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378 Sprains of Joints and Their Treatment.. 378 Ambulatory Treatment of Fractures in Children...
Officers of the N. A. R. S., 1896-7.
F. J. LUTZ, St. Louis, Mo.
W. R. HAMILTON, Pittsburgh. Pa.
J.N.JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo. O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa.
CONTUSIONS AND THEIR TREATMENT.*
BY WILLIAM MACKIE, M. A., M. D., SURGEON IN CHIEF MILWAUKEE HOSPITAL, MILWAUKEE, WIS.
It has been suggested to me that contusions and their treatment would be a very appropriate subject for our discussion. They are of very frequent occurrence among railroad employes, and of a much graver character than those ordinarily met with on account of the magnitude of the contusing force, as a moving car or a fall from a moving train. I shall omit all reference to contusions affecting joints, bones, or internal organs, and limit the subject to the soft tissue.
A contusion may be defined as a laceration of the subcutaneous structures from external violence, the skin remaining intact or being only abraided, and not apparently primarily destroyed throughout its entire thickness. Two results are to be considered in the production of a contusion: First, the direct, the crushing and overstretching of the tissues. Second, the indirect, the forcing of the fluids of the contused part away from the point of contact of the contusing force.
First, as to the direct effect: The tissues are crushed together or against an underlying As a result the loose connective tissue, small vessels and capillaries are lacerated; the blood and lymph escape and thus results the swelling. The extent or depth to which the destruction extends will vary with the magnitude of the contusing force. The subcutaneous tissue alone may be involved, or it may be torn from the underlying fascia. It is in this case, according to Gussenbauer, that the effused fluid is largely composed of lymph, be
*Read at the fourth annual meeting of the C. M. & St. P. Railway Surgeon's Association at Chicago, Nov. 12 and 13, 1896.
cause of the laceration of the lymph vessels which pass through the subcutaneous tissue. With a greater force the muscles are torn, crushed or even pulpified. You are all familiar with the bluish appearance of the muscles in a limb crushed by a car wheel. The same condition may exist in a contusion. The larger veins may suffer, and it is from them that most of the blood escapes. The arteries, at least those of any size, are seldom injured on account of their elasticity and deep location, yet if an artery be compressed against a bone, the intima may be lacerated and a thrombosis result. In the case of injury to an artery with subsequent thrombosis may arise the question of amputation, or what is more unlikely a false aneurism may develop. This is to be distinguished from effused blood by its pulsation, always bearing in mind that this pulsation may be communicated from an intact vessel. If an artery be injured, and thrombosis incomplete, a bruit may be detected in the vessel, as found by Waldeyer in punctured wounds. The arrest of hemorrhage follows on the coagulation of the effused blood, and the equalization of intravascular and connective tissue pressure. When the blood is evenly distributed through the contused tissue, it feels firmer and more resistant from this infiltration. It may collect in large cavities, and gives a doughy or indistinct feeling of fluctuation if deeply situated, or if more superficial, fluctuation may be evident. Around these collections of blood a new connective tissue wall may develop, and the blood remain fluid for a long time-it is encapsulated. A sense of crepitation is occasionally to be detected from the fluid breaking up or passing through the connective tissue spaces.
The nerves are always involved, to a greater or less extent. There is a stinging sensation when the hand is struck against a hard object, due, according to Billroth, to a concussion of the nerves. This is only a temporary perversion of sensation, but if the contusion is more severe, it may continue for some time, and whether a neuritis may follow such a condition of concussion, is open to question. Further, the structure of the nerve may be partially destroyed; either the supporting connective tissue, the neurilemma or the nerve substance proper. the sheath of Schwann and axis cylinder. When this occurs there is immediate disturbance of function throughout the whole distribution of
the nerve, indicated by numbness and tingling. Subsequently there may result a neuritis with its characteristic symptoms, pain along the course of the nerve, hyperæsthesia in the early stage, and later anæsthesia, muscular atrophy and the peculiar glassy condition of the skin The ultimate result will depend upon the regenerative power of the nerve. The fascia may be torn, but the tendons generally escape injury. The indirect results are due to the forcing of the fluids of the contused part away from the point of contact. From this point the fluids. are squeezed out, as it were, and will follow the direction of least resistance. This is into the inter-mu inter-muscular spaces, and along the course of vessels, where there is always more or less loose connective tissue. When the contusing force is kept up for some time, the quantities of liquid thus forced into the uninjured textures are often very considerable and in this way large cavities are formed. As pointed out by Ogston, muscles not firmly attached to their intervening septa are often detached from them and pass, without any connection, through the center of a cavity containing fluid blood. It is this forcing of the fluids away from point of contact that explains the appearance of discoloration remote from the site of contusion. The fluids having been forced along underneath the fascia, which gives way at its weakest point, reach the surface.
The subsequent course of the contusion is dependent greatly on the extent of the injury sustained by the skin. It remains intact, but its vitality may be so depressed that necrosis results. The appearance of the skin at first will not enable us to determine the extent of its injury. The larger the area of the contusing body, the less likely is it that gangrene of the skin will result. Sensation may be lost in the contused skin, yet its vitality remains. On pricking or incising there may be no hemorrhage an indication of a devitalized condition. Still, subsequently the circulation may be partially restored so that the whole thickness does not perish, or the destruction may only occur in circumscribed areas. When the arrest of the circulation is absolute, gangrene results. Contused skin is always liable to infection from its diminished resisting power.
In the most favorable termination, the effused blood is removed by absorption. This is the rule where the extravasation is diffuse.
Where the blood is effused in large quantities it may become encapsulated as already pointed out. Contused muscle may be absorbed. Where suppuration follows, it is the result of infection, either from a small skin abrasion, gangrene of the skin, or the bacteria may be forced through the skin. (Tillmann.)
The symptoms of contusions are all well known. There is one, however, not ordinarily met with, present in railroad contusions, and that is shock. The greatness of the contusing force and the surroundings account for this. It is not different from ordinary shock, and is of short duration.
The remote results of contusion are various. Pain may persist for an indefinite period, due, probably, to some change in structure or compression of nerve fibres. There may be impaired muscular power, if part of the muscle has been destroyed, or adhesions may form between adjoining groups of muscle. In the former case a depression may mark the site of injury. A thickening of all the contused tissue often persists. When the nerve has suffered, and a neuritis follows, there will remain perversion of sensation, and motion to the extent of the nerve destruction, with atrophy of the muscle or muscles under its control.
The prognosis should always be guarded at first. The laity, and the profession likewise, are often satisfied that it is only a bruise. The condition of the parts is often deceiving. One should ascertain as accurately as possible the method in which the injury was received, the character and size or force of the contusing body, and whether its application was of short or long duration. These facts are of the greatest prognostic value. Take, for example, a man injured by being struck on the arm by a passing train, and another by having his arm. caught between two "dead woods." The injury in the former would be trivial as compared with the latter, and yet to all outward appearances much alike.
The indications for treatment are the prevention of infection and subcutaneous hemorrhage, the alleviation of pain, the promotion of the removal of effused blood and contused tissue by absorption or otherwise, and the restoration of the parts to their normal condition. All contusions should be treated antiseptically, because we are unable to foretell the condition of the skin. We have also included contusions
with skin abrasion-an opening by which infection may enter, and further, as Tillmann states, the microbes may be forced through the intact skin. The first step, then, is thorough disinfection of the injured and surrounding parts. For the prevention of swelling, cold and evaporating lotions have long been recommended. The vitality of the tissues is already lowered, and the treatment should be simulating rather than depressing. Cold will arrest hemorrhage and act as a depressant, hence its use must be condemned. The same applies in a less degree to evaporating lotions. The best means to arrest the hemorrhage is elevation and equable compression. With the parts elevated where practicable, they should be covered with several layers of antiseptic or aseptic gauze (the parts having already been thoroughly disinfected), then covered with several layers of cotton, and a bandage evenly and snugly applied. Some prefer dry dressings, but it has been my experience that patients prefer moist. In applying the gauze I moisten it in a hot, mild antiseptic solution, cover with disinfected rubber tissue, and over this apply the cotton. This is to be changed once or twice in twenty-four hours. Theoretically, the application of moist heat continuously increases the swelling by paralyzing the vasomotor nerves, and relaxing the tissues, and for this reason dry heat by rubber coil has been advised. Practically this objection docs not hold. I have repeatedly observed that the substitution of a moist dressing for a dry one was followed by a diminution of the swelling. For the alleviation of pain, rest is to be added to the foregoing. If an extremity it should be fixed on a splint. Opium is generally necessary where the contusion is severe. It relieves the pain and allays that nervous excitement so often present. The absorption of the effused blood is promoted by the use of the moist compress. This takes place by transudation. Its removal may be hastened by a few linear incisions of the skin where it is tense. This also favors a more speedy return of the circulation in the skin by the removal of tension. The incision will heal by granulation or may be sutured on the subsidence of the swelling in twenty-four or forty-eight hours. Prior to antiseptic times, the treatment of contusions by incision was condemned until suppuration appeared. At the present time the large cavities
containing bloody fluid, to which Ogston first directed attention, should be treated by incision and evacuation of the blood clots. The cavity should be thoroughly irrigated with normal salt solution, a small tubular or gauze drain introduced for twenty-four or forty-eight hours, and an elastic dressing applied so as to obliterate the cavity as completely as possible. In default of this method of treatment, the fluid part should be removed by the aspirator. All collections of lymph in the subcutaneous tissue should be treated in the same manner.
If the skin should become inflamed, linear incisions should be made down to the fascia and not beyond, because the infection might be carried deeper. Satisfied that infection is confined to the subcutaneous tissue, we should apply our moist antiseptic dressing. This alone may prevent the infection extending under the fascia. When suppuration extends beyond the fascia then we should resort to free incision and tubular drainage.
For adhesions which may result, massage is of the first importance. It is also useful in promoting the absorption of the effused blood by mechanically forcing it into the lymph channels. Should a neuritis result from injury to a nerve it must be treated on ordinary principles.
DISCUSSION OF DR. MACKIE'S PAPER,
Dr. Spillman: I regard this as a very excellent paper, because it treats of matters we come in contact with almost every day and that sometimes annoy us a good deal. Of course, in the case of minor contusions we can allow them to rest and get well, but if they are really painful and severe they must have some treatment. I certainly agree with the views set forth as to treatment. I think immersion of the part in hot water, as hot as can be borne, is good treatment, but it seems to me in certain cases where we cannot attend to them very closely, a bandage over moist gauze and cotton is very excellent.
Dr. T. C. Clark I simply wish to say I find a solution of chloride of ammonia very useful, applied hot, or at least warm, to the outside of the compress to promote absorption of blood.
Dr. Marks: This is a very excellent paper and I have no criticism to make upon it, but merely wish to say that I believe that when the pressure is such as to cut off any part of the circulation of a limb, we should always open
and allow the blood to escape. I believe that should be the rule. I remember the case of a boy who was hurt in the railway yard; I forget just how. I decided to operate, and believed and felt it ought to be done, but they wouldn't allow me to. He was taken to a hospital, and the third or fourth day I amputated the limb. I think if I could have opened it in the first place I could have saved the limb.
Dr. Stewart: I would like to report to the members a case which was unlike in its nature those that have been described, but similar in its appearance. A lady was picking berries back on the bluffs near Winona, when she was struck by a rattlesnake. I saw her an hour and a half after the occurrence. I found a wound five or six inches above the ankle that had exactly the same appearance as a contused wound. I injected first permanganate of potash in four or five different places one inch from the wound and waited about two hours until necrosis from the poison had occurred and then went right around the circle with a knife and removed the necrosed tissue and then kept the limb bathed for four or five days in a weak solution of permanganate of potash. Recovery was complete. The whole thing appeared like a contused wound. For the injection I used one-twentieth of a grain in about. half an ounce of water. For the solution I used more and bathed the whole limb from knee to ankle.
INJURIES OF THE SPINE.*
BY DR. D. M. COOL, FARIBAULT, MINN.
I have selected this subject for my paper because I felt that by eliciting discussion, I might profit thereby. The subject I have chosen to write upon (Injuries of the Spine) will embrace fractures and dislocations of the vertebræ, with or without injuries to the cord. I am aware that it is a subject covering a much larger field than I shall attempt to embrace in this paper. About 20 per cent of these injuries are fractures alone, about the same number dislocations, and about 50 per cent are dislocations combined with fractures. Many times there are a number of vertebræ broken and the injuries of the bones are quite extensive. This feature of the injury is of the
*Read at the Fourth Annual Meeting of the C., M. & St. P. Railway Surgeons' Association at Chicago, November 13, 1896.
As in fractures of the skull, the injury to the brain is the predominating feature, so in fractures of the spine, it is the injury to the cord that is of such vital importance. When life is spared we may have paralysis of sensation, or of both sensation and motion, also of the sphincters of the rectum and bladder.
Like other fractures, fractures of the spine may be simple or compound, and simple fractures may be complicated with injury to the cord sufficient to destroy action, or even life. Injuries of the spine may be produced by falls, railroad accidents, gunshot wounds, caving in of embankments or mines, either of which may produce extensive injury not only to the vertebræ, but of the cord itself, resulting in immediate death or disabilities sometimes worse than death.
Hemorrhage sometimes occurs complicating the otherwise milder cases, by producing severe, if not irremediable compression. Very serious effects are also frequently the result of fracture of the vertebræ, with depression of the bone, compressing the cord, or at times completely dividing it as if cut with a knife. At other times small pieces of bone are forced into the cord, paralysis complete or partial, permanent or temporary, always attend such. lesions. At other times concussion is the prominent feature; the patient is very sick at the stomach and looks pale, is helpless and the sphincters may be relaxed. Death may occur in this form of spinal injury, but recovery frequently takes place. Fortunately fractures of the spine are not very frequent in proportion to the number elsewhere in the bony structure of the body. I am not certain, but I think they amount to about three or four per cent of the total number, and dislocations about the same. It is claimed by some writers that the bodies of the vertebræ are more frequently fractured than the arches; there is apt to be displacement of the crushed bones, causing quite extensive lacerations of the cord. Even when the arches alone are broken, fragments may be thrust into the cord and cause serious injury. On the other hand, there may be fractures of the arches or even of the bodies without injury of the cord. If the fracture be compound, the aseptic finger makes the best instrument for examining the injury. A probe should never be used or, if necessity compels
its use, great care should be taken not to injure the cord.
As a rule, one should not attempt to verify his diagnosis by eliciting crepitation, as in other fractures, except, perhaps, where the spines alone are broken, since the attempt might increase the danger to the cord or the nerves, given off at the seat of injury. The same rule holds good in determining excessive mobility and the diagnosis should be arrived at from the general symptoms. Usually there will be profound shock and tenderness of the injured part, and generally a well marked pain, surrounding the body on a level with the seat of injury. The patellas reflex and ankle clonus will aid in the diagnosis paralysis of the sphincters of the rectum and bladder, with numbness and pricking sensation of extremities, with paralysis more or less complete, will verify the diagnosis. The symptoms will, of course, vary according to the seat of the injury. If it is in the lower lumbar vertebræ (which is rare) the injury is below the cord and can only involve the caudal nerves, in which case the paralysis will be confined to the legs and if recovery takes place the gait is apt to be feeble; fractures of the spine are mostly above this point.
The seat of the injury can be ascertained by noting what muscles are paralyzed. One point will be of service to us, and that is the inflammation or myelitis will always extend upward in the cord and, of course, the paralysis will increase after the accident. It will be well to understand what muscles loose their power at first, and also from day to day, so as to be able to determine whether the myelitis is extending or not. In most of the text books you will find explicit indications, for the government, of ourselves, in minutely diagnosing these cases. Charcot, Allen Starr, Holmes and others have given, so far I know, reliable literature on this subject. These injuries are not so frequent that they present themselves very often, even to our best surgeons, men who have extensive practice, both hospital and private, yet any railroad surgeon may be confronted by a case of this kind, and that, too, when he least expects it. We should have a knowledge of our duties at such a time, and be able to render the needed assistance so necessary. Those injured in this way do not stand transportation seventy-five or a hundred miles, to