- Email: [email protected]
FRACTURES OF THE LATERAL CONDYLE OF THE HUMERUS
141 too much on a subject about which much remains to be learned ; but he suggests that the invigorating effects of Bad Gastein as a health resort have their origin largely in the fact that the whole air of the narrow ravine, down which the main stream plunges directly among the houses in abrupt cascades, is impregnated with the spray of the torrent, so that even those who are not taking a formal bath of so many minutes and
Gastein in particular, without
dogmatising
of an allotted strength are receiving an informal airbath throughout day and night. It is to this fact that he attributes the gradually energising effects of a sojourn at Bad Gastein, which have earned for the spa its popular reputation, that it is a ’good place for old people,’ a reputation otherwise expressed in the Austrian description of the treatment as’a Christmas cure,’ meaning that the invigoration derived from summer and autumn visits are fully appreciated when the trials of winter come." "DE GENERATIONE ANIMALIUM" ANALYSED
HARVEY’S fame rests secure on the " De Motu Cordis." His longer work, the " De Generatione Animalium "1 has remained comparatively unnoticed. The professor of anatomy at Stanford University has found that very few of the Harveian orators have more than mentioned it ; few of them have made it the subject of detailed comment, nor has it received adequate appreciation elsewhere. Prof. Meyer has therefore examined it critically, and in spite of difficulties has succeeded in producing an interesting account of the work. There are various one which Harvey himself sources of difficulty: recognises is the phraseology. He says: "He who enters on this new and untrodden path, and out of the vast realm of Nature endeavours to find the truth by means of anatomical dissections and experiments, is met by such a multitude of facts, and these of so unusual an aspect, that he may find it more difficult to explain and describe to others the things he has seen, than he reckoned it labour to make his observations : so many things are encountered that require naming; such is the abundance of matter and the dearth of words." There is a further and more serious difficulty : the work contains contradictions and entanglements of ideas, in marked contrast with the clarity and logical sequence of thought which characterise the "De Motu Cordis." It is probable that Harvey was himself not unconscious of this imperfection, and that the knowledge was at least in part the cause of his reluctance to publish the work. The treatise was not the work of his old age, though he was 73 the year it was published. He had been investigating the subject ever .since his time at Padua, when he had taken as his master Fabricius, who had written on the development of the chick. For many years he had made experiments and observations, and at some period he had arranged his material in a series of exercitationes and prefaced them with an introduction, in which he discussed the methods of acquiring knowledge. Prof. Meyer finds this introduction " rather tedious reading," but all will not agree with him. It is at least a profession of faith on Harvey’s part, written in the language and the spirit of the true researcher. He then records his observations and experiments in a series of numbered chapters, many of which are even now of the greatest interest. To these he "
"
1 An Analysis of the " De Generatione Animalium" of William Harvey. By A. W. Meyer, Professor of Anatomy, Stanford University Press. London : Stanford University. Humphrey Milford, Oxford University Press. Pp. 167. 13s. 6d.
" added what he called " additamenta on parturition, The the foetal membranes, and on conception. whole is inconclusive and thus probably disappointing to one who was convinced that he had been working on the right lines. The " exercitationes " are full of accurate observations, but contained too many of those vain speculations which Harvey himself condemned. Hence arise contradictions and obscurities of thought which make it hard to ascertain what Harvey himself believed. The famous dictum " Omne vivum ex " ovo does not occur anywhere in that precise form, though it is implied in several passages-e.g., " Ovum esse primordium commune omnibus animalibus," and also in the inscription on the egg " Omnia ex " ovo which appears in the frontispiece to the first four editions. Yet in other passages the dictum is contradicted, for Harvey says elsewhere that " some animals are born of their own accord, concocted out of matter spontaneously or by chance." In other words he accepted, however reluctantly, the doctrine of spontaneous generation, and made no attempt to reconcile the contradictions. In the " De Generatione " Harvey in fact records his failure. Willis, writing an introduction to his translation in 1847, truly says : " On the doctrine of the circulation the dawn had long been visible : Harvey came and the sun arose. On the subject of animal reproduction all was night and darkness two centuries ago : and though the light has still been waxing in strength since Harvey wrote, it is only in these times that we have seen it brightening into something like the day." "A failure, it is true," says Prof. Meyer, "but nevertheless the best treatise produced up to that time."
FRACTURES OF THE LATERAL CONDYLE OF THE HUMERUS
THE isolated fracture of the lateral condyle of the lower humeral epiphysis is a lesion of childhood. It is not very common, but is of note on account of the considerable difficulty of reduction and the unsightly deformity in which non-reduction results. The cause of the fracture is nearly always a fall on the arm or hand ; but, as it is not usually possible to extract from a child a clear account of how he has fallen, the exact mechanism is not certain. In all probability the elbow is forcibly adducted while in a position of imperfect extension. This may result in some cases from a fall on the outstretched hand. Dr. Philip D. Wilson 1 describes the typical displacement as a rotation of the separated fragment outwards, downwards, and backwards. The full displacement is due to the pull of the extensor muscles attached to the lateral epicondyle and, as is pointed out by Wilson, this pull can only act at all powerfully when the adduction has been so forcible as to tear the muscular aponeurosis which ordinarily confines the extensors. The injury, as demonstrated in the radiogram, is mainly an epiphyseal separation, but there is always a thin splinter of bone torn from the metaphysis, chiefly from its lateral border and posterior aspect. The fracture line runs from the lateral side, starting about t in. above the epiphyseal line, to split the articular cartilage and enter the elbow-joint in the region of the trochlea. The fragment separated is triangular in shape. There is a very definite agelimit for this fracture ; it occurs between the age of 3 years, when the centre first appears for the capitellum, and the age of 13, when fusion takes 1 Jour. of Bone and Joint Surg., April, 1936, p. 301.
142
place between the various elements of the lower epiphysis. Fusion of epiphysis and metaphysis has already commenced by the latter date, so that, after 13, fracture is much more likely to occur than epiphyseal separation. With a slight degree of displacement, treatment with the elbow in flexion,
advocated for most elbow-joint, may suffice. Any injuries considerable displacement of the condyle results in an apposition of the smooth articular surface of the capitellum with the fractured surface of the humerus, and, without reduction, non-union is a certainty. No individual surgeon is likely to gain a large experience Wilson has met the fracture of such reduction. 11 times in a series of 439 cases of fractures and dislocation around the elbow. His impression is that attempts at non-operative reduction are a waste of time. He would perform open reduction in every case of definite displacement. A lateral incision exposes the site of fracture. The tear in the aponeurosis will probably be obvious, and through it a forceps is inserted to pull on the ligamentous and muscular attachments to the condyle and draw it up. The fragment is replaced by means of the fingers, and may be held in position by suture. Wilson uses a silk suture passed inferiorly through the ligaments and muscles on the condyle and above through a hole drilled in the lateral supracondylar ridge. The effects as
around the
of non-reduction
are an
increasing degree
of
valgus
deformity at the elbow, and, in a certain number of cases, the late development of ulnar nerve paresis. Flexion and extension and pronation and supination may fully recover, and even with a quite definite deformity the strength of the limb may be unimpaired. Interference with the growth of the metaphysis is not a usual feature, although owing to the nonunion of the lateral condyle the growth is irregular. CHEST TROUBLES AFTER ANÆSTHESIA
of
complications was reduced by half when the action of the intercostal was not interfered with and rib-movement was not abolished. The most striking influence on respiratory complications was shown by the duration of operation. Operations of an hour or less had a morbidity less than the average for their group, and the percentage of complications following operations lasting two hours was more than three times that of the one-hour series. THE SURGICAL TEMPERAMENT
Is there a surgical temperament ? Prof. 0. Lambret answers1 the question in a pleasantly " debunking" spirit. The surgical temperament, he thinks, no longer amounts to much. Looking round at his colleagues, he can find among them no common factor to serve as a basis for a definition. In the early days when such as it demanded was, rapid decisions and surgery, dramatic the aid of antswithout operations quick thetics, surgeons were indeed " seigneurs," a source of gratitude and wonder to mankind. If there was ever a surgical temperament it is among these pioneers of surgery that one would expect to find it, but "ils differaient terriblement les uns des autres." Looking back 40 years, Prof. Lambret recalls some of the great surgeons of his youth; the solemn Pean, floundering amid a forest of artery forceps, Doyen with the spade-like fingers, Tuffier who modelled himself on Doyen but surpassed him in neatness and elegance, and Terrier, least brilliant of the four, whose methods, however, have survived. Nowadays, says Prof. Lambret, surgical technique has become largely stereotyped. Your modern surgeon is trained and equipped for emergencies. When a danger arises ... " un doigt le jugule une une ligature ... le danger est passe." The pince whole affair is reduced to the level of a skilled handicraft. A tumour may be removed with more or less dexterity, but thanks to anaesthesia and asepsis the end-result will not be far different. It is true that some surgeons are better than others but that is true of every craft; the superiority is only relative, a matter of degree. Prof. Lambret thinks that 80 per cent. of humanity could be made into competent surgeons, but if they become business men, engineers, lawyers, mechanics, or generals, careers for which nobody thinks a special temperament necessary, they will do just as well. But, he adds, the surgeon of the future must be more than a clinician; he must be a biologist in the widest sense. He who has to work with the organs and tissues of the human body must be conversant with the laws which govern them. ...
...
THE aetiology of chest complications after operation is still often a controversial question. There are some who believe that these sequelae have nothing at all to do with the anaesthetic, but are brought about entirely by the site, nature and severity of the operation. Others maintain that ether is more irritating to the air passages and is actually more often followed by chest complications than other agents. The work of W. Pasteur on massive collapse of the lung must not be lost sight of in connexion with postoperative chest conditions ; some cases may certainly be explained by the partial paralysis of the diaphragm and lack of movement on the affected side of the chest. A statistical inquiry carried out by E. A. Rovenstine and Ivan B. Taylor into the sequelae of 7874 anaesthesias at Wisconsin Hospital1 does not bring to light any new factor or explanation ; it does provide instructive confirmation for some accepted views. For instance, that the presence of any respiratory tract affection in the patient before operation is a potential danger. The authors find, too, that there is a seasonal variation associated with the prevalence of respiratory diseases in the population outside the hospital. For this reason it was found advisable during months with a high incidence of respiratory infections to omit certain operations of convenience, particularly plastic operations on infants. The influence of the particular anaesthetic agent was not found by the authors to be important, but this is not true of anaesthesia technique." The degree of narcosis affected the percentage of complications, and when spinal anaesthesia was used the number
fatalities hitherto attributed to dinitroand -cresol appear to have been due either phenol to overdosage, or to hypersusceptibility, or a complicating agranulocytosis. The usual symptoms of intolerance are headaches, lassitude, tachycardia, palpitation, vertigo, and so forth, and toxic hepatitis with jaundice, maculopapular eruptions, urticaria, These symptoms purpura, and extreme pruritus. closely resemble those which have been reported occasionally as following the exhibition of N.A.B. or its substitutes, and are not unlike the occasional ill-effects ascribed to atophan and other drugs of the benzene-ring type. It is therefore not astonishing to read of a case of exfoliative dermatitis, of which
1 Amer. Jour. Med. Sci., June, 1936, p. 807.
1 L’Echo Médical du Nord, 1936, v., 1.
"
DERMATITIS EXFOLIATIVA FOLLOWING DINITROPHENOL THE
Gastein in particular, without
dogmatising
of an allotted strength are receiving an informal airbath throughout day and night. It is to this fact that he attributes the gradually energising effects of a sojourn at Bad Gastein, which have earned for the spa its popular reputation, that it is a ’good place for old people,’ a reputation otherwise expressed in the Austrian description of the treatment as’a Christmas cure,’ meaning that the invigoration derived from summer and autumn visits are fully appreciated when the trials of winter come." "DE GENERATIONE ANIMALIUM" ANALYSED
HARVEY’S fame rests secure on the " De Motu Cordis." His longer work, the " De Generatione Animalium "1 has remained comparatively unnoticed. The professor of anatomy at Stanford University has found that very few of the Harveian orators have more than mentioned it ; few of them have made it the subject of detailed comment, nor has it received adequate appreciation elsewhere. Prof. Meyer has therefore examined it critically, and in spite of difficulties has succeeded in producing an interesting account of the work. There are various one which Harvey himself sources of difficulty: recognises is the phraseology. He says: "He who enters on this new and untrodden path, and out of the vast realm of Nature endeavours to find the truth by means of anatomical dissections and experiments, is met by such a multitude of facts, and these of so unusual an aspect, that he may find it more difficult to explain and describe to others the things he has seen, than he reckoned it labour to make his observations : so many things are encountered that require naming; such is the abundance of matter and the dearth of words." There is a further and more serious difficulty : the work contains contradictions and entanglements of ideas, in marked contrast with the clarity and logical sequence of thought which characterise the "De Motu Cordis." It is probable that Harvey was himself not unconscious of this imperfection, and that the knowledge was at least in part the cause of his reluctance to publish the work. The treatise was not the work of his old age, though he was 73 the year it was published. He had been investigating the subject ever .since his time at Padua, when he had taken as his master Fabricius, who had written on the development of the chick. For many years he had made experiments and observations, and at some period he had arranged his material in a series of exercitationes and prefaced them with an introduction, in which he discussed the methods of acquiring knowledge. Prof. Meyer finds this introduction " rather tedious reading," but all will not agree with him. It is at least a profession of faith on Harvey’s part, written in the language and the spirit of the true researcher. He then records his observations and experiments in a series of numbered chapters, many of which are even now of the greatest interest. To these he "
"
1 An Analysis of the " De Generatione Animalium" of William Harvey. By A. W. Meyer, Professor of Anatomy, Stanford University Press. London : Stanford University. Humphrey Milford, Oxford University Press. Pp. 167. 13s. 6d.
" added what he called " additamenta on parturition, The the foetal membranes, and on conception. whole is inconclusive and thus probably disappointing to one who was convinced that he had been working on the right lines. The " exercitationes " are full of accurate observations, but contained too many of those vain speculations which Harvey himself condemned. Hence arise contradictions and obscurities of thought which make it hard to ascertain what Harvey himself believed. The famous dictum " Omne vivum ex " ovo does not occur anywhere in that precise form, though it is implied in several passages-e.g., " Ovum esse primordium commune omnibus animalibus," and also in the inscription on the egg " Omnia ex " ovo which appears in the frontispiece to the first four editions. Yet in other passages the dictum is contradicted, for Harvey says elsewhere that " some animals are born of their own accord, concocted out of matter spontaneously or by chance." In other words he accepted, however reluctantly, the doctrine of spontaneous generation, and made no attempt to reconcile the contradictions. In the " De Generatione " Harvey in fact records his failure. Willis, writing an introduction to his translation in 1847, truly says : " On the doctrine of the circulation the dawn had long been visible : Harvey came and the sun arose. On the subject of animal reproduction all was night and darkness two centuries ago : and though the light has still been waxing in strength since Harvey wrote, it is only in these times that we have seen it brightening into something like the day." "A failure, it is true," says Prof. Meyer, "but nevertheless the best treatise produced up to that time."
FRACTURES OF THE LATERAL CONDYLE OF THE HUMERUS
THE isolated fracture of the lateral condyle of the lower humeral epiphysis is a lesion of childhood. It is not very common, but is of note on account of the considerable difficulty of reduction and the unsightly deformity in which non-reduction results. The cause of the fracture is nearly always a fall on the arm or hand ; but, as it is not usually possible to extract from a child a clear account of how he has fallen, the exact mechanism is not certain. In all probability the elbow is forcibly adducted while in a position of imperfect extension. This may result in some cases from a fall on the outstretched hand. Dr. Philip D. Wilson 1 describes the typical displacement as a rotation of the separated fragment outwards, downwards, and backwards. The full displacement is due to the pull of the extensor muscles attached to the lateral epicondyle and, as is pointed out by Wilson, this pull can only act at all powerfully when the adduction has been so forcible as to tear the muscular aponeurosis which ordinarily confines the extensors. The injury, as demonstrated in the radiogram, is mainly an epiphyseal separation, but there is always a thin splinter of bone torn from the metaphysis, chiefly from its lateral border and posterior aspect. The fracture line runs from the lateral side, starting about t in. above the epiphyseal line, to split the articular cartilage and enter the elbow-joint in the region of the trochlea. The fragment separated is triangular in shape. There is a very definite agelimit for this fracture ; it occurs between the age of 3 years, when the centre first appears for the capitellum, and the age of 13, when fusion takes 1 Jour. of Bone and Joint Surg., April, 1936, p. 301.
142
place between the various elements of the lower epiphysis. Fusion of epiphysis and metaphysis has already commenced by the latter date, so that, after 13, fracture is much more likely to occur than epiphyseal separation. With a slight degree of displacement, treatment with the elbow in flexion,
advocated for most elbow-joint, may suffice. Any injuries considerable displacement of the condyle results in an apposition of the smooth articular surface of the capitellum with the fractured surface of the humerus, and, without reduction, non-union is a certainty. No individual surgeon is likely to gain a large experience Wilson has met the fracture of such reduction. 11 times in a series of 439 cases of fractures and dislocation around the elbow. His impression is that attempts at non-operative reduction are a waste of time. He would perform open reduction in every case of definite displacement. A lateral incision exposes the site of fracture. The tear in the aponeurosis will probably be obvious, and through it a forceps is inserted to pull on the ligamentous and muscular attachments to the condyle and draw it up. The fragment is replaced by means of the fingers, and may be held in position by suture. Wilson uses a silk suture passed inferiorly through the ligaments and muscles on the condyle and above through a hole drilled in the lateral supracondylar ridge. The effects as
around the
of non-reduction
are an
increasing degree
of
valgus
deformity at the elbow, and, in a certain number of cases, the late development of ulnar nerve paresis. Flexion and extension and pronation and supination may fully recover, and even with a quite definite deformity the strength of the limb may be unimpaired. Interference with the growth of the metaphysis is not a usual feature, although owing to the nonunion of the lateral condyle the growth is irregular. CHEST TROUBLES AFTER ANÆSTHESIA
of
complications was reduced by half when the action of the intercostal was not interfered with and rib-movement was not abolished. The most striking influence on respiratory complications was shown by the duration of operation. Operations of an hour or less had a morbidity less than the average for their group, and the percentage of complications following operations lasting two hours was more than three times that of the one-hour series. THE SURGICAL TEMPERAMENT
Is there a surgical temperament ? Prof. 0. Lambret answers1 the question in a pleasantly " debunking" spirit. The surgical temperament, he thinks, no longer amounts to much. Looking round at his colleagues, he can find among them no common factor to serve as a basis for a definition. In the early days when such as it demanded was, rapid decisions and surgery, dramatic the aid of antswithout operations quick thetics, surgeons were indeed " seigneurs," a source of gratitude and wonder to mankind. If there was ever a surgical temperament it is among these pioneers of surgery that one would expect to find it, but "ils differaient terriblement les uns des autres." Looking back 40 years, Prof. Lambret recalls some of the great surgeons of his youth; the solemn Pean, floundering amid a forest of artery forceps, Doyen with the spade-like fingers, Tuffier who modelled himself on Doyen but surpassed him in neatness and elegance, and Terrier, least brilliant of the four, whose methods, however, have survived. Nowadays, says Prof. Lambret, surgical technique has become largely stereotyped. Your modern surgeon is trained and equipped for emergencies. When a danger arises ... " un doigt le jugule une une ligature ... le danger est passe." The pince whole affair is reduced to the level of a skilled handicraft. A tumour may be removed with more or less dexterity, but thanks to anaesthesia and asepsis the end-result will not be far different. It is true that some surgeons are better than others but that is true of every craft; the superiority is only relative, a matter of degree. Prof. Lambret thinks that 80 per cent. of humanity could be made into competent surgeons, but if they become business men, engineers, lawyers, mechanics, or generals, careers for which nobody thinks a special temperament necessary, they will do just as well. But, he adds, the surgeon of the future must be more than a clinician; he must be a biologist in the widest sense. He who has to work with the organs and tissues of the human body must be conversant with the laws which govern them. ...
...
THE aetiology of chest complications after operation is still often a controversial question. There are some who believe that these sequelae have nothing at all to do with the anaesthetic, but are brought about entirely by the site, nature and severity of the operation. Others maintain that ether is more irritating to the air passages and is actually more often followed by chest complications than other agents. The work of W. Pasteur on massive collapse of the lung must not be lost sight of in connexion with postoperative chest conditions ; some cases may certainly be explained by the partial paralysis of the diaphragm and lack of movement on the affected side of the chest. A statistical inquiry carried out by E. A. Rovenstine and Ivan B. Taylor into the sequelae of 7874 anaesthesias at Wisconsin Hospital1 does not bring to light any new factor or explanation ; it does provide instructive confirmation for some accepted views. For instance, that the presence of any respiratory tract affection in the patient before operation is a potential danger. The authors find, too, that there is a seasonal variation associated with the prevalence of respiratory diseases in the population outside the hospital. For this reason it was found advisable during months with a high incidence of respiratory infections to omit certain operations of convenience, particularly plastic operations on infants. The influence of the particular anaesthetic agent was not found by the authors to be important, but this is not true of anaesthesia technique." The degree of narcosis affected the percentage of complications, and when spinal anaesthesia was used the number
fatalities hitherto attributed to dinitroand -cresol appear to have been due either phenol to overdosage, or to hypersusceptibility, or a complicating agranulocytosis. The usual symptoms of intolerance are headaches, lassitude, tachycardia, palpitation, vertigo, and so forth, and toxic hepatitis with jaundice, maculopapular eruptions, urticaria, These symptoms purpura, and extreme pruritus. closely resemble those which have been reported occasionally as following the exhibition of N.A.B. or its substitutes, and are not unlike the occasional ill-effects ascribed to atophan and other drugs of the benzene-ring type. It is therefore not astonishing to read of a case of exfoliative dermatitis, of which
1 Amer. Jour. Med. Sci., June, 1936, p. 807.
1 L’Echo Médical du Nord, 1936, v., 1.
"
DERMATITIS EXFOLIATIVA FOLLOWING DINITROPHENOL THE