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A CASE OF ANEURYSM OF THE HEART.
405 their aetiology and in the resulting displacement. In the great majority of cases the essential injury is a fracture of the lower end of the fibula caused by violent abduction or external torsion of the foot. The fracture may be transverse and occur a little above the external malleolus, but more often it is oblique and runs through the malleolus itself and into the joint. In some of these cases the fracture of the fibula is uncomplicated, the tibia and ligaments remaining intact, without any displacement. More frequently, however, the internal lateral ligament is ruptured or the internal malleolus is avulsed by a more severe degree of violence. In these cases the lower end of the fibula, with the foot, are displaced outwards into a valgus position, and there is frequently some overlapping of the fragments, with shortening of the fibula. Occasionally there is marked backward displacement of the foot in addition, but this is generally caused by an associated fracture of the posterior margin of the lower end of the tibia. No. matter how severe the displacement, accurate reduction can nearly always be obtained by nianipulation under an anaesthetic. The essential steps in the technique are as follows :-
by encasing the
foot in a bivalved plaster in full After this the patient is allowed up with a thickened inner border of the shoe and a long arch support, mobility of the joints being preserved by massage and exercises. Osteo-arthritis can be attributed to incomplete reduction of displacement. The joint-line is broken and rough ends project into and irritate the joint, and osteo-arthritis is the result. The older the patient the greater is the likelihood of osteo-arthritis. The ankle becomes swollen, stiff, and very painful, the patient inversion.
The knee is first flexed to relax the tendo Achillis. The surgeon then grasps the foot with one hand and the leg with the other, and very deliberately corrects every element of displacement. In the usual case of fracture with outward displacement the foot should be forcibly pulled down, and then twisted inwards until the astragalus is brought completely under the lower end of the tibia. Definite contact must be made between the astragalus and the internal malleolus. In this manner the outward displacement is corrected and the fibula realigned and restored in length. It is this realignment of the fibula which is the essential step in the reduction of the fracture. In addition, any backward displacement must be corrected by pulling the heel forwards until full dorsiflexion of the ankle is obtained.
The crucial part of the treatment lies in the fixation of the limb in a retentive apparatus, without allowing redisplacement to occur. Actually the danger of this is exaggerated, but undoubtedly the safest thing to do is to apply a three-piece sectional plaster case, which completely overcomes the risk of redisplacement. First the foot and then the leg are encased in plaster bandages, a two- or three-inch interval being left at the fracture site. When the leg and foot pieces have hardened, the third piece of plaster is applied by an assistant, while the surgeon holds the foot in full inversion and slight dorsiflexion. Great care must be taken to prevent circulatory embarrassment by adequate padding, and it may be necessary to remove the first plaster after the oedema has subsided and apply In three weeks the a fresh and closer-fitting case. plaster is removed, a light bivalved case is applied, and movements started. Excellent reduction can be obtained by the above technique, even in fractures Six months after the with gross displacement. fracture the functions of this patient’s ankle and foot were absolutely normal. Traumatic flat-foot is an exceedingly common result of fractures of the ankle. Although predisposed to by shortening of the fibula, the main cause is premature and unguarded weight-bearing, which has the effect of causing the young callus to yield and so leads to progressive valgoid displacement of the foot. This variety of flat-foot is curiously painful and rigid, and causes very severe disability. At first the rigidity is produced by muscle-spasm, but it becomes fixed later by the formation of adhesions. Fortunately, the prevention of traumatic flat-foot is a simple matter ; the essential point is to prohibit any weight-bearing until the end of the second month. For the first six months after this protection should be afforded by wedging up the inner border of the shoe by one-third to half an inch, while in heavy people an outside iron with inside T-strap is recommended in addition. Either boots or strong shoes should be worn for the first few months. When flat-footis an accomplished fact it is best treated by thorough mobilisation under an anaesthetic, the object being to break down adhesions and restore the arches of the foot. For a few weeks the correction should be maintained
being severely disabled. The prevention of osteo-arthritis depends entirely on securing absolute reduction of displacement, which must in all cases be immediately confirmed by X rays. If the radiogram shows any residual displacement, it is wiser to obtain exact anatomical reduction by open operation than to leave things to nature.
Clinical and
Laboratory Notes.
A CASE OF ANEURYSM OF THE HEART. BY W. S. RUSSELL THOMAS, M.B. CAMB. THE
following
case
presents some interesting
features. A
fairly stout
man, aged 58, died suddenly after defsecaHe had not consulted a doctor for years, and, according to his wife, the only complaint she had heard him make about his health was of some shortness of breath and occasional pain over his heart. Post-mortem examination revealed a distended pericardium, containing a very large quantity of blood. The heart was removed very carefully. It was larger than normal, and there was a good deal of fatty infiltration, but the most striking feature was an obviously thin-walled sacculation, bigger than the half of a walnut shell, on the anterolateral side of the left ventricle. On the superior part of this sacculation was a ragged hole through which a pencil could be passed. The mitral and aortic valves were slightly thickened and the left ventricle dilated, with walls somewhat thickened at the base, but rapidly thinning towards the apex. The thickness of the walls above the sacculation was about one-eighth of an inch ; at the sacculation only the thickness of the membranes of a foetus, and nearer the apex they became slightly thicker, but not more than one-eighth of an inch. The myocardium showed definite signs of fatty degeneration, and the aorta some patches of atheroma ; otherwise there was nothing abnormal. The other organs were in fair condition except for one stone in the gall-bladder, and what appeared to be a small quantity of pus in the pelvis of the right kidney; the kidney substance was almost normal.
tion.
Here, then, was a man with an extremely thinwalled left ventricle-so thin in one part that it formed a very marked sacculation-yet feeling well enough to work. His symptoms were not sufficient to make him want to consult a doctor. One day the sacculation became so thin that it burst after the act of defeecation, and death followed almost immediately. CASE OF
GANGLIONIC NEUROMA OF THE MEDIASTINUM IN A CHILD AGED NINE. BY W. C. HARVEY, M.D.
GLASG., D.P.H.,
MEDICAL SUPERINTENDENT, DUMFRIES AND GALLOWAY SANATORIUM, LOCHMABEN.
THE following are some notes on a rather unusual and interesting cage which was recently admitted to the Dumfries and Galloway Sanatorium, Lochmaben,. for observation purposes. A child, aged 9 years, was said to have been quite well until
May, 1928, when she developed broncho-pneumonia. After her recovery from this she was left with a persistent cough
by encasing the
foot in a bivalved plaster in full After this the patient is allowed up with a thickened inner border of the shoe and a long arch support, mobility of the joints being preserved by massage and exercises. Osteo-arthritis can be attributed to incomplete reduction of displacement. The joint-line is broken and rough ends project into and irritate the joint, and osteo-arthritis is the result. The older the patient the greater is the likelihood of osteo-arthritis. The ankle becomes swollen, stiff, and very painful, the patient inversion.
The knee is first flexed to relax the tendo Achillis. The surgeon then grasps the foot with one hand and the leg with the other, and very deliberately corrects every element of displacement. In the usual case of fracture with outward displacement the foot should be forcibly pulled down, and then twisted inwards until the astragalus is brought completely under the lower end of the tibia. Definite contact must be made between the astragalus and the internal malleolus. In this manner the outward displacement is corrected and the fibula realigned and restored in length. It is this realignment of the fibula which is the essential step in the reduction of the fracture. In addition, any backward displacement must be corrected by pulling the heel forwards until full dorsiflexion of the ankle is obtained.
The crucial part of the treatment lies in the fixation of the limb in a retentive apparatus, without allowing redisplacement to occur. Actually the danger of this is exaggerated, but undoubtedly the safest thing to do is to apply a three-piece sectional plaster case, which completely overcomes the risk of redisplacement. First the foot and then the leg are encased in plaster bandages, a two- or three-inch interval being left at the fracture site. When the leg and foot pieces have hardened, the third piece of plaster is applied by an assistant, while the surgeon holds the foot in full inversion and slight dorsiflexion. Great care must be taken to prevent circulatory embarrassment by adequate padding, and it may be necessary to remove the first plaster after the oedema has subsided and apply In three weeks the a fresh and closer-fitting case. plaster is removed, a light bivalved case is applied, and movements started. Excellent reduction can be obtained by the above technique, even in fractures Six months after the with gross displacement. fracture the functions of this patient’s ankle and foot were absolutely normal. Traumatic flat-foot is an exceedingly common result of fractures of the ankle. Although predisposed to by shortening of the fibula, the main cause is premature and unguarded weight-bearing, which has the effect of causing the young callus to yield and so leads to progressive valgoid displacement of the foot. This variety of flat-foot is curiously painful and rigid, and causes very severe disability. At first the rigidity is produced by muscle-spasm, but it becomes fixed later by the formation of adhesions. Fortunately, the prevention of traumatic flat-foot is a simple matter ; the essential point is to prohibit any weight-bearing until the end of the second month. For the first six months after this protection should be afforded by wedging up the inner border of the shoe by one-third to half an inch, while in heavy people an outside iron with inside T-strap is recommended in addition. Either boots or strong shoes should be worn for the first few months. When flat-footis an accomplished fact it is best treated by thorough mobilisation under an anaesthetic, the object being to break down adhesions and restore the arches of the foot. For a few weeks the correction should be maintained
being severely disabled. The prevention of osteo-arthritis depends entirely on securing absolute reduction of displacement, which must in all cases be immediately confirmed by X rays. If the radiogram shows any residual displacement, it is wiser to obtain exact anatomical reduction by open operation than to leave things to nature.
Clinical and
Laboratory Notes.
A CASE OF ANEURYSM OF THE HEART. BY W. S. RUSSELL THOMAS, M.B. CAMB. THE
following
case
presents some interesting
features. A
fairly stout
man, aged 58, died suddenly after defsecaHe had not consulted a doctor for years, and, according to his wife, the only complaint she had heard him make about his health was of some shortness of breath and occasional pain over his heart. Post-mortem examination revealed a distended pericardium, containing a very large quantity of blood. The heart was removed very carefully. It was larger than normal, and there was a good deal of fatty infiltration, but the most striking feature was an obviously thin-walled sacculation, bigger than the half of a walnut shell, on the anterolateral side of the left ventricle. On the superior part of this sacculation was a ragged hole through which a pencil could be passed. The mitral and aortic valves were slightly thickened and the left ventricle dilated, with walls somewhat thickened at the base, but rapidly thinning towards the apex. The thickness of the walls above the sacculation was about one-eighth of an inch ; at the sacculation only the thickness of the membranes of a foetus, and nearer the apex they became slightly thicker, but not more than one-eighth of an inch. The myocardium showed definite signs of fatty degeneration, and the aorta some patches of atheroma ; otherwise there was nothing abnormal. The other organs were in fair condition except for one stone in the gall-bladder, and what appeared to be a small quantity of pus in the pelvis of the right kidney; the kidney substance was almost normal.
tion.
Here, then, was a man with an extremely thinwalled left ventricle-so thin in one part that it formed a very marked sacculation-yet feeling well enough to work. His symptoms were not sufficient to make him want to consult a doctor. One day the sacculation became so thin that it burst after the act of defeecation, and death followed almost immediately. CASE OF
GANGLIONIC NEUROMA OF THE MEDIASTINUM IN A CHILD AGED NINE. BY W. C. HARVEY, M.D.
GLASG., D.P.H.,
MEDICAL SUPERINTENDENT, DUMFRIES AND GALLOWAY SANATORIUM, LOCHMABEN.
THE following are some notes on a rather unusual and interesting cage which was recently admitted to the Dumfries and Galloway Sanatorium, Lochmaben,. for observation purposes. A child, aged 9 years, was said to have been quite well until
May, 1928, when she developed broncho-pneumonia. After her recovery from this she was left with a persistent cough