744

last fortnight they became so severe that he sought relief atthe hospital. On examination there was some enlargementof veins over the front of the leg, but no oedema of the foot.There was a well-marked pulsating swelling at the back ofthe knee, more in the lower half of the popliteal space thanthe upper ; it was about the size of an orange and causedsome bulging backwards and measured vertically about2g inches. The pulsation in the sac was easily controlledby compressing the femoral, and the swelling was almostobliterated. The pulsation in both tibials was strong andnot appreciably diminished. He could not completelystraighten his leg.On July 23rd I removed the aneurysm. An incision

6 inches long was made in the line of the vessel from theinner side above to the mid line below. There was

practically no matting of tissues ; the sac was limited andwell defined, and the vessel above and below appearedhealthy. It was an ideal case for local treatment, but thepoint debated was should this be complete removal or one ofthe methods of treatment of the sac advocated by Matas.In view of the favourable local conditions expressed before Idecided on excision of the sac. The sac was placed betweenthe heads of the gastrocnemius with the vein a littleadherent to its posterior wall, but it was easily separated.The artery supplying the sac was to the inner side and deepto the vein, but there was an upper additional head of thegastrocnemius between them with a bundle of fibres of thelatter again between the artery and the bone ; it was imme-

diately after passing through this slip that the artery startedto dilate. The artery was ligatured with silk above this extraslip and again 1 inch below the sac. The sac was easilyshelled out from the surrounding tissues, one feeding vesselon its anterior or deep aspect having to be tied. The dilata-tion was a saccular one, and the vessel wall was resilient and

apparently normal. There was no inconvenience from hæmor-rhage nor did the nerves interfere with the removal of the sac.The cut fascia was stitched up with catgut and the woundsutured without drainage. Except for slight serous oozingfrom the lower part of the wound union was by first intentionand general progress was uneventful. Although at first thepulsation in the tibials was lost the foot always kept warmand the pulsation was soon restored.

. The specimen from Case 2 is preserved in thehospital museum, 1706 A, and bears the followingdescription: "A popliteal aneurysm, 1 3/4 inches inlength, with portion of the artery, from one side ofwhich it arises. The clot filling the sac is withoutlamination and of recent formation, and is due tocoagulation occurring within the sac after theligature of the vessel on either side preparatory tothe excision of the aneurysm." It will be agreed, !I think, from the foregoing description that thecase was one most favourable for local treatment.Whether a more conservative operation on thelines laid down by Matas would have been equallysatisfactory must remain undetermined; thefreedom from matting of the sac to surroundingparts certainly warranted the more radical pro-cedure.Upper Wimpole-street, W.

DUSSELDORF ACADEMY OF PRACTICAL MEDI-CINE.—Later in the year the following courses for practicalmedicine will be held at Dusseldorf. 1. A general post-graduate course, together with a course for medical officersto railways and mines (May 4th to 16th). 2. A fortnightlycourse of social medicine, treatment of accidents, andprognosis of invalidity (July 6th to 18th). 3. As in previousyears a course will be given upon the recent advances inpractical surgery and gynæcology, consisting of lectures,operations, and demonstrations, with the cooperation ofhome and foreign surgeons and gynxcologists under thedirection of Geh. Med. Rat Professor Dr. Witzel and Pro-fessor Dr. Pankow (the last week in September). 4. TheMedical Clinic will give this year for the seventh time acourse of pathology, diagnostics, and treatmert of heartand vascular diseases under the direction of Geh. Med. RatProfessor Dr. Hoffmann (Oct. 19th to 27th).

THE "AMBULANT" TREATMENT OF FRAC-TURES WITH PLASTER-OF-PARIS

AND FRACTURE CLAMPS.

BY SANITÄTSRAT PROFESSOR HACKENBRUCH, M.D.,CHIEF SURGEON TO ST. JOSEPH’S HOSPITAL, WIESBADEN.

THE extension treatment of fractures of thelower limbs has the great disadvantage of keepingthe patient in bed for weeks, while the treatmentof these fractures with plaster-of-Paris only hasoften been productive of bad results, and expe-rience has shown that this method has failed to

prevent malposition of the fragments and has ledto a shortening of the limbs. Moreover, plasterbandages immobilise the neighbouring joints andcause stiffness which in many cases is very difficultto cure.In 1893 Eiselsberg, in order to prevent shortening

of the limb, recommended applying a plaster-of-Paris bandage from the foot to the pelvis, thenmaking a circular cut through the bandage at thelevel of the fracture, and extending the fragmentsby iron bands fitted with rubber springs. Thisfracture apparatus of Eiselsberg led Kaefer, in1901, to the construction of his clamp, applied, inthe case of fracture of the leg, to one side of the

circularly divided plaster-of-Paris bandage.As it is of the utmost importance that patients

with fractures of the lower extremities should soonbe able to get up and walk, in 1902 I applied thefracture clamp to both sides of the plaster-of-Parisbandage in case of shortened oblique fractures ofthe leg, thus enabling the patient quickly to obtaina firm and steady tread..As the Kaefer clamps, however, allow the exten-

sion of the fragments in a longitudinal direction onlyand fail to obtain an accurate adaptation in lateraldisplacement, I connected the fastening wings withthe extension bars by means of ball joints (Fig. 1).After the fragments have been drawn apart byturning the extension screws of the clamps, appliedin the above-mentioned way (on both sides of thecircularly divided plaster-of-Paris bandage), thefragments can be adapted most accurately after

loosening the screws of the ball joints, and then theycan be fixed in the desired position till union iscomplete.Experience has shown that the clamps are best

applied as soon as possible after the accident, theextension and adaptation succeeding easily whenthe muscles are still flaccid.

In case of an oblique fracture of the tibia andfibula, combined with displacement of the

fragments, the fracture should be radiographed assoon as possible and the clamps adapted in thefollowing way. The knee of the patient is flexed toa right angle and an elastic stocking placed overthe leg, from the toes up to the knee. Pads con-

sisting of fiat " factis " (pulverised rubber) cushionsare tightly fastened underneath the patella andround the ankles (Fig. 2). Over these is placed (theknee of the patient still being bent to a right angle)a fairly thin plaster-of-Paris mould, from the toes

. right up to the knee, but not covering the latter.

.

As soon as this has hardened the plaster is cut:

right through circularly at the level of the fracture,and then both wings of the clamps are fastened bymeans of plaster-of-Paris bandages (symmetricallyon both sides of the leg, inside and outside) on the

j plaster-of-Paris mould, so that the extension screwsof both clamps are on a level with the circular slit

745

of the plaster dressing (Fig. 3). The clamps nowserve as supporting splints for the circularlydivided plaster-of-Paris dressing. The patient

remains in bed (theknee still kept bentat a right angle).On the followingday, with the leg inthe same position,extension is com-

menced by turningthe extensionscrews, and, underthe nrotection of

the "factis" cushions, it may beproceeded with so energeticallythat after a short time the gapbetween the upper and lower partof the dressing will measure aninch or two.When the Roentgen rays exa-

mination shows the shortening ofthe limb to have been correctedit is necessary to try to bring thelower, and usually outward point-ing, fragments in apposition tothe upper ones and into theirnormal position; this is broughtabout by loosening all four ball-

joints of both clamps, so that thelower part of the plaster-of-Parisdressing (and accordingly the lowerfragments) become movable in alldirections. At the same time anyabnormal rotation of the footshould be corrected. In order todo this great care has to be takenthat the knee part of the plaster-of-Paris dressing is firmly heldin position by an attendant, andas soon as vile lower

part of the plasterdressing has been

brought into thedesired position thefour ball-joints arequickly and tightlyfixed, and the correctposition therebymade permanent.

The fastening wingsconnected to theextension bars, thesegments of whichare numbered, byball-joints.

The pair of clamps, which beforeformed a square, now form a paral-lelogram.

If a further Roentgen examinationproves the fragments to be in theirproper position, the patient may getup and walk about by the aid ofcrutches or sticks, the steel clampsbeing reliable supports. (The exten-sion screws may be suitably fixed byinserting into their holes an elasticsteel spring.) Should, however, theRoentgen rays reveal that the lateraldisplacement of the lower fragmentsis not sufficiently corrected the fourball-joint screws will once more haveto be loosened, the lower fragmentsput in their proper position by greaterpressure, and the screws fixed againfirmly and quickly.in (limcuit cases 1 use a contrivance

consisting of a small round rubber cushion

I("pelotte") and a connecting screw, with a forkattachment. The pelotte is placed against the

sleeve of the clamp, and by turning the screw of thislittle instrument a firm lateral pressure is applied,and the fragment driven in the desired direction.The plaster-of-Paris mould does not cover the

knee so that that joint may be moved, and as thesole part of theplaster soon getssoftened by walk-ing the patientmay then alsomove his ankle-

joint.These clamps

can also be em-

ployed in cases

of fracture of thefemur, of thehumerus, and ofthe bones of theforearm, themode of applica- tion being modi-

fied according tothe site of thefracture.

It may be men-tioned that, as arule, the plaster-of-Paris dressingshould remain in

place about fourweeks, but itshould be re-

newed if there is

any delay in for-mation of callus,but by no means

should it be removed before the fracture hasbecome so thoroughly consolidated that a freshdisplacement is rendered impossible.

, Oblique fracture of tibia and fibula :application of pads.

I In summing up, it may be stated that the clampshave been used with great success innearly all forms of fractures, includingcompound fractures, and they cantherefore be recommended as uni-versal fracture clamps. In manycases they may be further used withgreat advantage for extending andmobilising stiffened joints. If thefracture clamps are applied shortlyafter the accident, in the mannerdescribed above, the pain of the

patient is relatively insignificant,especially since " factis " cushionshave been employed in the treatment,as these mitigate the pressure of theplaster-of-Paris dressing.

I recommend very moderate ex-

tension to begin with, by slowturning of the extension screws;it should go on uniformly and

slowly, stopping at once when the

patient complains of pressure, inthe case of a fracture of the leg,at the knee or foot. It seems thatthe extension causes hardly anypain at the seat of the fracture, andby this cautious way of proceedingone is fairly sure to avoid gangreneeven at those spots where the skinis the only covering of the under-lying bone.

Oblique fracture of tibia andfibula: the clamps in position.

B It is hardly necessary to lay any stress on the

fact that in cases of fracture of the bones of theleg the patient as a rule may get up and walk

746

about in the course of the second week after the

accident, and sometimes even earlier.The appliances are made at the Veifa works,

Frankfort/a/Main, and can be obtained through allsurgical instrument makers.Wiesbaden.

___________________

RECURRENT INTUSSUSCEPTION :

WITH SUGGESTIONS AS TO THE ETIOLOGY.

BY H. TYRRELL GRAY, M.A., M.C. CANTAB.,F.R.C.S. ENG.,

ASSISTANT SURGEON, WEST LONDON HOSPITAL AND HOSPITAL FOR SICKCHILDREN, GREAT ORMOND-STREET; SURGEON, WEST HAM AND

EASTERN GENERAL HOSPITAL, ETC.

IN view of the rarity of recurrent intussusceptionrecently commented upon in THE LANCET, and afterreading the report of Mr. G. Grey Turner’s interest-ing case/ I thought it might be of interest to placeon record the notes of the following case.On May 25th, 1909, a male child, 2 years and 1 month of

age, was brought to hospital with the following history.Two hours previously he had a screaming fit, and half anhour later passed blood and mucus per rectum. The childvomited shortly after arriving at the hospital. A typicalsausage-shaped mass could be felt in the upper abdomen.On two occasions previously this child had been operatedupon for intussusception by another surgeon, and on eachoccasion recovery was uneventful. The details are as

follows. In March, 1908, laparotomy revealed a typicalileo-colic intussusception which was reduced, the abdomenbeing closed in the usual way. The wound healed perfectlyand convalescence was uninterrupted. In October of thesame year the abdomen was again opened, and an intus-susception was found which had started at the caecum.Reduction was effected as on the first occasion, and againrecovery ensued. On this occasion, however, the mobilecseoum was fixed by sutures.

In May, 1909, I opened the abdomen under spinal anass-thesia and reduced the intussusception, which on this, thethird, occasion was enteric in type and was situated somelittle distance from the ileo-cascal valve. Under spinalanaesthesia intestinal peristalsis continues unhampered bythe inhibitory stimulus of the operation, and during theexamination of the intestine an intussusception started, forthe fozrt3 time, in a coil of gut in my hand. Nothingabnormal was discovered in the abdomen which couldaccount for the tendency in this child for intussusception todevelop. Recovery was again uninterrupted, doubtlessowing to the promptness with which the mother, by this timewell acquainted with the symptoms, sought surgical aid.The great interest of this case lies in the fact

that on each occasion the intussusception startedat a different part of the intestine. And this seemsto me to raise again the question as to the etiologyof the condition. In Mr. Grey Turner’s case theintussusception started at the lower end of theileum on each occasion, and he found a definitelesion to account for the tendency to recurrence.In my case no such explanation could be dis-covered ; in fact, the recurrence seemed quiteinexplicable.Presupposing that infants (in whom the mesentery

is exceedingly elastic and pliable), and subjects whohave a congenitally long mesentery, are liable todevelop intussusception, we are still left with thetask of finding an exciting cause. Irregular peri-stalsis has been quoted as a factor; and this may,perhaps, be of some importance in cases where apersistent Meckel’s diverticulum is present to

interrupt normal peristalsis. On other occasionsan inverted diverticulum, acting as a polyp, may beresponsible, as in one of my cases already reported.

2

Such cases, however, are rare.

1 THE LANCET, Dec. 20th, 1913, p. 1785; Jan. 17th, 1914, p. 169.2 Annals of Surgery, 1908.

FitzWilliam has shown, in a statistical review of1000 cases, that diet is certainly the most importantcausative factor in the majority of cases. ’Whereaserrors in diet usually cause enteritis, it is notdifficult to believe that wrong feeding in infancy,not sufficiently gross to set up acute enteritis(inflammation of the mucous membrane), may yetcause chronic inflammation of Peyer’s patches.Finally, a glaring error of diet causes acute con-

gestion and swelling of this lymphoid tissue, whichbulges into the lumen of the gut ; such a swellingwould act in the same way as a polyp, and intestinalperistalsis would tend to drive it along the canalwith the intestinal contents. Where the mesenteryis elastic or unusually long, an intussusceptionwould be likely to result.Such a view is supported, perhaps, by the uniform

presence of a mass of enlarged mesenteric glandsin the neighbourhood when the intussusceptionstarts at the lower end of the ileum. These glandsseem to be enlarged whether the abdomen is

opened soon after the onset no less than whenthere has been considerable delay. Further,glandular enlargement is not a feature to anythinglike the same extent, I think, in enteric intussus-ception. The inference seems to be that theglandular enlargement precedes the intussuscep-tion, and is caused by infection from the Peyer’spatches. The frequency with which intussliseep-tion starts at the lower end of the ileum and thefact that diet is responsible in the majority of casesseem to support the following view. That inflam-mation and swelling of Peyer’s patches (usually theresult of errors of diet) are responsible for the onsetof intussusceptions starting at the lower ileum;but that these factors leave unexplained the originof intussusceptions starting at other situations inthe intestinal tract.

I have recently shown how general infections

may cause intestinal colic ; that both acute andchronic general infections might be responsible; and’in that paper I quoted cases in support of the state-ments made. Without again entering into detailit seems reasonable to suppose that acute generalinfections, which may cause effusions in the skinand subcutaneous tissues and in other regions,may also be responsible for effusions into theintestinal wall. I suggested that such an effusion,by preventing the proper contraction of the intes-tinal muscle in its vicinity, creates an inert aJ’C(t

in the bowel wall. The bowel wall being compara-tively insensitive, there is no pain arising directlyfrom such a lesion; but such an inert area constitutes,as it were, a " foreign body " in the intestinal wall;and this affected piece of bowel tends to be driven

along the canal (with the intestinal contents) in thesame manner as an intestinal polyp or the inflamedPeyer’s patches already referred to. The result isthat d1tring peristalsis the mesentery is dragged onby the efforts to drive along this portion of boweland typical colicky pain results. In acute rheu-matism such an effusion sometimes reaches a sizesufficiently large to rupture the mucous membrane,when haemorrhage from the bowel results; thecondition is then known as " Henoch’s purpura."I have encountered a similar condition in diph-theria. The effort made by the muscular action ofthe intestine to drive along the canal such inert

, areas as I have described will, when anatomicali conditions are propitious, actually invaginate thebowel wall at such a situation and intussusception

. results.

3 Practitioner, January, 1914.