Laminectomy for Fracture of the Tenth and Dislocation of the Eleventh Dorsal

Vertebræ.

BY CLIFF LINDSEY, M. D., Surgeon to Fergus County Hospital, Lewiston, Mont.

Patient, William A., aged thirty-nine years, gives the following history: He was stacking hay in July, 1893, using a harpoon hayfork, when the two poles which held up one end of the cable on which the fork ran fell, striking him across the back in the lower dorsal region. They were green pine poles thirty feet long. He was knocked down and was unconscious for nearly three hours, and when he regained consciousness he was unable to move or feel anything in either leg. He subsequently found that he had no control over either bladder or rectum. He was brought into the County Hospital and treated by the surgeon then in charge, who diagnosticated fracture of the tenth dorsal vertebra.

I first saw him in January, 1894, or about six months after the accident. Very little had been done for him, no effort having been made to correct the deformity, not even making extension and putting a plaster cast on him up to the time I was called to see him. On examination

I found the following symptoms: Complete

loss of motion and sensation in both lower extremities, extending above the crests of the ilia, taking in all the region supplied by the lumbar and sacral nerves. He had no control over either bladder or rectum, could not be turned over in bed without being rolled in a sheet, and every movement causing quite a good deal of pain in the region of the fracture. There were four large bedsores over the sacral region. A considerable amount of gas would accumulate in the intestines, which would cause him to have colicky pains in the abdomen until it was passed off. There was quite a severe cystitis, the urine being loaded with phosphates and pus; it also contained some albumin and blood. The skin was dry, but not branny on the lower extremities. He complained of severe pain at times at the seat of the fracture, but at no other place. The toe-nails grew but very little, if any, after the accident, and the bedsores showed but slight tendency to heal.

Treatment.-I immediately put him in a plaster cast extending from his shoulders to his hips, using Sayre's extension apparatus. I washed out the bladder every day with an antiseptic solution; also used electricity, employing a dry chloride of silver cell battery, as high as seventy-five cells on him; also strychnine in conjunction with the electricity. I continued

three or four weeks.

In four weeks he could walk around the ward with the aid of two crutches, and at the end of six weeks could walk all about with a cane. After that the improvement, while steady, was slower than at first, until the Ist of March, 1895, when he again proposed an operation, I having previously advised him not to have one, owing to the length of time elapsing since the accident. I again urged him not to be operated on, but he insisted that he could not consent to remain in the condition he was being cured by an operation; for when the cast then in while there was a possible chance of was removed he was in about as helpless a condition as when he first received the hurt.

I at last consented to operate on him, which was done on March 16, 1895. Placing him on two tables of an equal height, I proceeded with the operation. There was some difficulty in getting him under the ether, owing to the vomiting, and it took nearly half an hour. I then made an incision five inches long directly over the spinous processes, and nipped off the spinous processes of the ninth, tenth, eleventh and twelfth dorsal vertebræ with a rongeur forceps, then dissecting off the deep attachments of the muscles with a periosteotome. I readily found the fracture and removed the small spicula of bone; but owing to the adhesions it was difficult to reduce the dislocation, yet I succeeded after nearly half an hour's work. I then stopped the hemorrhage by packing the wound with warm compresses of gauze. The venous oozing was quite severe from the bone. The cut was then closed up by a deep row of catgut sutures, and the outside with silkworm gut. Closing up all the cut without drainage, I dressed it with a large quantity of iodoform gauze and absorbent cotton (sterilized), then separated the tables, and, making extension, put on a good heavy plaster cast extending from his neck to his hips.

He rallied well from the immediate effects of the operation, and had very little pain. A catheter was kept in the bladder all the time. Everything progressed well, his temperature never reaching 99.2 degrees at any time until the 19th, when he had a uræmic convulsion, and during the day and night vomited about twenty times. On the 20th he had two more convulsions, and no urine was passed after the morning of the 21st at 3 a. m. He was vomiting every fifteen or twenty minutes during the night of the 20th and the morning of the 21st, and was lying in a semi-comatose condition all the time. On the night of the 20th he had two convulsions, and on the morning of the 21st three more, and he died in the last one at II

a. m.

Conclusions. I have no doubt that, if proper treatment either by operating or plaster

jackets had been adopted at the time of the accident, he would have made a perfect recovery. I examined the seat of operation afterward and found everything in fine shape, no pus and the vertebræ in place.-New York Med. Journal.

A Case of Anterior Dislocation of the Head of the Radius.*

By G. W. Booт, M. D., HARTLEY, IOWA.

The case I wish to report is one of a class of accidents that are of comparatively rare occurrence, yet from the poor results that may be obtained, and the possible legal complications that may follow, its consideration is impor

tant.

The case is that of a boy, aged five. His father reports that three weeks before he came under my notice, he fell from a low pile of lumber and dislocated his right elbow-joint. A physician was called, and the father supposed the dislocation was reduced, but the elbow still being tender and motion quite limited at the end of three weeks, the boy was taken to another physician.

On examination, it was seen that flexion of the forearm upon the arm was possible only to about a right angle. Complete extension was not possible. Pronation was not much interfered with. Supination was not possible, on account of pain.

On the anterior surface of the forearm, at the junction of the upper with the middle third, there was a tender spot. Just above the bend of the elbow was seen a prominence-not large. Palpation of this prominence, which was caused by the head of the radius in its abnormal position gave much pain. At the normal position of the head of the radius there was a depression. The head of the bone could not be felt there. This comprised about all the symptoms. A brother physician confirmed the diagnosis of anterior dislocation of the head of the radius.

every

Under chloroform anæsthesia, means we could devise was used to reduce the dislocation, but no force we considered safe would accomplish it. Manipulation was of no avail. A prognosis of only a moderately useful joint resulting was given.

The disappointment of not being able to reduce the dislocation, and the possibility of being called to be a witness against a neighboring physician in suit of malpractice were incentives to look up the bibliography of the subject. The cause given for this dislocation are:

A fall on the hand with the forearm extended.

A fall on the elbow.

* Read before the Missouri Valley Medical Society, Council Bluffs, Iowa, Sept. 17, 1896.

A violent pulling of the forearm, such as often occurs when a child is lifted by the wrist or forearm.

Excessive supination and excessive pronation are given as causes.

The action of the biceps is also a cause. Forward dislocation is the most frequent of all the simple dislocations of the head of the radius.

Hamilton, out of thirty-two cases, had twenty-seven which were either forward or forward and outward, and five which were backward.

The following are given as the signs and symptoms of forward dislocation of the head of the radius

Flexion impossible beyond a right angle.
Supination not complete.

Pronation not usually complete.

Pain in the upper third of the forearm, due to laceration of the interosseous ligament.

The head of the radius is absent from its normal position, but can be felt in its new location, and on rotation of the forearm can be felt to

Roberts mentions one case that came under his notice that could not be reduced.

Danyan mentions the case of a girl, aged three, caused by being lifted by the wrist. This case was irreducible.

Malgaigne reports twenty-five cases. Of these six were not diagnosed until too late for reduction, eight were successfully reduced, and eleven were irreducible.

Moore in the "Reference Hand-book of the Medical Sciences," says: "The reduction of this dislocation is extremely difficult; indeed, such slight success has followed the efforts to effect a reduction that it is not easy to prescribe any formula for the purpose."

The

Theoretically, reduction should be accomplished most easily by traction on the forearm, counter-traction upon the arm with the forearm semi-flexed and semiprone, combined with direct pressure on the head of the radius. joint should be dressed with the forearm in flexion at a right angle, or if anchylosis is not feared, in complete flexion. This is to remove the most common cause of failure-the action of the biceps.

Because of the insertion of the biceps all attempts at voluntary flexion of the forearm are apt to cause a renewal of the dislocation. If this action of the biceps cannot be overcome by

the mode of dressing, tenotomy might be done to give the parts the rest needed for repair.Medical Herald.

Penis Divided by Silk Ligature.

BY JAMES C. KENNEDY, M. D., BROOKLYN, N. Y.

A boy, aged fourteen, entered St. Catherine's Hospital with the following history: Being troubled with nocturnal incontinence of urine, for which he was frequently reprimanded, he determined to use extreme and radical measures whereby, at least his nightrobe would not be soiled.

He carefully applied over the urethra and around the penis, midway between the glans penis and the scrotum, rather nearer the scrotum, a double ligature of medium-sized silk, which was drawn sufficiently tight to prevent the escape of urine. On the following morning he was astonished to find the organ twice its natural size, and his carefully applied ligatures out of sight. Disappointed and mortified, he determined at all hazards to keep his secret. He suffered all the tortures of retention until the ligatures cut their way through the urethra, when an immediate mitigation of the symptoms, caused by retention, took place.

The accompanying symptoms of a violent inflammation soon compelled him to take to his bed, and a physician to be sent for.

Dr. M. found the boy in such bad shape that he advised his immediate removal to the hospital, where the following conditions were noted: Urethra cut through; left corpus cavernosum severed; right corpus cavernosum almost separated, yet uniting the extremities by the slenderest thread. It was noticed that the glans penis and its accompanying extremity maintained a comparatively healthy color, and it was surmised that in this slender thread of union was inclosed the artery of the corpus cavernosum, the branches from the dorsal artery of the penis which perforate the fibrous capsule must of necessity have been severed. Wet dressings were applied, and the penis supported for several days until cicatrization was complete. Then under an anæsthetic, a sound was passed into the bladder, the edges of the stumps freshened up, the extremities of the urethra dissected out and a circular piece taken from each, and the ends carefully sutured with the finest silk. The extremities of the left corpus cavernosum brought into apposition, the extremities of the right up to the small film, which held them together, this being left intact to insure nutrition. Silk sutures were passed through the edges of the separated corpora cavernosa, crossed and brought out through the integument; these were continued

about the organ until all was closed, except the slender attachment which united the extremities originally, and which contained the artery of the corpus cavernosum.

Rubber protective, covered by iodoform gauze, completed the dressing. A soft No. 7 female catheter was left in the bladder for several days. The dressing was not disturbed for a week, when complete union was found to have taken place; the sutures were then removed, the fine silk sutures in the urethra remaining; the dressings were renewed every two days for a week. A small urethral fistula at the point left for nutrition was found.

Three weeks later this channel of union was cut away, the edges denuded, and flaps of skin from either side raised and brought together, completely covering the fistula which united in due time, leaving the boy with a respectable and useful organ. The minutest pin-point opening, through which an occasional drop of urine finds its way, remaining; this is being treated at present writing, and shows every sight of rapid closure. No evidence of stricture is yet noticed, a No. 17 French steel sound passing smoothly into the bladder.

The point worthy of notice here was the fortunate preservation of a single channel of nutrition, which was sufficient to sustain the vitality of the parts until the art of surgery came to the rescue.-Brooklyn Med. Journal.

Foreign Bodies in the Male Urethra.

BY HARRY C. HAYS, M. D., TOLEDO, OHIO, Assistant Physican, Toledo State Hospital.

Outside of an institution for the care of insane patients, foreign bodies in the male urethra are not very common, aside from the infrequent cases observed in small boys whose spirit of curiosity and investigation is worthy a higher aim, and an occasional accident, selfinflicted or otherwise, to a man while intoxicated. In most cases it is generally understood to be an indication of a more or less unstable neurotic temperament, which has as its motive the excitation or gratification of that sexual passion which is either perverted or has been so abused that its normal manifestation is impossible.

The following case is interesting, in that it shows to what extent it may be practiced by insane patients and how long the real trouble may be concealed, even when the physical suffering and mental distress is great, if the physician in attendance fails in his duty of making a careful physical examination, as is so often the case with this class of patients, outside hospital treatment. John R, aged sixty-five, German; occupation, farmer. Form of mental disease, chronic melancholia; duration of insanity, several years. The patient came un

der my charge from the care of another physician, who thought he was aware of the real nature of the trouble existing, respecting the genito-urinary system, and had pronounced it hypertrophy of the prostate, but had taken no steps to relieve the suffering, although he had had charge of the case for over a year. The clinical signs and symptoms were simply those of great pain and distress when micturition was attempted, the flow of urine being slow, interrupted, and at times suddenly stopped altogether, with intense pain in the glans penis. The necessity existed of passing water very often both day and night. The symptoms, as a matter of fact, were typical in all respects of stone in the bladder.

On attempting to pass a sound an obstruction was met immediately after entering the external meatus. This first foreign body could be plainly felt by taking the penis between the thumb and forefinger, and no great difficulty was experienced in extracting with a pair of simple artery forceps what proved to be a piece of rubber tubing or catheter about one inch in length with a diameter of one-quarter of an inch: It was covered with a deposit of urinary salts, but the lumen of the tube remaining open and lying lengthwise in the urethral canal allowed the urine to pass through without difficulty.

Passing the sound still farther, a second obstruction was met and its distal end found to be located at or near the peno-scrotal junction. This was easily detected on manipulation and seemed to be about three to three and one-half inches in length. Evidently either two foreign bodies were lying side by side, or one was turned upon itself and lying in the long axis of the urethra, as was the first. On grasping this with a pair of forceps and attempting its extraction, it was found that when traction was made the two ends moved forward at the same time, although only one seemed to be caught between the blades of the instrument. Finding that the loose end was in danger of penetrating through the urethral wall into the surrounding structure, an incision was made to the urethra, the foreign body serving as a guide, and with a pair of small forceps a largesized hairpin was withdrawn. This was also covered with a deposit of urinary salts and rust, showing that it had been in the urethra some time.

Introducing the sound finally into the bladder, the unmistakable and characteristic click was produced which indicated stone.

The patient was allowed to recover from these two slight operations, and after getting him into as fair condition as possible, the median operation of lithotomy was made, with the result of extracting a stone weighing four hunand nine grains. It was of the mixed or fusible variety of phosphatic calculi, on breaking

up which its nucleus for deposit was found to be a piece of fine iron wire, coiled upon itself, and measuring in length when straightened out five and one-half inches.

This was as far as I thought practicable to pursue the investigation in this case, but our curiosity was aroused to the degree of wondering if perchance something more might not be discovered, either in the ureters or in the pelvis of one or the other kidney.

The patient, notwithstanding his age, condition, and length of time of his distress, made an uneventful recovery. The only thing necessary now is to pass a sound occasionally, to be assured that he has not introduced something more into his urethra.-Medical Record.

Median Calcanean Incision.

A. Landerer, Surgeon-in-Chief to the Karl Olag Hospital in Stuttgart (Centralblatt f. Chir., 1896, No. 36, pp. 857-859), describes a new and extremely valuable and simple method of removing the os calcis in case of disease of that bone. The simplicity of the procedure is such that, as the author remarks, it seems strange the method has not been reported long since, but an inquiry into American and European authors fails to disclose anything similar.

Professor Landerer calls attention to the fact of so much having been said and written during the past few years on the subject of tarsal resection, the reason probably being the great variety of cases and the consequent impossibility of following any single fixed plan. The method presently to be described has been recently employed by Landerer in five cases of extensive carious destruction of the tarsus and foot, and for osteo-myelitic necrosis of the cal

caneum.

Beginning at a point either directly over or slightly above the insertion of the tendo-achillis into the lower rough part of the posterior surface of the os calcis, an incision is made by means of a strong resection-knife in the median line of the foot and directly down to the bone, then carried as far forward on the plantar surface as the individual case requires. By this incision the skin and subcutaneous fat are divided, the tendo-achillis split longitudinally at its attachment to the os calcis, and if the incision is carried far forward the external plantar artery is severed. The edges of the incision are held apart by sharp retractors, and. the plantar fascia, together with the flexor digitorum brevis separated in the direction of its fibers. All tendons and tissues are retracted from the median line; then, aided by the scissors and periosteal elevator, the tarsal bones can be removed without difficulty. By removing the diseased os calcis, which is an easy matter, all the details of the tarsus can be reviewed, the

removal of the calcis leaving a large cavity, extending backward and downward. Through this gap, Professor Landerer has easily excised the external malleolus situated seven centimeters higher up. However; it must be stated, that the median calcanean incision is not indicated unless disease of the os calcis is present, or it is the operator's purpose to remove that bone. The cavity left by the excised bone is tamponed lightly. This method allows of excellent drainage, the wound-discharges escaping easily by reason of gravity.

If, as is usually the case, the periosteum is not affected and need not be removed, there is excellent functional result. Slight shortening of a few centimeters is present in the long axis of the foot, but is not troublesome, and is easily counterbalanced by a properly constructed shoe. The plantar cicatrix does not impair walking, as it retracts so deeply as not to be pressed upon.

This method certainly gives a better cosmetic and functional effect than do the usual methods, and for the ease with which it is carried out rivals Ollier's external angular and Guêrin's spur incision.-Brooklyn Medical Journal.

Conservative Surgery in the Treatment of Spina Ventosa.

Dr. Thiel (Centralblatt f. Chir., 1896, No. 35, pp. 833-837) reports an extremely interesting case of spina ventosa occurring in the service of Professor Bardenheuer at the Kölner Bürger Hospital. The case, a severe one in a girl of twelve years, had been unsuccessfully treated for upward of a year by the usual conservative methods. The index-finger of the right hand was the member affected, the middle phalanx being two and one-half times larger than the corresponding phalanx in the left index; not only being valueless, but a direct impediment to the usefulness of the hand. In order to restore the hand to its former usefulness, the following procedure was devised and carried out by Professor Bardenheuer with excellent results.

Chloroform and ether narcosis. Esmarch's anemia. A longitudinal incision was made on the radial side of the distal phalanx at its middle, and continued as far as the metacarpophalangeal articulation. Parts of the skin, the seat of tubercular fistulæ, were circumscribed and excised. The soft parts were carefully separated, particular attention being given to the tendons and tendon-sheaths of the volar and dorsal surfaces, and the entire middle phalanx removed. This was found to be diseased throughout, with the exception of a thin, bony lamella on the volar surface. It was the operator's purpose to replace the excised phalanx by substituting for it part of the basal pha

lanx. With this end in view, the head of the basal phalanx was brought into the wound, with as little injury to the tendons as possible, and was perforated transversely from the radial to the ulnar side. A silver wire was drawn through this perforation to serve as an axis on which the replacing portion of the basal phalanx might turn. The periosteum covering the basal phalanx was now incised in the median line of both volar and dorsal surfaces, the incisions extending from within one-quarter of an inch of the distal head to the junction of the middle and proximal thirds of the bone. A third periosteal incision was made in a semicircular manner on radial side, which served to connect the proximal extremities of the two previously made incisions. The bone was then fissured in the line of the periosteal incisions, care being taken not to injure the narrow strip of periosteum at the distal extremity which was left to serve as the periosteal bridge between the main portion of the basal phalanx and that part of it which was to replace the excised middle phalanx. The longitudinal fissuring is best done by means of a sculptor's chisel. A small saw .may be used for the transverse separation. The mobilized piece was rotated on the silver wire as a pivot until it assumed the anatomical position of the middle phalanx, its volar surface, of course, becoming dorsal and vice versa, the silver wire being drawn taut to retain the bone in place. A catgut suture was introduced to connect the distal with the new middle phalanx. Previous to the introduction of this suture the joint surface of the distal phalanx should be slightly freshened. Hemorrhage was completely arrested, the wound closed without drainage, dressed, and a splint and bandage applied.

Following the operation the patient suffered from neither pain nor fever. The first dressing took place ten days after the operation, the wound was entirely healed with the exception of a small surface, one and one-half centimeters. long, that was granulating. Eight days later there was complete healing. Massage was instituted from the time of this dressing to the middle of the fourth week; from then on, ambulant treatment.

Pas

It can now be completed demonstrated that the transplanted bone has been preserved in its entirety. A solid, bony ankylosis has formed at the site of the first internodal articulation. Active movements in the second interphalangeal joint are not quite satisfactory, but doubtless will become so by further treatment. sive movements of the distal phalanx can be performed in almost normal extent. There is no impairment of passive or active motion in the metacarpo-phalangeal joint. The cosmetic effect is excellent, there being no appreciable difference between the two forefingers.Brooklyn Med. Journal.