systematic Treatise on the Theory and Practice of Surgery, by Authors of Various Nations. Edited by John Ashhurst, Jr., M. D., LL. D. In seven volumes. Vol. VII, Supplementary Volume. Wm. Wood & Company, New York, 1895.
For many years we have thought that this encyclopedia was the most comprehensive and valuable presentation of surgical knowledge. Any library will certainly be lacking without it. To the honest investigator it will become apparent that the amount of individual thought and work is enormous. It is not a mere compilation, but a well-condensed, original work. As to the making of books there is no end, but of such works as this but few have ever been produced. It is invaluable in the study of the history and progress of surgery. We have consulted it for years and it has added to our capacity, and endeared itself to us for the reason that it is full of original thought and experience, and not a vapid rehash of oft-told things.
This supplementary volume (Vol. VII) contains articles to the number of fifty-five, by forty-eight different authors, covering almost the entire field of surgery, and is indeed a splendid work. We were especially pleased with the following chapters: Anæsthetics and Anæsthesia by Dr. A. I. Bouffleur, a thoroughly condensed and invaluable chapter upon a dangerous element in the surgeon's calling. Its condensation is masterly. Dr. B. Farquhar Curtis certainly possesses a well-ordered mind, one which comes easily and readily to lucid condensation. His article upon tumors is a model in its way, and will well pay for its perusal. Injuries of Bones, by John H. Packard, M. D., is what we would expect from this author, a masterly exposition of the subject. Surgical Diseases of the Head, by W. W. Keen, M. D., is in our estimation one of the best condensed and most practical articles which it has been our fortune to read. Joseph Ransohoff, M. D., gives a chapter on Injuries and Diseases of the Neck, which, while condensed, is pre-eminently practical. We have not time to individualize, but certain it is that the makers of this book made better than they knew. This supplementary volume,