sensitivity of common pathogens to CHLOROMYCETIN

and three other major antibiotic agents

n —_ a < O a a

more effective against more strains...

AEROBACTE

Chloromycetin. for today’s problem pathogens

ceeenaces

Because of the increasing emergence of pathogenic strains resistant to commonly used antibiotics, judicious selection of the most effective agent is essential to successful therapy. In vitro sensitivity studies serve as a valuable guide to the antibiotic most likely to be most effective. Both clinical experience and sensitivity studies indicate the greater antibacterial efficacy of CHLOROMYCETIN (chloramphenicol, Parke-Davis) in the treat- ment of many common infections.

OF 173 STRAINS OF 19 STRAINS

CHLOROMYCETIN is a potent therapeutic agent and, because certain blood dyscrasias have been associated with its administration, it should not be used indiscriminately or for minor infections. Furthermore, as with certain other drugs, adequate blood studies should be made when the patient requires prolonged or intermittent therapy.

a - 4 ANTIBIOTIC A—NONE OF 506 STRAINS , :

ANTIBIOTIC B—17% OF 488 STRAINS

CHLOROMYCETIN-—91

° ' CHLOROMYCETIN—95% ' '

Adapted from Altemeier, W. A.; Culbertson, W. R.; Sherman, R.; Cole, W.; Elstun, W., & Fultz, C. T.: J.A.M.A. 157:305 (Jan. 22) 1955.

DETROIT. MICHIGAN

Volume 38

GENERAL PRACTICE SYMPOSIUM

LABORATORY AIDS

Neurodermatitis Carcinoma in situ of the Uterine Cervix ener Louis A. Brunsting, M.D., Rochester, Minnesota .... 291 David C. Dahlin, M.D., Rochester, Minnesota .......... ¥

Differential Diagnosis of Tumors of the Neck Oliver H. Beahrs, M.D., Rochester, Minnesota ......... 293 CASE REPORTS

Fractures of the Upper Extremity in Children os 0 John C. Ivins, M.D., Rochester, Minnesota ................ 296 Hemobilia Following Blunt Trauma to the Liver sahet

Management of Recent Injuries of the Hand Paul R. Lipscomb, M.D., Rochester, Minnesota ........ 299

Precautions in the Use of Cortisone for Treatment of

Rheumatic Diseases

L. Emmerson Ward, M.D., Rochester, Minnesota ....

H. M. Broker, M.D., and L. J. Hay, M.D., Minne- How I PONS, TIMES O Ay 525.25. Arsensccscdsas tesco cevesecesewecuscsvessthes 1

Association of Intracranial Meningioma with Pituitary 304 Adenoma ce J. Grafton Love, M.D., and Charles M. Blackburn,

Digestive Ailments of Older Patients M.D., Rochester, Minnesota ........:.ccesceeeseseeeesesseeeen ea Albert M. Snell, M.D., Palo Alto, California ............ 309 ax D ation

Management of Acute Abdominal Diseases William H. ReMine, M.D., Rochester, Minnesota .... 315

CLINICAL-PATHOLOGICAL CONFERENCE

Hematuria Case Presentation John L. Emmett, M.D., Rochester, Minnesota .......... 320 A. C. Aufderheide, M.D., Duluth, Minnesota ............ 3

The Technique and Interpretation of the Vaginal atroge Examination Char Edward A. Banner, M.D., Rochester, Minnesota ........ 323 PRESIDENT’S LETTER

The Treatment of Anemia

Charles H. Watkins, M.D., Rochester, Minnesota .... 327

In Appreciation Arnold O: “Swenson; WMD. a. cciisiccccciccescctesicvcssssvcscscecetses j

Owner and Publisher

Published by Minnesota State Medical Association

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Contents. for May, 1955

JTORIALS WOMAN’S AUXILIARY eneral Practice Symposium ...............c:cccccccccessceescceeceeeee 341 International Health Organization, Part I Lsessssees ER BERT SESIEE EROM Cee Rer noe er neuen Te 341 Bes. ED. BP. Walthquist 1..o-.osssesesesssnsssnvscanserieecsneesinoconenes i my Praming in: Alletgy ....2.:...:0..<..s0ss.e0sedsencsesexsceeee 342 Cilarhficld Blois HleaBibe Wey ccosecccocscccsccsccceccoceccsossossee MEE IN EG 2 5525520255, Seen eds cc sales caee Coco Saves dachabecaseen anion 342 Ramsey Auxiliary Reports Activities os of Hearing in Children 200.000.000.000. cccccecceseeeeeeeees 343 a ee ne ee oe ee ee r jabetes Detection Programs. ..................:ccccceccessceeeeeeeeeees 343 Minne- [Mow Long Should One Keep Valuable Papers? ............ 343 mie , , " IN MEMORIAM ituitary Wadia is As Vitae 2205 otek tee ICAL ECONOMICS hubené:-Rowriseme Sheen aiie cc. ctis. ccsnceedicecsceeereen tune: ickburn, fi Pum ~ iemanneas C lala CRAIN 52a nce ceca aines cent reece ieee qgpMA Reviews Legislation Status..................ccccccscsscssssseree S49 ax Deferment Bills Make Slow Progress ......................+ 346 ational Board Notes Exam Requirements .................... 347. OF GENERAL INTEREST NCE TRCUAMMIMEETINO@ WES «<< cace ccs cxcssoxescvasexrosesaceetassaiis eee eas 1 OC JOSS | oS ee ee en ROR Race ete a atone OPE eer oy sr oe pRRENT CARDIAC CONCEPTS Minnesota Blue Shield-Blue Cross Plans ..........:::0c0-000 atrogenic Heart Disease K REVIEW ; sei th. Resse: Wi Sea. tly PO ice asa cra ROSTER—MINNESOTA STATE MEDICAL A 4@PORTS AND ANNOUNCEMENTS ........--:0::-5 349 ASSOCTATION, 1955 «......--:cc-cscsssssserscssscrsrssosesenseeses ains the various types of illustrations listed separately and numbered in the order Editing and Publishing ; hich they appear in the text. All photographs must be in black and white, clear Committee ) East Fi contrasting, and on glossy prints. Instructions for combining photographs are E. M, Hammes, M.D. ers prepalintable. Any number of illustrations over 4 are charged to the author. Combinations Chairman, Saint Paul d of Edita photo h . y ‘ 3 F. M. Owens, Jr., M.D. graphs up to one-half page (6 x 43@ inches) count as 1 illustration. Satae Daal id be typ T. A. Peprarp, M.D. ot a carbd Minneapolis 3 . H U ,» M.D. if eae institun"iters and Reviewers ’ he may | Board of Editors Jame sho he right is reserved to reject material submitted for reading or advertising columns. he Oe ae. views expressed in this journal do not’ necessarily represent those of the Minnesota Editor-in-Chief, Duluth Medical Association or any of its constituents. — W. Arneicer, M.D. hy.” Tht Minneapolis phy. Joun F. Briccs, M.D. rst occur Saint Paul if ti A E. B » M.D. ibers : "‘Rechanat ‘sii ence 10 “Berti ; S. Francis C , M.D. a ae tiers and Subscribers preancis Cuptzcia 3 The st lasified advertising—10 cents a word; minimum charge $2.00; key number, 25c a et rnal this #@tional, Remittance should accompany order. Display advertising rates on request. a B. Howan, M.D. : Jun Minneapolis nal, volul elephone Nestor 2641. Henry G. Moenrinc, M.D. umber, il Duluth nual Subscription—$3.00. Single Copies—$0.40. Foreign and Canadian Subscriptions Guenn J. Mouritsen, M.D. B50, Fergus Falls ‘ be af a. B.A. ely and "ommunicati . + oo gs aint Pau on unications concerning advertising and subscriptions should be addressed to Cine Sites. 60% ions) Wl'KNEsora MepICI

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General Practice Symposium

Neurodermatitis

HE commonest disease of the skin is eczema,

and the commonest form of eczema is neuro- dermatitis, which is merely a word to express the relationship between the nervous system and the skin. Various forms of neurodermatitis occur, such as the exudative form characterized by blis- ters on the fingers or oozing widespread plaques, which may occur in childhood as well as in older persons. The commonest form, however, is the circumscribed thickened plaque called “lichen simplex chronicus.” These plaques, single or multiple, may occur in various places or they may become a diffuse process to the extent of exfolia- tive dermatitis. The patient may be entirely in- capacitated and be miserable day and night be- cause of the outstanding symptom of itching, often paroxysmal in nature; many patients are driven to distraction and almost to suicide.

Lichen simplex chronicus occurs in certain types of persons who may have hay fever, asthma or urticarial tendencies. Thickening of the skin results from scratching. This thickening brings on exudation and nonspecific cellular reaction; the tissues are thus changed so that itching results and a vicious cycle is established.

The most familiar site for the appearance of lichen simplex chronicus is along the lateral sur- face of the thighs, on the shins, about the ankles and on the elbows or knees, where the lesions tesemble those of psoriasis. A peculiar form occurs in the nuchal region of women almost ex- clusively, as well as behind and in the ears; an extremely common form of neurodermatitis, or

Read at the meeting of the Minnesota Academy of eneral Practice, Rochester. Minnesota, October 20, 1954. From the Section of Dermatology, Mayo Clinic and Mayo Foundation.

The Mayo Foundation, Rochester, Minnesota, is a part of the Graduate School of the Universitv of Minnesota.

May, 1955

LOUIS A. BRUNSTING, M.D.

Rochester, Minnesota

lichen simplex chronicus, produces the symptoms of pruritus vulvae or ani.

The presence of neurodermatitis around the ankle always brings up the question of whether or not varices are present. One must distinguish neurodermatitis of the lower portion of the legs from so-called stasis dermatitis. Whenever any disturbance occurs in the lower part of the legs, hydraulic factors come into play, and any time the skin is injured, the circulation becomes stagnant in that region. It is rare to relieve these patients of their symptoms by treatment of varicose veins, although the use of an ace bandage is helpful for two reasons, namely swelling is prevented and the site is covered so that scratching is not possible.

When the disease reaches the proportions of exfoliative neurodermatitis, it is extremely diffi- cult to arrive at a satisfactory diagnosis. The contiguous lymph nodes are invariably enlarged and present an almost irresistible demand for biopsy. Other diagnostic facilities should be utilized first, for in such patients the site from which the specimen has been removed for biopsy frequently becomes infected. The microscopic picture of the nodes is usually one of reticulum cell hyperplasia, plus the presence of pigment and fat. Pathologic diagnoses such as lipomelanoretic- uloendotheliosis may be returned, although the condition is nothing but a scavenger reaction in the lymph nodes as the result of extensive chronic dermatitis. Biopsy of the skin shows a rather nonspecific picture that may be almost impossible to distinguish from that of psoriasis. A patient who has dermatitis of this magnitude is entirely incapacitated. As already indicated, some patients who have this syndrome have had asthma, eczema, hay fever and urticaria off and on since infancy.

291

In not a few of them, opacities in the lenses will develop that are typical of allergic cataracts. Therefore, one test in these patients should be routine screening by slit-lamp examination to detect such changes in early stages. If such lesions are found, serious restrictions are placed on the patient’s activities.

The localized plaque of neurodermatitis may be treated by topical measures. Protective pads, such as an elastoplast cutout, placed over the plaque are sometimes helpful. Tying the hands at night is of aid in some of these conditions, as is any artificial device to break the cycle of the scratching reflex. Systemic measures, such as allergic surveys and dietary restrictions to remove supposedly allergenic foods, are practically worth- less. A mistake is often made in prescribing oint- ments containing a local anesthetic agent, such as dibucaine hydrochloride (nupercaine) or ben- zocaine, for the relief of itching. Sooner or later, sensitivity to these agents develops and the origi- nal condition becomes aggravated and widespread. The same is true in the presence of slight infec- tion, when the prescribing of sensitives, such as nitrofurazone (furacin) is to be condemned. The use of roentgen therapy in moderate doses is helpful; however, excessive amounts of such treatment produce actinodermatitis, which leads to no end of complications.

Dietary control is prescribed for patients who have gained weight; patients who have hyperten- sion should have proper restrictions from the standpoint of their general health. Sometimes in women this condition first appears during the menopausal years; under these conditions, some estrogenic support is helpful. When neuroder- matitis becomes widespread and the patient is extremely unstable, some restrictions should be made on the excessive activity. These people usu- ally are hyperactive and like to improve every shining minute. The typical woman who has neurodermatitis never sweeps anything under the rug. She may be on a committee; soon she is chairwoman and soon there are no other members on the committee but this woman—she’s the chair- woman and the entire committee. It is useless to attempt to find an ointment in this jar or that to correct the symptoms which are trying to tell us that such a patient is about to blow a fuse. Phenobarbital is helpful but it is also sometimes capable of provoking allergic reactions. Some

292

NEURODERMATITIS—BRUNSTING

favorable results have been attained by use of reserpine (serpasil), even in the absence of hyper- tension, because of the tranquilizing effect of this

agent. Chloral hydrate is a useful bedtime sed-

ative.

Topical applications in the acute stage include use of moist compresses of boric acid (saturated solution) or aluminum subacetate. The latter is prescribed as an 8 per cent solution that is to be diluted 1 fluidounce to a pint. It is not used as a wet poultice but as a moist dressing ; it is useful in relieving the irritation.

One of the most successful but rather messy treatments is the use of tar. It can be prescribed as an ointment containing 1 or 2 per cent each of crude coal tar and salicylic acid. If tar is used in the hair, it should be incorporated in a water- soluble base.

Dermatitis of the ear canal is often neuroder- matitis, and fungi are not involved. It is neces- sary to clean out the canal frequently. A small wick of moist dressing may be helpful. The most characteristic reaction in this location is intense itching, and the patient perpetuates the condition by scratching. In the treatment of ear conditions, nuchal eczemas and pruritus vulvae et ani, use of an ointment containing 1 per cent hydrocorti- sone is helpful. The effect of this steroid applied locally wears out in time unless the underlying disturbances are corrected, but it has been a most significant advance in treatment. I have no brief for those who would use cortisone or corticotropin (ACTH) systemically for the treatment of neuro- dermatitis, even when the condition becomes generalized, because the patient becomes depend- ent on it and it is difficult to discontinue treat- ment without a rebound reaction. Occasionally, when the condition is uncontrollable, it is useful to give 15 to 25 mg. of ACTH intravenously as an eight-hour drip in a 5 per cent solution of glucose.

As already emphasized, patients who have wide- spread neurodermatitis are incapacitated and really need hospitalization for immediate relief. In long-range treatment they need readjustment of their habits of living and sometimes a change of environment. Some of the mafiana influence of the Southwest is helpful and the sunlight there is also beneficial.

MINNESOTA MEDICINE

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Differential Diagnosis of Tumors of the Neck

: eh tumor of the neck, as is one in any other

place in the body, is potentially dangerous and should be treated accordingly. The only way to establish a definite diagnosis is by histologic study, which requires biopsy or removal of the lesion. The best time to carry out primary treat- ment of a tumor in the neck, especially if it is malignant, is at the time of biopsy. Therefore, it is important to use every possible means to estab- lish a preoperative working diagnosis so that the physician can better explain to the patient and his relatives what might be expected in the way of definitive treatment.

It is for these reasons that one always should keep in mind the differential diagnosis of tumors in the neck when a patient is being examined. For instance, if a lesion should prove to be a squamous cell epithelioma metastatic from a pri- mary tumor in the mouth, there is no better time to do the necessary radical dissection of the neck than when the primary lesion is removed. If one strongly suspects that a lesion is squamous cell epithelioma, possibly primary dissection of the neck should be done in preference to biopsy, be- cause biopsy in squamous cell epithelioma may increase the chance of recurrence because of “seeding” at the operative site or persistence of the carcinoma because of incomplete removal of the tumor. Thus in the course of examination of the neck, one should always inspect the lip, the endoral cavity and the larynx, because of the potential danger of metastatic involvement of lymph nodes in the neck arising from primary carcinoma in these regions.

General Aspects of Examination

The examiner must consider a tumor of the neck from the standpoint of the history and the results of inspection, palpation and auscultation

——

Read at the meeting of the Minnesota Academy of eneral Practice, Rochester, Minnesota, October 20, 1954. From the Section of Surgery, Mayo Clinic and Mayo oundation.

The Mayo Foundation, Rochester, Minnesota, is a part of the Graduate School of the University of Minnesota.

May, 1955

OLIVER H. BEAHRS, M.D.

Rochester, Minnesota

of the tumor. If the tumor has been present for many years without any evidence of recent change, that means one thing to the examiner; if the tumor has been present for ten or twenty years and in the past month has shown a sudden in- crease in size, that means something else; if the tumor was first noted a month ago and is painful and tender, that means yet another thing. One should also note whether or not there has been any difficulty in swallowing, or any recent evi- dence of hoarseness. One factor that is sometimes misleading is whether or not the tumor varies in size. The patient may say that the lesion increases and decreases in size. It is difficult to judge this because with change of the position of the neck, as in moving the head from side to side, the ap- pearance of the tumor will change; it appears best to ignore this particular symptom.

For inspection, it is helpful to have the patient stand directly in front of the examiner, perhaps 2 or 3 feet away. This establishes whether or not asymmetry of the neck is present; if it is, the tumor is obvious and merely from inspection one should get some idea of its nature. Motion of the tumor up and down as the patient swallows gives certain information, perhaps indicating a nodular goiter. A tumor that is not easily appar- ent on inspection sometimes becomes prominent when the patient swallows. Also, movement of the head from side to side occasionally makes the tumor more prominent. Any dimpling or attach- ment of the skin over the tumor should be noted.

Palpation should not be attempted until after thorough inspection. The physician should feel the neck rather carefully, as some people are rather sensitive to such palpation. The tumor preferably should be grasped between the thumb and the fingers. Occasionally, however, one is unable to feel the tumor between the fingers and then it must be palpated against the deeper struc- tures of the neck. At times, one can depress the structures of the neck with the opposite thumb, causing the tumor to become more prominent and more palpable. One should note whether the

293

tumor is firm or soft, encapsulated or infiltrative, solid or cystic, tender or nontender, fixed to sur- rounding tissues or freely movable, in which di- rection it moves and, if possible, from which struc- tures of the neck it arises. When the lesion is in the upper cervical region, especially the sub- maxillary triangle, bimanual palpation with the fingers in the mouth is of value. One should also determine the degree of hardness or firmness. A tumor that is calcified is like a rock and usually is benign, in contrast to a firm tumor that feels as though it is infiltrating adjacent tissue; the latter type of tumor frequently is malignant. One should feel for attachment to surrounding tissues.

In the course of palpation, one should notice if there is any pulsation of the tumor. Occasionally, an aneurysm or a vascular tumor might arise from structures in the neck. It is extremely important to know this before exploration of a tumor. Auscultation of the lesion may aid in this diagnosis.

Regardless of how expert the examiner is and how certain he may be that a lesion is of this type or that, the only way to prove the point is to excise the lesion for histologic diagnosis. Then the lesion can be forgotten or the indicated defini- tive treatment can be carried out.

Tumors of the neck may be divided into con- genital lesions, primary tumors, metastatic tumors, tumors of the salivary glands and inflammatory lesions. This presentation is primarily concerned with the characteristics of these lesions that might be of diagnostic value.

Congenital Lesions

Among congenital lesions occurring in the midline of the neck are cysts of the thyroglossal duct. This tumor occurs in the midline and lies either over or below the hyoid bone. If it is much below, the cystic mass may move slightly to the right or the left of the midline. Most often this lesion is definitely cystic; however, if it is tense it is somewhat difficult to establish its cystic na- ture. If one grasps the tumor and creates pres- sure on it downward and then feels above the tumor, between the tumor and the hyoid bone, one frequently can feel the cordlike structure that represents the tract from the cyst through the hyoid bone to the base of the tongue; palpation of such a tract renders it fairly certain that the tumor is a cyst of the thyroglossal duct. If the lesion has been previously incised, or if it has

294

TUMORS OF THE NECK—BEAHRS

previously drained, the character of the discharge is important. A discharge from a cyst of the thyroglossal duct is mucoid in type. A cyst of the thyroglossal duct may not have been noticed in childhood and may be initially discovered in pa- tients sixty or seventy years of age.

Among the lesions in the lateral aspect of the neck are branchial cleft cysts, which occur in the submaxillary triangle, usually just anterior to the anterior border of the sternocleidomastoid muscle. The cystic nature of a branchial cleft cyst can usually be determined. It is superficial, has a smooth surface, is freely movable, unless it is large or has been previously infected, and is not attached to any of the underlying tissues. Sinuses sometimes are assdéciated with branchial cleft cysts if the cysts have been previously operated on and not completely removed. One should always inspect for a branchial cleft sinus or fistu- lous opening, which occurs along the anterior border of the sternocleidomastoid muscle usually just above the clavicle. The characteristic dis- charge is mucoid in type. A branchial cleft fistula has no cystic component as a rule. When the course of the tract is put under tension, a cord- like structure can be felt along the edge of the muscle.

Another lateral cystic lesion is a cystic hy- groma, which often occurs in the lower portion of the cervical region, especially if it is small. If it is large, it may involve the entire neck. Such a lesion is cystic, soft and multilocular. A ranula is possibly a similar structure occurring in the upper portion of the neck. A ranula frequently can be identified by inspection of the floor of the mouth, where it shows as a watery bleb that disappears when punctured. Such lesions also can be felt in the submandibular region as cystic structures, usually bilateral.

Tumors of the Thyroid

Adenomas of the thyroid are frequently en- countered. One should always be suspicious of a thyroid adenoma and should palpate the lateral aspects of the neck in all cases of nodular goiter for possible metastatic lesions. My colleagues and I consider that a nodular goiter is frequently enough malignant so that all nodular goiters should be removed. Whenever a node is found in the neck that has the characteristics of a meta- static lesion, the thyroid always should be care- fully palpated. In our experience, about 4 per cent

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DICINE

of nodular goiters that are not producing symp- toms will contain unsuspected carcinoma.

Occasionally confused with a cyst of the thyro- glossal duct is an adenoma of the pyramidal lobe of the thyroid gland. An adenoma may or may not be firm but rarely does it feel cystic. There is no palpable tract above an adenoma as is often noted with a thyroglossal duct cyst. Adenomas usually move up and down when the patient swallows and frequently the presence of other adenomas of the thyroid gland supports the diag- nosis of this midline tumor as an adenoma.

Also to be confused with an adenoma of the thyroid gland or a cyst of the thyroglossal duct is a delphian node, which also occurs in this re- gion. A delphian node is a metastatic lesion from a primary carcinoma in the thyroid. When the carcinoma is located in or near the isthmus, one of the first areas of spread is to a lymph node located over the thyroid cartilage; such meta- static lesions, however, are firm, usually small, and freely movable.

Tumors of the Salivary Glands

Tumors of the salivary glands are important in examination of the neck. A mixed tumor of the parotid gland will have been present for a long period; it is hard but yet as a rule it is freely movable unless it is in the deep portion of the gland. If a tumor that has been present for many years shows sudden growth, one has to be sus- picious of malignant degeneration. The facial nerve is rarely involved regardless of the size of the tumor unless a malignant tumor is super- imposed on the mixed tumor. However, a cylin- droma, an adenocarcinoma, or another type of malignant tumor of the parotid gland is not only hard but is usually fixed within the tissue; such tumors frequently cause paralysis of the facial nerve, which is extremely important in evaluating a tumor and advising the patient regarding the treatment that should be carried out. Warthin’s tumor, which is cystadenoma lymphomatosum, occurs in the parotid gland; it is soft, usually presents itself below or slightly behind the parotid gland and appears to be encapsulated on palpa- tion. One should not confuse this lesion with a mixed tumor,

Miscellaneous Tumors

Among the primary tumors of the neck are tumors of the carotid body. These lesions occur in about the same area as do branchial cleft cysts

May, 1955

TUMORS OF THE NECK—BEAHRS

but are deeper in the neck and are not cystic. Tumors of the carotid body may be elongated, extending upward and downward; because of their fixation to the carotid vessels, they can be moved laterally but not up and down, which is an important diagnostic finding. Lymphosarcoma occurs in a similar region in the upper part of the neck and in the lower portion of the neck in the internal jugular lymph nodes, Usually lympho- sarcoma in the neck involves multiple nodes, frequently matted together. These nodes are usually rubbery in consistency.

A parathyroid cyst has to be considered occa- sionally, although this is a rare finding. A neuro- fibroma might occur along the lateral aspect of the neck under the sternocleidomastoid muscle. It is an elongated tumor in contrast to a lymphosar- coma, which is round or associated with a matted group of nodes. Neurofibromas frequently are bilateral. Lipomas are seen usually in the supra- clavicular region and the posterior cervical tri- angle. They are soft and multinodular.

Inflammatory Lesions

Inflammatory lesions of the neck include acute lymphadenitis associated with respiratory and oral infections; this condition does not create a diagnostic problem since the enlargement of the nodes is of recent origin and usually bilateral. lf, however, such lymphadenopathy does not disappear within two weeks, it should be regarded with suspicion. The chronic lesions of tuber- culosis, sarcoidosis or other granulomas occa- sionally.are confusing ; biopsy is required to estab- lish the diagnosis but one should be suspicious of this type of lesion from the history.

Metastatic Tumors of the Neck

Metastatic tumors in the neck are usually of recent origin and are firm and nontender. They may be movable but, if large, may be fixed to the surrounding tissues. Again, when one is suspi- cious that a tumor may represent metastasis to a node, careful search should be made for a primary lesion on the lip, in the oral cavity, or in the larynx, as well as on the skin of the face or scalp. Lesions of the lip spread in an orderly fashion to the submaxillary nodes in the neck. A node that is the seat of metastasis may be misleading if it has a necrotic center and feels soft. If a

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Fractures of the Upper Extremity

in Children

RACTURES in children are different than similar ones in adults. Ordinary good treat- ment produces better results in children than it does in adults. The heavy periosteum that sur- rounds the bone in children may help to prevent displacement ; most of the time it makes for sat- isfactory manipulation and easier closed reduc- tion. In preadolescent children, the potential for rapid growth will produce an excellent end result even after mediocre reduction. This same growth potential is responsible for the usual speedy union and the rarity of nonunion in children. This generally optimistic outlook must be tem- pered by the knowledge that with improper treat- ment the complications of fractures in childhood can be disastrous. The general principles of treat- ment are not complex. Alignment is the chief requirement. While it is desirable to produce restoration of length and anatomic apposition, such restoration certainly is not necessary and failure to produce such a result is no indication for open reduction and internal fixation in chil- dren. As a rule, completely satisfactory results can be obtained by traction or by closed manipu- lation and immobilization in plaster. This rule, however, has the usual exceptions. Some frac- tures, notably certain types about the elbow, often require open reduction. In this discussion, I wish to consider the commoner major fractures of the upper extremity in children and to emphasize those that may be attended by complications or that require open reduction.

Fractures of the Humerus

Fractures of the humerus occur through the condyles, through the shaft, below the tubercles or through the upper epiphysis in about that order of freqency. Fractures of the shaft are

Read at the meeting of the Minnesota Academy of General Practice, Rochester, Minnesota, October 20, 1954.

From the Section of Orthopaedic Surgery, Mayo Clinic and Mayo Foundation.

The Mayo Foundation, Rochester, Minnesotz, is a part of the Graduate School of the University of Minnesota.

296

JOHN C. IVINS, MD.

Rochester, Minnesota

rarely accompanied by palsy of the radial nerve and may be satisfactorily treated by application of a hanging cast. If the general alignment and rotation are good, one need not worry about end-to-end apposition or overriding and shorten- ing of up to a half inch; sound union will occur and the proper length will be restored by sub- sequent overgrowth.

Separation of the upper humeral epiphysis may be treated the same way. Restoration of function and normal bony contours is usually rapid. If the epiphysis is completely displaced, manipula- tion with the patient under general anesthesia will be required, but even then one need not insist on strict anatomic reduction, and open reduction is rarely required,

Supracondylar fractures are common. Ac- curate reduction is difficult to achieve and even more difficult to maintain. Neural and vascular complications are more common than the physi- cian usually suspects. Because of the close prox- imity of major nerves and arteries, in a typical supracondylar fracture the artery or one of the nerves may be impaled on the end of the proximal fragment or actually may be caught between the ends of the fractured bone. Once the diagnosis is established by initial roentgenograms, prompt treatment can be effective. Of prime importance is accurate evaluation of the patient’s condition. Simple sensory and motor testing should be done to determine the status of the major nerves. The presence or absence of radial pulsation should be established ; if it is present, one should note its quality. Closed reduction is then carried out with the patient under general anesthesia by trac- tion in the long axis of the arm combined with flexion and pronation. It was formerly taught that these fractures should be put up in supina- tion, but I believe the rotary components can be reduced best by putting the forearm up in pronation. Satisfactory reduction can be main- tained only by means of a posterior plaster splint that holds the arm in flexion. If this causes dis-

MINNESOTA MEDICINE

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