COMMINUTED FRACTURE OF LEG-GANGRENEAMPUTATION-RECOVERY.

W. M. POWELL, M. D., ALBANY.

A. A. C., aged thirty-six, tuberculous diathesis, of dissipated habits, while in a high state of intoxication got into a difficulty and was knocked down by his antagonist, simply falling backwards on the level sidewalk, sustaining a comminuted fracture of the leg, the tibia being broken about the point of lower third, and the fibula in the middle third. The accident occurring within a few steps of my office, I saw the case within a minute or so afterwards. The foot and leg below injury being partially flexed upon itself, backward and outward, I at once took hold of the foot and pulled the limb in position, while the patient yet lay on the sidewalk, and then had him carried to my office and placed upon a lounge, and a hack ordered to carry him home as he thus lay on the lounge.

I had no particular trouble in setting the fracture and applying a temporary dressing till morning, when I returned, and found him duly sober and conscious of the fact that he had received a very severe injury. Cn removing the temporary dressing, I found the part seemingly in perfect apposition and in good shape, so I proceeded at once to apply the silicate of soda dressing, which was done symmetrically, and with ease and comfort to the patient. On the second or third day, the limb began to swell, and gave the patient great pain, so I cut away my permanent dressing, find

ing an ecchymotic spot, about the size of a grain of corn, at the point where the sharp end of the lower segment of the tibia came so nearly penetrating through the skin, and the posterior aspect of the leg red, and considerably swollen. A very intense inflammation set up in the leg, which could not be controlled, and resulted in gangrene.

I called my friend, Dr. S. H. Stout, of Cisco, in consultation, and at his suggestion made deep and free incisions in the soft parts, letting out a considerable amount of sanious pus. A dry antiseptic dressing was then applied, and the leg suspended from the ceiling, in a fracture box, but to no purpose, for the ravages of gangrenous inflammation kept up unabated, and in thirteen. days from receipt of injury, assisted by Drs. Stout and Moody, I amputated above the knee joint, by the circular flap method, and the patient stood the operation very well, except some bad effect from the chloroform, due to organic lesion of the heart.

After the operation, Dr. Stout and myself dissected the limb and removed the bones, which I show you, that you may get some idea of the extent of injury done to the soft parts. I saw the difficulty myself, from across the street, and the man being so very drunk, made two efforts to get up and stand on his feet, not realizing the fact that his leg was broken. The post mortem examination revealed the fact that the muscles and tissue were badly lacerated, evidently from this attempt to stand on foot, and this evidently was the cause of this active inflammatory process.

The longer piece of the two smaller spiculæ, or pieces of the fibula, occupied and was found in an oblique position, the end toward the inner aspect of the leg having torn through the deep fascia and imbedded itself in the tibialis posticus muscles, etc. The smaller piece was also out of place. It will be seen, then, that while the tibia was easily set, it was possible for the fragments of the fibula to remain as they were found after the operation. Hence, we have but two conclusions to arrive at: One is, that it came so nearly being a compound comminuted fracture that sloughing very soon took place at the point above mentioned, where the sharp point of the tibia was so nearly thrust through the integument, that air was admitted sufficient to augment the tendency to gangrene, together with position of fragments of fibula. The other is, the condition of the patient's system, since he drank an inordinate quantity of beer, thus rendering the soft parts more liable to this quick morbid inflammatory condition, by reason of these internal injuries. After considering the relation the fibula bears to the tibia, its muscular attachments, its posi

tion normally, it was scarcely possible to coaptate the fragments of this bone, while it was easy to set the larger bones; and viewing it from this standpoint, union would have been impossible, and if gangrene had not set up, resection would have been the ultimate operation, which in all probability would have been impracticable, because of the seat of fracture of this bone and the extent of it.

I either employ the plaster paris, starch bandage or silicate of soda in dressing fractures of this kind, but prefer the latter, because it dries nearly as quickly as the plaster paris, and is not so cumbersome and heavy.

To myself, at least, this is an interesting case, because of such an extensive injury to the hard parts from a simple fall backwards on a level floor. Several physicians who were in the late war have seen these bones, and say they never saw any worse fracture from gun shot wounds. I am indebted to Dr. Stout for the method in dressing wounds, such as was employed on this stump. I have performed several minor operations since this, and employed this dressing with the very best results.

Mrs. R., native of North Carolina, while pruning in her husband's vineyard, suddenly experienced a sharp pain in her left breast, and, on examining, found a tumor, as large as a partridge egg, imbedded in the mammary gland.

The severe pain continued several hours. After the pain subsided, there were no symptoms pointing to trouble in the breast for several months. Patient moved to Texas about three years ago, soon after which the small tumor began to grow and continued to enlarge till the whole breast seemed made up of a number of hard tumors. The breast continued to grow till it was three times as large as the sound breast, which necessitated her to wear a suspensory bandage to support it.

about five years

At this time an and very soon a

There was no ulceration until August, 1889, from the first appearance of the small tumor. abrasion, not large, appeared near the nipple, fungus growth as large as an ordinary sized fist protruded and began to discharge a thin, very offensive pus. The lymphatic glands in neck and axilla seemed to be normal, but the patient stated that the axillary glands were a little swollen at one time. The skin of the breast was infiltrated over two-thirds of its extent.