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we are gratified to state that the members to whom the proposition has thus far been presented are doing all they can to make "the daily" a success. A number of pages of advertising space have already been taken, and we are prepared to give our rates and best attention to all comers.
THE ROENTGEN RAY.
At a recent meeting of the Chicago Medical Society the utility of the Röntgen process was demonstrated by the exhibition of a variety of skiagraphs illustrative of bone surgery in many phases. Among other cases one was reported by Dr. Arthur D. Bevan in which a man was shot in the side of the head, the ball penetrating the temporal bone, wounding the middle meningeal artery and then passing into the orbit through the great wing of the sphenoid, and lodging just behind the eyeball. Without the aid furnished by the Röntgen picture it would have been absolutely impossible to locate the ball, although its presence in the orbit would have been suspected from the symptoms present. Dr. Bevan safely extracted the bullet, however, by the aid of the little black shadow of the piece of lead in the fainter shadow of the bones of the skull in the skiagraph, and "the patient is doing well." But the thing which we wished chiefly to say and which we are reminded of by the demonstration above referred to, is something of the dangers attending the use of the Röntgen rays in surgery. Numerous cases have been reported of late of dermatitis of greater or less. severity due to prolonged or repeated exposure of the skin to these rays; but the most serious case of which we have knowledge, and which we believe has not yet been reported, is one in Cook County Hospital, in the service of Dr. J. B. Murphy. A number of skiagraphs of the head were taken in a short time, a dozen or more, one after another, and in due time a dermatitis appeared which has resisted treatment and has produced such an amount of scar tissue that the deformity of the eyelids threatens the loss of one or both eyes. We call attention to the case as a warning to surgeons who may be tempted to expose themselves or their patients too long or too often to the strange effects of these rays.
Notes of Societies.
The Western Ophthalmological, Otological, Laryngological and Rhinological Association.
The second annual meeting of the above society of western specialists will be held in the Planters' Hotel, at St. Louis, Mo., April 8 and 9, 1897. Dr Adolph Alt of St. Louis is president and Dr. Hal Foster is secretary. An enormous programme of seventyfive papers is promised and if half of them. are read and adequately discussed, the meeting will prove of great value to those who are so fortunate as to be able to attend.
The Tenth Annual Meeting of the National Association of Railway Surgeons.
The following is a list of the members of the National Association of Railway Surgeons who have already pledged papers for the annual convention to be held in Chicago. May 4, 5 and 6, 1897, with the titles of their contributions as far as announced:
Dr. John Punton, Kansas City, Mo., title not announced.
Dr. Frank H. Caldwell, Waycross, Ga., "Relief and Hospital Departments."
Dr. H. L. Getz, Marshalltown, Ia., title not announced.
Dr. Solon Marks, Milwaukee, Wis., title not announced.
Dr. W. T. Sarles, Sparta, Wis., "Traumatic Infections and Their Treatment."
Dr. Jabez N. Jackson, Kansas City, Mo., title not announced.
Dr. G. P. Conn, Concord, N. H., "Relation of Railway Companies to State Boards of Health."
Dr. C. W. Tangeman, Cincinnati, O., “An Exhibition of the Various Devices for the Determination of the Color Sense of Railway Employes."
Dr. A. L. Clark, Elgin, Ill., "A Case in Practice."
Dr A. C. McClanahan, Red Lodge, Mont., "Plaster of Paris and the Difficulty of Applying it to Recent Fractures."
Dr. W. R. Hamilton, Pittsburg, Pa., title not announced.
Dr. Thomas H. Briggs, Battle Creek, Minn., "Problems."
Dr. A. C. Wedge, Albert Lea, Minn., title not announced.
Dr. Rhett Goode, Mobile, Ala., "A Case of Osteo-sarcoma from Railway Injury."
Dr. E. W. Lee, Omaha, Neb., "The Treatment of Burns."
Dr. A. I. Bouffleur, Chicago, Ill., title not announced.
Dr. W. A. McCandlass, St. Louis, Mo., "Brain Abscess."
Dr. T. O. Summers, St. Louis, Mo., "Shock in Its Relation to Permanent Injury."
Dr. W. B. Outten, St. Louis, Mo., title not announced.
Dr. A. L. Fulton, Kansas City, Mo., "The First Care of the Patient in Railway Traumatism."
The St. Joseph and Grand Rapids Railway Surgeons' Association.
The semi-annual meeting of the surgeons of the the St. Joseph and Grand Rapids railway was held in St. Joseph, Mo., February 18. A score of doctors from points all along the system were present. Essays were read by Dr. B. S. Farley of York, Neb.; E. S. Garner of St. Joseph; R. S. Dinsmore of Troy, Kan., and F. K. Willett of Wathena, Kan. Officers for the ensuing year were elected as follows: Dr. R. S. Dinsmore, Troy, Kan., president; Dr. E. W. Bliss, Hiawatha, Kan., vice-president; Dr. Harry Redding, Sabetha, Kan., treasurer;
Dr. Daniel Morton, St. Joseph, secretary. The semi-annual meeting will be held in April and October hereafter, the next meeting to be held the third Thursday in October.
Central of Georgia Railway Surgeons' Association.
The annual meeting of the Central of Georgia Railway Surgeons Association will be held in Macon, Ga., on April 20, 1897. The Committee on Programme asks that papers be written on the following questions on Emergency Surgery: "How to Prepare Simple and Compound Fractures for Transportation;" "Shock, its Nature and Treatment," "Can Aseptic Surgery be Practiced in Railway Work," "Contusions and Their Treatment," "Lacerated Wounds and Their Treatment," The Use and Abuse of Adof Traumatic Surgery."
No titles will be received after March 20, and all communications should be sent to
HOWARD J. WILLIAMS, Committee on Programme. hesive Plaster," "Reports of Interesting Cases
More About Amputations Prothetically Considered.
Chicago, Ill., February 16, 1897.
To the Editors.
Dear Sirs: I think that the paper entitled, "Amputations Prothetically Considered," by Dr. J. M. Thorne, in the last issue of The Railway Surgeon, should interest every prothetician who cares for the future of his profession, as well as every modern disciple of Æsculapius, I consider it the best article upon the subject, taken as a whole, that I have had the pleasure of reading. Speaking from the vantage ground of long experience, I know that if these directions were followed by every operator, stump legs would average better, and have increased capacity; irritable,
stumps and adherent ends would disappear and discomfort to the patient would be reduced to the minimum; moreover, the prothetician would less frequently meet the stump of good length, but so bunglingly treated by the operator as to have the general appearance of having been amputated with the cleaver. In fact, these methods and a uniformity in practice will rem
edy most of the evils of which we complain, yet
not all of the bad or neuromatic stumps are due to faulty surgery; a reasonable percentage are directly chargeable to the efforts of wouldbe artificial limb makers and artificial legs constructed on principles which result in constriction of the circulation, producing poorly fed stump legs, and swollen and usually open ends, due to continuous pressure.
I am safe in asserting that unless the whole system is vitiated by disease or the wearer a hard drinker, the artificial leg is alone responsible for such a condition of the stump leg and is in all such cases the reasonable cause for reamputation.
Every surgeon must have a diploma or go before an examining board and get a permit before he can practice and I believe that the prothetician should go before the same board and prove his right to practice. After a patient has been supplied with new extremities by the prothetician the difference between poorly and well formed stump legs is at once apparent; the man with the good stump legs
walking so comfortably and easily as almost
to defy detection, and in numerous cases indulging in athletics; the man with stumps of equal length, poorly formed, using crutches a part of the time, is nearly always in pain and a burden to himself and to others. The writer is personally acquainted with a man who has suffered the amputation of both legs, the right one in the middle third, the left at the junction of the middle and lower thirds, resulting in a pair of well formed stumps, with nonadherent ends, and will vouch for the statement that he has walked 8,000 miles in the last four years without soreness or pain. It is needless to state that a pair of stumps amputated "any old way" (pardon use of the term, which is so fitting), will not sustain any such test.
The only point on which I differ from Dr. Thorne is in the statement that "when it is not possible to save three inches of the tibia a knee disarticulation should be done." I have seen and can cite a score of cases with less than three inches of tibia, having a good knee action and counted as good walkers, moreover a disarticulation has no point of advantage over a good knee-bearing stump leg. However, one inch of tibia only is not worth saving or risking anchylosis of the knee joint with a stump extended on the thigh and a disarticulation of the knee should be performed. I have advocated the excision of the fibula in cases of short stump, but at this writing I am figuratively "on the fence," due to the fact that I have lately served two cases, both declaring that they realized at least twenty-five per cent more from power applied to the leg with the fibula closely fitted than with it free from contact.
I thoroughly agree with Dr. Thorne on partial amputations of the foot; the only operation deserving consideration being the modified Syme operation, as performed and advocated by W. H. Hamilton, M. D., of Pittsburg.
Thanking you in advance for the privilege of expressing myself on this subject, I am, Yours fraternally,
J. F. ROWLEY.
Dr. Truman W. Miller has been confined to his home for some days with an attack of acute appendicitis. As we go to press it is reported that he is better and Dr. Senn, who is in attendance, hopes to avoid an operation: Dr. Miller is chief surgeon to the Chicago & Grand Trunk railway and to the North and West Chicago Street railways.
Operative Treatment of Traumatic Meningocele
In a recent article Dr. Rahm (Beitraege z. klin. Chir., XVI, 1) reviews the various methods of treating traumatic meningocele (hydrencephalocele) in children, and, on the basis of the result obtained in two cases operated upon by Professor Krönlein at Zurich, he arrives at the following conclusions:
In cases of slight traumatic meningocele, compression, associated if necessary with tapping, may result in recovery, or rather transform the hydrencephalocele into a simple hole in the osseous substance of the skull; this is therefore the treatment that should be adopted in such cases.
In grave cases, necessitating surgical intervention, the cavity of the meningocele should be extirpated, and the porencephalic cyst should be drained also when necessary.
Of the two patients operated upon by Professor Krönlein, one was a woman, twentyone years of age, in whom at the age of nine months the skull had been fractured, this accident being followed by meningocele, spastic paralysis of the left side, and Jacksonian epilepsy. Eleven years later there could be seen on the left frontal and parietal bones a slight depression of the scalp with manifest pulsation. Palpation showed that there was a rent in the skull, 9 centimeters in length by 3 in width. At the time of the operation, that is to say, nine years after this, the rent still measured 8 centimeters in length. The pulsation was somewhat less perceptible, but the epileptic seizures were more frequent. Prof. Krönlein, assuming the existence of a traumatic cerebral tumor, decided to operate. He found in fact a cyst, the size of a nut, which he extirpated, when he discovered another of the same size, situated behind the former. cysts were lodged in porencephalic cavity. from 3 to 5 centimeters in extent. Professor Krönlein drained this cavity and closed the wound. Recovery was obtained within three weeks, and the attacks ceased for some months, after which they reappeared, though they were less frequent and less severe than before the operation.
The second patient was a boy of fifteen months, who suffered from traumatic meningocele as a result of the application of forceps. The little patient presented in addition facial hemiatrophy and paralysis of the right arm. Tapping, associated with pressure, having only produced an ephemeral effect, Professor Krönlein extirpated the meningocele and resected a part of the integument. The loss of osseous substance was closed by a very thin membrane. Drainage was established and the
skin was sutured. Union was obtained by first intention. A year after the operation the condition of the little patient was good, except that the paresis of the right arm still persisted.
These favorable results of operation are explained, it seems to us, by the fact that neither of these cases at the time of operation presented the typical features of traumatic meningocele, there being in the first case no longer any meningocele, but only an endocrania porencephalic cyst, whereas in the second the hydrencephalocele was no longer in communication with the interior of the skull. principal difficulty associated with a surgical treatment, which is the communication existing between the meningocele and the interior of the brain, more particularly the lateral ventricle, consequently did not exist in these cases. Dr. Rahm is doubtless right, however, in considering free incision with drainage, as already proposed by various authorities, associated with the excision of the meningocele as practiced by Professor Krönlein, as the treatment of election in cases in which there is, at the time of operation, communication between the extracranial cavity and the interior of the skull or lateral ventricle, provided the disease is continuously progressing.-Sem. Med.
Some Remarks on the Treatment of Fractures of Upper Extremity.
By W. M. HOLLADAY, A. B., M. D., HAMPDEN SIDNEY, VA.
Joseph Lumniczer' gives the return to functional activity as the test of cure of fracture; and in a study of cases from 1880 to 1896 he gives the shortest period as twenty-four days for fracture of the clavicle, thirty-five days for fracture of the bones of the forearm, and sixtytwo days for fracture of the humerus. These are the results from Landerer's method of massage and passive movements; and it is claimed have shortened the treatment from thirteen to sixty-two days. These periods are, in many instances, too long, as can be shown from many cases, some of which will be briefly detailed, and some conclusions drawn from the
Case I. Mr. S. Fracture of anterior third of clavicle; treated by adhesive strips. On the tenth day, Mr. S. being very much opposed to the odor of the dressing, insisted on its removal, when the arm was found to be functionally perfect. As a precaution he was made to carry the arm in a sling for four days longer.
Case II. Mr. J. T., youth of 18, fell on his
1 Lancet, Oct. 29, 1894.
arm and broke the left clavicle at the junction of inner and middle third. Treatment the same as above; arm released on the tenth day, and sling used for three days.
Case III. Mr. B. W., æt. 19, while playing football fractured radius a trifle too high to be called a Colles' fracture. A single s.raight splint was applied, and the hand flexed on the arm so that the ulnar-metacarpal joint should be stretched, and the radio-metacarpal joint relaxed. All dressings were removed on the tenth day, with a most perfect result.
Case IV. Mr. T., a year after breaking his collar-bone, was thrown from a horse and fractured the lower extremity of the humerus, an oblique transverse fracture two inches above the joint, and the condyles split apart. The day of the fracture Dr. J. D. Eggleston of Hampden Sidney put the fracture up in a near-by extended position after the manner of Landerer and Allis, in pasteboard splints. On the third day we put on the flexor surface of the arm a splint having a screw, so that the arm could be extended and flexed by turning it posteriorly, a cardboard splint, so bound that it made a hinge at the elbow-joint. Mr. T. was told to turn the screw six threads a day, and then turn back two. On the fourteenth day all dressings were removed and there was perfect motion of the joint.
Case V. P. B., a boy of seven, fell from top of a tree, causing fracture of humerus just above condyles of joint and a portion of inner condyle was chipped loose. Arm was dressed nearly in extension, but the swelling of the joint was such that the dressing had to be removed and the arm. laid on a pillow. On the second day the dressing or cardboard was replaced, and on the ninth day altogether removed, with a mobile joint.
Case VI. E. V., girl of nine. Right hemiplegic from hereditary spastic paralysis. Fell. and broke her left humerus at the lower epiphyseal juncture. It was put up in cardboard splints for ten days and then removed. Six months later she fell on the same arm and fractured the humerus at the middle of the shaft. The fracture was completely cured, so far as fracture was concerned only, by the tenth day, when the dressing was removed.
In simple fractures there is no doubt that the dressing is kept on longer than there is any need.
Lane has shown' that slight hemorrhage and inflammation tie the bones together in a way that makes them resist any violence; and these are sufficient to hold the fragments in place when rightly approximated. Then, too, Lumniczer has shown that two days are long enough for the formation of provisional cal
lus; and Landerer,' that in massage and passive movements there is no danger of its absorption, whilst Hartig has shown, in his ambulatory treatment of fractures of the lower extremity, how great an amount of strain it can bear.
The first thing to be learned from this is, not to delay in putting up your fractures. After two days your bone is fixed and you will almost have to fracture it again if you await to overcome the deformity.
Secondly. Having placed the bones in and kept them there for several days-say five or six-the sooner gentle, passive motion is made the better, Lane having shown the shortening is due rather to the tying together of the parts by effusion than by muscular contraction. So the sooner some mode of absorbing the effusion is commenced the better.
Thirdly. The fear of shortening from muscular contraction being in part removed, there is a great deal less use of a heavy and stiff bandage. The lighter the dressing the better.
Fourthly. In fractures of the lower end of the humerus, not only is it best in the first days to dress the limb in extension, but the forearm should be pronated to a more or less degree, as in this way the extensor and flexor muscles are both more or less relaxed, and this makes apposition of the fragments of the humerus easier. After forty-eight hours the arm can then be placed midway between the two; then there should be the application of a light-hinged anterior splint, the hinge being so arranged as to give both flexion and pronation and supination anteriorly. The dressing should be of three strips of cardboard, one from elbow to wrist, and one from this joint to near the shoulder, having a larger one over these from near the shoulder to wrist; and so long as this dressing is on the patient should move the screw of the hinge backward and forward daily, flexing the arm more and more each day say moving the screw six threads and letting back four, the next day more, and so on. There is no danger of the fragments losing their apposition. Lane had to use a jawed forcep to move those faultily placed.
Fractures of clavicle need not worry if they are kept still a short while. No one mode of dressing has been always successful with me, but generally the adhesive plaster has been the most useful. In this, as in most other fractures, I find early fixation best; and am convinced that too long continued mobilty of the fracture is the cause in a large number of cases of the formation of false joints.
In fractures of the radius near the wrist, my preference is a straight splint, and very early, active and passive motion.
I hope I may be allowed to say just a few
* Loc. Cit.
6 Archives für Klinische Chirurgie, 1894.
words here in regard to one of the fractures of the lower extremity, that of the bones of the leg with rupture of the joints of the ankle. Here the surgeon at the start has a great deal of swelling to contend with before attempting to dress the fracture. Dress the sprain in the manner of Dr. Davis, as related by Dr. Gibney,' and then the surgeon will have no difficulty forty-eight hours after of applying any dressing he may desire.
Finally, I may be allowed to say that in the small number of fractures to be met with in a country practice, I have found that the time. necessary for functional action is far less than I have seen stated in any article on their treatment, and am assured that anyone who will shorten the period he has hitherto kept his dressings on, he will be pleased by the greater mobility he finds in the adjacent joints, besides giving great relief to his patients by shortening their confinement.-Virginia Med. Semi-Monthly.
Subcutaneous Wiring of the Patella.
Dr. Barker (British Medical Journal, April 18, 1896) describes his method of operating for fracture of the patella. The ligature used is silver wire instead of silk. The operation is to be done at once on the entrance of the patient to the hospital, usually within twelve hours of the fracture. The method is not adapted to old cases, but only to recent ones. No splint is used, simply the dressings, and massage and slight passive motion are made immediately following the operation. He operates as follows: The field of operation is made aseptic and the lower fragment steadied between the operator's left finger and thumb, while a narrow-bladed knife is thurst exactly through the middle of the upper attachment of the patellar ligament, with its upward edge cutting on the bone. When the blade has entered the joint it is withdrawn, still cutting on the lower edge of the lower fragment, and enlarging the skin wound upward to the extent of two-thirds of an inch. Through this opening a long stout needle is thrust into the joint behind both fragments and made to pierce the tendon of the quadriceps close to the upper edge of the upper fragment, exactly in the middle line. A knife is then entered alongside of the needle. and a cut made down to the bone. A stout silver wire, the size of a No. 1 English catheter, is then threaded in the needle and withdrawn. The needle is unthreaded and passed from the lower to the upper opening between the skin and upper surface of the fragments. It is then threaded with the wire and withdrawn. two ends of the wire emerging from the lower opening are then wrapped around a couple of rods to secure a firm hold, and crossed, drawn tight, and twisted three times. Before twist