Before separation occurs, the symptoms are those of chronic synovitis with considerable localized pain and tenderness. After separation occurs the symptoms are those of a loose cartilage in the joint. The treatment is of course purely operative. 4. Rupture of Crucial Ligaments.-This condition is usually caused by over-extension of the joint, and it is undoubtedly much more common than is ordinarily supposed. It will readily be appreciated that in a joint with a loose capsule, rupture of the crucial ligaments would be attended by loss of considerable support, and sub-luxation could easily be produced. Mayo Robson has recently reported a case in which he restored the continuity of these ligaments by suture several years ago with perfect recovery. All of these conditions result in chronic synovitis and, as you all know, this condition is likely to result in the production of a loose joint by a weakening of the ligaments from pressure from within. It is also well to keep in mind the fact that chronic synovitis is somewhat of a menace to the patient from the fact that such a joint is more likely to become the seat of tubercular infection. A more careful examination of the severe sprains with the aid in part of an anesthetic, if necessary, will undoubtedly frequently reveal the presence of one of these special conditions. Certainly all cases of chronic synovitis following trauma should be carefully investigated. With a positive diagnosis, an accurate prognosis can be given, and rational treatment resorted to. Some recent experiences have greatly impressed me with the frequency of these conditions, and also with the benefit of operative treatment. YEAR BOOK OF A MINE AND RAILWAY HOSPITAL. III.* BY JONATHAN M. WAINWRIGHT, M. D., OF SCRANTON, PA. Surgeon in Chief to the Moses Taylor Hospital, Surgeon to the Lackawanna & Wyoming Valley Railroad. During the year ending February 1, 1904, which is the period covered by the third series of these reports, there were 443 admissions from all causes; 182 of these cases were traumatic. Ten of these cases died, four inside of twelve hours, and six, or 3.3 per cent of all the traumatic cases, after twelve hours. The causes of these six deaths were as follows: (1) Pulmonary embolus on the twentythird day, after fracture of the neck of the femur. This occurred in a carpenter, 52 years old. He was apparently in perfect health till the embolism lodged, when his death occurred in about fifteen minutes. The leg had been in a plaster spica. An autopsy was not allowed. This is the only time that embolism has occurred in the 232 fractures noted in these reports. (2) Rupture of middle meningeal artery. (3) Severe burns. (4, 5 and 6) After amputations. These latter cases are noted more in detail below. AMPUTATIONS. The list of amputations during the year has been as follows: *See I, Railway Surgeon, VIII, p. 335, and II, Railway Surgeon, IX, p. 279. Two of the amputations of the leg were for old-standing injuries. The remainder were all for fresh accidents, and were operated on immediately, except in the case of emphysematous gangrene noted below. Eliminating this case and the two for old injuries, there have been sixteen amputations, with three deaths. The amputation of both legs was in a boy who had been run over by a locomotive, the wheels passing just below the knees. He died on the table. A case of amputation of the toes died from pneumonia. One amputation of the thigh died five days after the operation, from what cause we could not definitely determine. The two shoulder-joint amputations recovered, making five immediate shoulder-joint amputations for fresh injuries reported in this series, all of whom recovered. The case of emphysematous gangrene was one of especial interest. It occurred in a brakeman, 32 years old. He slipped under a car and his leg was caught by the flange of the wheel. A flesh wound was inflicted, extending obliquely from the knee nearly to the ankle. This involved only the skin and subcutaneous tissues. Neither the muscles, bones, nor the saphenous veins were injured. The wound in the skin was by no means completely circular, but involved only about one-quarter of the cir cumference of the leg. The local surgeon saw the man in a few minutes, and after applying a sterile dressing brought him to the hospital, which was reached about two hours after the injury. The injury, while extensive. was not such as to raise the question of amputation. The man was, however, etherized and the wound, together with the whole leg, cleansed with great care. The skin was then sutured and a number of iodoform gauze drains inserted, as some grease and dirt had been ground into the tissues; dry dressing. The next morning (12 hours) after the accident) the wound was dressed. There was slight superficial sloughing of the skin edges at one or two points and some tension, but on the whole the local condition seemed good. On the second morning, the leg was in about the same condition, but the patient had some rise of temperature and pulse rate. From this time his general condition grew worse, and when seen again in the evening, there was an angry, moist gangrene extending 6 inches above the knee and subcutaneous emphysema could be felt up to the axilla of the affected side. The temperature was 105° F. An amputation at the upper third of the thigh was performed at this time. Gas could be heard to escape from a knife puncture in the lower part of the thigh, in much the same manner as when opening the peritoneum after intestinal perforaDeath occurred nine hours after the amputation (57 after the accident) from the septic poisoning. This picture of emphysematous gangrene reaching a fatal point tion. Horseshoe This last case was of some interest. It was in a mineworker, who was caught in a fall of roof. He was brought to the hospital about four hours after the injury. His friends could give little account of the accident or .his condition between it and his admission, but said that he had been unconscious since his injury. When admitted, he was profoundly unconscious. The right pupil was widely dilated, the left normal. He moved his right side at times, but never his left, which was spastic on passive motion. Respiration was 16, pulse 64 full, temperature (rectal), 100° F. There was very marked edema over the right parietal region, which precluded the possibility of detecting a depression. Cerebral pressure was evident and was presumed to be from a depression, especially as the history at this time was one of continuous unconsciousness. An operation was undertaken immediately, i. e., about five hours after the accident. flap of skull and periosteum. A fine linear fracture of the parietal bone, running down to the base, was found. There was no depression. A large trephine opening was made over the fracture; the button of bone removed contained one of the grooves for the middle meningeal artery; a large blood clot was found in the extra-dural space. The trephine opening had to be extensively enlarged with the rongeur in order to reach all of the clot, which was fully 4 inches in diameter, and depressed the brain at least an inch and a half in its deepest part. A gauze drain was placed in this cavity and the flap replaced. Dural pulsations did not return during the operation. The patient died about thirty hours after the operation without ever regaining consciousness, the only sign of improvement being the return of the right pupil to normal. An autopsy showed the brain had not expanded at all from its depressed condition at the time of the operation. The brain tissues appeared normal on gross inspection, except for a slight effusion of blood in the temporo-sphenoidal lobe. It is presumable that the degree of compression of the brain was so great that it could not re-expand, although the operation was done inside of five hours. Several days later a typical history of middle meningeal rupture was obtained from one of the patient's Englishspeaking friends. He was made unconscious by the fall of roof, but recovered while being removed from the mine, walking from the shaft to the ambulance, and expressing a wish to be taken home. It was only after reaching home that he again became unconscious, and remained so till admission. Two more unsuccessful laminectomies were added during the year to the four previously reported. In the year-book for last year (Railway Surgeon, May, 1903), attention was called to a fracture of the tibia in a broken back, which united without the aid of the cut-off nerve impulses. One of the men this year had a broken femur, which also united in the usual time. A very interesting experimental study of the influence of nerves on bone repair has recently been presented by Penzo of Padua (Gazetta degli Ospedali, March 29, 1903). Penzo operated on the zygomatic processes of rabbits. In one series, he resected the cervical sympathetic on one side, leaving the sensory nerves of the V pair intact. The zygomas were then broken on both sides. After varying times, the process of repair was studied, and it appeared that union was more advanced on the side where the sympathetic had been cut. Penzo attributes this to the fact that a better blood supply was obtained on the operated side on account of paralysis of the vaso constrictors. In another series the sympathetic fibers were left intact, but the sensory fibers cut. This seemed to have no influence on the process of bony repair. These two cases add clinical evidence at least to this second conclusion. Only once in these 87 fractures was it deemed advisable to adopt the immediate open method of treatment. This was in the case of a section hand who, by way of a choice between two evils, jumped off an embankment in order to avoid an oncoming train. He landed on both elbows, with the forearms flexed. On the right side, the external condyle of the humerus and the olecranon was broken; on the left, the internal condyle was broken. No hold could be kept on any of the fragments by dressings, and considerable callus from displaced fragments, with consequent impairment of function, seemed probable. Both joints were therefore opened. On the right side, it was found that two small fragments were broken off the external condyle from its joint surface. These fragments were both removed. The olecranon was not pulled up by the triceps, but was held well in place by the ligaments, so it was not interfered with. On the left side, the fragment representing the inner condyle was much larger, involving half the joint surface. This was fixed in place with a wire nail after much difficulty. A plaster dressing was applied to this side in almost complete extension, as it was only in this position that the fragment could be held. The dressing was changed and the cast Before separation occurs, the symptoms are those of chronic synovitis with considerable localized pain and tenderness. After separation occurs the symptoms are those of a loose cartilage in the joint. The treatment is of course purely operative. 4. Rupture of Crucial Ligaments.-This condition is usually caused by over-extension of the joint, and it is undoubtedly much more common than is ordinarily supposed. It will readily be appreciated that in a joint with a loose capsule, rupture of the crucial ligaments would be attended by loss of considerable support, and sub-luxation could easily be produced. Mayo Robson has recently reported a case in which he restored the continuity of these ligaments by suture several years ago with perfect recovery. All of these conditions result in chronic synovitis and, as you all know, this condition is likely to result in the production of a loose joint by a weakening of the ligaments from pressure from within. It is also well to keep in mind the fact that chronic synovitis is somewhat of a menace to the patient from the fact that such a joint is more likely to become the seat of tubercular infection. A more careful examination of the severe sprains with the aid in part of an anesthetic, if necessary, will undoubtedly frequently reveal the presence of one of these special conditions. Certainly all cases of chronic synovitis following trauma should be carefully investigated. With a positive diagnosis, an accurate prognosis can be given, and rational treatment resorted to. Some recent experiences have greatly impressed me with the frequency of these conditions, and also with the benefit of operative treatment. YEAR BOOK OF A MINE AND RAILWAY HOSPITAL. III.* BY JONATHAN M. WAINWRIGHT, M. D., OF SCRANTON, PA. Surgeon in Chief to the Moses Taylor Hospital, Surgeon to the Lackawanna & Wyoming Valley Railroad. During the year ending February 1, 1904, which is the period covered by the third series of these reports, there were 443 admissions from all causes; 182 of these cases were traumatic. Ten of these cases died, four inside of twelve hours, and six, or 3.3 per cent of all the traumatic cases, after twelve hours. The causes of these six deaths were as follows: (1) Pulmonary embolus on the twentythird day, after fracture of the neck of the femur. This occurred in a carpenter, 52 years old. He was apparently in perfect health till the embolism lodged, when his death occurred in about fifteen minutes. The leg had been in a plaster spica. An autopsy was not allowed. This is the only time that embolism has occurred in the 232 fractures noted in these reports. (2) Rupture of middle meningeal artery. (3) Severe burns. (4, 5 and 6) After amputations. These latter cases are noted more in detail below. AMPUTATIONS. The list of amputations during the year has been as follows: *See I, Railway Surgeon, VIII, p. 335, and II, Railway Surgeon, IX, p. 279. Two of the amputations of the leg were for old-standing injuries. The remainder were all for fresh accidents, and were operated on immediately, except in the case of cmphysematous gangrene noted below. Eliminating this case and the two for old injuries, there have been sixteen amputations, with three deaths. The amputation of both legs was in a boy who had been run over by a locomotive, the wheels passing just below the knees. He died on the table. A case of amputation of the toes died from pneumonia. One amputation of the thigh died five days after the operation, from what cause we could not definitely determine. The two shoulder-joint amputations recovered, making five immediate shoulder-joint amputations for fresh injuries reported in this series, all of whom recovered. The case of emphysematous gangrene was one of especial interest. It occurred in a brakeman, 32 years old. He slipped under a car and his leg was caught by the flange of the wheel. A flesh wound was inflicted, extending obliquely from the knee nearly to the ankle. This involved only the skin and subcutaneous tissues. Neither the muscles, bones, nor the saphenous veins were injured. The wound in the skin was by no means completely circular, but involved only about one-quarter of the circumference of the leg. The local surgeon saw the man in a few minutes, and after applying a sterile dressing brought him to the hospital, which was reached about two hours after the injury. The injury, while extensive, was not such as to raise the question of amputation. The man was, however, etherized and the wound, together with the whole leg, cleansed with great care. The skin was then sutured and a number of iodoform gauze drains inserted, as some grease and dirt had been ground into the tissues; dry dressing. The next morning (12 hours after the accident) the wound was dressed. There was slight superficial sloughing of the skin edges at one or two points and some tension, but on the whole the local condition seemed good. On the second morning, the leg was in about the same condition, but the patient had some rise of temperature and pulse rate. From this time his general condition grew worse, and when seen again in the evening, there was an angry, moist gangrene extending 6 inches above the knee and subcutaneous emphysema could be felt up to the axilla of the affected side. The temperature was 105° F. An amputation at the upper third of the thigh was performed at this time. Gas could be heard to escape from a knife puncture in the lower part of the thigh, in much the same manner as when opening the peritoneum after intestinal perforaDeath occurred nine hours after the amputation (57 after the accident) from the septic poisoning. This picture of emphysematous gangrene reaching a fatal point tion. Three of these fractures, all of the closed variety, died. One case was that of one of the broken backs, who died within seven hours, having also probably a visceral injury. Another was the case of embolism following fracture of the neck of the femur, above referred to. Another was a fissured fracture of the skull, with rupture of the middle meningeal artery. This last case was of some interest. It was in a mineworker, who was caught in a fall of roof. He was brought to the hospital about four hours after the injury. His friends could give little account of the accident or .his condition between it and his admission, but said that he had been unconscious since his injury. When admitted, he was profoundly unconscious. The right pupil was widely dilated, the left normal. He moved his right side at times, but never his left, which was spastic on passive motion. Respiration was 16, pulse 64 full, temperature (rectal), 100° F. There was very marked edema over the right parietal region, which precluded the possibility of detecting a depression. Cerebral pressure was evident. and was presumed to be from a depression, especially as the history at this time was one of continuous unconsciousness. An operation was undertaken immediately, i. e., about five hours after the accident. Horseshoe flap of skull and periosteum. A fine linear fracture of the parietal bone, running down to the base, was found. There was no depression. A large trephine opening was made over the fracture; the button of bone removed contained one of the grooves for the middle meningeal artery; a large blood clot was found in the extra-dural space. The trephine opening had to be extensively enlarged with the rongeur in order to reach all of the clot, which was fully 4 inches in diameter, and depressed the brain at least an inch and a half in its deepest part. A gauze drain was placed in this cavity and the flap replaced. Dural pulsations did not return during the operation. The patient died about thirty hours after the operation without ever regaining consciousness, the only sign of improvement being the return of the right pupil to normal. An autopsy showed the brain had not expanded at all from its depressed condition at the time of the operation. The brain tissues appeared normal on gross inspection, except for a slight effusion of blood in the temporo-sphenoidal lobe. It is presumable that the degree of compression of the brain was so great that it could not re-expand, although the operation was done. inside of five hours. Several days later a typical history of middle meningeal rupture was obtained from one of the patient's Englishspeaking friends. He was made unconscious by the fall of roof, but recovered while being removed from the mine, walking from the shaft to the ambulance, and expressing a wish to be taken home. It was only after reaching home that he again became unconscious, and remained so till admission. Two more unsuccessful laminectomies were added during the year to the four previously reported. In the year-book for last year (Railway Surgeon, May, 1903), attention was called to a fracture of the tibia in a broken back, which united without the aid of the cut-off nerve impulses. One of the men this year had a broken femur, which also united in the usual time. A very interesting experimental study of the influence of nerves on bone repair has recently been presented by Penzo of Padua (Gazetta degli Ospedali, March 29, 1903). Penzo operated on the zygomatic processes of rabbits. In one series, he resected the cervical sympathetic on one side, leaving the sensory nerves of the V pair intact. The zygomas were then broken on both sides. After varying times, the process of repair was studied, and it appeared that union was more advanced on the side where the sympathetic had been cut. Penzo attributes this to the fact that a better blood supply was obtained on the operated side on account of paralysis of the vaso constrictors. In another series the sympathetic fibers were left intact, but the sensory fibers cut. This seemed to have no influence on the process of bony repair. These two cases add clinical evidence at least to this second conclusion. Only once in these 87 fractures was it deemed advisable to adopt the immediate open method of treatment. This was in the case of a section hand who, by way of a choice between two evils, jumped off an embankment in order to avoid an oncoming train. He landed on both elbows, with the forearms flexed. On the right side, the external condyle of the humerus and the olecranon was broken; on the left, the internal condyle was broken. No hold could be kept on any of the fragments by dressings, and considerable callus from displaced fragments, with consequent impairment of function, seemed probable. Both joints were therefore opened. On the right side, it was found that two small fragments were broken off the external condyle from its joint surface. These fragments were both removed. The olecranon was not pulled up by the triceps, but was held well in place by the ligaments, so it was not interfered with. On the left side, the fragment representing the inner condyle was much larger, involving half the joint surface. This was fixed in place with a wire nail after much difficulty. A plaster dressing was applied to this side in almost complete extension, as it was only in this position that the fragment. could be held. The dressing was changed and the cast renewed, with a little more flexion on the seventh, and again on the fourteenth days, and left off on the eighteenth day. On the right side, no retentive apparatus was used and massage and passive motion began at once. On this side, a perfect functional result was obtained. On the left side, although massage and passive motion was begun on the eighteenth day, there was considerable limitation of flexion. This was attributed partly to the more severe injury, but more to the necessity for the use of plaster in a joint fracture. The open fracture of the patella was a longitudinal one. The joint was extensively opened. The joint cavity was flushed out with salt solution and the patellar fragments united by chromic gut, placed through the anterior half of the bone, so as not to involve the joint surface. The union was firm and the functional result perfect. The closed fracture of the patella was transverse, with considerable longitudinal displacement. This was treated by chromic stitches through the anterior half in the same Union took place with no appreciable separation of the fragments. Extension was complete, but on discharge there was some limitation of flexion, which, however, was rapidly improving. One saddle-back nose, from a horse kick three years previously, was treated by the paraffin method with very gratifying results. In a case of facial paralysis due to a lacerated wound of the region behind the ramus of the jaw, a nerve anastomosis was attempted. It was seen that the case was not favorable, and on operation, while the main trunk of the facial was isolated with no especial difficulty, the injury was found to be in the terminal branches, so that anastomosis was impossible. MUSCULO-SPIRAL PARALYSIS AFTER FRACTURE HUMERUS. OF THE He This case was a Slav mine laborer, 36 years old. received a compound fracture of the humerus from a fall of roof on March 28. This was put up in plaster without anesthesia. The wound healed at once, but when the cast was removed, complete musculo-spiral paralysis with wrist drop was present; union in the fracture was firm. An operation was done for the paralysis June 11, ten weeks after the accident. The nerve was found stretched across a sharp spine of bone, projecting from the lower fragment. This spine was chiseled away and the bone surface covered with a thin layer of triceps muscle, making a little bed for the nerve to lie in. No retentive apparatus was applied. The wound healed per primam. A slight power of extension in the fingers was noticed on the sixth day. At the end of a month, extension in the fingers was complete and was present to a considerable degree in the wrist. In seven weeks, extension in both wrist and fingers was normal, and in three months the patient returned to his work as a mine laborer, at which he has continued without trouble. A very complete review of the musculo-spiral paralysis has been published by Launois and Lejars of Paris (Revue de Chirurgie, May, 1903). These authors report a case of their own operated on four months after the accident. The nerve was running through a complete canal in the callus. Recovery did not begin till about It was very rapid, seven months after the operation. They show that the operative results for this condition are very good. They quote Blencke's collection of 68 cases, with 41 complete cures, 6 almost complete, 8 notable improvements, and 3 slight improvements; i. e., 58 out of 68 with a positive result. There were 7 failures and 3 unknown results. So far as statistics go, they do not show much difference in operations done in the second to the sixth month. Four to sixth months is about the usual time for recovery to take piace, which is about the same time as for nerve suture. In one case an operation at six weeks did not give positive results till after two years. Blencke reports one case in which the trouble was from cicatricial tissue around the nerve. The fingers could be extended the day after the operation, and recovery was complete on the fortieth day. Rinne had a successful case in which the operation was done after three and one-half years. Mills and White (Univ. of Penna. Medical Bulletin, March, 1903) report a case operated on after one month for paralysis by cicatricial tissue around the nerve. Improvement was marked at one month and finally complete. The conclusions that one draws from the literature of this subject are that the chances of recovery after operation are very good; that the operation should be done early, although delay up to at least three and onehalf years does not preclude recovery; that the recovery can be expected to be complete in from three to six months; that the operation is much the best treatment, although Rethius saw eight out of seventeen cases recover without operation. November 29th the writer was called by Dr. A. B. Shideler, of North Branch, Ia., to see C. P., aged 23 years, who gave the following history: Had always been healthy and family history good; November 4, 1902, was operated on for varicocele at a clinic; anesthetic given and history of this not known to writer. About the fourth or fifth day after operation he experienced a sharp pain in the chest. Attention of house surgeon was called to it, he stated, but was told that nothing had gone wrong with him. On the tenth day he was discharged from the hospital. Still had pain in the chest; stitches removed and operative wound had healed without any suppuration. He did not go immediately to his home, but visited at Van Meter for a few days. While there he had a cough and noticed that his expectoration was offensive smelling. This gradually increased, with constitutional depression, and a few days after his return home his family physician, Dr. Shideler, was called. This was about November 26. He found him with a temperature of nearly 102 and a most vile smelling expectoration. His diagnosis was pulmonary-embolus, with resulting gangrene, and advised calling the writer in consultation. Saw *Read at the annual meeting Iowa State Association of Railway Surgeons, Des Moines, October 17 and 18, 1903. |