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to use the foot within the limits of pain from the second day. The plaster may need to be renewed as the swelling recedes.
3. In the severe form, where there is extensive rupture of the ligaments, much contusion, and extravasation of blood into and about the joint, the treatment is the same as just described for forty-eight hours, but the limb had better be placed on a splint. The splint is removed daily and a warm bath given with massage and gentle passive motion by the medical man, care being taken that the ruptured ligaments are kept in apposition, as in a sprain about the external malleolus the foot is kept slightly everted.
This procedure is followed until the swelling has receded to a great extent, which may take from one to two and a half weeks. Then the adhesive plaster-dressing is applied, reinforced by one or two long strips like a stirrup, extending from below the knee on the inner side of the leg beneath the heel, over the outer malleolus, and finishing near the head of the fibula.
The patient is urged to use his foot some every day within the limits of pain. The plaster may be renewed as the swelling recedes ---and the last dressing is generally allowed to remain until it loosens and comes off itself. Recovery is complete in five or six weeks.
The advantages claimed for this plan of treatment are: Early use of the foot, and consequent saving of the patient's time. Relief from pain and assurance of security, for the applied plaster furnishes support to the injured ligaments just where it is needed. Early disappearance of swelling, for the use of the foot and pressure of the dressing supplies the place of massage and passive motion. The ligaments are held in accurate apposition, and so secure and proper healing is assured.
Dr. F. X. G. Starr said the reader is to be congratulated first upon the choice of subject, and, second, upon the manner in which he dealt with it.
Many years ago the speaker used a large amount of wool tightly bandaged for 24 hours, and then applied what is now called the Gibney adhesive plaster dressing. The great thing is to avoid too prolonged rest, and the next most important point is to avoid the possibility of flat-foot following.
The chronic untreated cases may give more trouble, but may be helped materially by the use of the hot air bath, followed by massave and subsequently by strapping.
DR. G. E. ARMSTRONG (Montreal), expressed his appreciation of
the thorough and carefully prepared paper. The treatment of these cases depended, first, upon a careful diagnosis. If only a strain of tendons and ligaments, rest for a few hours or days, according to the severity of the lesion. The application of ice inhibited swelling and effusion into the joint by lessening the blood supply through stimulation of the vaso-motor nerves. Later on heat applied locally promotes the removal of the swelling and effusion by dilating the blood and lymph vessels.
Another valuable aid is fixation in the normal position during the acute stage.
Of the value of strapping as practised by Dr. Gibney and Mr. Carter, it is of very great value. The strips should be so applied as to support the strained and injured tissues. In one case they should be applied on the inner side and in another on the outer side.
The removal of fluid from the joints, which has resisted other methods, by aspiration is desirable. The patient should use the joint as early as he can do so without pain.
Dr. Thos. HUGH BALFE (Hamilton). In cases of sprains of ankle, it is always important to have complete rest and ice locally for the first 24 hours and firm bandaging, preferably by elastic bandage. It is also well to start passive motion early, with hot bathing, etc., to promote absorption of effusion into joints and to avoid adhesion of joint. I think it is well, if there is much effusion or hemorrhage, to aspirate, or if this is not done, not to allow the patient about too soon, and start early massage.
DR. GIBNEY complimented the reader of the paper on the excellent pathological detail, especially the point he made on the protrusion of a bit of torn ligament into the joint, thus explaining the persistent pain sometimes found.
He called attention to the necessity of conducting the case to an absolute cure, with complete restoration of function.
He took issue with one of the speakers on the statement he made about the necessity for rest for a week or ten days, believing that such a plan would result in impairment of function.
He called attention to the importance of an X-ray as a valuable aid to diagnosis, claiming that if a fracture or dislocation were thus eliminated in the diagnosis, that mild, medium and severe sprains were all amenable alike to the strapping treatment.
LATERAL SINUS THROMBOSIS AND CEREBELLAR ABSCESS.*
BY J. P. MORTON, M.D., HAMILTON, ONT.
Our purpose is to compare two cases one of lateral sinus thrombosis with one of cerebellar abscess.
These cases were under our care at the same time and offered us opportunities for contrast. We found it difficult to steer ourselves through them without mistakes.
The lateral sinus case was in a man of 45 years, who had suffered from right chronic otorrhoea for three years. He was well nourished, of decidedly lymphatic temperament, and was a very heavy drinker.
When we saw him first he was in bed with a T. of 101 degrees and P. 110. He was not complaining much, and his wife thought he was much worse than he pretended to be. He seemed dull, but had been out on a spree for two or three days before. He looked very sick to us and was perspiring heavily. There were no pupillary disturbances. He was constipated, with furred and coated tongue. Slight tenderness was present over mastoid very high up. There was no sagging of walls, and a perforation through Shrapnell's membrane seemed to be plugged with dried matter.
We immediately enlarged this opening down as far as meatal floor and curetted the middle ear and otic, which seemed filled with cholesteatomatous substance, and there seemed to be very little free matter. During the next three days he was much better, T. being 99.5, the ear-ache and tenderness over mastoid disappeared. We used ice over mastoid. On fifth day his temperature rose to 101 and he was perspiring profusely. Mastoid tenderness was very difficult to elicit. He seemed drowsy, although in this connection you must remember his natural apathetic condition and his alcoholic condition. He answered intelligently, but slowly. We sent him to the hospital and watched him for two days. Perspiration continued to be profuse; his temperature went to 103.5 on second day in hospital. IIe seemed to be duller mentally. There was twitching of facial muscles. No pupillary disturbance and fundus normal. No tenderness in neck over internal jugular vein. There was now profuse discharge from middle ear, but if there had been tenderness over mastoid he now would admit of no more on the
* Read at annual meeting of Ontario Medical Association at Hamilton.
right than on the left. This was very disconcerting, and the diag. nosis was between intercranial abscess and lateral sinus trouble. Operation revealed a very much sclerosed mastoid, a middle ear and antrum with well-formed cholesteatomous formation.
On uncovering the sinus, we found a discolored dura, no pulsation of vein, the walls were not smooth or yielding to touch. An incision 1-4 inch long brought no bleeding, and instead pus was found in sinus and behind it. We extended the incision to 1 inch in length, and by means of a blunt curette endeavored to secure bleeding from above and below. We were successful at the torcular end, but the bulbar end, which we would rather have had bleed, remained closed. We now proceeded to excise the jugular from clavicle to above the entrance of facial vein, but our anaesthetist informed us that the patient was in very bad condition and asked to be allowed to stop anaesthetic.
Temperature remained normal for two days and mental condition was improved. On third day after operation T. rose to 112 degrees, with profuse perspiration. The nurse said she had never seen such sweating." In evening T. dropped to 99. This seemed to indicate severe systemic infection from internal jugular, and was shown even more distinctly on sixth day, as T. went to 105 in morning and dropped to 97 at night. We advised removal of internal jugular very persistently, but one of us as a consultant advised against this, and so it was not done. During the next week the patient was very sick. The ear was dressed each day; no syringing was done. The T. dropped to 96 and 97, and this seemed to predominate, but now and again it would rise to 104, 105, and once to 106. He lay on his left side and would not turn to right. Cerebration was very slow, and often he would never answer. He seemed to be very deaf. No aphasia. Pupil on right was dilated slightly, and they both reacted very sluggishly to light and accommodation. He felt dizzy. There was marked twitching of facial muscles, with ptosis of right side. Fundus was normal. ,
The muscle power seemed normal. Slight nystagmus was present when he looked to left side. Urine normal, and blood count showed leucocytosis.
We were pretty sure the patient was going to die. We warmly discussed the probability of brain abscess, and one of us advised exploring for cerebellar abscess. Weight of opinion was against this, chiefly for three reasons:
1. The lateral sinus condition was known to be so bad that it would account for the condition without supposing the other.
2. Absence of optic nerve trouble.
3. The T. did not remain subnormal, but rose every now and again to as high as 106. This was a very important deciding point.
4. Indefiniteness of what cerebellar or cerebral symptoms there were. Nystagmus was only found on having patient look to left for quite a while, and might be due to exhaustion. Slight pupil dilation might be due to his always lying to left side; I have read that this occurs. (In Allbutt, System of Medicine.).
) His alcoholic condition and natural apathy, with the toxine, would easily account for his sluggish pupil reflexes and his dull mental condition and the poor reflexes, knee, elbow, Babinsky, etc. If his T. had stayed subnormal, operation would have been done.
Extra dural abscess was ruled out because of the freedom with which we opened things up at time of operation. The tegmen tympani was removed and no abscess could have been near the sinus without having been opened: in fact, there was an extra dural abscess opened; it lay around the sinus. We were correct in our judgment, for the patient gradually improved, and is drinking as hard as ever to-day.
Permit me to say that, although the internal jugular was not excised in this case, some of us believe that the patient was allowed to run an unjustifiable risk.
Our second case was in a child of fifteen, and when first seen she had a typical right suppurating mastoid. T. was 105 when we operated, showing very extensive bone destruction, as the case had been badly neglected. We uncovered 3-4 inch of lateral sinus and found it normal. The T. was normal for four days after the operation, and then for three days it went to 99, 100, 101. The child seemed to be getting dull, although when its parents came it seemed as bright as ever.
During following week we noticed these points: T. went to normal, with slight variations, and then to subnormal, with slight variation, but it never went above 99. The child always wanted to turn on its left side and keep its right cheek up. If turned in any other position she would immediately turn back, and there seemed to be retraction of the neck muscles, but this was probably due to action of opposing sterno mastoid, the right muscle now having no mastoid attachment. One of us made the diagnosis of meningitis, but this was ruled out on account of T. and mental condition. There was no nystagmus, even in long trials to either side. No pupillary disturbances. No fundus indications. No aphasia. No vomiting, except once on eating some sweets. Severe diarrhoea. Muscles of right arm were weaker than those of left. Leg muscles equal in strength. Cerebration was undoubtedly slow.