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The appellate division of the supreme court. of New York holds, in Tully vs. New York & Texas Steamship Company, December 1, 1896, that $25,000 is too much to allow for the loss of a leg to a person twenty-eight years of age, presumably in good health and strong, but who has no established business, and earned about $12 a week at such employment as he could obtain; yet it holds that $15,000 would not be out of the way.-Journal of the A. M. A.
Extracts and Abstracts.
Cases of Rupture of the Quadriceps Extensor Tendon Treated by Suture.
BY ANDREW J. McCоsн, M. D., OF NEW YORK CITY.
A rupture of the quadriceps extensor tendon is not a rare accident, neither should its diagnosis be difficult, and yet from a perusal of reported histories of such cases the impression is received that in many of them the injury was overlooked, because the examining physician was not alive to the possibilities of such an accident. In these cases it is of the utmost importance that appropriate treatment should be at once begun. What treatment shall be adopted? Shall it be rest in bed with the elevation of the limb, etc., or shall it be an operation for suture of the divided tendon? There are certainly many cases where surgical treatment is not needed, but, on the other hand, in the majority of cases, when complete rupture has occurred, either above or below the patella, the results from non-operative treatment are far from satisfactory. This is especially so when the rupture is above the patella. In forty such cases, collected by Maydl, there was complete recovery in 60 per cent. only, and in the twenty-three cases collected by J. B. Walker in 70 per cent. Contrast with this the final result after suture in the twenty-one cases collected by Walker with complete recovery in 90 per cent. Such operations, however, are not devoid of risk, and while so far no disastrous results have followed it must not be forgotten that the majority of these patients have been under the care of surgeons of skill and experience. It is only by such men that the operation should be attempted, and if the proper conditions for an aseptic operation do not exist, it is probably wiser to adopt, for a time at least, a nonoperative plan of treatment. Should this fail, the suture can be done at some later date, when the surroundings are more favorable for a successful issue.
When shall the operation be performed? The most favorable time is probably at the expiration of five or six days after the injury, when the acute stage of the joint hyperæmia has subsided. While a delay of several weeks does not seem to be advisable, yet it does not contraindicate the operation. In the three operations here recorded, a delay of eight weeks in the first case did not interfere with a perfect recovery, while in the second case a similar delay seemed to influence in a slight degree the final result.
Case I: M. McG., aged nineteen years, admitted March 15, 1894. Seven weeks ago fell down a flight of stairs, the left knee being forcibly hyperflexed under him. He was able to walk home. On the following day the knee became swollen and painful. He sought treatment in a dispensary, where the diagnosis of sprain of the knee was made. After this he walked to the dispensary twice weekly for treatment, which consisted of a bandage and counter-irritation. Unable to work on account of pain and disability. On examination there was found to be complete separation of the quadriceps extensor tendon from the superior border of the left patella, the distance being one and a half inches. Two fingers pressed into this space could clearly feel the anterior surface of the trochlea and the condyles of the femus. Flexion at knee unimpaired, but almost complete loss of extension. Slight swelling and tenderness of joint. End of tendon felt to be thickened.
Operation March 20; fifty-five days after accident; ether. Vertical incision, six inches long, at once entered the joint and exposed the lower part of the tendon and the patella. End of tendon decidedly thickened and hard, as if there had been a deposit of bone. The ragged and hardened end of the tendon trimmed off, as likewise border of the patella. The tendon had been torn directly from its point of attachment to the bone, probably pulling off with it some of the periosteum, so that no part of the tendon remained attached to the patella. The lateral expansions, however, were only partially torn off. Joint contained a few small partially-organized blood-clots and some fluid, but was comparatively clean. Irritation with hot salt solution. Three small openings were drilled through the upper end of the patella, into which and then through the entire thickness of the tendon were passed silkworm-gut sutures. Synovial membrane and the lacerated portions of the lateral expansions sutured with catgut, silkworm sutures tied, and incision closed by silk sutures without drainage. Plaster-of-paris splint, the limb being hyperextended. On the following day considerable pain. April 6, temperature has not reached 100 degrees F. since operation; splint removed; primary union; sutures removed; patella freely movable laterally; new splint.
April 23: Fenestrum cut in splint and daily massage. Patient out of bed May 5: splint removed; passive motion; a few adhesions felt to snap. May 23: Discharged cured. No stiffness; rapidly regaining power of extension. May, 1896: Reports that one leg is as good as the other; no disability; no pain: extension and flexion perfect.
Case II: Rupture of Quadriceps Extensor Tendon of Each Knee.-C. J. K. aged fifty
two years. A short, heavy man, who has always been an awkward walker, fell down stairs on June 17, 1896, the right knee being flexed under him; felt something break, but was able to rise and walk. Injury followed by some pain and swelling. His physician called it a sprained knee. Patient able, with great effort, to attend to his business as clerk, walking with the aid of crutches. On July 17, while hurrying to cross the street, fell and felt a snap in his left knee. He could not rise. With assistance he was helped to a carriage and taken home. Admitted to hospital on July 18. On examination is felt a depression, admitting two fingers between the superior border of the patella and the end of the quadriceps extensor tendon. Between these was felt distinctly the trochlea of the femur. Considerable swelling of knee; slight tenderness; flexion good, but extension absolutely lost. Examination of right knee reveals a similar condition, though with more exudation in the joint.
Operation July 23; ether. A curvilinear incision, concavity downward, was made across the left limb about one and a half inches above the superior border of the patella and directly over the end of the tendon; tissues œdematous and infiltrated with blood. Joint at once opened and found filled with bloodclots, shreds of tissue, and synovial fluid. Irrigated with salt solution. Rupture through the tendon found to be a transverse one for the most part, about half an inch above its point of attachment to the patella, the tear being ragged, a strip some three inches long having been torn from the anterior layer of the tendon and remaining attached to the patella. The lateral expansions were almost completely torn off, small shreds being left attached to the sides of the bone; the gap between the patella and the end of the tendon measured one and a half inches; persistent irrigation needed to remove the clots and shreds of tendon; ends of tendon trimmed off by scissors, the tongueshaped strip being removed with the exception of a half inch at its base. After the trimming there remained one-third of an inch of tendon attached to the patella; a double strand of silk was then passed through each end of the entire thickness of the tendon and at the patellar attachment through the edge of the bone itself; a suture of chromicized catgut was then passed on each side of the silk suture through the tendon, but without piercing the bone.
After thorough irrigation the lateral and anterior expansions were united by catgut sutures and the three tendon sutures tied. The fascia was united by catgut and the skin by silk sutures; no drainage. As a result of the curved incision the line of skin union was situated one inch superior to the line of union in the tendon.
Right. A similar incision opened directly
into the joint, which was filled with bloodclots and synovial fluid. The rupture of the tendon was a transverse one, directly at its point of attachment to the patella. Laceration of the lateral expansions less extensive than in the left joint. Separation between superior border of patella and end of tendon one inch and a quarter. End of tendon trimmed off and border of bone freshened. As no part of the tendon had been left attached to the patella, a hole was drilled through the upper part of the bone and a double strand of silk passed through this and through the end of the tendon. Suturing completed as on left side. Considerable force was needed to approximate the end of the tendon to the patella. Plaster-of-paris splint from ankles to upper part of thighs; for forty-eight hours considerable pain; afterward patient comfortable; temperature never rose to 100 degrees F.
August 6: Fenestrum cut in splint; primary union; sutures removed; patella movable laterally, the right less freely than the left. August 12: Massage to each knee daily. August 18: Splints removed: passive motion ordered; comfortable flexion to fifty degrees in each knee. August 25: Walks about with aid of crutches; flexion of right knee somewhat limited.
September 2: Discharged cured; walks unaided; flexion and extension of left knee perfect; flexion of right to 90 degrees only; extension perfect.
November 15: Patient walks almost as well as ever; slight limitation to flexion of right knee; flexion and extension of left knee perfect. Annals of Surgery.
Metallic Silver and Silver Lactate and Citrateni Surgery.
At a recent meeting of the Dresden Gesellschaft für Natur-und Heilkunde, as we learn from the Deutsche Medizinal-Zeitung for March 26, Dr. Credé gave the results of his investigations of silver and some of its salts as antiseptics. He has satisfied himself that metallic silver, when brought into contact with colonies of schizomycetes, kills them without exerting any unfavorable action on the animal tissues. So it may be remarked that the late Dr. Marion Sims' choice of silver wire as a material for sutures was happier than could be realized at the time. Credé says that aseptic wounds coated with silver foil remain aseptic for weeks at a time, and heal better than with any other dressing. Instead of silver foil, he has lately employed a dressing material made by Max Arnold of Chemnitz, in the fabric of which metallic silver is intimately blended in such a manner as to
admit of its being cut or torn into any shape Notes, News and Personals.
desired. There is also a dressing in the form of a mull containing powdered silver that may with advantage be substituted for iodoform gauze in packing deep wounds.
Numerous experiments have shown that silver forms a lactate with the lactic acid produced in the metabolism of the micro-organisms and that this compound kills them. Therefore it occurred to Credé to make direct use of silver lactate, instead of silver in the metallic state. This preparation, known by the trade name of actol or aktol, he thinks fulfills all the requirements of an antiseptic better than any other. He has given as much as fifteen grains of it subcutaneously without the least ill effect; there was only a slight burning pain at the site of the injection, lasting for but a few minutes. Silver lactate forms no insoluble compounds with the alkaline secretion of a wound or with tissue juice, as, for example, corrosive sublimate does, but only soluble ones, which gradually permeate the tissues and thus extend their action to some distance from the surface.
Silver citrate, however, seems to be quite as efficient and to be free from some minor disadvantages (not specified) of the lactate. The citrate has the trade name of itrol. Credé says that it is a perfectly harmless antiseptic and an excellent dusting powder for wounds. In the course of four months he has treated many hundreds of wounds with it, and with never the least untoward effect.-N. Y. Med. Journal.
The Cause of Death Following Burns.
Ajello and Parascandolo conducted numerous investigations concerning the death after burns, and conclude that the deaths are caused by toxic ptomaines. Death is not due to the toxin of the bacterium proteus, nor to any anatomical changes which the blood or burnt parts may suffer. The ptomaines of burnt organs are the same when the organ is first removed from the body and then burnt. Healthy animals inoculated with this die with the same symptoms as burnt animals. Death after burning is therefore due to the absorption of ptomaines produced by chemical changes in the tissues due to burns. The immediate re
moval of the burnt part prevents this absorption, and consequently all specific symptoms of the burn and death. The same objects may be attained by venesection and the immediate transfusion of healthy blood or artificia serum.-Gazz. degli Oppedali e delle Clin., No. 83, 1896; Centralblatt für innere Medicin, No. 51, 1896.
Dr. Nicholas Senn will deliver the "Address on Surgery" at the Twelfth International Medical Congress, to be held in Moscow in August.
A railway and navigation sanitary conference will be held in Brussels in September. The secretary is Mr. M. J. de Lantsheere, Rue de l'Association, No. 56, Brussels, Belgium.
At the recent meeting of the Tri-State Medical Society, held in St. Louis, Dr. Emory Lanphear, Ph. D., LL. D., of St. Louis, was unanimously elected president for the ensuing year.
Dr. Nicholas Senn has purchased the entire library of the late Professor Du Bois Reymond and has presented it to the Newberry Library in this city. The collection consists of about 14,000 volumes, largely devoted to physiology.
At the annual meeting of the Chicago Medical Society, April 5, the following officers were elected for the ensuing year: President, Dr. Fernard Henrotin; vice-president, Drs. Arthur D. Bevan and Junius C. Hoag; treasurer, Dr. Arthur R. Reynolds.
The following addresses will be delivered at the meeting of the American Medical Association in Philadelphia the first week in June: Presidential address, by Dr. Nicholas Senn of Chicago; "Address in Surgery," by Dr. William W. Keen of Philadelphia; "Address in Medicine," by Dr. Austin Flint of New York; "Address in State Medicine," by Dr. John B. Hamilton of Chicago.
The College of Physicians and Surgeons of Chicago has recently become a medical department of the University of Illinois. This alliance should strengthen an already vigorous medical college and must also be a good thing for the State University. We trust that the result will be still better work on the part of the College of Physicians and Surgeons, which has graduated some of our best physicians and which numbers among its teachers men of international reputation.
The twenty-sixth congress of the German Surgical Society will be held in Berlin on April 21 and three following days, under the presidency of Professor Bruns. The questions proposed for discussion are: I. The surgical treatment of gastric ulcer. 2. The use of the Roentgen rays in surgery. 3. The operative treatment of hypertrophy of the prostate. A report on the collective investigation now being prepared on anæsthetics throughout Germany will be presented.
Notices and Reviews.
Intercollegiate Medical Journal.
We have just received the initial issue of the Intercollegiate Medical Journal, which is to be published every second month and is the official organ of the Nu Sigma Nu Fraternity. It is edited by Drs. F. Gurney Stubbs and Will Walter of Chicago, with the co-operation of a number of editors in the various college towns elsewhere.
The following abstract from the Salutatory indicates the scope and field of the new journal:
"The official organ of the fraternity, it seeks through a scope enlarged beyond the usual confines of a society journal, to fill its proferred space with views of the study of the medical sciences from general standpoints to the exclusion of case reports, to devote many of its pages to methods of teaching and considerable space to post-graduate work at home and abroad-subject matter of interest more nearly in like measure to its subscribers."
We believe that there is a field for such a journal and wish it the success which is its due. The mechanical execution of the journal is excellent.
BOOKS AND PAMPHLETS RECEIVED.
"Introductory Clinical Lecture," by L. Webster Fox, M. D. Reprinted from the New England Medical Monthly, December, 1896.
"Ophthalmia Neonatorum," by L. Webster Fox, M. D. Reprinted from the Medical Council, February, 1897.
"The Chicago Lying-In Hospital Dispensary." Second annual report, 1896-97.
"The Philadelphia & Reading Railroad Relief Association." Eighth annual report for the year ended November 30, 1896.
Sixteenth annual report of the Illinois Training School for Nurses, 1896-97.
"Regulations Governing the Philadelphia & Reading Relief Association." Edition of February, 1897.
"The Pathology of Unintentional Abortion," by Karl F. M. Sandberg, M. D. Reprinted from the American Gynecological and Obstetrical Journal, February, 1897.
"Four Cases of Thiersch's Skin-Grafting for Pterygium," by F. C. Hotz, M. D. Reprinted from the Annals of Ophthalmolgy, Vol. vi., No. 1., January, 1897.
"Report of a Case of Sporadic Cretinism or Infantile Myxoedema," by James B. Herrick,
M. D. Reprinted from Archives of Pediatrics.
"Tricuspid Stenosis with Reports of Three Cases with Autopsies, together with Abstracts of Forty Cases Reported since Leudet's Thesis (1888)," by James B. Herrick, M. D. Reprinted from the Boston Medical and Surgical Journal, March 18, 1897.
"A Synopsis of the Practical Work in Ophthalmoscopy and Refraction at Rush Medical College," by Cassius D. Wescott, M. D. Reprinted from The Corpuscle, March, 1897.
"Subconjunctival Injections in the Treatment of Certain Diseases of the Eye," by William H. Wilder, M. D. Reprinted from Medicine, December, 1896.
A Case of Dermatitis from Exposure to X-Rays.
In the February number of the Scottish Medical and Surgical Journal Prof. E. Weymouth Reid, of Dundee, relates the following case which occurred in his own person: Having to deliver a lecture on Röntgen's discovery he wished to obtain a photograph of his own chest and abdomen through the clothing, to exhibit the contents of the pockets in addition to the skeletal structures. The exposures to which he was subjected were as follows: The abdomen, on November 2, twenty minutes, followed by another exposure of forty minutes. The chest, on November 3, fifty minutes, followed two days later by an exposure of ninety minutes. The coil was of ten-inch spark fed by ten amperes, and the Crookes tube ("focus" pattern) was some three inches from his waistcoat as he lay upon the table.
On the evening of each exposure marked erythema of the skin on the abdomen and chest was noticed immediately beneath the position of the vacuum tube, and, in addition, slight redness of the skin of the back over an area corresponding to the exit of the rays from the body. The Professor at once began to rub in lanolin and continued to do so for the next twelve days.
Vesicles soon appeared, continues the author, and gradually coalesced, so that by fourteen or fifteen days the cuticle was loose. On the back vesicles also were formed, but soon subsided.
By seventeen days the cuticle began to peel off, leaving a surface exactly like that seen when the cuticle was rubbed off a dissectingroom subject, except that it was of a bright red color. The peeling of the skin of the chest, in correspondence to its time of ex