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eye he had. January 9, he consented to have it taken out, which was done under cocaine without any pain. On cutting it open, a long splinter of glass was found in the anterior part of the eye to the inner side, corroborating my first opinion. He now wears an artificial eye, and is one of those in whom the fit is so perfect as to deceive anyone but the greatest expert.
Case 2. J. A. C., 28 years of age, was working at the Old Dominion Nail Works, engaged in cutting scrap iron. A piece of the iron struck him on the right eye between the inner canthus and the cornea, splitting the sclera directly in a horizontal line for a distance of at least one-third of an inch, exposing the uvea which protruded into the wound. He came directly from the shop to my office the day of the accident, December 9, 1895. It was an ugly looking wound. All that I could do at his first visit was to render the parts as aseptic as possible and apply a bandage. This I did daily for nearly two weeks, when the parts were perfectly united. At his first visit there was considerable disturbance of the vitreous, whether from blood or serous effusion I could not determine. He could see little or nothing. At the end of two weeks his vision had much impr improved.
January 6, 1896, the wound had entirely healed up, was perfectly smooth outside, whilst the ophthalmascopic examination showed some remnant of the effusion into the vitreous in slight choroidal and retinal changes in the neighborhood of the injury.
On February 8 the eye was so good that his vision was 20-30. The president of the company happened to meet me about this time and asked me the condition of the man. I told him his eye, much to my astonishment, would be as good as it ever was, except in the immediate region of the wound, as his vision was now nearly perfect, just two months after the accident. The shops had diminished force, and this man was dropped out along with others. This put him in an ugly mood and he was disposed to demand damages on account of his injury. He asked me about it and I dissuaded him from any such thing. He consulted a lawyer, however, to whom he stated that his sight was very bad, and the lawyer, I believe, advised a suit. As I had said his eye was good, and he had stated it was very bad, the lawyer was loathe to undertake the case without having a re-examination of the eye; so he came with a letter from the lawver on March 26, on which day he claimed to be perfectly blind in that eye. I examined him very carefully and came to the conclusion that he was lying, but still I wanted to give him every show, and I got my Chief of Clinic, Dr. Dunn, and also my assistant, Dr. Woodward, to examine him. Dr. Dunn decided that probably the man was right in his statement, as the contraction of the cicatrix had so distorted the
parts, in his opinion, as to give some ground for his statement. By the use of prisms, however, I found he was malingering, and I also, on careful examination with the astigmometer and retinoscopy, measured the astigmatism, which resulted from the contraction. It was only 1.50. D. I wrote the facts to the lawyer, told the applicant I would kill his case, and in ten days he returned to me with his vision restored, so that, with correcting glasses, it was again 20-30.
Case 3. H. L., age 21, colored, was sent me from West Virginia, injured on the extension of the C. & O. R. R., January 13, 1896. He was preparing for a blast, and a piece of steel from the drill flew off and cut the eyeball. I saw him first, January 16. On that date the eye was very much swollen and inflamed, great cedema of the lids and conjunctiva, ragged looking wound of cornea downwards and outwards, and evidently inflammation of the interior structures. My diagnosis was suppurative choroiditis and I took it for granted that a foreign body had passed through the cornea and into the back of the eye. In the three days from the time he was hurt until he came to Richmond he had been treated by a physician, "local talent," near the place he was injured. I could do nothing except to advise enucleation. The eye-ball was removed under cocaine without pain. A careful examination failed to reveal any foreign body, but the retina and choroid were elevated by an accumulation of pus, a little to the outer side of the optic nerve. As there was no other evidence of purulent inflammation about the eye, I was at a loss to account for the pathological condition, and, moreover, I was astonished not to find a foreign body, because I could have sworn in advance that one was there. I happened to remark, to one of my assistants, that I thought this strange, when the negro says to me: "Boss, that is what the doctor up yonder said, because he done stuck his probe down in my eye and couldn't find nothin'." This remark illuminated the case at once. Anyone could see where the germ came from that caused the purulent choroiditis at the back of the eye, when there was no foreign body. The germ had been introduced by the probe. The case resolved itself into a simple wound of the cornea which, if let alone, would have, in all probability, healed perfectly and left a good eye; whereas, the injudicious use of a probe, that was not aseptic, resulted in its destruction. Had the physician been a local surgeon of the railroad, this man would have had first-class suit for damages which would have had to be settled out of court, as the railroad could not afford to go into a trial.
Remarks. The above three cases have been selected from a large number of injuries to the eye in railway and other service, because I thought they would more particularly interest
you from their bearing on the question of the responsibility of railroads and other corporations.
Case I. Had his eye destroyed by the explosion of a feed glass of a lubricator. The bursting of these lubricators is not at all an uncommon thing, even in the experience of engine drivers, and on account of the risk of a destruction of an eye, it is proper that the railways should take every precaution against such an unfortunate accident. Each one of these lubricators is accompanied by a metal protector which, even if the glass tube bursts, protects anyone near from any risk of damage. The railroads should supply these metal protectors; not only should supply these metal protectors, but should insist that the engineers keep them on the lubricator, or else take the responsibility of serious damage on their own. shoulders. If the railroads did this I do not see how they could possibly be held responsible. I have been interested in this subject since this case came under my attention, and find the accident is, as above stated, not at all uncommon. One engineer who works in the same yard with the man who was injured, told me that he had the same accident happen twice within the last three months, and exhibited scars on his face and ear where the broken glass had cut him. He also informed me that the railway did not supply them with protectors necessary to prevent the possibility of injury. I do not know whether this is true or not, but if true it unquestionably makes the railroad responsible for any injury to individuals, on the ground that they have not taken proper precaution to protect their employes.
Case 2. Although not a railway employe,
was selected because of the nature of the wound, similar to injuries of the eye I have often seen in railway service, and secondly, on account of the superb result from treatment, and third, on account of the man's attempt to extort damages from the company by pretending to be perfectly blind, when in reality he had good vision.
The slight distortion given to the corea might possibly have deceived an expert into supporting his pretensions, unless he had been familiar with the case, for the man was very shrewd in his attempt at malingering, when there was not only in all probability no responsibility on the part of the corporation, but the result gave him an eye nearly as good as before, and there was no possible excuse for demanding damages except the slight expense incident to treatment of his eye and loss of time from work.
Case 3, was one, as you can see at a glance by reading the history, where somebody was responsible for the loss of the eye, because there is no question under the circumstances, that the eye was irretrievably ruined by the attempt of the physician to locate a foreign
body within it. Of course, you and I, and all of us, thoroughly understand that this was done with the best of motives; but the ignorance of the proper thing to do in a case like this, amounted, practically, to malpractice, and if this had been done by a surgeon of the road, the man would have been entitled to the largest damages permissible in such a case. As it was, he has no redress save a civil suit against the physician.
It is not out of place for me to say that under no circumstances is it permissible to introduce a probe into an eye to look for a foreign body. If it cannot be located with the ophthalfoscope it is better to trust to aftersymptoms to determine its presence, as probing can only do harm to the delicate structures inside the eye.
In connection with these cases it may be also interesting to note that Case I was very positive there was no foreign body in the eye, although I found a large piece of the glass in it after removing it, whilst Case 3 was equally positive that there was a piece of steel in his eye, although none was found; showing that the statements of the patients are not at all to be depended upon under such circumstances. -International Journal of Surgery.
Traumatic Peritonitis and Rupture of the Bladder.
lymph. A portion of the ileum lying in close relation to that portion of the abdominal wall which received the blows was gangrenous to the extent of four inches. The kidneys were normal and both ureters intact. The bladder was partially filled with clear urine. At the fundus of this organ was found a complete laceration one and one-half inches in length running posteriorly. The edges of the tear uneven and grangrenous. The organ was otherwise in a perfectly healthy condition. A diagnosis of rupture of the bladder was not offered without reservations. The quantity of urine drawn off at regular intervals during the man's sickness would indicate that the bladder retained its contents perfectly, and consequently the peritonitis could not have taken origin from leakage of urine, but from the lesion of the gut alone.
It seems probable that the rupture of the viscus extended primarily through the mucosa and muscularis coats, the serous covering remaining intact until a few hours before death. -Medical Record.
Union of a Severed Finger Tip.
BY W. V. GAGE, M. D., McCOOK, NEB.
On Monday, February 17, the patient, E. W—, while applying a lubricant to the chain of his bicycle, had the misfortune to catch the index finger of the right hand between the chain and the rear sprocket of the rapidly revolving wheel. The pressure of the opposing surfaces completely severed the finger at the root of the nail, cutting through the middle of the last phalanx. The accident occurred in a bicycle store, a block from my office, and a few minutes after the patient was under my care. On examination I found that there was not sufficient uninjured tissue to make suitable flaps, and a temporary dressing was applied, in view of an early operation, when it was my intention to shorten the bone so that I could utilize the tissue for flap coverings. About half an hour after the patient arrived in the office, one of the young men of the town brought me, as a curiosity, the severed end of the finger, wrapped in a piece of tissue paper. The fragment had passed through several hands since the accident, and had been used as the subject of one or two practical jokes, before coming into my possession, and was covered, as had been the hand of my patient, with dirt and oil deposited during the bicycle-cleaning process. Although realizing that there was little hope of success, I scrubbed the fragment with soap and water, and immersed it in a five per cent carbolic solution; I removed the dressing I had just placed, and fixed on the end, pushing the matrix of the nail which remained on the severed end well under the tissue, and then
replaced the dressing. I did not suture, as I did not wish to cut with needle any small artery which might possibly furnish a source of nutriment to the severed end. Thirty-six hours after the accident I applied two narrow strips of adhesive plaster, crossing each other at right angles over the end of the finger, to guard against any possible accident from slight blow and dressed with iodoform and five per cent carbolic acid dressing. The end at the time. looked white and lifeless, and there really seemed to be little chance of union taking place. The process of healing took fifty days; the skin and a small amount of the superficial tissue on the end of the finger dried and separated before union was complete.-Medical Record.
Sprains of Joints and Their Treatment.*
Because of their common occurrence, we are apt to overlook the importance of sprains, though the amount of damage in these injuries is often greater than it is in fractures. Constitutional causes, such as gout or rheumatism, and in some people a feebleness of the power of repair, have, it is true, much to do with the final result; excluding these, however, there are few injuries which yield more readily to the proper treatment, if we only observe two things. These are, first, to begin treatment at once; second, to see that our treatment is carried out in a thorough and systematic manner.
Before considering the question of treatment of these accidents, it might be well to consider the underlying anatomical causes which are responsible for most of these accidents. The development of the muscular system determines the strength and security of a joint. One can almost assert as a positive fact that sprains never occur unless the muscles are either weakened or tired out by prolonged exertion, or caught by some sudden slip, unawares, before they can recover themselves. Speaking generally, it may be said that sprains are the result of a twist so rapid and sudden that recovery cannot take place in time. The function of a joint is movement. Considering the way in which sprains interfere with this, the muscles which direct and execute these movements are as much concerned as the ligaments, which have only the passive mission of checking them when they become excessive. The question of diagnosis is, generally speaking, not difficult, though in sprains of some of the complicated joints, it is often by no means
Fractures near joints and, in children, the separation of the epiphyses of the bones, must all be excluded. Without an anesthetic, in the severe sprains of the larger joints, it is often impossible to make a positive diagnosis. Mus
John F. Culp, M. D., Steelton, Pa., in Medical Record.
cular sprains are, as a rule, distinguished by a peculiar sensitiveness of the skin, most marked over the joints or at the point of attachment to the bones or tendons. Very often, after the joint has almost recovered from a sprain, and an imperfect diagnosis or no diagnosis has been made, we can clear up the matter, with some joints at least, by carefully observing the tender points. A tender spot just back of the greater trochanter nearly always affords valuable information as to a hip-joint sprain. In the knee this tender spot is toward the under side of the knee cap, slightly below the joint center. With the ankle joint, while the sprain is constant, its location is not so constant, though it is usually toward the inner side of the external malleolus. The tender spots, probably, generally mark the location of adherent bands, or, perhaps, roughened synovial fringes, or sometimes spots where there has been extravasation of blood into the joint capsule.
Our results will depend on the earliness with which we see these cases, and on the thoroughness with which we carry out certain fixed indications. These indications are just three: 1. To limit the extravasation of blood and lymph.
2. To promote the absorption of effusion. 3. To promote the healing of the torn structures, and to restore the usefulness of the joint. We can best control the extravasation due to broken blood vessels by local applications, by placing the joint in the proper position and by the use of judicious pressure and thus securing rest for the joint. Unless the cases are seen within one or two hours after the injury, or unless, later in the case, inflammation sets in as a complication, cold applications do not answer as well as do hot ones. Soaking the part in very hot water in delayed cases not only relieves the pain better, but it seems to produce a more permanent impression on the swelling. The various other local applications almost invariably owe whatever virtue they possess to the spirits they contain. We can, however, make an exception with the old timehonored lotion of lead-water and laudanum. Much may be done to check the bleeding from torn vessels by placing the articulation in such a position that the joint cavity is diminished. If left to itself, in most sprains, we find the joint in a condition of considerable flexion. While this position gives the most comfort temporarily, it conduces to a continuance of the bleeding, because it enlarges the joint cavity to its full exent. We can rely on the judicious application of pressure, however, not only to limit the amount of effused material, but to relieve the pain as well. Pressure, as usually applied by bandaging, does more harm than good. The bony prominences, which do not need it, receive the support, while the hollows
and irregularities about the articulation do not get any at all. It has been my practice to loosely envelop the joint with a couple of layers of absorbent lint, which has been saturated with a lead-water and laudanum solution. Over this a good, thick padding of cotton wool is applied, care being taken to make it thick over the hollows and irregularities. Wellpicked oakum is a good substitute for the cotton. A bandage carefuly applied over such a dressing will make the ideal compression and support.
Sprains of most joints, when treated with proper local application, position, bandaging and rest, do not require a splint. It is good routine practice, however, to exclude from this the knee and the elbow, the two most complicated joints. It is well, in these sprains, to apply a felt splint if the injury is at all severe. Rest in these cases is a necessity, and while it is the first indication in this class of injuries, vet, after the subsidence of the swelling, in most cases, we can begin movement within three or four days. Unless we have to deal with a rheumatic or gouty subject, this, as a rule, is not too. early. Acute inflammation, so often dreaded as a complication, rarely comes on as a result of early movement. We must, however, know just what damage has been done before we begin to move a joint, or we may make matters worse. For example, in making passive motion in a sprain of the ankle, where the external lateral ligament is so often torn, it would be bad practice to adduct the foot. If, after cautious and well-regulated movements, the joint swells and becomes tender, it is well to wait at least a week or more before resuming
The second indication, in treatment to promote the absorption, is to be met to a great extent by bandaging and rest. After two or three days, soaking the joint in hot water, or, better still, a strong solution of vinegar and salt, applied just as hot as can be borne for ten or fifteen minutes, three times a day, does much to soften and absorb the coagulated effusions. These baths should be followed by frictions with some good stimulating liniment, the rubbing being done firmly but gently in the direction of the return current of the lymphatics. It is a most excellent practice to begin these frictions above the seat of the injury in order to empty the absorbents, so that they may the better accommodate the lymph from the injured tissues. This lymph is probably more viscid than that found circulating in normal vessels. If after ten days the thickening about the joint has not disappeared and there still remain tender spots in moving the articulation and on making pressure, counter-irritation by iodine, or, often better still, by a fly blister, is indicated.
In two weeks' time with the treatment outlined, we will nearly always find the joint
which has been quite severely sprained, in good condition and ready for work. At this period sometimes, however, owing either to the severity of the injury or to some constitutional peculiarity, it remains painful and insecure, and even the slightest movement may cause acute suffering, with swelling. The joint structures are in a condition of subacute congestion. What is now needed is absolute rest, and rest must be had or there will be a long history of disability, which may become permanent. A plaster of Paris splint will nearly always give the required rest. Put on properly, it will last at least a month, when, as a rule, it should be taken off and the joint examined. It may be necessary to reapply this splint one. or more times, though usually four to weeks of this treatment is enough. We are now in great danger of carrying our rest too far; and it often requires the nicest descrimination to tell when to begin forcible movements. Forcible movements are movements made with some force, let us understand, and when we are of opinion that they are necessary ⚫ to break up any adherent bands and to restore motion to the joint, they should be carried out in a thorough manner. Half-hearted, inefficient attempts do more harm than good, and, by producing pain and swelling without getting motion, often doom the joint to still further rest, when rest does positive harm. The trouble at this time is, to a great extent, in the muscles, which really are the true ligaments of the joint. Frictions, with stimulating applications, together with the use of electricity, are extremely useful in restoring their tone and strength. The faradi current in these conditions is probably more generally useful than the continuous current, especially if there be simply muscular wasting and stiffness without much pain. When there is marked tenderness accompanying atrophy, the galvanic or constant current meets the indications better, not only improving the nutrition of the muscle, but removing the pain as well. The various elastic appliances which are so frequently worn after sprains have much to do, very often, with keeping them weak and uncertain. They are of unquestionable value at times, but their indiscriminate use without the proper medical supervision does much harm. Constitutional treatment is often necessary; rheumatic and gouty patients often require colchicum and the iodides and the salicylates. Where there is a peculiar feebleness of the power of repair without any special diathesis, iron and strychnine are of great value.
In thirty-eight hundred cases of accidents. were recorded two hundred and sixty-one sprains of all kinds, or an average of one sprain in about every fifteen accidents. The least time for treatment was three days; the longest time eight months. The general average was
a trifle over nine days. Sprains of the wrist, the ankle, the back, and the knee were the most common, there being forty wrist-joint sprains, which were under treatment about six days. Knee sprains, while common, are not so numerous as those of the ankle, there being twentysix cases in this record, which were under treatment on an average of about twenty-three days. Of ankle-joint sprains there were seventy-two cases, which got well on an average of about thirteen days. Sprains of the back were most numerous, there being eighty, with an average of eight days for treatment.
These back injuries were, with few exceptions, marked cured on the record, though, as a matter of fact, there are, it seems, few bad sprains of the back which are ever really cured permanently. In the total of eighty cases there was not one in which the spinal cord was seriously involved. The muscles or their tendinous attachments, or the investing membrane of the fascia, were almost invariably the parts to suffer. There were but two cases of sprain of the elbow, and the same number of the hip-joint, while there were thirteen of the shoulder-joint.
Ambulatory Treatment of Fractures in Children.
Bradford (Annals of Surgery, October, 1896) recommends the use of a modified form of Thomas' knee-splint in fractures of the lower extremity in children. Thomas' splint consists of two side pieces continuous below the foot with the two upper ends attached to a padded ring on which the patient sits. Bradford has modified this splint by adding a winch beneath the foot to which the adhesive plaster extension is applied, and also a hip-band fastened to the outer side of the perineal ring by a joint. The adhesive plaster extension is applied to the limb and fastened to the winch, which is then turned until extension is sufficient. Coaptation splints are also applied at the seat of fracture. The apparatus is confined to the leg by plaster-of-Paris bandages.
In fractures of the upper portion of the thigh the ordinary long traction splint as used in hip disease is advised with the use of coaptation splints. A cheap emergency appliance has been suggested by Dr. W. H. J. Hall. It consists of an ordinary wooden crutch strapped to the inner side of the thigh. It is allowed to project an inch or two beyond the foot and has an iron bracket secured to its lower end. In all these three forms of apparatus a high shoe is to be worn on the sound limb and axillary crutches used. The hipband is to be used when it is desirable to correct any tendency to eversion. The patients are allowed to go around in about a week after the injury.