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permanent dressings fail to keep the ends in place, especially when the fracture is very oblique.
The treatment by extension and counterextension is as old as surgery, but the manner of applying the extension differs materially. The raising of the foot of the bed making the body weight the counter-extension force, was a happy thought. The body pulling one way and a weight over a pulley the other, is the whole principle. Hospitals are furnished with all the appliances to put up a fracture after Buck's method, a fracture bed, weights, pulley, etc. In private practice, however, the surgeon is obliged to rely upon what he finds in the house and what he has with him. We can usually get a bed or cot with a firm mattress, six bricks to raise the foot of the bed, three or four flatirons for a weight and in the absence of these an old tin pail to hold rock, carefully weighed; four long bags, made from firm cotton cloth, two to extend from the foot to the perineum, two to extend to axilla; they should be about two inches in diameter when filled with fine dry sand. We must have a strip of adhesive plaster four inches wide to extend from the bottom of the foot to four inches above the knee, on each side of the leg; a block of soft wood 4x5x1 inch, with a hole in the center to fasten the cord for the weight (it must be long enough to keep the adhesive plaster away from the ankles) and an ordinary threeinch roller bandage. If we have a pulley, it can be easily fastened to the foot of the bed; if not, we can bore a hole through the footboard and pass the cord through it. We must not forget to shave the leg before applying the adhesive plaster. This having been done, we should proceed as follows:
Bandage the foot from the toes to above the ankle. Properly adjust the block at the bottom of the foot with the cord fastened to it. The adhesive plaster is now applied over the block and up either side of the leg to above the knee, clipping the edges of the plaster every few inches with the scissors so that it will lie smoothly on the leg. Now continue the roller over the adhesive plaster to two inches above the knee, turning the ends of the plaster down on the roller and covering them with its last turns. If we take hold of the cord and make extension we will
observe that it will sustain any weight necessary. The pulley must be so placed that the extension will be on an exact line with the leg. Raise the foot of the bed six inches by placing three bricks under each leg. For a weight nothing is better than flatirons, and they are found in every house. For the first few days it will require a considerable weight, but as the spasmodic contraction is overcome, less will do. Carefully surround the leg with the sand bags, two on the inner side extending to the perineum, the longest on the outer side extending to the axilla. They must be so placed that pressure is made at the place of fracture. Sometimes I tie them in place by a piece of bandage; this, however, is hardly
Great care is now necessary to determine the exact amount of weight necessary to keep the ends of the broken bone in coaptation. The feelings of an intelligent patient will aid us greatly. If the ends are in place, he will be perfectly easy, if the extension is too great, he will complain of the pulling; if it is too light there will be more acute pain, etc. Particular attention must be paid to the heel, it must not be allowed to press by even the weight of the foot on the mattress, as an ulcer is easily formed which is not easily cured. We should be very particular to keep the leg in its natural line, and the foot in its normal position. There are many little things that one must watch closely. There are no two cases alike, and each must be studied by itself. After a few days we will know the exact weight necessary to keep the balance; if the weights are marked in pounds, we will know what it is; if not so marked it must be weighed, as it is necessary to know the exact amount.
At the end of two weeks union will have commenced; with care the weight can be removed, the bed let down, and passive motion of ankle and knee made. I commence this sooner than 'formerly and have only good results to report. The patient can now be given more liberty, the weight can also be lightened a pound or two, at the same time letting the bed down an inch. At the end of the third week we can make another reduction in the weight and lower the bed another inch. When I am sure I have a firm union, I put the leg up in plaster. The last few days the
weight has been cut down half and the bed let down to three or four inches, the joints have been put through their normal motions, the dressings all removed and the leg thoroughly bathed and rubbed. The plaster is applied from the knee to the perineum. A close, thin drawer leg underneath is sufficient; the plaster must be heavy enough to keep the femur from bending. In my opinion, more crooked legs are made by too early use than in any other way. Crutches can now be used but the patient should be admonished to put no weight on the foot for a week or two. The plaster is generally worn about two weeks, when it is cut open and sprung off and the leg is thoroughly bathed and rubbed, after which the cast is reapplied. If all is favorable, I then permit the patient to put some weight on the foot. The dressing should now be removed every few days and the limb bathed as before. If everything is all right the patient can now care for it himself. This he usually does at the end of five weeks from the injury.
This mode of treatment gives a greater percentage of good results than any other. In my own practice there is less shortening, and straighter legs, the time of treatment is less, the patient has more comfort and is not bound up with splints and strapped on his back. From almost the first day he can sit up without disturbing the dressings, and do many things that cannot be done under any other method. I am aware that I have advanced nothing new, I have only described an old method which has not received its proper credit by those in search of better methods. Hoping to say something to recall attention to an old and tried treatment is the excuse for this paper.
1001 Harrison street.
BY J. D. MILLIGAN, M. D., PITTSBURG, PA.
Dermatitis is sometimes called acute eczema, and while this term may be correct, I will draw the line if possible and consider only that acute inflammation of the skin which follows injury to the soft parts, particularly of the hands and feet. The disease is ushered in by chilliness, thirst, loss of appetite, head
ache and insomnia, and there is elevation of the temperature which may reach 103 degrees F. The mucous membrane of the mouth is red and dry and the tongue is red at the point, with a white fur over the base. The parts affected assume an appearance closely resembling what we see in cases of poisoning by rhustoxicodendron, characterized by vesicles, elevated above the surrounding parts, but which quickly coalesce, destroying the cutis, and invading the corium or deeper layers of the skin, by the ulcerative process. The ulcers have undermined edges, assume a bluish tint and correspond closely to a phagedenic slough or local gangrene with a characteristic odor of decomposed fat. This pathological condition is attended by an intense burning and itching pain, heat and swelling with a congested condition of the circulation and enlargement of the lymphatic glands and a heavy, aching sensation, at first local, but quickly extending to the whole body, irritability of the nervous system, with suffusion of the face and all the constitutional disturbances found in acute inflammatory diseases. Constipation is the rule with scanty, acid, urine.
The following cases came under my observation during the summer of 1896:
Case 1. Crush and laceration of the great toe, causing destruction of the nail and soft parts of the ball of the great toe, laying bare the nerves and blood vessels. The wound was carefully washed with sterilized water, with the addition of etheral antiseptic soap (Johnston's) after which a 1-4000 solution of bichloride of mercury was freely applied. It was then sponged dry with cotton previously saturated in the above solution and squeezed dry. The wound was then dusted freely with iodoform, covered with iodoform gauze (ten per cent.) and then by eight or ten layers of dry sublimate gauze standard strength (1-1000), and lastly a thin layer of antiseptic absorbent cotton, and a gauze bandage. The wound was dressed daily, the same care being exercised, and the same solutions used except that no soap was used after the first cleansing. The wound progressed favorably, and the patient was discharged well but came back the second day after with a dermatitis, which quickly extended over the entire foot and lasted for about three weeks.
Case II. Crush and laceration of second and third fingers of the right hand, attended by considerable sloughing, leaving the nerves and vessels exposed. The wound was healthy in appearance and healing kindly when on the twelfth day the patient was attacked with dermatitis which quickly extended over the right hand and forearm and on the following day appeared on the left hand involving the entire hand to the wrist joint; a few blebs were also found on the great toe of the left foot. This case resisted treatment for four weeks.
Case III. Crush of right foot and ankle joint. Amputation at lower third of leg. A small slough occurred where a branch of the long saphenous vein was dissected out during the operation close to the exit of the musculo-cutaneous nerve. The wound healed rapidly and soundly except where the slough had been about the size of a silver quarter of a dollar when dermatitis set in, involving the entire stump and as far as the knee joint. It was apparently well in three weeks but was followed by recurrent attacks less severe but always attended with an intense burning itching pain starting from the point where the slough had been, and was only cured by resection of the nerve, which was found to have a neuroma at its end the size of a large bean. There has been no recurrence since the last operation, over five months ago.
The treatment adopted in these cases was practically the same. Calomel and soda was given at once upon the appearance of the dermatitis, followed by analkaline purge; quinine and sodium bicarbonate, in decided doses, was continued for the first week, followed by arsenic and iron, as a tonic. The local treatment was thorough cleansing of the affected parts with Thiersch's solution, and the application of lead and opium until the cedema began to yield, then black wash. Both of these remedies were applied hot and by saturating sterilized gauze and wrapping up the parts heavily, with rubber protective over all to retain the heat and moisture. When exfoliation began the parts were freely dusted with zinc stearate and bismuth subnit. (I dr. to IV dr.) and covered by sterilized gauze saturated by pure vaseline.
These cases all came under observation during the months of July and August, 1896.
The patients were not in contact with one another, neither was there any possibility of infection. There was no history of idiosyncracy to either iodoform or iodine.
There was in all three cases a marked similarity as to constitutional disturbance and all presented the same pathological condition save the extent of surface involved. Was the dermatitis due to injury to the nerves? If so, why did it not manifest itself at a period prior to the almost complete union of the injured parts? Was it caused by iodoform? If so, why was it necessary in the one case to do excision of the nerve to effect a cure? 410 Third avenue.
TREATMENT OF FRACTURE OF THE OLECRANON PROCESS OF THE ULNAR, NOT USUALLY PRACTICED.*
BY B. J. BYRNE, M. D., ELLICOTT CITY, MD.
William P., aged ten years, came to my of fice with an injury to the elbow. On examination I found that the olecranon was fractured and drawn up by the triceps muscle about one inch from its natural position. There was very little swelling. With the elbow bent at a right angle, I grasped the forearm with one hand and with the bent fingers of my other hand pulled down the upper fragment and felt that I brought the fractured ends in close and perfect apposition. It occurred to me that I could desire nothing better if I could only keep them so. I therefore made a small compress of absorbent cotton and with some narrow strips of surgeon's plaster succeeded in making these materials perform the service my two hands had done. I placed the compress posterior to and a little above the upper fragment to prevent chafing. With the plaster I made a loop, placing it in the depression just above the upper fragment. The strips were given a twist in a manner to better prevent the retraction of the upper fragment by the muscle. The ends of the strips were drawn on a line with the limb slightly converging and made adherent to the posterior aspect of the forearm. I then placed some circular bands of plaster around the
* Read at the meeting of the B. & O. Surgeons' Association, at Philadelphia, January, 1896.
forearm to make the strips more secure and to prevent the integument from sliding. By these means the fragments were held in close apposition. I then put a roller bandage on the arm to control the triceps and a light pasteboard splint to keep the elbow at a fixed angle. The result was a bony union and an unimpaired joint. In no work on surgery have I read that this fracture could be treated in this manner.
It may not always be practicable to treat the fracture in this way, but the result in this case was so satisfactory that I am led to believe that in a young subject, and when it is found that the fragments can be securely held, it makes a very much more convenient and comfortable method for the patient than having the arm extended, and that it can be safely resorted to.
Rusty Nails and Lockjaw.
This is an age of great progress, and nowhere possibly is this more apparent than in our own domain of medicine. Yet when we consider, in the light of modern science, much of the empirical knowledge of the fathers of medicine, we cannot too highly praise the closeness of their observations and the logic of their deductions. One of the first of the bacilli to be studied in connection with the modern science of disease was the bacillus of tetanus, the principal work being done by Nicolaier, and the bacillus was named after him. This bacillus is club-shaped, or, as expressed by Bonome, a fine bristle-shaped, pinheaded bacillus. There was much difficulty at first in cultivating this bacillus, as has been the case with many other pathogenic forms, but Mr. R. T. Hewlett, in London Lancet, described how this could be successfully and readily done. The bacillus of tetanus had always been noticed associated with petrefactive bacteria. The reason for this appears from Mr. Hewlett's method. This bacillus is anærobic, but, as he points out, is readily cultivated in an atmosphere of hydrogen. With a better laboratory knowledge of every form. comes a better knowledge of its life habits, and so of this one.
Prof. Welch, of Johns Hopkins, says that of all pathogenic bacteria which appear in the soil the most frequent are those of malignant oedema and tetanus. It is a fact well known that after certain battles the wounded were very liable to be afflicted with tetanus. This would be explained, as pointed out by J. Lewis Smith, by the presence of the baccilli
in the soil of the battlefield. He also mentions case occurring in hospital practice where patients coming to the surgical wards from certain districts developed tetanus. It seems to be now well settled that the tetanus bacillus thrives in the soil, and more especially in those soils where putrefaction is going on, as around houses where refuse matter is thrown. This brings us back to our first paragraph. We are all acquainted with the supposed popular connection between an injury to the foot by a rusty nail and lockjaw. Here we have that extremity which is always nearest the ground injured by the most common object, for the purposes, likely to be in the putrefactive area of civilization. In other words, you have a most successful inoculation of the bacillus nicolaier.-Dominion Medical Monthly.
To Prevent the Absorption of Poison During Operations on Septic Patients.
1. After the hands and arms are made aseptic, dip them in strong ammonia water, or in a saturated solution of oxalic acid. This procedure will instantly reveal to the surgeon the least abrasion of the skin from any cause. All small abrasions, or separations of continuity of skin, should be painted with flexible collodion, and immediately covered with a few fibres of absorbent cotton. Dry this dressing quickly with heat from alcohol lamp, and again. paint with flexible collodion, and dry in the same manner. Then sterilize finger in I to 100 bichloride solution. 3. If the wounds are on the joints, apply a strip of adhesive plaster over the cotton and collodion dressing, passing the plaster quite around the finger, at least twice. Fasten this dressing securely with thread. Or, instead of the adhesive plaster, draw on a rubber cot or glove. Sterilize finger or hand and dressing in 1 to 100 bichloride solution. 4. If the hand or finger is wounded during an operation, stop long enough to place on the wound a drop of saturated solution of carbolic acid, or lysol, or creolin, or touch it with a nitrate of silver point. Cover the wound with a small pledget of absorbent cotton, well saturated with carbolized or creolin water, and cover this cotton thoroughly with adhesive. plaster. Fasten this plaster securely with thread. Sterlize the finger and dressing by immersing it in 1 to 100 bichloride solution, and proceed with operation. 5. Remember that your health is, or should be, as valuable as the patient's, and that if you have a good assistant to watch the patient, five minutes' time given to dressing your own wound will make no appreciable difference in the result of the operation you are performing.-Horace T. Hanks.
Officers of the N. A. R. S., 1896-7.
F. J. LUTZ, St. Louis, Mo.
First Vice-President.. W. R. HAMILTON, Pittsburgh, Pa.
Seventh Vice-President...E. W. LEE, Omaha, Neb.
C. D. WESCOTT, Chicago, Ill. Treasurer..... ..E. R. LEWIS, Kansas City, Mo. Executive Committee:-A. I. BOUFFLEUR, Chicago, Ill., Chair
J. N. JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa.
THE ANNUAL CONVENTION.
In another column we publish the preliminary programme of the tenth annual meeting of the National Association of Railway Surgeons, which is to be held in Chicago, May 4, 5 and 6, 1897. The list of names of the surgeons who will contribute to the scientific value of the occasion includes those of some of our best known and most honored members whose words are always listened to with both pleasure and profit. One or more clinics will be held in connection with the meeting, and it is expected that one or more addresses will be read by prominent surgical teachers not members of the association.
From present indications there will be an abundant programme and the value of the discussions will be enhanced by selecting gentlemen especially qualified to open the discussion of each paper. All those who would like to read papers at the coming meeting should communicate at once with the secretary of the association, Dr. Cassius D. Wescott, 31 Washington street, Chicago. We hope to publish the complete programme early in April.
A DAILY AT THE CONVENTION.
The publishers of The Railway Surgeon take pleasure in announcing that during the forthcoming annual convention of the National Association they will publish a daily paper to report the proceedings of the convention. There will be four issues of The Daily Railway Surgeon and a copy of each will be sent to every railway surgeon in the
While we are aware that the undertaking is a daring one and will involve considerable financial risk, we believe that the enterprise will attract so much creditable attention to both the association and its official journal that in the end the sum of the mutual benefits derived will offset any financial loss that may result. We are determined that in enterprise, quality and tone The Railway Surgeon shall be second to no surgical publication in America. The remarkably strong position which it holds to-day, after less than three years of existence, is, we believe, ample justification for the belief, so generally entertained, of a great future for this journal. Its influence has been felt in all parts of the country and in all departments of surgery. Since it began publication it has given to its readers some of the most brilliant papers on traumatic surgery that have ever been contributed to surgical literature. And the end is not yet. There is more of the same sort of work to be done.
The Daily Railway Surgeon will mark another great step in the progress of the National Association of Railway Surgeons. No other similar body can, we believe, boast of any such exponent of its annual conventions. The association will more than ever have occasion to feel proud of its official journal, and