454

A NEW TREATMENT OF COLLES’S FRACTURE.

IT might be thought that the last word had beensaid on the most common of all fractures, whichhas been discussed times out of number since itwas first described a century ago by Abraham Colles.In the Boston Medical and Surgical Journal ofDec. 4th, 1919, Dr. F. J. Cotton, a leading Americanauthority on fraotures, gives a new pathology andtreatment for this injury. He finds that the badresults often obtained are due to failure torecognise and deal with the backward tilting ofthe distal fragment. As long as this persistsproper reduction of the ulna is impossible, andit is to ulnar luxation rather than to thefracture itself that he ascribes the resultingdisability. When the wrist is broken the radiusgives way, but the whole damage, according to Dr.Cotton, is best expressed as a rotation backward ofthe hand about the ulnar head as a fixed point,which tears the ulnar ligaments loose and alsobreaks the radius. The hand is displaced, with theradial fragment, upwards and backwards, to a

varying degree, always with tilting backwards ofthe lower fragment. After long experience of theaccepted manipulations to correct the displacement,it occurred to Dr. Cotton to reverse the mechanismof production. As the ulna is the fixed point aboutwhich the hand is displaced, he makes it the fixedpoint about which he reduces. As the hand is

displaced in extension, he reduces it in flexion. Asit is displaced in a rotation of supination about theulnar head, he reduces it in pronation. The oldermethods of reduction aimed almost entirely atcarrying forward of the lower fragment on theupper. For this they are good, and are still usedby Dr. Cotton. The new method is, after correct-ing the obvious displacement of the radius, tocarry the hand about the ulnar head as a

fixed point into pronation and flexion. This isquite simple. With the hand a little extended,traction and a rocking movement are made so

as to free the displaced radial fragment and thedislocated ulna., Then, with the thumb under theulna, making it a fixed fulcrum, the hand is draggeddown into flexion and pronation, traction beingmaintained at the same time. The finishing move-ment is a twist of the whole hand about the ulna.The whole may be done as one twisting sweep,rarely needing repetition. For retention the ordinarysplints are often inefficient if a first-rate result isdesired. Muscle tone holds the fragments againstre-displacement in toto, but not against tiltingbackwards of the lower fragment, especially as thereis often much crushed and missing bone at the backedge of the fracture, thus leaving a gap. Tiltingcan be prevented only by maintaining flexion ; thisis best done by plaster, preferably applied as

strip splints of eight to ten layers of plaster-of-Paris bandage, one on the back from elbow to

knuckles, one in front from upper forearm to palm.These are held with a few turns of plaster-of-Paris bandage. The same thing may be done lessefficiently with splints provided with an exaggeratedpad on the back of the hand and front of the fore-arm. While the wrist is in flexion the posteriorligaments prevent the radial fragment.from tiltingbackwards, and so long as the ulna is held to theback of the flexed wrist the ligaments can heal tonear their normal length. This is important, fortheir laxity means weakness and often permitssubluxation of the ulna with each supination-a common factor in disability. Dr. Cotton finds

that this slipping ulna is always undiagnosed.The flexion position need not be maintained morethan a fortnight, but if plaster is used it is wiseto slit it along one side and keep a careful watch,as the position impedes the circulation. Indeed, thechance of this trouble has prevented Dr. Cottonfrom publishing the method, long as he has usedit. After the flexed position is abandoned, straightsplints with the pads described above are used for athird week-never longer except for special reasons.Then a supporting strap of adhesive plaster with apad in front of the ulna (the ligaments are the lastto heal) is worn and changed every three to fivedays until the hand is strong. Dr. Cotton findsthat the hand recovers function more quickly afterflexed fixation than after straight splints, thoughhe does not know why.

THE RONTGEN SOCIETY AND RADIOGRAPHIC

RESEARCH.

THE exhibition organised by the Rontgen Society,and held at the rooms of the Rcyal PhotographicSociety last month (THE LANCET, Jan. 31st), waslargely due to the initiative and organising abilityof Dr. George Rodman, a past president of theRontgen Society. At this exhibition an oppor-tunity was given to become acquainted with theenormous strides made during 25 years in everybranch of radiographic work. It was, however,an exhibition of finished prints ; and only theinstructed imagination could picture the corre-

sponding development in the whole technique ofradiography, in the intermediate stages, includingthe introduction of machinery for the productionof high-tension current, the improvements in theX ray tube, the skill and ingenuity of the physicistand of the technical expert. We should like tosee a further exhibition showing side by sidethe first apparatus used in radiography in 1896and an up-to-date model of the present day. The

Rontgen Society possesses a collection of X raytubes illustrating all the steps in the develop-ment of this all-important factor in radiography,but so far no effort has been made to provide adisplay of these improvements in apparatus. The

past 25 years have been productive, and it is

plausible to suggest that the greatest discoverieshave already been made, and that future work willbe rather in the nature of improvements in existingapparatus and methods. But since the discoveryof X rays paved the way for the no less importantdiscovery of radio-activity, other discoveries mayrevolutionise our present methods. The tendencyof the time is to produce more energy by increasingthe size and output of the generating apparatus, andthe discovery of a simpler method of producingX rays might do away with the bulky apparatusat present in use. Coordination and researchare still needed in all branches of radio-graphy. The application of X rays to indus-trial problems is likely to become general.The exhibition at the Royal Photographic Societywill have served useful purpose if it directs theattention of the public to the need for furtherinvestigation and for the whole-hearted support ofthe efforts of medical men and scientists in thisdirection. An appeal will shortly be issued forfunds to establish a memorial to the late Sir JamesMcKenzie Davidson, and a suitable form for this totake would be the foundation of a RadiologicalInstitute for teaching and research. Attached tothe institute should be a historical museum

455

containing collections of apparatus, tubes, and prints,demonstrating the early work and subsequentadvances, and the contents of the museum shouldbe constantly kept up to date. Such an institutewould become a centre for the coordination ofthe developments in all branches of radiography-medical, industrial, and scientific.

BLOOD-PRESSURE OBSERVATIONS IN SURGICALOPERATIONS.

THE first Bulletin of a National AnaesthesiaResearch Society in U.S.A. deals with the import-ance of blood pressure observations before andduring surgical operation. The systolic anddiastolic pressures are taken by the auditorymethod, using the armlet and snugly binding thestethoscope below it with elastic webbing. Ptead-

ings can then be taken without disturbing sterilesheets or the continuity of anaesthesia. If thediastolic pressure is between 25 and 75 per cent. ofthe systolic a case is probably operable, if outsidethese limits probably inoperable. During operationa 10 to 15 per cent. increase in pulse-rate withoutchange of pressure, or 10 to 15 per cent. decrease inblood pressure without change in pulse-rate, issafe. A 15 to 25 per cent. increase in pulse-rate,with 15 to 25 per cent. decrease in bloodpressure, is dangerous. A progressively increasingpulse-rate above 100, with systolic pressurefalling to 80 or less, and a pulse pressure(difference between systolic and diastolic pres-sures) of 20 or less, lasting more than 20 minuteswill be fatal. The condition of shock so

denoted results in a vicious circle, the lowblood pressure and stagnation of blood now

occasioning increasing failure of heart and brain.The anesthetist must avoid over-dosing the patientin an effort to please the surgeon, who may bedemanding a flabby musculature. Relaxationextends to the non-striated muscle, and shockresults from hypostatic congestion of blood in thegenerally relaxed capillaries and veins of the body.citrous oxide and oxygen anaesthesia is the best

preservative against shock ; it does not relax ’,muscle.

-- IBLIND MASSEURS.

THE Association of Certificated Blind Masseurs,registered last July, is now licensed under theBoard of Trade. The objects of the Association,over which Sir Arthur Pearson presides, are :-To promote the welfare and protect and advance the

interests of all certificated and qualified masseurs andmasseuses who are too blind to perform work for whicheyesight is essential.To assist and secure the recognition and status of

such blind masseurs as aforesaid in and for the purposesof their work.To provide for such blind masseurs any assistance or

advantage calculated to help them to work on terms ofequality with sighted masseurs.To promote cooperation in all matters relating to

massage and physical culture between the blind andsighted persons.To advocate and extend the general use or employ-

ment of massage and other physical methods or

exercises.

Membership of the Association is conditional on theholding of the certificate of the IncorporatedSociety of Trained Masseuses-the limitation oftitle is now too familiar to need comment-or thatof the late Dr. Fletcher Little, or such other cer-tificate as may be prescribed by the executive

council. The registered office of the Associationis at 224-6-8, Great Portland-street, London, W.l.With the objects of the Association we have the

deepest sympathy ; and it is eminently satisfactorythat care has been taken to provide adequatetraining for all its members. Far the best way toassist the blind is to render them capable ofperforming useful and remunerative work, andSir Arthur Pearson’s efforts in this direction havebeen most successful. There is much to be saidfor choosing massage as a profession for the blind,though, alas, even here, the blind cannot enjoy alladvantages possessed by their unafflicted fellow-workers. Many patients require remedial exercisesand re-education as well as massage, and then theblind administrator is handicapped. Unless thelimitation is recognised, the blind administratorwill be tempted to mete out to patients inferiortreatment. Teachers of massage will do well tomake this clear to their blind pupils.

SEX DISPROPORTION.

Ix one of a series of lectures on Social Unrest,delivered at the Royal Sanitary Institute on’Feb. 4th, Dr. R. Murray Leslie marshalled in anarresting manner the facts in regard to sex dispro-portion and its consequences. He started by suggest-ing that the numerical preponderance of femalesover males in England and Wales, amounting toa million and a quarter in 1911, had probablyexceeded two millions by the end of the war.The figure is a likely one. Male births, itis true, exceed female births by about 4 percent., but the mortality among infant boys is so

much higher than that among infant girls thateven in 1911 the excess of females per 1000 malesat all ages was represented by a figure of 68 forEngland and Wales, while it was 62 for Scotlandand only 3 for Ireland. Austria, France, and

Germany then occupied an intermediate positionwith 36, 35, and 26 respectively. From these well-established facts Dr. Leslie went on to deduce social,economic, and national consequences of a momentousnature, associating with the disproportion of thesexes some, at least, of the assumed increase insexual immorality, the falling off of religious observ-ance, and the decline of the birth-rate in certainelements of the population. He concluded with aclassification of women into types, and a suggestionthat in racial questions women may become thedominant sex. We agree with Dr. Leslie that hisclassification may be held by women themselves tobe presumptuous, and we distrust the value of theattempts, now so often made, to place men or

women into categories in accordance with whatare called " types." ____

COCCIDIOIDAL GRANULOMA.

Coccidioidal granuloma, of which Dr. WilliamB. Bowman,l of Los Angeles, recently reportedfive cases with the X ray findings to the AmericanRoentgen Ray Society, is an acute, subacute, orchronic disease due to infection by a parasiticorganism known as the Oidium cocciclioides. It issometimes called the Californian disease, as with butthree exceptions all the reported cases have lived inor visited that State before contracting the disease,a large percentage of them coming from one

district-namely, the San Joaquin Valley. TheOidium coccidioides, which is a spherical body

1 The American Journal of Roentgenology, November, 1919.