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of the normal relationship of the structures injured in a compound fracture, our first thought reverts to the injured bone and, perhaps, this is not improper, for in many instances it requires our sole attention, and in other cases the greatest share of our activity. The reason why we are solicitous about the reduction of the fracture is not only because we desire to place the broken bones in such a position as will enable the reparative process to re-establish the contour and line of the bone, but also because the injury which the displaced bone may continue to do to the surrounding structures, may become an additional source of injury and of danger subsequently and it is a matter of prudence to remove every possible source of irritation at the earliest possible moment. Experience teaches that the best results are obtained when reduction is accomplished promptly and properly, and when the bones are held in their proper relationship permanently after having been once reduced. The methods by which this reduction is accomplished are numerous, and many of them applicable to a variety of cases, none, however, to all; and each individual case should be judged and treated in this respect upon the indications which it presents. When there is no tendency to displacement, the dressing necessary for the compound fracture, and such lateral supports as are furnished by long splints, if the fracture occurs in any of the extremities, or by the retaining roller if the fracture involves the thorax, the pelvis or the head, will ordinarily suffice. If, however, the line of fracture be oblique with a tendency to over-ride, and this applies only to the fractures of the long bones, then immobilization of the fragments by silver wire, to be afterward removed or to remain permanently, or by ivory or bone pins, to remain in situ, best accomplishes the object.
But we must not lose sight of the fact that besides the bone, other structures may be and are injured by the same force which caused the dissolution of continuity in the bone; and of the structures injured the most important are the blood vessels. It is true that the heavy weight passing over a limb or inflicting a compound fracture of the skull, ordinarily does not so tear the blood vessels as to permit longcontinued primary hemorrhage, but we can all recall cases in which the secondary hemorrhage became a menace to the life of the patient. Upon the condition of the blood vessels will depend, to a large extent, the determination of the question of amputation in fractures of the extremities. We should therefore not overlook the fact that the condition of the circulation in the limb should be an important factor in determining the question of the treatment. With modern views of wound treatment and of biological processes, comparatively few limbs are sacrificed to amputation. The exposure and ligation of bleeding vessels, the
union by suture of injured vessels, the position of the limb surrounded by warmth to favor the obstructed circulation are all matters of vital importance, and must be applied according to the necessities and indications of the case.
How little attention is given to injured nerves in connection with compound fractures, and how often do we not see as the result of neglect in the treatment of nerve injuries associated with fractures, paralyses of groups of muscles or of an entire limb, and its usefulness thereby impaired, although so far as the bone is concerned a perfect result seems to have been obtained.
Of no less importance is the necessity of repairing tendons and muscles. Whenever possible, the severed tendon should be reunited with catgut or silkworm gut, or such other material as the preference of the surgeon suggests.
III. Drainage. A compound fracture means laceration of tissue, it means the opening of lymph spaces, the tearing of connective tissue; it may mean the laceration of muscular tissue and of other soft structures, all of which is followed by wound secretion, more or less abundant, dependent upon the amount of the local injury. The manipulations necessary to thoroughly cleanse subcutaneous structures and spaces add an additional reason why thorough and complete drainage reaching into all the interstices should be established in cases of compound fracture. Sometimes gauze packed in various directions answers a valuable purpose; then, again, a drainage tube passed through the limb or emerging from the angles of the wounds serves a good purpose. Whatever the method, it should be sufficient to drain the wound and prevent the stagnation of wound secretions, thus avoiding the danger which threatens from infection. Thorough drainage established from the first limits the necrotic processes.
All of this should have been attended to before the surgeon proceeds to meet the
IVth Indication-Immobilization of the fractured bone. You will not think it presumptious if I call your attention to a sin of omission which I have so often found committed that I fear the old rule of Boyer is being overlooked and forgotten. I refer to the neglect of immobilizing the joint above and below the site of fracture; unless this is done, proper immobilization can not be accomplished. An abundant dressing to the wound with thorough covering of all projecting bony prominences will enable us to apply a plaster of Paris stirrup splint, or the less safe circular plaster of Paris bandage, or long lateral splints of sufficient tightness to insure the immobilization of the bones without interference with the circulation or without disturbing the processes necessary for the repair of the injurv.
If it be of importance to inspect a simple
fracture at least once a week during the reparative process it is no less imperatively demanded that solicitous care be exercised and constant vigilance in keeping informed concerning the wound progress in the case of compound fractures. A fracture thoroughly and scrupulously cared for at the first dressing can safely be left undisturbed for a week unless the thermometer indicates at an earlier period the removal of the dressings and the cleansing of the wound.
It would lead too far to embrace in this synopsis particular fractures. I wish however to refer to one class of fractures more difficult to manage, and more serious in their consequences than others-I refer to compound fractures involving the joints. I believe that the principles already enunciated will suffice in all instances, provided there is added complete drainage and immobilization of the injured joint.
Pistol-Shot Wound of the Second and Third Cervical Vertebræ.*
BY CHARLES PHELPS, M. D.
The subject, a man thirty-five years of age, was shot in a street altercation, and the bullet, of 32 calibre, entered the tongue at the tip, made exit at its base on the same side, and secondarily entered the posterior wall of the pharynx just to the left of the epiglottis. He was shortly afterward admitted to St. Vincent's Hospital. His tongue at that time, and till within a day or two of his death, was so greatly swollen as to prevent exploration of the pharyngeal wound, which was known to exist only from the statement of a medical man who examined him previous to his admission. He had great pain in the back of his neck extending toward the shoulder on the left side. His articulation was difficult, respiration labored, and deglutition painful. His temperature was 99 degrees, pulse 80, and respiration 18.
Aside from the functional difficulties connected with the swelling of the tongue and adjacent parts, which subsided on the fifth day, and continued pain and a sensation of stiffness in the back of his neck without rigidity, his subsequent symptoms were purely those of a general septic infection. His temperature was high from the second day, when it rose to 104.8 degrees, and his pulse and respiration were frequent. The temperature, with the exception of the sixth day, when it did not exceed 100 degrees, varied each day from 101°+ or 102° to 104°+, and on the seventh and
Read before the Society of Alumni of Bellevue Hospital, Jan. 8, 1896.
eighth days rose to 105+. Its daily irregularities were somewhat increased by the use of alcohol baths. Intense hæmatogenous jaundice was developed from the fifth day, and on the tenth day stupor was followed by slight delirium, with intervals of mental lucidity and of tremor, and death.
On necropsic examination the subpharyngeal connective tissue was found to be gangrenous from the site of the wound, for a finger's breadth, as far as the inferior border of the larynx. The bullet was lodged between the second and third cervical vertebræ at the base of the transverse processes, both of which were fractured. The spinal membranes were uninjured, but they had been transuded by the gases of decomposition, which had penetrated the cranial cavity and given it a fœtid odor, and stained the external border of the left cerebellar lobe through the cortex a distinct slate color. The brain was hyperæmic and moderately œdematous, and there was moderate subarachnoid serous effusion.
The liver was of normal size and consistence, and like the other viscera deeply yellow.-New York Med. Journal.
Intravenous Saline Injections in Conditions of Severe Shock.
BY LEWIS A. STIMSON, M. D., OF NEW YORK.
The advantages to be obtained by intravenous injection of large quantities of the "normal salt solution," during or immediately after operations accompanied by much hemorrage or shock, are now well understood. It is, perhaps, not so well known that similar advantages may be obtained by the same means in cases of injury followed by marked shock, with or without important hemorrages externally, or into the natural cavities, or among the tissues of the body. The following cases may serve as illustrations:
Case I.-A. R., aged thirty-one, was struck, December 17, 1895, on the right side and front of the abdomen and squeezed against a wall by a piece of structural iron weighing 700 pounds which he was engaged in moving. He was immediately brought to the New York Hospital. When I saw him, three hours later, the condition of extreme shock, which was present on admission, persisted; the abdomen was tender and distended, the flanks dull on percussion, and a slight intra-abdominal wave could be obtained. There was evidence of an intraparietal hematoma on the right side. between the ribs and the ilium. The urine did not contain blood.
Twenty ounces of the salt solution were at once introduced through the median basilic
vein. This was followed by a prompt improvement in the general condition; and as the local signs grew no worse the attitude of expectation was maintained. Complete recovery
Case II.-Chas. A., admitted to the New York Hospital December 11, 1895, after having just fallen from the third floor of a house. Several ribs on the left side were broken, and there was an extensive emphysema of the chest wall; marked shock.
Twenty ounces of the salt solution were injected into the median basilic vein. Re
Case III.-James S., admitted to the New York Hospital December 13, 1895, with fresh burns, covering almost the entire body. Extreme prostration. The patient was placed in a hot bath and received a large saline injection, but died 3 hours after admission.
Case IV.-William B., twenty years old, was admitted to the New York Hospital October 23, 1896, having just been run over by a dummy engine. The left foot and ankle were crushed, the joint being widely opened; compound fracture of the right radius; compound dislocation of the right thumb; simple carpo-metacarpal dislocation; profound shock; semi-conscious.
The left leg was immediately amputated, the patient receiving meanwhile a saline intravenous injection of 34 ounces; this brought his pulse down to 88, but an hour later it rose to 160; a second injection of 34 ounces was then given, bringing the pulse to 120. Re
There is also reason to think that similar advantages may be gained by the same means in severe septic conditions. In July, 1896, I saw in the wards of my friend, Professor Pozzi, in the Broca Hospital, Paris, a woman, who had been admitted three days previously, gravely ill with puerperal septicemia. only treatment had been the immediate administration of a large intravenous saline injection. This was promptly followed by a marked reduction of the temperature and improvement of the general condition, which still persisted when I saw her. The following case may be quoted in connection:
Case V.-Chas. L., aged twenty-seven, was admitted to the New York Hospital December 1, 1896, suffering from general peritonitis, due to perforative appendicitis. The attack began on the night of November 28-29th, about sixty hours before admission. The abdomen was distended, tense, and painful; the surface dusky; the pulse rapid, small, and of bad quality; temperature 102 degrees F. Fecal vomiting.
The abdomen was immediately opened, and the appendix, which had been completely divided near its base by ulceration, was removed.
Several ounces of pus from the neighborhood of the appendix was removed, and then a large quantity of turbid serum from the general peritoneal cavity. The intestines were congested, distended, and coated in many places with a fibrinous exudate. The general peritoneal cavity was thoroughly irrigated and sponged with salt solution, drained with gauze and two large rubber tubes, and the wound partially closed.
The patient's condition, as shown by his pulse and surface circulation previous to the operation, occasioned much anxiety. About 24 ounces of the salt solution were injected by an assistant while I was operating. This was followed by an immediate improvement, which persisted through the day. On the following day the general improvement was maintained, and the local conditions were better, the left side of the abdomen being soft and painless. This continued until December 4th, when the vomiting was renewed, all efforts to secure a movement from the bowels having failed. The pulse again became almost imperceptible, the surface dusky, and the nose cool. An injection of 60 ounces was made, and the same improvement followed, but the vomiting persisted, and the patient died early on December 5th. It seems clear to me that in this case the injection prolonged life fully three days, enabled me to perform the operation and check the peritonitis, and only failed to save the patient because of the persistence of the intestinal paresis.
The good effect of these intravenous injections is doubtless due to the change in the physical conditions created thereby; the intraarterial pressure is increased, and presumably, osmosis is carried on more freely. Possibly, too, the presence in the body of the large additional amount of water favors metabolism and excretion, and thus diminishes the production of deleterious compounds and aids the removal of those that are produced.
While no direct curative effect has been proved, yet the injection gives to a patient, who apparently has but a few minutes or hours to live, a respite, during which his organism may recover from the shock received, or throw off a septic assault that is pressing, or during which the physician may, perhaps, successfully employ remedial or helpful meas
The technic is simple. A sterilized, graduated vessel, provided with a rubber tube about three feet long, ending in a fine pointed glass or metal nozzle, is required. The solution can be readily made by mixing common salt and water in the proportion of ninety-two grains (a large, but not heaping, teaspoonful) to a quart, and sterilizing it by boiling. It should be injected at a temperature of about 105 degrees F. The vein should be exposed, a liga
in neurotic individuals. The symptoms may consist of stupor, vertigo, headache, and these may end in collapse with severe precordial anxiety. Clonic and tonic spasms are noted, which may produce sleeplessness and restlessness in some people and unconsciousness in others. Mental excitement and a mild degree of mental aberration may be observed. Paralysis, tremor, slight loss of co-ordination may also be noted among the motor symptoms. If respiratory difficulty, cyanosis, loss of consciousness supervene, the prognosis becomes very serious. The unfavorable action of cocaine on the heart rarely becomes threatening, the respiratory symptoms being most significant. A feeling of suffocation with irregular stertorous breathing may arise, and eventually Cheyne-Stokes breathing. Death may result from respiratory paralysis. Idiosyncrasy to cocaine is sometimes very marked, so that the size of the dose may be almost without perceptible influence on the intoxication symptoms produced. The author records two cases of cocaine poisoning, the first he had seen among several thousand of bladder cases which had been cocainized. In comparing experiments on animals with observations on man, it is proved that cocaine can be absorbed from the bladder, but the absorption is so slight as to be practically without significance. With increased dexterity in the use of the cystoscope, perhaps weaker solutions of cocaine can be employed or no local anesthetic used at all. Cardiac and vascular diseases, pernicious anæmia, are contraindications to its use. The horizontal position should be adopted when it is used. Chloroform may be given when spasms arise, but the chief remedy against cocaine poisoning is artificial respiration. The proposal of Gauchier to add nitroglycerin (coc. mur., Merck, 0.2; aq. dest., 10; sol. nitroglyc., I per cent., gtt. x.) is worth bearing in mind.-Berliner klinische Wochen schrift.
The Preparation of Chromicized Catgut.
Most of the methods of preparation now in vogue for the preparation of chromicized gut take up too much time. Recently Dr. J. F. Binnie of Kansas City has adopted an old method of preparation modified in a number of details which almost absolutely exclude the possibility of error, and render the ligature materials as free from contamination as the instruments are after boiling. The modified method is as follows:
(1) Cut the catgut into lengths of from four
to eight feet. Wash in soap and water, and wind each length on a separate glass reel.
(2) Place in a large quantity of a 1 per cent watery solution of chromic acid, and leave in this for from six to nine hours. Strain off this solution through aseptic gauze.
(3) Replace the chromic acid solution by a large quantity of sulphurous acid. After twelve hours place aseptic gauze over the mouth of the vessel, strain off the acid and replace it by
(4) A 2 per cent solution of salicylic acid in commercial (not absolute) alcohol. Place this in a water bath and boil for fifteen minutes or longer. The alcohol reaches a temperature of 175 degrees Fahrenheit when the vessel in which it is contained is not closed, but in practice if a stopper is applied loosely a higher temperature may be obtained. Alcohol, in a bottle closed by a plug of cotton, very loosely inserted, is easily raised to a temperature of 189 degrees Fahrenheit. This temperature is higher than that required to sterilize virulently tuberculous milk--viz., 184 degrees Fahrenheit. (Vide Sims Woodhead, British Medical Journal, February 1, 1896, p. 297.)
Common alcohol (80 per cent) at a temperature of 177 degrees Fahrenheit sterilizes anthracized catgut in one hour. Common alcohol (90 per cent) at a temperature of 172 degrees Fahrenheit does the same in three hours, while absolute alcohol at the same temperature is inert. Koch proved that 5 per cent carbolized alcohol is useless as an antiseptic at ordinary temperatures, but Saul shows that although anthracized catgut is unaffected by boiling in a 5 per cent solution of carbolic acid in absolute alcohol, yet if 10 per cent of water is added sterilization is attained rapidly even if the catgut is thickly covered by fat or vaseline. In Saul's tables we find it stated that 90 per cent alcohol plus 5 per cent of carbolic acid kills the spores of anthrax in ten minutes; on studying his experiments, however, one finds that the longest time required was seven minutes. In the preparation of ligatures for use. Saul merely exposes the raw catgut to the above solution for fifteen minutes after the boiling point has been reached. He makes use of a special apparatus to collect and return the evaporated alcohol so as to prevent a too great concentration.
In view of these experiments of Saul, it might, perhaps, be advisable to substitute for
the salicylated alcohol carbolized, 90 per cent alcohol.
To have the ligatures in a convenient form for carriage, Binnie places them in small, sterilized bottles, with rubber stoppers, and pours on a sufficiency of salicylated alcohol, and lest there should have been any contamination while the change is being made from one bottle to the other, they are again boiled in the waterbath for a few minutes and the stoppers pressed home. Just before operating the firmly-stoppered ligature bottles are immersed in a strong solution of corrosive sublimate, so that by the time they are required, not merely are the ligatures sterile, but the outside of the bottles are clean enough to be handled by the surgeon himself, and there is no danger that the ligatures, in being removed from the bottle, will be contaminated by touching the outside of the glass.
The reason for cutting the ligatures into lengths of from four to eight feet is that in very many operations but one or two ligatures or sutures are required, and if each reel contains many feet of ligature one is tempted to return what is left, while, if only a small quantity of gut is on the reel, one can throw away the remnant and so avoid chances of accidental contamination. If long ligatures are wound on ordinary glass reels there will be so many layers superimposed, one on the other, that the chemical solutions may not get into the deeper layers This is another point in favor of the short lengths of ligature advised.
The use of small bottles to contain the ligature is convenient because, in the course of an operation, one may accidentally contaminate the contents of one bottle and yet have plenty left in proper condition.
If small bottles are used for carriage because of their convenience, they should not be used in the original processes, because they do not contain enough of the chromic acid solution or of the sulphurous acid in proportion to the quantity of catgut to be acted upon.
A special feature of this method of preparation is that from beginning to end of the process of sterilization the ligatures are untouched by the fingers, and forceps are only used onceviz., to transfer the reels from the large receptacle to the small bottles; thus many chances of accidental contamination are avoided. Catgut which has been soaked in a one per cent watery solution of chromic acid for nine hours remains unabsorbed at the end of three weeks. When less resistant gut is desired, one merely lessens the time of exposure to the action of chromic acid.-Kansas City Medical Index, June, 1896.
The University Medical College of New Orleans is about to establish a training school for negro women as nurses.