SURGICAL CLINIC

OF

CHARLES S. BRIGGS, A.M., M.D.,

Professor of Surgery in the Medical Department of the University of Nashville.

REPORTED BY

SAMUEL S. BRIGGS, M.D.

COMPOUND FRACTURE OF TIBIA.

Rev. J. O. W., æt. 38, pastor of the Wharf Avenue Baptist Church, of this city, has kindly consented to come before the class this morning in order to exhibit the results of treatment in a fracture of the leg.

Four weeks ago, while driving in a buggy, the horse commenced to kick over the dash-board, a hoof striking him upon the right leg a hand's breadth below the knee, breaking the bone. When extricated from the wreck the patient realized that his leg had been injured, and grasped it so that in being moved into a house close by it was not further injured. It was found upon examination that a ragged, irregular wound existed in the soft parts just below the tibial tubercle, and that the tibia had sustained a comminuted fracture at that point. Hemorrhage was considerable. The special signs of fracture, crepitus, mobility and deformity, were all well marked. The fracture was plainly compound, as the wound in the soft parts communicated with the seat of the fracture.

You all know that compound fractures are more serious than the simple or subcutaneous variety. The union is slower, wound accidents are more frequent, and the remote effects, such as non

union, necrosis, etc., are to be feared. Sometimes, when the wound in the soft parts is not extensive and has not become infected, we can secure favorable conditions by hermetically closing the wound, thus converting it as nearly as possible into the conditions of a simple fracture. This we accomplished in the case before you.

The parts adjacent to the wound were shaved and thoroughly scrubbed with antiseptic solutions. The wound was irrigated with corrosive sublimate solution. No effort was made to ascertain the condition of the bone by finger or probe introduced into the wound. Iodoform was freely dusted over the parts, an antiseptic dressing applied, and the limb put up at once in the lateral plaster of Paris splints. Reduction was easily effected; in fact, the patient himself had done all that was necessary in this direction. The displacement at no time was great. Care was taken to prevent the discharges from the wound from soiling by lining them with oiled silk. The splints used were made and applied as follows: Eight or ten thicknesses of gauze were shaped to fit the sides of the leg from above the knee to the sole of the foot, each set being sewed together by a seam running down its middle. A mixture of plaster of Paris is made in water to which a little salt has been added, to about the consistence of thick cream. Care should be taken to add the plaster slowly, stirring and mixing thoroughly as the plaster is poured into the vessel. If made too thick it will set before we can use it; if not thick enough or not well mixed, it will not set. The splints, previously wet and squeezed, are one after the other dipped in the plaster mixture and thoroughly soaked in it. The excess is removed, and each splint applied to the sides of the leg so as to leave an interval of an inch in front and behind, and are held in place by a crinoline bandage which has been allowed to soak in water for some minutes. If impossible to secure crinoline, we may use sacking cloth, cheese cloth, old blanket, or nearly any material that will take up plaster.

One of the best splints I ever made was in a case of com. pound fracture of the leg in a lady, in which case I used double thicknesses of a piece of old blanket for each splint. I prefer the plaster splint to the bandage, because it is more manageable and less dangerous.

The subsequent progress of the case was eminently satisfactory. The physician in attendance, Dr. Altman, watched the patient for an elevation of temperature or for the appearance of pain, which were to be the indications for opening the splint. The temperature only once exceeded 100°.

Four weeks after the occurrence of the accident the splints were opened by cutting in the interval in front, and the wound found closed. Union was firm.

We open the splint now in your presence, and you will observe the cicatrix of the wound and that the progress of firm union is fairly well advanced. This is an exceptionally good result in an injury of such severity.

ABSCESS OF TIBIA.

This patient, John A., æt. 26, white, resident of this city, has come to the clinic for relief of an obscure trouble of the right leg below the knee.

You will observe that the patient is thin, anæmic, and evidently in bad health. He walks with a crutch and a stick. He gives a history of hip-joint disease of the right side, from which he has recovered with impaired motion, but with an unusually good result.

Cicatrices of fistulous openings from abscesses around the joint are seen on the back and front of the upper part of the thigh. The entire right limb is atrophied considerably as compared with the right side. The knee is swollen and stiff, motion being manifestly very limited in that joint. The leg below the knee is only slightly swollen. The skin is oedematous, but not discolored. The parts in this vicinity are tender, and I find a spot of excessive tenderness on the outer surface of the tibia just below the head, pressure upon which causes him to cry out with pain. The patient suffers chiefly at night, the pain being of a throbbing, boring character.

The origin of this trouble is obscure. There is no clear his tory of traumatism. The patient has suffered from it for over six months. Evidently he has been a sufferer from inflammation of the bone of scrofulous origin-a limited osteomyelitis, probably. I think the patient has an abscess of the bone, and I base my diagnosis upon the localized pain upon pressure and upon the

œdema of the skin in the vicinity. An abscess of the cancellous tissue of the bone just below the knee is known as Brodie's abscess.

The treatment of abscess of the bone is the same as applied to abscesses anywhere-that is, evacuation and drainage. In this case of suspected bone abscess I shall carry out this indication. I shall ascertain and mark the point of greatest tenderness, for it indicates exactly the seat of the pus accumulation.

The patient having been anesthetized with A. C. E. mixture and the parts rendered aseptic, an incision is made four inches in length, its centre corresponding with point of greatest tenderness. The periosteum is divided in the same line and turned aside. The periosteum is considerably thickened, you will notice. A drill is now bored into the bone at the marked point, and it enters a cavity with a sudden jump. Pus wells up by the side of the instrument, thus verifying the diagnosis. With the chisel a rectangular piece of bone about half an inch in width and an inch and a half in length is cut out, and the cavity thoroughly opened. About two drachms of pus are evacuated. The abscess cavity is thoroughly shut off by condensed bone tissue. It is irregularly ovoid in shape. This cavity is thoroughly curetted, packed with tow soaked in balsam Peru, the upper and lower extremities of the periosteum closed with sutures, and the skin wound closed with a number of interrupted sutures, except at a point corresponding with the abscess cavity, and the usual antiseptic dressings applied.

The diagnosis in this case is especially gratifying, in that the symptoms were by no means clear.

(The patient was immensely relieved by the operation. He was entirely free of the night pains which had given him so much trouble, and his health consequently began to improve at once. The wound filled up rapidly, and in six weeks had healed entirely.)

EPITHELIOMA OF PENIS.

Mr. J. A., white, æt. 38, from an adjoining county, appears before you with a cancerous condition of the extremity of the penis.

The patient asserts positively that he has never had venereal disease of any kind. He is married and has several children,

and for years has lived an exemplary life. He has always had a long, non-retractable prepuce, which frequently caused annoying balanitis. Ten months ago he noticed on the under part of the margin of the prepuce a hard, warty-looking growth, painless, dry at first, afterwards breaking, and, after some slight hemorrhage, a scab formed. The disease, in spite of close attention on the part of the patient, continued to grow, involving more of the prepuce, along the frænum to near the glans. He consulted his physician, who, recognizing the gravity of the case, cut the growth out by excising a V-shaped piece of the foreskin. The wound failed to heal, and his physician, in consultation with other physicians, performed a regular circumcision. By now the base of the glans penis was involved. Applications were were made of different kinds, but only with the effect of increasing the dimensions of the ulcer, which now involved all the lower part of the glans penis.

As he appears now before the class, an indurated, irregularly round, rather deep ulcer is seen on the anterior and under part of the glan, the size of the ulcer quarter. The edges are elevated. The surface is covered with a scab. enlarged.

being nearly that of a silver There is little or no discharge. The inguinal glands are not

It is undoubtedly epithelioma of the rodent ulcer type. A portion of has been excised and submitted to microscropic exami. nation by Dr. Larkin Smith, who reports it undoubtedly epithelioma.

Only one thing can be done for cancer of the penis, and that is amputation of the organ, taking care to go well beyond the limits of the disease. The operation may be done by a sweep of the knife through the organ, dividing everything in the same line, and afterwards stitching the skin to the mucous membrane of the urethra. This operation is objectionable on account of the disproportion of the skin and mucous membrane, making the stump puckered and irregular.

I shall perform the flap operation, as follows: The patient having been anæsthetized with A. C. E. and the parts prepared, I select a point about midway of the penis and cut a skin flap from the sides and dorsum. The penis is then transfixed just above the corpus spongiosum, and a flap containing the urethra cut for