fungus to prevent perfect results under usual plans of treatment. The same cause prevents ideal results in wiring and nailing operations. Even in the best hospitals and with the utmost antiseptic care infection with the Staphylococcus pyogenes aureus or S. epidermidis albus occurs (if not with some more virulent micro-organism) and failure follows. As a result of my own experience I have reached the conclusion that the best results are obtainable by widely opening the soft parts-usually one cut on the upper and two on the under surface, by choice; cutting away all the callus; removing the ends of the fractured bone, if necessary; sewing the periosteum over the junction of the ends as well as possible, using formaldehyde-catgut, previously boiled; packing the wound loosely with bichloride gauze, 1 to 2,000; putting on at fixation apparatus, and allowing the wound to heal from the bottom by granulation. This requires weeks of patient attention. For at first the wound must be dressed daily, and the utmost care must be exercised as to asepsis, lest from dirty fingernails the surgeon engraft a pus infection of a character to destroy the limb or life of the patient. No water or other liquid is permitted to come in contact with the wound it is simply cleansed as well as possible with sterile cotton around a probe, dusted with an abundance of iodoform or aristol, and fresh gauze pushed in. After two weeks the dressing can be made every alternate day and after four weeks every third day. At about the third month (with the large bones) the wound will have filled completely and the skin be cicatrized. The limb may The limb may then be put up in plaster of Paris and the patient allowed to go about. In six weeks more perfect result should be attained. (f) Amputation.-After all other plans of treatment have failed and a useless extremity persists, or when infection following operative treatment threatens life, amputation is to be performed. With the useful artificial limbs now made by numerous manufacturers, there is no excuse for a life on crutches or a useless hand as a result of a non-united fracture. FRACTURES OF ASTRAGALUS. Ombrédanne concludes his illustrated study of this sub- HENRY B. HOLLEN, PH. G., M. D. It has often been said that of all departments in the domain of surgery, that dealing with the subject of fractures has, during this age of advances, made the slowest progress, and, judging from most of the textbooks which we meet, we may easily believe it. The text on fractures, at least a good share of it, impresses one as having enjoyed an unentitled longevity. Certain it is that many of the lithographs, which are supposed to illustrate the proper procedure in reducing and "setting" the various fractures, are decidedly ancient. They go farther to prove the truth of the oft-repeated saying, "There's nothing new under the sun" than anything else in the line of surgery. While it is true that books are largely repetitions of previous existing literature, it is reasonable to suppose that no work is worthy of publication which does not add and advance something new on the subject with which it deals. But it is not the purpose of this brief paper to criticise books, and, lest some one accuse me of entertaining pessimistic ideas, let me refer at once to the best means of treating a Colles' fracture. treating a Colles' fracture. In all fractures, the avoidance of deformity and restriction to normal movements is sought for, and those methods which will render, universally, good results, deserve the attention of all practitioners. The following, which employs the posterior splint instead of the anterior splint so much in use, will be found to eliminate the stiffness and deformity which occurs so often. The reduction of the fracture is accomplished in the ordinary manner, viz., by extension and traction, in order to unlock the fragments, followed by forced flexion to approximate the broken ends. A flat, board splint is then applied to the posterior surface of the forearm. It should extend from the elbow to the middle of the palm of the hand, and its width should approximately equal the parallel axis of the affected member. Two adhesive strips, one about three inches from the elbow, and the other a short distance above the point of fracture, are used to fix firmly the splint to the forearm. To prevent the plaster coming in contact with the skin, bits of cotton wadding should be inserted under it on the inner and lateral aspects. The next step concerns the bandage. In applying it begin superiorly on the radial side, winding first across the anterior surface, and then over the posterior. Before bandaging the wrist and hand, flex the hand by applying cotton wadding between it and the splint. Finally, produce abduction by alternate turns of the bandage over the hand and the splint, and over the dorsal surface of the hand, in a figure of eight fashion. After three or four days, movement of the fingers should be instituted, and in three weeks the splint may be removed and passive motion in the wrist begun. Systematic massage will assist in hastening recovery.Medical Brief. Attention is called to the series of papers on fractures which is commenced in the present number, and will occupy at least two more issues. They were read before the International Association, the American Academy, the C., M. & St. P. Association, the Iowa State Association, and the C. of Ga. Association. Nearly all phases of frac tures, their complications, sequelæ and treatment, are considered, and the series will undoubtedly prove of permanent value. THE PRESENT POSITION OF OPERATIONS IN THE PRACTICE OF SURGERY. Under this title the annual oration before the Medical Society of London was delivered recently by Sir W. H. Bennett. He prefaced his remarks* by saying that only surgeons whose experience-like his own-extends back *London Lancet, May 23, 1903. to pre-Listerian days, can realize the enormous, even miraculous, changes which have followed the introduction of antiseptics. "Before the Listerian era, which, after all, is not so many years ago-septic diseases, like erysipelas, cellulitis, and kindred conditions, were common consequences of operations and formed a large proportion of hospital work-a time when the salvation of the patient and the reputation of the surgeon not infrequently depended upon the appearance of the pus which was called laudable—a time at which the author of one of the most successful textbooks of the day took the opportunity of congratulating his readers that the science of surgery had advanced so far that but little further progress could be looked for, and when one of the foremost surgeons in London chose as the subject of his presidential address at the Clinical Society 'Pyemia in Private Practice,' and gave many illustrative cases." At this time the main object in the practice of surgery was the avoidance of operations, because the results were so often disastrous and an uncomplicated progress after operations the exception. As a result of Lister's work the realization that operations could be performed with comparative safety led finally to an operative mania, or, as the author expresses it, to "the invention of operations which came at one time perilously near to the limits of reason." He believes, however, that a reaction has now taken place, and that operations may now be considered as regards their risks, their benefits, and their sphere of usefulness. Sir William Bennett divides the working life of every surgeon into three principal stages. In the first, or developmental, the fascination and apparent simplicity of the operative treatment, seemingly presenting the prospect of immediate and conclusive results, are apt to obscure broader and often more important issues. In the second, with wider experience and lessons of failures and disappointments, maturer judgment and better understanding of the proper relation of things follow. Toward the end of this period, he says, most surgeons begin to be less aggressive as regards purely operative treatment. With the third stage the surgeon is inclined to limit himself to certain operations with which he is most familiar. Owing to increased experience and maturer judgment, he is now able to exert a far-reaching influence of the greatest value. As regards the risks of operation, the author thinks it cannot be seriously contended that an operation can be absolutely safe, even assuming the greatest skill on the surgeon's part, for aside from merely accidental risks, the effects of the anesthetic must be taken into consideration, as well as the peculiarities of the patient's constitution, the conditions under which the operation is performed, and the ability of the assistants. The risk incurred may be immediate danger to life, the possibility of leaving the patient worse than before, or merely the chance of defective results. As the outcome of his long experience the author believes "that when an equally good result is obtainable by two operations, one being distinctly less dangerous than the other, the best practice is to chose the milder method, although for the moment it may appear less briliant in itself and perhaps less obvious in its im mediate result." Further he thinks that regarded from the standpoint of mere safety of the operation, the former may obscure the fact that the operation may not be always advantageous. In fact, the consequences are sometimes regrettable. Concerning exploratory operations, Sir William Bennett says the results of their free employment have on the whole been of great advantage both to patient and surgeon, but they are not always perfect and not altogether free from risk. The performance of routine exploratory operations is to be regarded with apprehension. In concluding he reiterates what has been frequently pointed out before, that operations, no matter how perfect, are, with the exception of those necessary by injury, deformity and some cases of senile change, a reproach, since they show our inability to prevent the occurrence of the diseases and conditions necessitating operation. Cancer of the tongue may be taken as an example. This is undoubtedly due to one or more of the irritations, many of which are preventable, to which the organ is subject. Yet how much attention is given to preventive oral hygiene, compared to the consideration of the elaborate operations for removing the cancer? Tuberculosis and cancer form a very large proportion of the cases demanding operative treatment. The prevention of the former, or its early treatment, will undoubtedly soon do away with the necessity for its cure by operation. As regards cancer, while its cause is at present unknown, the discovery of this cause, which may be made at any time, will no doubt lead to its relief by non-operative meas ures. The author finally ventures a forecast "that ere many decades have passed away the operating surgeon as we know him will be a far less imposing figure in the medical landscape than he now is, and that operations, excepting in a restricted degree, may be looked upon with as little favor as suppuration is now. In the meantime we should beware lest a single predominant factor be allowed to lead to our regarding through a small tube a subject the horizon of which is absolutely unlimited. It has been said that the basis of surgery is handicraft, and this, in a sense, is true; but there is lying behind a far greater thing, the knowledge of when to apply that craftsmanship of which everyone who now aspires to the practice of surgery should make himself a master. Nothing in the improvements connected with the practice of our art justifies, so far as I know, the modification by one iota of the edict of the great surgeon who, before advancing science had robbed operations of most of their horror, said, 'The all-important thing is not the skill with which you use the knife, but the judgment with which you discern whether its employment is necessary or not.' In other words, those who attach too much importance to mere mechanical dexterity not only fail to reach the high-water mark of greatness, but entirely lose sight of the grand possibilities of their calling." Remember in separation of epiphysis in the upper extremity of the humerus and the lower extremity of the femur, the line of fracture is so broad that there will be no shortening, but the fragments will project.-Fenwick. Translations. DELAYED OR NON-UNION OF FRACTURES- BY M. RICHARD. (Translated for The Railway Surgeon.) Pseudarthroses are rarely met with, if we take into consideration the large number of fractures that occur. Liston says he never met with them in his practice. Pearson found but 1 in 367 cases, and Norris 10 in 946 cases. Walther gives the proportion at 7-8 per 1,000, and Hamilton, in his treatise, states the average is 2 per 1,000. These general statistics are of but minor importance, for they are not applicable to fractures of different bones. While short, flat or long bones may be the seat of pseudarthroses, the long bones furnish the greatest proportion. This, of course, is due to the greater number of long bones fractured. Thus in Norris' table of 150 pseudarthroses they were seen in the Humerus Femur Tibia Forearm Lower jaw 48 times .48 times 33 times 19 times 2 times Though this table apparently shows that the humerus and femur are equally liable, at the present time it is found the humerus is most often involved. Thus of eleven cases under Malgaigne's observation it was affected in four. GENERAL CAUSES. These are numerous. Old age has been erroneously assigned as a cause, because we know that (excepting fracture of the neck of the femur) union takes place more slowly than at any other period of life. Malgaigne, however, in 104 case of non-union, found 83 in individuals between 20 and 50 years of age. Little is known as to the influence of sex, if any. While males furnish more cases of non-union, they also furnish more cases of fracture. Thus in 654 cases collected by Frank-Muhlenberg there were only 99 in women against 565 in men, and of Norris' 147 cases, but 18 occurred in women. Pregnancy seems to have some influence, and according to Reclus, was an obstacle to consolidation in a dozen cases, but, as a rule, after accouchement, union supervened normally. Dupuy reports a remarkable case in this connection. A young, healthy woman sustained a fracture of the shaft of the femur during the third month of pregnancy, but slight contusion. The apparatus was carefully applied and she got up on the thirtieth day; not a particle of union. Apparatus reapplied with six weeks of continuous extension. She remained in good health, and consolidation was not perfect until a month after delivery. Fabricius Hildanus and Astley Cooper have reported analogous cases. All severe or debilitating diseases have been assigned as causes. In a general way, as an immediate result of all these diseases, the body is rendered anemic, and the elements necessary for repair removed from the nutrition. Hewson relates several cases of pseudarthrosis following abundant venesection. Brodie and Larrey thought that diet and poor nourishment had a manifest influence. Lactation has also been assigned as a serious obstacle to the repair of fractures. There is no doubt but that in certain cases the state of the general health reacts on the evolution of the fracture, and delays the favorable termination. But it is exceptional to see any general affection, such as syphilis, scrofula, or the mineral poisons (mercury, phosphorus, arsenic) give rise to non-union. Of all these causes phosphaturia seems the most certain; paludism appears to retard callus formation still more, and thus leads to non-union. In other cases the patient is under the influence of some general febrile affection, with localization in the fractured limb. In such cases we may see an erysipelas or severe lymphangeitis not only stop further formation of callus, but cause that already formed to disappear. LOCAL CAUSES. It is the local causes, however, which act chiefly in the production of pseudarthroses. Sometimes it is a too abundant bloody effusion which prevents the coaptation and reunion of fragments. Heydenreich attributed the slow consolidation of fractures in the upper end of the tibia to this cause. But such profuse sanguineous effusions are noticed especially in epiphyseal fractures, and in these other causes may be important-penetration of the synovia, defcctive nutrition in the fragments, defective coaptation. Penetration of synovial fluid has been looked upon for a long time as a cause of non-union. It seems to be founded, however, on simple hypothesis, and not on manifest proof. Defective nutrition has been especially invoked to explain the absence of consolidation in fractures of the upper end of the femur. It has been claimed that the upper fragment is deprived of its nutrient vessels, that it only maintains a parasitic life, so to speak, and with not enough activity for new bone formation. This example is badly chosen, for of all the bony epiphyses, the head of the femur is the only one provided with special vessels. These contribute largely to its nourishment, as proven by the injections of Sappey and Guérin. Bérard and Guéretin advanced the theory that healing of a fracture is more rapid in that end of a bone toward which the nutrient artery is directed-for example, in the humerus the consolidation of the lower end occurs quicker than at the upper because the nutrient artery runs from above down. Malgaigne and Follin, however, criticised this opinion, and with good reason, and Norris in forty-one cases found the fractures of the upper humerus united as quickly as those at the lower end. Curling believed that the fragment of bone deprived of the nutrient artery underwent atrophy and rarefaction of its walls. This opinion also has proven to be unfounded. Lastly, too violent constriction of the limb in a frac ture apparatus, and especially a padded one, may cause marked reduction in the nutrition of the limb-a sort of local scurvy. Paré believed this was the principal cause of delayed union. Since Dupuytren's researches we know that ligation of the principal artery in the limb will stop the progress of callus formation. Paralyses in the fractured limb, or periosseous inflam mations, have also been alluded to, but they are rare if not doubtful causes. Moreover cases due to these causes should be classed as spontaneous fractures. Large numbers of fragments, suppurating foreign bodies among the fragments, defective coaptation, mobility of the fragments, their separation, or inability of retention, are evident causes of pseudarthrosis. Norris in forty-four cases of fracture saw twenty-two in which non-union was due to want of immobility. For a long time one of the chief causes of non-union has been assigned to interposition of muscle, aponeuroses or tendons between the fragments. One of the most striking instances of this cause is the case of Samuel Cooper. A woman who had a fractured humerus, with non-union for many months, died from an intercurrent affection. The sharply pointed lower fragment was engaged in the biceps muscle, from which it could not be separated. Dupuytren also on dissecting a non-united fracture found that the formation of callus had been prevented by the interposition of muscular fibres-Traité de Chirurgie de MM. Duplay et Reclus, Tome II., 283. INFLUENCE OF NERVES ON THE HEALING OF FRACTURES. Recent experimental work by Kapsamener, Muscatello and Damascelli has proven that normal healing of fractures takes place in limbs which have been artificially deprived of innervation through section of the sciatic or crural nerves or brachial plexus. Penzo has studied in rabbits the influence upon osseous repair of the vasoconstructor fibers alone, through extirpation of the superior cervical ganglion of the sympathetic followed by fracture of the zygomatic arch. For purposes of comparison section of the fifth nerve was practiced in three rabbits. The author sums up the results obtained as follows: In the reparative neoformative process which follows fracture of the zygoma in rabbits, the vaso-constrictor fibers of the sympathetic nerve play an important part. The active hyperemia following suppressions of these fibers favors and hastens callus formation, through the proliferation of cellular elements which it induces. This indirectly favorable influence which vaso-motor paralysis exercises through induction of active hyperemia may explain the more perfect healing of fractures with impaired innervation which has been noted by some observers. Section of the fifth nerve alone has no apparent influence upon the healing of fractures, and this fact suggests the possibility that abolition of motion and sensation alone do not suffice to retard the process of osseous repair.Med. News. Do not in fracture of the acromion put a pad in the axilla, or bandage the elbow too tightly to the chest, because the head (the natural splint in such fractures) is thrown outwards and the fragments separated.-Fenwick. Do not splint the palm of the hand in Colles' fracture; leave the fingers free, and work them after the third day, for the tendons as they cross the back of the radius-the seat of fracture-are apt to become adherent to their grooves.-Fenwick. First Aid and Emergency. (Conducted by CHARLES R. DICKSON, M. D., Toronto, Can.) FRACTURES. (FROM DICKSON'S FIRST AID IN ACCIDENTS.) The term fracture is applied to a break in a bone. There are several kinds of fractures, the most frequent being as follows: Simple, where the bone is broken in only one place and there is no other injury. Compound, where, in addition to the bone being broken, there is an opening or wound in the skin and flesh right down to the break, allowing air to get to the broken ends. Comminuted, where there is more than one break in the bone. This may be simple or compound. Comminuted, where othere important organs or structures such as muscles, blood vessels, nerves, the lungs, etc., as well as the bone, are injured. Other forms not so likely to be met with are the impacted fracture, where one end of the bone is driven into the other end, a difficult form to recognize; and greenstick fracture in children, where the soft bone may bend, and not completely break through; the latter is also called an "incomplete" fracture, in contradistinction to the "complete," where the bone is broken through. Fracture may be the result of some force acting immediately upon the bone, otherwise called direct violence, as when a wheel of a vehicle passing over a limb breaks it; or it may come in a more roundabout way, by indirect violence, as the fracture of a rib from crushing or pressure, fracture of the thigh from falling from a height on the feet. Bones may be broken by the action of muscles; thus the kneecap is fractured sometimes by sudden attempts to recover oneself when falling, and old people whose bones are very brittle may sometimes break them without such a degree of muscular violence. Symptoms.-The symptoms of dislocation and of fracture are similar in some respects, but not in all. In both, the parts affected cannot be moved so freely by the injured person, and there is usually pain and swelling very shortly at the seat of the injury. But in many respects they differ; for instance, dislocation occurs at a joint, fracture usually at some point between the joints; in dislocation there may be lengthening of the part, in fracture there is generally deformity and shortening; pulling on a dislocated limb gently will not restore it, gentle pulling on a fractured part may restore it for the time to its usual condition, from which it goes back to its abnormal shape when the pulling ceases; in dislocation there is stiffness at the seat of trouble, in fracture there is unnatural mobility; in dislocation no grating sound is heard when the bones are moved, but in fracture such grating or crepitus-is sometimes heard when the ends of the broken bone rub against each other; in dislocation a depression can usually be felt, which is the socket of the joint; in fracture some irregularity is usually felt, if the bone does not lie too deep. Treatment. The greatest care must be exercised in dealing with an injured bone, for by carelessness or injudicious handling in examining or in moving the injured June, 1903. person, a simple fracture which would heal without difficulty may be converted into a compound one, permitting the entrance of dirt or germs to the broken ends, with all their dire consequences; or worse still, an artery or some other important structure may be wounded by the sharp ends of the bone and a complicated fracture result, which may mean a long illness, tedious recovery, permanent disability, or even death. Your chief aim should be to prevent further damage being done; needless handling to ascertain if there is grating of the ends of the bone, or other unnecessary attempts at examination, must be avoided. Do not attempt to make the bones grate to hear the crepitus; it is much better to err on the safe side and treat the injury as a fracture, than do more damage by careless handling. Prolonged efforts to set a fracture must not be thought of; First Aid does not attempt to set a fracture, but only to put it in a more comfortable position, and secure it from receiving further injury. The muscles contract when a bone is broken and thus make the ends everlap, and increase the chances for them injuring the surrounding parts, and you should aim to put the part is as nearly the natural condition as possible without using force, and retain it in that position, and keep the muscles from pulling it out of shape again. This is done by means of splints and bandages, and your ingenuity will often be well tested in improvising suitable apparatus from the means at hand. You must not attempt to reduce a dislocation either, for you may tear some of the muscles which are already rendered tense by the accident, or even do worse injury to the displaced structures; you must only try to make the person as comfortable as possible, and keep the parts as free from motion as you can. The clothing should not be removed, either in fracture or dislocation, for it both serves to keep the parts warm after the shock of the accident and protects the parts from pressure by the splints, thus acting as a padding; if it is necessary to see the seat of injury, the seams of the clothing may be ripped, but if the clothing must be removed, be sure to take it first off the sound side, and so disturb the parts as little as possible, and in replacing start with the injured side. If it is not necessary to remove the injured person from the place of accident, just make him as comfortable as you can, steady the injured part with cushions improvised out of coats or anything you can utilize placed carefully about it, and much relief may be obtained by holding the parts steady to overcome muscular spasm. But never allow anyone with a fractured limb to be carried or moved unless a splint has been applied, or the limb is so supported that the bones cannot shift their positions, or irreparable damage may be done. If no other means be available hold the limb from beneath with one hand on each side of the fracture, grasping firmly to keep the limb in as natural a position as possible. (To be continued.) Do not forget that in epiphyseal fracture your prognosis must be guarded, because such injuries in the young are sometimes followed by suspended growth or by premature ossification of the bone. Deformity is thus produced.-Fenwick. |