as
much
as
possible.
A
few
years ago, treated two recent cases by Lister's method with success,: and I also operated on one successfully. There is no doubt, however, that this method requires great care on the part of the surgeon and also of his assistants; it is not always possible, outside a hospital, to ensure surgical cleanliness in one's assistants, and sometimes practitioners are offended by the supervision of their ablutions, and bj7 the suggestions made to them before such an operation as to cleanliness of the nails, &c. It requires a good deal of delicacy to avoid giving offence, and, at the same time, getting assistants up to the standard Men who are not often of such an operation. accustomed to operations and who practice more as general practitioners are apt to pooh-pooh the precaution necessary in such a case, and to be content with a very rapid application of soap and rinsing of the hands. Under these circumstances it is certainly better not to risk the joint or the leg, or even the life of the patient by operating. The following four cases are instances of different methods in cases recently under my care :?
Brigade-Surgeon Wellington Gray
Case I.?A European gentleman, over 40years of age and of strong build, fell while descending some stairs, and in the effort to save himself, fractured his right patella; immediately very great swelling of the joint and thigh came on with much separation of the fragments; after the subsidence of the swelling, it was found that the upper fragment consisted, of nearly the whole bone, whilst the lower was merely a small triangular fragment about an inch long. The vasti muscles were evidently a good deal torn, as shewn by the amount of swelling above the joint. For the first fortnight, the limb was kept on a Maclntyre splint, and at the end of this time, horse-shoe pieces of stickingplaster were applied and the fragments approximated as much as possible, but it was found impossible to bring them close, a gap of J inch separated them. A plaster of Paris bandage was then carefully applied and the part was kept quiet for six weeks ; at the end of that time, the
plaster
was
removed, and, very
FRACTURE OF THE PATELLA. By Suugn.-Lieut .-Col. W. K. Hatch, f.rc.s. Esq.,
Principal
and
Professor of Surgery, Bombay.
Grant Medical
College,
Comparatively few cases of fractured patella admitted into the Jamsetjee Jeejeeblioy Hospital, and thus I have not had a very large experience, even after a considerable number of years, of this accident. The usual plan has been, up to quite recently, to treat these fractures by the ordinary back splint and pieces of stickingplaster shaped like a horse-shoe applied above and below so as to approximate the fragments are
gently,
move-
There was very marked wasting of the muscles of the thigh, and it was evident that adhesion to the bone prevented their proper movements. Under these circumstances a thick piece of rubber tubing, of the size usually used for golf tees, was taken and passed once round the leg, the two ends were then fastened or held by an assistant round the leg of a table; at first, slight efforts were made by the patient to flex and extend the leg, the rubber tube being kept at very moderate tension ; but as the muscular strength was restored, gradually the tube was pulled tighter and tighter until the limb could be flexed to a right angle. This caused some stretching of ments were commenced.
168
INDIAN MEDICAL GAZETTE.
and a portion of the crureus adherent to the femur that I was much afraid more force would cause wide separation of the fragments. I was therefore obliged to proceed very cautiously, the patient being allowed to walk with a crutch ; he was also daily massaged. At the end of four months he was able to walk fairly, but flexion continued to be a difficulty beyond a right angle. The treatment, however, was steadily continued, and as the patient gave every assistance, he was able to walk well at the end of eight months and to bend the knee acutely. He uses the limb now very well, though he has a perceptible limp, and the muscles of the thigh are evidently still held in the centre of the limb. Case II.?The patient, a Hindoo, 35 years of age, about three months before admission had slipped while walking on rocky ground and fell; he got up from the ground and stepped forward, when he experienced a sensation as if something had given way in his left knee, and he felt a piece of bone rise upwards on the thigh; he became at once helpless and called for assistance, when some of the villagers came and carried him home. He was soon after taken to a hospital, the kneejoint becoming very much enlarged ; he was subsequently treated with splint and bandages for about two months. On admission (28th April 1897) at the Jamsetjee Jeejeebhoy Hospital, Boinba}7-, he was in fairly good condition, but unable to walk or extend the leg except by pushing it with the right foot. In the flexed position there was a veiy wide gap between the two portions of patella, the upper piece being extremely moveable ; when extended, the two pieces could be brought together by firm pressure and made to touch each other. He consented to undergo any operation which would improve his condition, and I accordingly operated on him on the 31st of April, by refreshing the edges of the fractured bone after freel}' opening the joint; the bones were then drilled by the American dental engine, and with thick silver were well brought together wire, which was then hammered down, and the joint closed after washing with weak perchloride The patient had been previously prolotion. perly prepared for the operation. That evening his temperature was 100*2. It gradually rose to 102 6 on the evening of May 3rd, but there was no pain and very little swelling; the dressings were removed and a little blood came away, the parts were again dressed several times, but on May 8th some pus came away from the outer part of the wound; his temperature kept up and some sutures On the 11th noon, were therefore removed. stitches were taken out, drainage tubes put in and the interior of the joint well washed. He, however, became very weak, delirious, and died on the 13th May. How the joint became infected I am unable to say, but I fear that an assistant had dressed a case in the wards before the operation, contrary to orders.
the fibrous
appeared
union,
to be
so
[May
1898.
Cases III 8f IV-?Were both cases of fractured patella ; both were transverse fractures. No. Ill?Was a male Hindoo, aged 35, and was admitted on May 5th; the fracture was caused by a blow with a stick. On the 7th May I operated on him by Barker's method, using silver wire passed in front and behind the bone. Next evening the temperature rose to 100?, but after that it fell to 99? and did not again rise. On the 23rd May the Maclntj're splint was removed and gentle movement was begun, and he was discharged on the 12th June, able to walk fairly well. No. IF?-Was a female Hindoo, aged 2G; she was carrying some food in a dish, when her foot slipped, she fell on her back and heard a snap in her right leg and could not get up. She was brought at once to hospital on 31st of January 1898. There was great swelling of the joint, and the bones could not be distinctly felt; the limb was put on a splint and an ice bag applied. The swelling became gradually reduced and the fragments, two in number, cuuld be approximated by pressure. On the 18th February, I operated on her bv Barker's method; a splint was applied and kept on until March 4th, when it was removed, and the limbs placed She complained of between two sand-bags. very little pain, and there was no rise of temperature. Passive movements were commenced on March 17th, and she began to walk on the 9th of April ; she was able to walk with ease on the 14th April, when she left hospital at her own
request.
The results of these two cases were so satisfactory that I shall certainly treat all future cases in this way.
much
as
possible.
A
few
years ago, treated two recent cases by Lister's method with success,: and I also operated on one successfully. There is no doubt, however, that this method requires great care on the part of the surgeon and also of his assistants; it is not always possible, outside a hospital, to ensure surgical cleanliness in one's assistants, and sometimes practitioners are offended by the supervision of their ablutions, and bj7 the suggestions made to them before such an operation as to cleanliness of the nails, &c. It requires a good deal of delicacy to avoid giving offence, and, at the same time, getting assistants up to the standard Men who are not often of such an operation. accustomed to operations and who practice more as general practitioners are apt to pooh-pooh the precaution necessary in such a case, and to be content with a very rapid application of soap and rinsing of the hands. Under these circumstances it is certainly better not to risk the joint or the leg, or even the life of the patient by operating. The following four cases are instances of different methods in cases recently under my care :?
Brigade-Surgeon Wellington Gray
Case I.?A European gentleman, over 40years of age and of strong build, fell while descending some stairs, and in the effort to save himself, fractured his right patella; immediately very great swelling of the joint and thigh came on with much separation of the fragments; after the subsidence of the swelling, it was found that the upper fragment consisted, of nearly the whole bone, whilst the lower was merely a small triangular fragment about an inch long. The vasti muscles were evidently a good deal torn, as shewn by the amount of swelling above the joint. For the first fortnight, the limb was kept on a Maclntyre splint, and at the end of this time, horse-shoe pieces of stickingplaster were applied and the fragments approximated as much as possible, but it was found impossible to bring them close, a gap of J inch separated them. A plaster of Paris bandage was then carefully applied and the part was kept quiet for six weeks ; at the end of that time, the
plaster
was
removed, and, very
FRACTURE OF THE PATELLA. By Suugn.-Lieut .-Col. W. K. Hatch, f.rc.s. Esq.,
Principal
and
Professor of Surgery, Bombay.
Grant Medical
College,
Comparatively few cases of fractured patella admitted into the Jamsetjee Jeejeeblioy Hospital, and thus I have not had a very large experience, even after a considerable number of years, of this accident. The usual plan has been, up to quite recently, to treat these fractures by the ordinary back splint and pieces of stickingplaster shaped like a horse-shoe applied above and below so as to approximate the fragments are
gently,
move-
There was very marked wasting of the muscles of the thigh, and it was evident that adhesion to the bone prevented their proper movements. Under these circumstances a thick piece of rubber tubing, of the size usually used for golf tees, was taken and passed once round the leg, the two ends were then fastened or held by an assistant round the leg of a table; at first, slight efforts were made by the patient to flex and extend the leg, the rubber tube being kept at very moderate tension ; but as the muscular strength was restored, gradually the tube was pulled tighter and tighter until the limb could be flexed to a right angle. This caused some stretching of ments were commenced.
168
INDIAN MEDICAL GAZETTE.
and a portion of the crureus adherent to the femur that I was much afraid more force would cause wide separation of the fragments. I was therefore obliged to proceed very cautiously, the patient being allowed to walk with a crutch ; he was also daily massaged. At the end of four months he was able to walk fairly, but flexion continued to be a difficulty beyond a right angle. The treatment, however, was steadily continued, and as the patient gave every assistance, he was able to walk well at the end of eight months and to bend the knee acutely. He uses the limb now very well, though he has a perceptible limp, and the muscles of the thigh are evidently still held in the centre of the limb. Case II.?The patient, a Hindoo, 35 years of age, about three months before admission had slipped while walking on rocky ground and fell; he got up from the ground and stepped forward, when he experienced a sensation as if something had given way in his left knee, and he felt a piece of bone rise upwards on the thigh; he became at once helpless and called for assistance, when some of the villagers came and carried him home. He was soon after taken to a hospital, the kneejoint becoming very much enlarged ; he was subsequently treated with splint and bandages for about two months. On admission (28th April 1897) at the Jamsetjee Jeejeebhoy Hospital, Boinba}7-, he was in fairly good condition, but unable to walk or extend the leg except by pushing it with the right foot. In the flexed position there was a veiy wide gap between the two portions of patella, the upper piece being extremely moveable ; when extended, the two pieces could be brought together by firm pressure and made to touch each other. He consented to undergo any operation which would improve his condition, and I accordingly operated on him on the 31st of April, by refreshing the edges of the fractured bone after freel}' opening the joint; the bones were then drilled by the American dental engine, and with thick silver were well brought together wire, which was then hammered down, and the joint closed after washing with weak perchloride The patient had been previously prolotion. perly prepared for the operation. That evening his temperature was 100*2. It gradually rose to 102 6 on the evening of May 3rd, but there was no pain and very little swelling; the dressings were removed and a little blood came away, the parts were again dressed several times, but on May 8th some pus came away from the outer part of the wound; his temperature kept up and some sutures On the 11th noon, were therefore removed. stitches were taken out, drainage tubes put in and the interior of the joint well washed. He, however, became very weak, delirious, and died on the 13th May. How the joint became infected I am unable to say, but I fear that an assistant had dressed a case in the wards before the operation, contrary to orders.
the fibrous
appeared
union,
to be
so
[May
1898.
Cases III 8f IV-?Were both cases of fractured patella ; both were transverse fractures. No. Ill?Was a male Hindoo, aged 35, and was admitted on May 5th; the fracture was caused by a blow with a stick. On the 7th May I operated on him by Barker's method, using silver wire passed in front and behind the bone. Next evening the temperature rose to 100?, but after that it fell to 99? and did not again rise. On the 23rd May the Maclntj're splint was removed and gentle movement was begun, and he was discharged on the 12th June, able to walk fairly well. No. IF?-Was a female Hindoo, aged 2G; she was carrying some food in a dish, when her foot slipped, she fell on her back and heard a snap in her right leg and could not get up. She was brought at once to hospital on 31st of January 1898. There was great swelling of the joint, and the bones could not be distinctly felt; the limb was put on a splint and an ice bag applied. The swelling became gradually reduced and the fragments, two in number, cuuld be approximated by pressure. On the 18th February, I operated on her bv Barker's method; a splint was applied and kept on until March 4th, when it was removed, and the limbs placed She complained of between two sand-bags. very little pain, and there was no rise of temperature. Passive movements were commenced on March 17th, and she began to walk on the 9th of April ; she was able to walk with ease on the 14th April, when she left hospital at her own
request.
The results of these two cases were so satisfactory that I shall certainly treat all future cases in this way.
