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Ankylosis—Ankylosis after the injury may be
desirable as when it offers the only alternation to Medical and Surgical Club of Kansas City amputation. Our constant aim is to avoid it. (Reported for The Medical Herald)
The factors that threaten integrity of a joint
and its mobility and tend to produce ankylosis JOINT FRACTURES
are: HERMAN E. PEARSE, M. D.
Tissue laceration. 1. When bones break near a joint, the frac Infection. ture sometimes extends into and through the Hemorrhage. joint surface; result, joint fracture.
The result of them, results that prevent mo2. When sudden great weight is thrown tion in a joint are, bony deposits about the joint, upon a joint in motion, it produces a grinding of adhesions between its surfaces, capsular deformthe structure that often breaks away portions of ities and adhesions. the articular surfaces; result, a joint fracture. Inhibition of motion caused by pain and sore
3. When a side strain is thrown upon a ness. whole structure and that structure contains one
Procedureor more joints, the joint ligaments tear and their
We may open the joint or not. insertions into the bone tear also, producing ugly
We may mend the fragments or we may refracture of projecting or holding bone processes;
move them. result, joint fracture.
We may drain with tubes, pack with gauze, or 4. When a bullet or a piece of steel or a close with no drainage. fragment of rock from a blast or a swift moving
We may use extension or not. wheel strikes a joint, it tears a path through that
We may immobilize. joint. The path is a fracture depending on the
Continuously. size and force of the moving body for its size,
Intermittently or not at all. direction, destructiveness, and complicating factors; result, a joint fracture.
We may do all of these. When to do them 5. You may be the authors, the writers, the
and when not to do them, how to do them and
how not to do them, constitute the education of classifiers, the namers as you like and name and
a surgeon's lifetime, but some things we must dassify these injuries. I will consider them
do in every case where hope for restored motion classically as joint fractures and treat of their care with a view solely to the saving of life, of
in a broken joint. limb and of motion in the joints of that limb.
1. We must keep gauze* out of the joint. The r-ray must be our means of diagnosis 2. We must use early passive motion withand here I wish to pay a tribute to one who will out pain or damage. appear before you today who has done so much 3. We must use surgical knowledge and surto forward the diagnosis of injury and disease gical sense in applying the five major procedures by the x-ray. Diligent, a hard worker, a fearless just mentioned to the four great classes of joint explorer, and honest reporter, it is fitting that fractures just described and we must give our Major Surgeon Edward H. Skinner should head personal study to these cases every day until they the Army School of Roentgenology at this sta- are well.
*And everything else.
Preserving Function—In the course of de FRACTURES OF THE LONG BONES velopment of animal life the structure of the joint
HOWARD HILL, M. D. is due to its functioning. In the interpretation One great objection to all open operations for its pathology and in the application of our fractures is that of converting a simple fracture, therapy, we should keep this in mind when we which rarely becomes infected, into an open one hope for movable joints after injury. We should which as is well known, is a dangerous condition restore the anatomy of the joint, displaced by the since it often becomes infected with serious coninjury and see to its blood supply and cleanli
sequences for the patient, not only as regards ness and drainage, and make possible its healing the future of the broken bone but may eventually and repair. We should preserve this function of lead to amputation to save the patient's life. motion by making use of motion free from the In discussing the treatment of fractures of injurious factors of weight bearing and strain, the long bone by means of Lane's plates, it is i. e., passive motion and massage at frequent proper to state that there is a well defined prejuintervals followed by rest, protection and easy dice against this method which has been growing posture.
stronger for some time due to the numerous bad
results which have attended its use in the hands 'Proceedings of Clinical Session held at the General
of good surgeons.
Hospital. December 11, 1918.
The greatest objection to Lane plates is that COMMENTS ON METHODS OF SUSPENof leaving in the tissues a large foreign body. SION AND TRACTION IN THE TREATThis excites a reaction in the tissues which lasts
MENT OF FRACTURES OF until it is finally, surrounded by a sheath of
THE LONG BONES fibrous tissue. Being held tightly against the
T. G. ORR, M. D. bone by the screws, absorption of periosteum and the cortical layer of bone occur to a vari
Suspension and traction splints allow limited able extent. In most cases the plates in time be- motion; this limited motion promotes repair of comes separated from the bone sufficiently to
fractures. allow repair of the damage to it, so that the
Ernest W. Hey Grove, in his experiments on periostoma can again cover the defect.
bone grafts, says: “Provided that secure fixaIt often happens that when the screws hold tion of the graft to its bed is not disturbed, mowell, a mortar-like growth of bone springs up bility of the limb favors ostro-genesis, whilst all around the plate in an attempt to cover the immobilization hinders it." foreign body. In the tibia this growth fre- Bucholz reports 2,000 cases of old fractures quently leads to sinus formation, necessitating treated with plaster casts in which there were incision and removal of the splint and the bony more than 25 with delayed union and then mengrowth.
tions Bardenheuer's series of 10,000 cases treated While the object in using Lane's plates is to by traction with not a single case of pseudo: hold the bones firmly together so that perfect arthrosis. In Bardeneuer's series no fractures of union can occur, evidence is not wanting to show the femoral neck were considered. that this method delays the healing of the frac
Bucholz states: “We wish to state our opinture in most cases and in certain per cent of ion that the traction represents the best methods cases union does not occur. It often fails in the for most kinds of fractures, and we believe that treatment of ununited fractures.
it is only a question of time until American surInfection is undoubtedly more common in geons will apply it more frequently and more this than in any other clean operation. The in- generally. jury to the bone nearly always damages the
The Hodgen splint with many modifications soft tissues severely to which is added the oper- has been used extensively in suspension and tracative trauma and the presence of a large foreign
tion work. These splints give much comfort to body.
the patient, allowing the patient to have a certain It is believed that only those who can master amount of freedom, enables the nurse to keep the details of the operation as set forth by Mr. bedding in better condition, and permits comfortLane, should undertake to use this method of able use of bed pan. An objection to the Hodgen treating fractures. In order to master this type of splints is that all need constant care and technique the surgeon has to drill the nurses and adjustment to obtain satisfactory results. everyone connected with the operation. This Blake, in the recent treatment of war fracis well nigh impossible in many hospitals, due tures, has used the suspension and traction
methods quite extensively, resorting to an elabconsequently many men are turning to the use
orate frame-work over the bed. In femur fracof obne grafts either as inlays or intra-medullary tures he used a Hodgen or modified type, allowsplints. hoping to get better results than is ob- ing traction in one or more direction. Blake says tained by Lane's plates. It remains yet to be seen that there is an immediate amelioration in the cirwhether or not they will do so. I. personally culation of affected parts. The edema disappearthink it quite doubtful unless they at the same ing early;
ing early, the interference with circulation retime improve their technique.
moved. He finds that best results are obtained I believe that fracture cases will do better by applying traction treatment with the muscles under non-operative measures in the hands of of the thigh relaxed, thigh being flexed on trunk the average surgeon. I also believe it would be and lower leg on thigh. much better if all cases in every community were Traction by Steinmann's method has been treated only by men who have prepared them- used rather extensively in the last few years, selves to treat fractures, by whatever method The method requires that a steel pin be put may be indicated in each case. At present the through the bone; the traction applied upon this general practitioner treats most of the cases pin by pulley and weight. This type is best primarily, calling in a surgeon when bad results adapted to femur fractures, the value being that are obtained.
great traction is easily obtained and much weight The instruments used in the operative treat- can be safely used. Eastman considers this ment of fractures resembles the tools used by method invaluable in overcoming partial unior skilled mechanics. The surgeon using them and muscle contracture. should not only be a good surgeon but in addi- The method consists in inserting the pir tion should be a first rate mechanic.
through condyles about 2 cm. above articula
surface, being careful not to pierce medullary ive force and cells are entirely supplied from the cavity. Traction weights are added gradually living bone. The graft, however, is an absolute until overlapping of fragments is overcome, necessity in the regeneration.” Others, notably fluoroscope, palpation, manipulation, and meas- McWilliams and Albee, do not believe that the urements helping to control proper reduction. graft is absorbed but that it becomes an intiThe objection some have against the use of the mate part of the osseous framework. Such bone pin is on account of the pain produced ; compared. grafts, when properly placed, reach beyond the to operative procedures the pain is negligible. immediate area of transplantation and carry new Infection, injury to nerves and vessels, if occur- bone forming elements from uninjured bone ing, are the results of careless operating. itself. This is unquestionably one of the import
In fat patients the Steinmann pin is especially ant reasons that union can be established even valuable, other forms of treatment being diffi- in those cases where there is absolutely perfect cult to apply. Also, in supracondylar fracture, approximation of the fragments, and yet where in patients having severe injury to skin and soft no union had occurred. parts of the thigh and in some fractures with How long the transplant remains in the tisconsiderable deformity and overlapping of frag- sue before its complete absorption or regeneraments, is this method useful.
tion is, as yet, undetermined. 'If firm, bony
union, however early, results, even with the perTHE TRANSPLANTATION OF BONE sistence of the graft, the ultimate disposal of the ERNEST F. ROBINSON, M. D.
transplant becomes one only of academic interest.
The great secret of success in all bone surgery The recent development of modern surgical
is asepsis. Without it failure is certain. As technic has at last placed the subject of bone
one's experience widens and his familiarity with transplantation on so firm and scientific a basis
technic is perfected he sees how it is possible to that it has finally made it a satisfactory and safe
operate these cases without even the gloved hand procedure. In fact, it has been found to be the ✓
e the being placed in the wound. In my cases of bone only one that will cause unión in many cases of
transplantation I have been able to carry out this
trs obstinately ununited fracture, and is often the
technic absolutely. I am confident it has maonly hope in bridging large bony defects or pre- terially aided in lessening the operative risk. venting mutilating deformity.
Any portion of bone of whatever thickness may The advantage and posibilities of this method be transplanted. of treatment are at once apparent. With proper asepsis, union is certain in even the most per
The accessibility and formation of the crest of sistent ununited fractures. No unabsorbable
the tibia makes it peculiarly adaptable to the foreign body is left in the wound, necessitating
fashioning of a transplant. This is the location early or later removal. There is little if any
from which most bone grafts should be procured. delay in the establishment of bony union. Large
By the use of proper instruments a piece of the deforming and often painful exuberant callus
crest of the tibia of the desired length can be are avoided and function is much earlier estab
.readily cut. This is triangular in shape and for lished.
the larger bones should measure about 12 by By bone transplantation bony defects may be
3-5 by 12 inches on its three sides. No effort is filled and many possible amputations prevented.
made to denude it of periosteum. It is detached By this procedure the surgical field is materially
with chisel after being cut with a motor saw to widened, for patients will submit to a resection
the desired depth. The newly formed granuor excision of bone (as in tumor of bone or giant
lations and medullary cavity of the fractured celled sarcoma), when an amputation would be
bones are bored out with the bone reamers. The refused. The bone graft may be extended even
transplant is at once, with as little handling as into the joint cavity with assurance of success.
possible, driven into the lower fragment far In many cases failure of broken bones to
enough to allow it to be inserted into the preunite is due to the fact that the bone-forming
pared cavity of the upper fragment. The bones process reaches a certain degree of development
are then firmly brought together. The wound is and then stops. It is arrested before the gap
closed without drainage and a well fitting plaster . between the bone is bridged over.
cast applied. Thus, with the "dowel peg" no
The bone transplant acts as a superstructure or framework
foreign body or non-absorbable material is left over which the osteoblasts are carried.
in the wound, while the “bone inlay” must be
retained by kangaroo tendon. This necessitates In the opinion of many surgical pathologists, more handling of the graft and less stable imwhen this structure has served its purpose it is plantation. Consequently, whenever possible, I then torn down, i. e., absorbed, as its place is use the “dowel peg.” Accuracy in the mechanitaken by new formed bone.
cal adjustment of the bony structure hastens “The graft,” says Murphy, "is per se not union, which occurs usually in from five to seven osteogenic but osteoconductive. The regenerat- weeks. A much longer period is necessary in the
"bone inlay” cases, often two to three months of important. Antitoxins given hypodermically do external fixation being necessary.
not yield full effect for 24 hours; intramuscuMy own experience now includes bone trans- larly, effect is reached in 18 hours. Intravenous plantation in ununited fractures of the inferior injections are almost immediately responsive. maxilla, ulna, radius, humerus, femur, tibia and From these facts, the method of injecting sera the vertebra. In most of these I have used the may be determined by the time in which the efso-called medullary splint or “dowel peg,” usu- . fects are in highest demand. ally taken from the tibial crest. The periosteum “Normal serum” has a more wide applicabilhas been left intact adherent to the transplant, as ity than many of us had dreamed. It may be apI believe it favors union.
plied locally, administered internally, or emReconstruction, rather than excisive surgery, ployed intravenously, but the chief thought in is the highest aim of surgical art. Transplanta- administering it is the introduction of an alien tion of bone is one of the greatest steps in this protein. I believe the doctor gave this as the modern surgical procedure and we can see in it basis of serum therapy, preference over the bacinfinite possibilities for good.
tericiđal idea in therapeusis by this method. (To be continued)
No preference was mentioned among the sera
of standard makes. Dr. Sophian spoke of the danCLAY COUNTY MEDICAL SOCIETY
gers which may be encountered by overdose, or
faulty technique. In pronounced "negative The Clay County (Mo.) Medical Society be- phase" he would bleed the patient, separate the gan its 64th year with a meeting at Snapp's serum from the blood obtained, and re-inject Hotel in Excelsior Springs, on the evening of with the patient's own serum. January 28. Some 20 members and visitors I wish I were capable of giving this lecture were present.
in full. The discussion of meningitis was an apDr. A. Sophian of Kansas City, addressed the propriate aftermath, and many points were society on “Successful Immune Therapy.” This brought out from Dr. Sophian's rich clinical exlive topic was listened to for some two hours perience. Many of our members were busy takwith the keenest attention. Dr. Sophian is a ing notes, for use in the field. The speaker fears tireless worker, a most thorough investigator, of that we are on the verge of an epidemic of this abundant experience, and a fluent speaker. His disease, and exhorts us to be ready for it. The handling of the subject was no less than master- weather conditions are similar, if not worse, than ful, and brought out a rousing vote of thanks. at the time of the severe scourge which Kansas coupled with an invitation to meet with us later City experienced. for further discussion.
If I have misrepresented the doctor, I hereby It would be futile for a general practitioner make the most blood-curdling apology of which to try to give the readers of the Herald anything Lam capable. With kindest regards to “friend like the full scope of Dr. Sophian's lecture. Editor" and the folks in K. C. Therefore I shall try to mention only such points
J. J. GAINES, Secretary. as were specially impressive to me. One of the striking statements to the writer, was that in BUCHANAN COUNTY MEDICAL SOCIETY many instances, the good results of vaccine and serum therapy are simply due to the introduction
Minutes of regular meeting, Wednesday evenof an alien protein into the system of the patient ing, Jan. 2, 1918; 28 members present: Dr. For instance, a coli-vaccine is often quite as use
Floyd Spencer in the chair. ful in typhoid therapy, as typhoid vaccine. The
The minutes of the previous meeting were · good effect being due to the alien protein. read and approved. The following bills were
The doctor's explanation of the “negative presented and a warrant ordered drawn on the phase” and the handling of its manifestations, treasurer to pay same: aroused much interest. During the intravenous Robidoux Hotel Company...............$27.50 injection of the serum or antitoxin, a fall of some Secretary, for postage on Bulletin and 125 · 20 mm. in blood pressure was the signal for im- addressograph tags................. 6.40 · mediate discontinuance of the process.
The secretary and treasurer's reports were The many manifestations of anaphylaxis were read, and the latter referred to the executive interesting. The doctor said that asthmatic at- committee for their approval. After the various tacks, and certain convulsive seizures were merely special committees had been called upon for their the expression of the action of a non-specific reports and discharged, the incoming chairman protein, which is being absorbed in overpower- was introduced and delivered his address, outing quantities.
lining a program and policy for the year 1918, Much was said as to the “valence" of sera subject, of course, to its adoption by the society. and vaccines. They have come to stay and are The following standing committees for the dependable. The locality of injection is most year 1918 were announced :
Paul Forse. B. 17, has orgadas a perma, an
displat the Dr. Band
theall membciety pay conded by
otion by Dr. Linmittee reques medical off
Executive-J. J. Bansbach, J. M. Doyle, W. Dr. Daniel Morton, who presided, stated that H. Minton.
he was heartily in favor of the fraternal ideas Public Health and Legislation—Floyd Spen- advanced by Dr. Robinson and was interested in cer, J. F. Owens, W. C. Proud.
the establishment of a medical library for St. Program—H. S. Conrad, A. B. McGlothlan, Joseph, as he had long advocated the plan. G. R. Stevenson.
The executive committee reported that the Library—C. R. Woodson, Jno. Wisser, B. W. Public Library Auditorium could be secured as Tadlock.
a meeting place for the society without expense Medical Service-Daniel Morton, 1918, L. J.
and upon motion the report of the committee was Dandurant, 1918-1919; W. H. Minton, 1918-1919- adopted, and the society will hold its sessions 1920.
- in the library building hereafter. A vote of Membership-Louis Bauman, Fred Ladd, W. thanks was extended to the Board of Education 11. Gray.
for its courtesy in giving the society the use of Tuberculosis-Horace Carle, Porter Williams. this excellent meeting place. Charles Geiger. Laboratory-Clarence Good, Paul Forgrave,
Buchanan County Members, Attention! Caryl Potter, P. I. Leonard, A. L. Gray, E. B. Medical Advisory Board No. 4, District No. Kessler, G. A. Lau.
17, has organized and selected Dr. C. R. WoodMotion by Dr. Bansbach, seconded by Dr. son's office as a permanent meeting place. The Lau, that the program committee be authorized Board will act en banc, and for purposes of effito dispose of the old projectoscope and secure ciency has divided into sections on the various an adequate stereopticon outfit for the society: medical specialties. The personnel of the Board carried.
is as follows: Dr. C. R. Woodson, president ; Motion by Dr. Spencer, seconded by Dr.
Dr. Daniel Morton, secretary ; Doctors W. H. Bansbach, that the society pay the county and
Minton, J. J. Bansbach, L. J. Dandurant, Fred state dues of all members entering the military
Eliscue, F. G. Thompson, A. R. Timmerman, service of the United States, and assigned to
J. B. Reynolds, O. G. Gleaves, John M. Doyle, active duty; carried.
J. M. Bell, A. B. McGlothlan, Floyd H. Spencer,
H. S. Conrad, J. F. Owens. All are members of Motion by Dr. Lau, seconded by Dr. Ladd,
our society and in addition, Dr. W. F. Ross repthat the library committee request the Public
resents dentistry. Library to secure such books as a medical officer may need, for service of the society; carried.
Hospital Staff Elected—After one year's trial Motion by Dr. Owens, seconded by Dr. Lau, the Welfare Board is greatly pleased with the that this society go on record as favoring the Hospital Staff Plan. The work has been done issue of Good Road Bonds.
with conscientiousness and efficiency and with Having no further business for the society, advantage to both patient and doctor. The staff the meeting adjourned.
has the hearty support of the Welfare Board in W. F. Goetze, Secretary. the determination to give to the poor the best
service St. Joseph has in a medical and surgical BUCHANAN COUNTY MEDICAL SOCIETY way. At the January meeting of the Board the
following stalf were elected for the year 1918: At the regular meeting of this society held
Internal Medicine, J. M. Bell, H. W. Carle, C. A. at the St. Francis Hotel, January 16th, Dr. G.
Good, J. T. Owens; General Surgery, J. I. Byrne, Wilse Robinson, Kansas City, read a paper on
L. J. Dandurant, J. M. Doyle, H. S. Forgrave, "Intra-Cranial Localization” with lantern slides,
W. J. McGill, F. H. Spencer, H. S. Conrad. Obwhich proved entertaining and instructive. An
stetrics, A. L. Gray; Nervous Diseases, C. R. excellent dinner preceded the lecture. Dr. Rob- Woodson: Genito-Urinary Surgery, J. J. Bansinson, in his preliminary remarks, urged the
bach, T. M. Paul; Eye, Ear, Nose, Throat, A. A. establishment of a medical library for the local
Disque, W. H. Minton, W. C. Proud; Medical society, and explained in detail the plan followed
Laboratory, A. B. McGlothlan.
1 by the Medical Library Club of Kansas City. He also recommended a more cordial and harmonizing relationship between the various New Officers-At the annual meeting of the county societies, and extended to the Buchanan Western Surgical Association, in Omaha, the County members a most urgent invitation to at following officers were elected: President, Dr. tend the meetings of the Jackson County society. J. F. Percy, Galesburg, Ill. ; Drs. D. N. EisendDr. Robinson further agreed to arrange for a rath, Chicago, and D. C. Brockman, Ottumwa, St. Joseph evening in Kansas City, when a pro- vice-presidents; secretary and treasurer, Dr. A. gram would be presented by members of the T. Mann, Minneapolis (re-elected). Next meetBuchanan County Medical Society.
ing in San Antonio, Texas.