IMAGE EVALUATION TEST TARGET (MT-3) 1.0 ^^ ^ ^S ^ i^ ■2.2 w lift 11.1 J.-^KS Photographic Sdmces Corporation 4^ ♦ --._ 13 Wm MAIN tTMIT WIUTIN.N.Y. UIM (7U)l7a-4S03 ^^ ^\ ^r> CIHM/ICMH Microfiche Series. CIHIVI/ICMH Collection de microfiches. Canadian Instituta for Historical IMiororaproductions / Institut Canadian da microraproductions hiatoriquas Tachnical and Bibliographic Notaa/Notas taehniquaa at bibliographiquaa Tha Inatituta liaa attamptad to obtain tha baat original copy availabia for filming. 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D D D D D D D D Colourad pagaa/ Pagaa da coulaur Pagaa damagad/ Pagaa andommagiaa Pagaa raatorad and/or laminatad/ Pagaa raatauriaa at/ou pailicuiiaa Pagaa diacolourad. atainad or foxad/ Pagaa dAcolor*aa. tachattea ou piquAaa Pagaa datachad/ Pagaa ditaehiaa Showthrough/ Tranaparanca Quality of print variaa/ QualltA inigala da I'impraaaion Includaa aupplamantary matariai/ Comprand du material auppl4mantaira Only adition availabia/ Saula Mition diaponibia Pagaa wholly or partially obacurad by arrata alipa. tiaauaa, ate. hava baan rafilmad to anaura tha baat poaaibia imaga/ Laa pagaa totaiamant ou partiaiiamant obacurciaa par un fauillat d'arrata. una paiura. ate., ont 4ti filmiaa A nouvaau da fa^on i obtanir la maillaura imaga poaaibia. Thia itam ia filmed at the reduction ratio eheeked below/ Ce document eat film* au taux de rMuetlon IndlquA ei'deeaoua 10X 14X im ax MX SOX 1 1 y 12X 1IX »X a4x ax Th* copy fllm«d hw has bMn raproduesd thanks to th« o«n«roatty of: MMinl Librwry MeQill Univmity quality logibiHty tho Tho imaoao appaaring hara ara tha possibia considarlng tha condition of tt«a original copy and in icaaping filming contract spaciftcatlona. Original eoplaa in printad popar oovara ara fllmad baginning with tha front cover and anding on tho laat paga \with a printad or iiiuatratad impraa- •ion. or tho bacit cover vwhon appropriata. All other original copiaa ara filmad baginning on tho first paga with a printad or Mliiatratad impraa- slon. snd anding on tho laat paga with a printad or iiiuatratad impr Tha laat racordod frama on aaeh microflcho shaH contain tho symbol -i^ (moaning "CON- TINUID"). or tho aymbol ▼ (mooning "IND"). L'axamplaira fiim4 f ut raproduit grica i la giniroaitA da: IMMlicai tibrary McGill Univtraity MontTMl Laa imagaa suhrantaa ont 4ti raproduitaa avac la plua grand soin. compto tanu da la condition at da la nottat* da l'axamplaira fllmA, at an conformitA avac laa conditiona du contrat da flimaga. Laa axamplairaa originaux dont la couvortura an papiar aat imprim4a sont fiimAs an common^ant par la pramiar plat at an tarminant salt par la damMro paga qui comporto uno amprainta d'impraasion ou dlHustration, soit par la sacond plat, salon la caa. Tous laa autras axamplairaa originaux sont flimis sn commandant par la pramlAra paga qui comporto uno amprainta dimpraaaion ou dlllustratlon at an tarminant par la damlAra paga qui comporto uno talla ampralnta> Un daa symbolaa suhrants apparaltra sur la damMra imaga da chaqua microflcho. colon la caa: la aymbolo — »> signifia "A 8UIVRI". la symbolo ▼ signifia "FIN". Maps, plataa, charts, ate., may be filmed at different reduction ratloe. Thoeo too large to be entirely included in one expoeure ara fHmed beginning in tho upper left hand comer, left to right and top to bottom, aa many framee aa required. The following diagrama liluatrate tho planchee. tablaaux. etc.. peuvem *tre filmie i dee taux da reduction diffirants. Laraqua la document eet trop grand pour Atra reprodult en un soul ciichi. il cot filmA A pertir do i'angle supArieur gauche, do geuche A droite. et do haut en baa. en prenent le nombro d'Imagae nAceeeaire. Lee diegrammee suhranta llluatrent le mAthode. 1 2 3 1 2 3 4 5 6 PBr^ .TVm» Vt/^.^^- lUprinUd from the ¥ ntredi Medical Jowrrud, March, IC ^s%^\ TRAUMATIC SEPARATION OF THE LOWER EPIPHYSIS OF THE FEMUR.* By John M. Eldeb, B.A., M.D.C.M., Auistant Demonitrator of Anatomy, MoOill Univenity. Mr. President and Gentlemen^ — The scant attention given to the aubjeot of separation of the condyloid epiphysis of the femui; by the standard works on surgery, coupled with a eonyic> tion that' the accident is not as rare as was at one time supposed, has led me to hope that a short paper on this subject might prove interesting to the members of this Association, and at the same time might add somewhat to our knowledge on this question. In connection with the paper I am fortunately able to show you an example of this surgical accident in the person of this young man ; and ^ *hink, when you hear the report of his case, you irill agre3 he is fortunate in being able to carry with him this specimen, at one time the lower diaphysis of his femur, even if he has to do so in his pocket. Ln a clinical lecture on the surgery of the epiphysis, delivered in 1885,t Wheelhouse drew attention to the important part played by the epiphyses in all dislocations and fractures in the neighbourhood (^joints, and hinted that many supposed oases of dislocations in young persons have really been fractures through . the epiphyseal line, as shown by the frequency with which de- * A iMHoeri with lllnitnUlTt oMe, rtkd befort th« OMwdua MtdlMl Anoolatlon, at MontrMl. S«pt«nb«r, IMl. t Brltlih Mcdtoia Jooreftl. Vol. I. IMS. p. 47A. formity has followed their reduction, and that this may account for the paucity of literature on this subject * A glance at those specimens, kindly put at my disposal by Dr. Shepherd, will enable you to see how easily, in the case of young patients, any one might mistake fracture through the lower femoral or humeral epiphyseal line for dislocation of knee or elbow. Morover, in the case of the femur, the liability to just this kind of accident extends over a goodly period of time, for you will recollect that while this epiphysis is one of the first to be formed (9th month, foetal), it is one of the last to join its corresponding diaphysis (21st year). While I have these speci- mens in hand, I would ask your attention to the mechanism of this form of injury. When fracture takes place, the epiphysis will be tilted forward by the two heads of the gastrocnemius, thus presenting its articular surface to the patella. At the same time the diaphysis will bo thrust backwards and downwards by the pull of the quadriceps extensor muecles in front and the ham-string muscles behind, and will impinge on the vessels and nerves in the popliteal space, or slipping past them, may be forced out through the skin altogether, and thus become com- pound. One peculiarity of the injury, when compound, ie that the protruding diaphysis is always stripped of its periosteum, which is turned back like a stocking on a foot. I have premised thus far that we may be able to see dearly what has happened in the case of this young fellow whom I acci- dentally stumbled upon a couple of years ago in my last practice. When seven years old, he was standing on one foot, with the other resting on the hub of a waggon wheel ; a pile of lumber behind him fell forward and struck the standing limb just below the knee, driving the lower part of the leg violently forward, and letting the lower part of the femur impinge on and perforate the popliteal space, through which the bone protruded for about three and a half inches, letting the boy down as it were. The two nearest medical men were at once summoned, and diagnosed compound dislocation backward of the femur, not noticing the absence of the condyloid cartilage on the protruding bone. Two • of. BriohNn'i and HoIntM' " Syitcm of Sargtrjr." 8 different attempts, under chloroform, were made at redaotioh, bttt neither successful, so amputation above the knee was advised. To this the boy's father strongly objected, and failing this they sawed off what they could not reduce (about an inch and a half), tucked in the remainder, and left the case in disgust at the ob- duracy of the father. It was hot weather and before the days of modern antisepticism, so that the neglected wound soon became septic. The father (an intelligent French- Canadian blacksmith) (hen took the case in hand, and henceforward was the only sur- geon employed. He killed the maggots by pouring whiskey into the wound, improvised a sole-leather back-splint, and in four weeks the lad was propelling himself around the garden, and in two months was walking, at first stiffly, but as time went on he got the perfectly good knee-joint, which he now presents. The injured limb is shorter than the other by exactly the amount of bone removed thirteen years ago (l^ inches), but in every other respect is as strong as its fellow, and he is able to do any kind of work. The specimen of bone is not quite perfect, owing to the father having singed it at his forge ** to burn off the stink," but anyone can see it is the lower end of a femur. The above history (which I took pains to verify by the doctors who attended) puzzled me not a little ; and I exhibited the case to several of the medical men here a couple of years ago, when Dr. Shepherd suggested the explanation of what had occurred as a compound separation of the lower epiphysis of the femur. In the Nevf York Medical Record for Jan. 3rd last (1891) a case is reported by Dr. John H. wings almost identical with this one, and the treatment and result tally so well that I will ask your forbearance to quote ic in a condensed form. *• On Aug. 29th, 1890, was called to see a ten-year-old girl whose left leg had been caught in a waggon wheel and fractured at the knee. A careful examination under an anaesthetic showed that the condyloid epiphysis had been separated from the dia- physis, and that the shaft of the femur had lacerated the soft parts and was protruding through the skin over the popliteal space fully five inches. Amputation was advised, but owing to absence of the father, the strenuous objections of the mother, and 4 4 tendency to coUapise on the part of the patient herself^ we deemed it best to attempt reduction. We did so, but much to our gurprise, we utterly failed to reduce the protruding shaft of the femur. Dr. Minshall and I called Dr. Douglass to our aid, and we made another attempt at reduction, but with no better result. As the patient now began to show signs of suffering from the continued anmsthetic (one hour), I advised amputation of the protruding end of bone to facilitate reduction, and my cou" frdres concurring, I removed three-quarters of an inch, which allowed us easily to reduce the remainder. Beyond the impossibility of reduction, I had other reasons for the course I pursued, viz. (1), the danger of pinching some im- portant vessel or nerve between the diaphysis and epiphysis ; (2) the probability of necrosis following the denudation of peri- osteum ; (8) the greater probability of bony union between the fragments if the smooth end were sawed off. The wound was then thoroughly douched out with bichloride solution, and the external wound closed by tan silk sutures. Iodoform was dusted over the parts, antiseptic dressings applied, and the limb left in a flexed condition at both hip and knee. The only antipyretic ordered was quin. sulph. gr. i, 4t& hor&. Next day we put up the leg on Smith's anterior wire splint, and suspended the limb from the ceiling. The temperature was then 101^^, but gradually subsided to normal on Sept. 8rd, patient having suffered very little in the meantime. But next day (prob- ably owing to want of drainage) temperature went up a little, and wound showed signs of sloughing. We removed sutures and gave vent to some bloody serum, and by Sept. 8th temperature was normal again, and we removed all sutures and held the edges together by adhesive strips. The wound then healed rapidly, and on Oct. 25th I removed the splint and found no articular effusion and some motion. Put leg up again on anterior copper splint and starch bandage, and left it until Nov. 14th, when I substituted a short knee splint, and found more motion and evidently good bony union. Ordered patient up on crutohes, and from that on her improvement was rapid. On Deo. 1st she walked with only a slight limp, had a good moveable knee-joint, with one inch shortening of the affected leg." I \ I An exhaustive article on this same subject, by Dr. Packard of Philadelphia, appeared some time ago in the AnnaU of Gynn- eology and Poedriatic% (vol. iv, p. Ill), and to this I am indebted for many references ; though, as Dr. Packard says, many of the cases have been so carelessly reported as to leave room for doubt whether they were not simple supra- condyloid fractures instead of simple diastases : regarding the compound cases there is no room for doubt. Dr. Packard at the same time relates a com< pound case of his own where amputation was necessary, and figures the specimen removed, with the gastrocnemius, as wo have seen, attached to and tilting the epiphysis, and the bare diaphysis sticking out. I mention this particularly, because Mr. Mayo Robson,* in an article on this same subject in which he cites several cases and gives drawings of specimens in Guy*s Hospital museum, makes the strange statement that the gastro- cnemius is attached to the diaphysis, and that it is the muscles of the calf instead of the muscles of the thigh which prevent reduction. Accordingly, in his remarks on treatment, he logi- cally enough recommends tenotomy of the tendo-Achillis to assist reduction, which he practically regards as impossible in com- pound cases, and his conclusion is that amputation above the knee is the correct surgical procedure in these cases. An analysis of the seventy (70) odd cases I have managed to dismter from medical journals, with a view to determining the kind of violence most likely to produce this form of injury, give :; the following facts : Entanglement of the liiob in a moving wheel (as of a carriage), 33 oases ; a fall while running, 3 cases ; one case of a fall from eighty feet ; body thrown forwards while leg was in a hole up to knee, 2 cases ; one case while boy was play- ing leap-frog, and alighted with feet widely separated ; direct blow to lower part of limb (as in this case), 4 cases ; run over by vehicles, 4 cases ; and finally, as result of surgical procedures for correction of anchylosis or deformities, five oases. In 33 of the oases the compound character of the lesion is men- tioned. « AnnalBofSurBery. Feb. 1889. QuoUd by Dr. Shepherd, in Montreal Medioal Journal, vol. xviii, p. 188. 6 In oonclusion, I think we are jastified in drawing the following deductions regarding the proper treatment of this form of injury : 1. In all oases, simple as well as compound, there is danger to the popliteal vessels, and the first thing to be done is to ascer- tain their condition. If ruptured, or in any way irreparably damaged by pressure of the diaphysis, our plain duty is to ampu- tate, and thufl prevent gangrene. 2. But if we have reason to think the popliteal vessels are functionally intact, we should, in simple cases, reduce the injury by traction (and possibly tenotomy of the tendo-Achiliis), and then put up the leg in plaster or on a Mclntyre splint, with the knee semiflexed. 8. In compound cases, we should first try reduction of the protruding fragment. For my own part, I cannot see why every attempt to do this has hitherto tailed. But failing this, I think these cases we have would justify the surgeon in cutting off what he could not reduce, and then put the leg up in plaster, with a window through which to dress the wound. I do not think we can any longer justify the classical treatment of amputation above the knee, at least as a first resort, for I am sure you will agree with me that the result before you to-day, even though not pre- meditated, is infinitely better for the patient than a wooden log would be. Subjoined is a list of references to the literature of this sub- ject, so far as I have been able to investigate it : Fontenelle, Archives Q-4n4rale9y etc., Oct. 1825. G. Bell, " Observations on Injuries of the Spine and Thigh- ^ne." London, 1826, p. 42. R. Alcock, Medico- Ghirurgical Transactions, 1840, p. 311 Listen, *' Elements of Surgery," London, 1840. C. Hawkins, Lancet^ May 7th, 1842! White, Ihid. James, Ibid. R. Adams, Todd's Cyclopaedia of Anatomy and Physiology ; art. "■ Knee-joint," vol. iii, p. 69. London, 1839-47. Quain, Lancet^ March 11th, 1848. Jarjavaiy, " Traite d'Anatomie Ghirurgicale," 1852, tome i, p. 70. (^ n Xr^lat, Arehivea G4n4rale%^ etc., July, 1854 ; also, Ze Pro- gr4» M4diealey Aug. 21st, 1875. Canton, Lancet, Aug. 28th, 1858 ; also. Trans, of Pathologi- cal Society of London, 1860. Hilton, Med. Times and Gazette, Feb. 12th, 1859. Holmes, Trans, of Pathological Society of London, 1862 (two cases) ; also, ^* Surgical Treatment of the Diseases of Infancy and Childhood," System of Surgery, vol. i. London, 1868. Hutchinson, Trans, of Pathological Society of London, 1 862 ; also, i6ii, 1864. Little, N. Y. Journal of Medicine^ Nov. 1865 ; also, ** Illus- trated Medicine and Surgery." New York, 1862. Bryant, Manual of the Practice of Surgery, second Am. ed., p. 804. Voss, N. Y. Journal of Medicine, Nov. 1865. Buck, Ibid. Volkminn, Vtrchoto^s Jahresbericht, 1860, Bd. ii, p. 337. Gay, Lancet, Oct. 12th, 1867. Rougon (reported by Dolbeau), Bull, de la Soci^tS de Ohir- urgie, 1867, p. 120. Hey, British Medical Journal, Dec. 4th, 1869. Wheelhouse, Ihid. Ibid, 1885, vol. i, p. 475. Maunder, Lancet, Feb. 5th, 1870. Leisrink, Archiv. fur Klin. Ghirurgie, 1872, p. 436. Chauvel (quoted by Spillmann). Diet. Encydop^dique, art. " Cuisse," 1872. Callender, St. Bartholomew's Hospital Reports, 1873. Tapret and Chenet, Bull, de la SodStS Anatomique, Jan. 8th, 1875. . St. Thomas' Hospital Reports (statistical table), 1875. Marcano, Bull, de la SociSti Anatomique, 3i'd series, tome x, 1875, p. 228. Richet, U Union M6dicale, March 16th, 1876. Sheppard, St. Thomas' Hospital Reports, 1877. Simon, Ihid (quoted by Sheppard). Smallwood, *' Hamilton on Fractures and Dislocations," 1877. Reeve, Cincinnati Lancet and Clinic, Nov. 16th, 1878. Allis, Trans, of Pathol. Society of Philadelphia, 1878, p. 7. • \ Targis, BvU. de la SoeiSU de Chirurgie, 1878, p. 787. Holthouse, Holmes' ** System of Surgery," vol. i, 1880. Menard, RSvue de Ohirurgiey 1881, p. 738. Davison, Oross* " System of Surgery," 1882. Shepherd, Montreal Med. Journal^ yo\. xviii, p. 198. Pusey, Brit. Med. Journal^ Oct. 2l8t, 1882. Bruns, ArehivfUr Klinieehe Uhirurgie, 1882, p. 254. Delore, Ibid (quoted in Bruns' tables). MoBuroey (quoted by Little), *'• Illustrated Medicine and Surgery," 1882. Halderman, New York Med. Record, June 3rd, 1882. Atkinson, Brit. Med. Journal., July 14th, 1883. Robson, Liverpool Medico- Ckirurgieal Journal, July* 1883. Black, Ihid (quoted by Robson). Rathbun^ St. Louis Courier of Medicine, March, 1884. Verneuil, M&moireB de Chirurgie, tome iii, 1884, p. 400. Broca, Bull, de la SodStS Anatomique, 4th series, 5, tome ix, 1884, p. 407. N.Y. Med. Record, Jan. SrA, 1S91. Winslow, Maryland Med. Jourual, June 21st, 1884. Bryant (reported by Rhys), Br. Med. Jour.,Ma.y Slst, 1884. Bryant (reported by Walker), Ibid. Wheelhouse, Ibid, May 24th, 1884. McGill, Ibid. Delens, Archives GSnSrales, etc, March and April, 1884. 'Bxwdi, Bull, de la SociStS Anatomique, 4th series, tome x, 1886, p. 228. Reverdin, RSvue de la Suisse Romande, May 16th, 1886. Hutchinson, lllustratious of Clinical Surgery, vol. ii, 1888. Annals of Q-ynceeology and Poediatrics, vol. iv, p. 111. J. M. Elder, case given above. X