Progress in medicine : Graves' disease.

Date:
1895
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Licence: Public Domain Mark

Credit: Progress in medicine : Graves' disease. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    Medical Progress and Hospital Clinics. [The Editor will he glad to receive offers of co-operation and contributions from members of the profession. All letters should, be addressed to The Editor, at the Office, 428, Strand, London, W.C.~| THE CAUSES AND TREATMENT OF UNUNITED FRACTURE. By Wheelton Hind, M.D., B.S.Lond., F.R.C.S., Assistant Surgeon to the North Staffordshire In- firmary. Daring the last few years I have had to operate on three case of ununited fracture of long bones, once on the femur, twice on the tibia—but in these cases one was at the junction of the upper and middle thirds, the second at the junction of the lower and middle thirds. All cases were in men. After a brief summary of the causes and treatment of ununited fracture of bones, I shall proceed to give details as to the methods of pro- cedure I adopted and the results. Ununited fractures are due to two classes of causes. The one consists of general systemic causes; in the other class the causes are purely mechanical, and it is this class which furnishes as a rule the cases for operative treatment. Class I—Systemic Causes—Syphilis, Scurvy, Wasting' Disease, Insufficient Food.—Of these scurvy is the most potent. The others are almost hypothetical causes, which with others of the same class are generally known in onr text-book accounts, in order to give ex- aminees a chance of concocting an answer ; but clini- cally these causes are seldom or never ob served. Clas s II—Mechanical Causes.—1. Nonapposition of fragments, which may be subdivided into separation of ends, as in fractured patella, and oblique fracture and misplacement of fragments, so that the raw and bony surfaces are not in contact. 2. The interposition of muscle or fascia between the ends of the bone. 3. Necrosis of the ends of the bone in compound frac- tures. 4. Rupture of the nutrient artery, the fracture being near the point of entrance. The latter is a doubtful cause, as the callus-forming material is thrown out by periosteum and other tissues in the neighbourhood of the bone to a very large extent. 5. Imperfect blood supply to the limb, owing to concomi- tant damage to the main vessels. 6. Mobility of the fragments. Treatment.—The treatment of ununited fractures ob- viously falls into two categories. First, general, which may be dismissed in a few words. The general health and nutrition of the patient should be looked after, and the specific treatment for scurvy or syphilis be per- severingly followed. The local treatment has for its object first, rest and the proper apposition of the ends of the fragments; second, that the ends should be rendered immobile; third, that endeavours should be made to excite callus formation. To this end tenotomy, careful splinting, rubbing the ends of the bones together, counter-irritation by blistering, friction, or seton. Failing these, more active measures may be adopted, such as subcutaneous incision or the driving of ivory pegs into the ends of the bones to cause a certain amount of irritation, simple resection, resection with pegging ligature or screwing, and finally bone graft- ing after resection. These, then, are the various means at our disposal, one or other of which may be selected according to the suitability of the case. In the case of necrosis of the ends of the fragments, nothing remains but to remove the dead tissue either by resection, which I have seen successfully carried out in the tibia, or by waiting for pathological processes to separate the necrosed portions. The first case on which I had to operate was one of a bad oblique fracture of the lower end of tibia and fibula. The accident happened on January 1st, 1892. It had been treated for several months by rest and splints, but although the leg was fairly firm, there was no bony union, and the leg would bear no weight. The patient came from a neighbouring workhouse union, and was fifty years of age. On November 7th, 1892, with every aseptic precaution an incision was made for about 4 inches in length over the seat of the fracture, and the bone was cut down upon, and the tissues on all sides were freed by a blunt dissector and raspatory, all extraneous callus, of which there was a good deal, being removed by bone forceps. It was then seen that the fracture had been very oblique, and that the fragments had become displaced upwards and down- wards. The fibrous union was then broken down and the ends of the bones freed, so that they could be drawn down —the most difficult part of the procedure, for it necessitates detaching all the tissues round each fragment. Then I carefully resected the ends of each bone, using first a saw, and afterwards bevelling each bone with chisel and mallet, so that the foot came into its proper position, and removed the sharp projecting angle of each bone. Then, with a drill, holes were made obliquely in each fragment, and a thick soft silver wire was passed and firmly twisted up, the ends being hammered into the bone. All fragments and bone chips were then carefully removed, and the toilet of the wound completed and the skin united by incisions without drainage. The subsequent history of the case was simply that the wound healed by first intention, and the patient left the hospital on December 15th, 1891, and when I saw the man last, some few months after operation, there was complete bony union, but he had not then recovered good use, owing to long interference with the muscle nutrition. The fibula caused no trouble in bringing the ends of the tibia into complete apposition. Case 2 was much more formidable. It occurred in a canal boatman, aged forty, who had lost one leg just above the knee, and who came in with a fractured femur about the middle of the thigh, on June 21st, 1894- The leg was a very thick and muscular one, and there was great displacement and bruising. After four months’ treatment it was decided to operate. An in- cision six inches long was made on the outer side of the left thigh, and continued through the muscle. The leg was enormously swollen and full of callus, and it was a matter of the utmost difficulty to chisel this away and bring the fragments together. The lower fragment had passed behind and outside the upper one for some