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cize them in any way, but there is one question I woud like to ask the gentleman in regard to boric acid and acetanilid. At what stage he would apply that?
Dr. Clark: As a primary dressing. I meant to speak of using acetanilid. I use it as a primary dressing, and use it clear. I used it three weeks ago. A man was caught in a cog-wheel and the flesh was mashed to the bone in three places. I applied acetanilid, with the result that it dried the wound up.
Dr. Binnie: Have you ever had any bad results from it?
Dr. Clark: I have never had any bad results from the use of acetanilid. I consider it best as a primary dressing. I would like to ask the gentleman who has just spoken what he uses?
Dr. Binnie: I use acetanilid, but reduce it four or five times. I have used it in connection with boric acid and bismuth.
Dr. Drake: In those cases of mashed hands we can do more in saving, I think, than in any other injuries we have to treat. Every piece of skin and every piece of tissue that can be saved should be saved. I usually use in my operations, as an irrigation, a solution of carbolic acid. Carbolic acid, properly used, has never done any harm. Of course, you can abuse it and it will do a great deal of injury. I think as a stimulant carbolic acid. is much better than alcohol when we use it with water just as hot as we can operate in. The doctor's hand is the guide as to the heat to be used.
Dr. Binnie: I have been pleased and displeased with carbolic acid. That has depended on the strength and conditions under which I used it. I use alcohol now more than any other one thing. I reduce it from four to nine times with hot water.
Dr. Philler: I believe continuous submersion in tepid water is one of the best things for wounds in the hand.
The Columbus Medical Journal has removed from 150 East Broad street to its new quarters, 68 Buttles avenue, Columbus, Ohio.
It is reported that the Southern Railway Company will soon begin the erection of three large hospitals along its line in the south, and an effort is being made to induce them to take the uncompleted Erlanger Hospital at Chattanooga, Tenn.
ABOLITION OF PRIMARY AMPUTATIONS IN THE TREATMENT OF MANGLED HANDS.*
By Jos. A. CROWELL, M. D., IRON MOUNTAIN, MICH.
On June 6, 1896, E. K., a stationary engineer, while adjusting a nut on the eccentric of his engine, had his left hand caught and forcibly crushed between the crank wheel and the pillow-block, a space just sufficient to admit an ordinary lead pencil. He was sent at once to the hospital, and the attendant wrapped the hand with gauze moistened with a solution of creolin. A few moments later when examined by Dr. Cameron and myself, it was found that the force had been applied along a line corresponding with the heads of the metacarpal bones and the first phalanx of the thumb, opening these joints, crushing bones, lacerating the soft tissues and stripping all before down to the first phalangeal articulations; the capsules of these joints were torn open and most of the bones dislocated, leaving merely a thin layer of contused tissue on the palmar surface of the hand. If ever a hand looked as if amputation of all the fingers and a part of the thumb were an absolute necessity, this certainly did, but so little was to be lost and so much could possibly be gained by delay, and as the patient's right hand had been crippled by a previous injury, we decided not to amputate. The patient agreed after an explanation, and he was anæsthetized to allow of more complete examination and dressing.
After a thorough irrigation with a warm solution of creolin, all dislocations were reduced and the capsules of the joints lightly closed with interrupted silk sutures that had been antiseptically prepared after the manner of Kocher, by boiling in a one per cent solution of arsenous acid. Displaced fragments of bone were replaced, and the shredded soft tissues brought as nearly as could be into their nor mal relative positions, the whole dusted with iodoform, swathed with sterile gauze wet with a saturated boric acid solution, and the usual cotton and rubber tissue applied, and the patient put to bed with the arm elevated. Later a small opening was made in the rubber tissue through which the boric acid solution was fre
* Read at the fourth annual meeting of the C., M. & St. P. Railway Surgeon's Association, at Chicago, November 1896,
quently applied for forty-eight hours. There was an astonishingly small amount of tissue devitalized, consisting mainly of shredded tissue and small islands in the dorsal integument, and although moist dressings were continued until these were all thrown off, the wound rapidly closed with the exception of two sinuses, through which small pieces of necrosed bone were discharged, and to-day (five months after the receipt of the injury) the patient has a useful hand. The metacarpophalangeal articulations admit of full motion; the phalangeal joints are partially ankylosed, but the function of the thumb is perfect, and he can pick up the smallest objects between the thumb and any finger, grasp and use a knife or fork, hammer or chisel, and easily handle the levers of his engine; in fact, his left hand is of more use than his right, and a more grateful man it would be hard to find.
I report this case because it is such as this that we, as railway surgeons, are constantly meeting, and because I believe that our usefulness as railway surgeons is enhanced far more by our ability to save, or our custom to attempt the preservation of the function of a hand or finger, or even the part of a finger of one of our unfortunate brakemen, than in our readiness to perform any of the rarer major operations, or even in our ability to remove a slightly reddened and inflamed appendix, through an inch and one-half incision, from the abdominal cavity of our division superintendent. In adding my modest plea for my modest plea for such extreme conservatism in the treatment of these injuries as to amount practically to the abolition of all primary amputation of the hand or fingers, I am well aware that I am thrashing over old straw, so long has it been the approved rule of action to conserve every part of a hand possible in all whose principal occupation was that of manual labor. Much has been written lately advocating conservatism in the surgery of such injuries, in which, a few years ago, it was but a question of when and how much to amputate. Prominent among the advocates of this newer and better surgery is our worthy secretary, who not later than May last, read a most interesting and instructive paper at the annual meeting of the National Association of Railway Surgeons, at St. Louis, which was discussed in a manner so agreeable that one would be
led to infer that such primary amputations were exceedingly rare; but notwithstanding all this and despite all that has been said, and all that has been written, hands and parts of hands continue to be primarily amputated. Nor is the reason far to seek. Our passionate ardor in the pursuit of primary union in nicely coaptated flaps; our modern dread of even the semblance of suppuration; the exaggerated significance of lengthened temporary disability; our everpresent apprehension of stiffened joints and crooked fingers, whose owners, traveling about on wheels are ever ready and willing to exhibit with anathemas for the doctor that "did not set it right," and the consequent subtle consciousness that amputated members, like devitalized humanity, tell no tales each and all tend to sway us just a little toward the knife. And we are many of us conscious of the fact that we have not always given that benefit of the doubt to the injured little member which our experience, often the result of provoking obstinacy on the part of our patient, has demonstrated might profitably have been done.
If then we are to defer the amputation of these mangled members, what shall we do? What do we seek to obtain? The prevention of sepsis and the restoration in whole or in part of normal function. Schimmelbusch says that there are three conditions favorable to the infection of wounds: (1) The presence of blogd. (2) The collection of wound secretions. (3) The presence of loose or badly nourished pieces of tissue. Now all of these conditions we have exemplified in a mangled hand, and more often, yes, nearly always, we have the presence of septic foreign bodies; so that our treatment to be safe, must be that of an infected wound; it must not only be aseptic, but it must be antiseptic. And while Zimmerman has demonstrated that it is not possible to sterilize with certainty pieces of flesh that have been momentarily contaminated with micro-organisms by a contact of five minutes with a I-1,000 sublimate solution, he also has shown that the intensity of the infection was very much lessened by a marked diminution in the number of colonies, and that they took a much longer time to appear. If this is true, then post-traumatic antiseptic applications, if extremely bland and long continued, must materially assist in the destruction of these
colonies by the antiseptic salts of the blood serum or the continued attacks of the phagocytes. So, then, while our treatment must be antiseptic, it should be by the use of only the mildest of solutions, for we must not forget that while the rendering of the wound aseptic is perhaps of paramount importance, almost equally so is the restoration to vitality of doubtful tissues, and at a time when histolysis or revivification trembles in the balance, any irritant, be it never so mild, may turn the scale the wrong way. Under all these conditions, we believe that the ideal treatment of these injuries would be by the continuous submersion in a constantly changing current of a physiological salt solution, and while this may savor more of a mechanical than of chemical antisepsis, the former is of far the more importance; but sodium chloride is by no means an impotent germicide, and certainly one of the earliest known antiseptics. But unfortunately the ideal is not always the most practicable, and perhaps all things considered, the most satisfactory results are obtained by continuous antisepsis in the form of the antiseptic gauze poultice, thoroughly moistened and frequently changed. I care not what particular antiseptic you use; boric acid, carbolic acid, creolin, lysol, acetate of aluminum, or one of the newer silver salts so highly recommended by Crede, but whatever you use, let it be mild. How mild some of these solutions may be and yet be potent, Prudden has shown us by ascertaining that the growth of the staphylococci may be completely stopped by corrosive sublimate in the proportion of 1-300000, boric acid 1-800 and carbolic acid 1-850. In our little hospital we have for years habitually used a saturated boric acid solution, but a very much weaker one would undoubtedly answer equally well and possibly better. These poultices are by far the most grateful to the patient, for with these and a well-elevated arm he will be almost free from pain. And right here I wish to say, that the doctor who dresses a lacerated finger by thoroughly irrigating with his favorite antiseptic, dusting it with sterile iodoform, covering with gauze, and over all neatly applying with beautiful reversed turns a roller bandage, never himself had such an injury similarly dressed, or if he did he howled all night or until his good mother removed the dry dressing and put on a nice warm flaxseed poultice.
Dry dressings have their places, iodoform is a useful drug, but together they were never intended for the primary treatment of lacerated and contused wounds.
After forty-eight hours of such continuous disinfection, when all probable danger of primary infection has passed, we may attempt such permanent adjustment of tissues as may appear most conducive to the restoration of normal, or as near as may be, normal function. Wholly devitalized members should be removed and sloughing pieces of tissue clipped off a line or more below rather than above the apparent line of separation, for the presence of necrotic tissue, while implying the presence of saprogenic bacteria, does not necessarily include the presence of any pyogenic cocci, or hinder an aseptic healing of the wound. Fractured bones must be reduced, and even when badly comminuted these may be maintained in fair apposition by simply bundling by interrupted bands of silk, silver wire or any slowly absorbable material. Open joint capsules should be reunited, severed tendons spliced and attached to the periosteum or into the flap itself. We should not sacrifice even the proximal phalanx until we have attempted this, and you will often be surprised at the amount of function restored, and if not, there is plenty of time to amputate later through healthy tissue that will give us but little trouble and but short disability.
If in spite of all we can do infection follows, particularly that dreaded phlegmon so prone to attack the hand, continuous submersion and free drainage is our only hope; and disregarding our anatomy, especially that of the palmar arches, we should make our incisions full, free and frequent.
I offer an apology, gentlemen, for offering a paper containing nothing new, and having, perhaps, not even the merit of brevity; but we are an association of local surgeons, the actual workers in the surgical department of our great railway, and it is to you, in behalf of the mangled hand, that I appeal for delay. Unfortunately, perhaps, all things considered, the vast majority of our accidents do not occur before the doors of our great hospitals, presided over by the accomplished chief surgeon or by those princes of railway surgeons, members of the American Academy of Railway Surgeons; and while with them we all agree,
that: "The higher the order of railway surgery the greater the protection to the employe, the passenger and the company," we want this high order of railway surgery to extend all along the line and wherever the red lights flash, and wherever that lowly but ever conscientious worker, the local railway surgeon, is to be found.
CONSERVATIVE SURGERY OF THE
BY W. B. JOHNSON, M. D., SAVANNA, ILL.
It is not my intention to call to notice anything essentially new, nor to make any pretentious claims. It is my intention, however, to renew suggestions already made bearing on the subject of conservative surgery of the hand, that most useful member, every part of which is of inestimable value to the possessor. The first point I wish to make is that in my opinion all injuries occurring between the cars or on the track are necessarily septic and in these cases the railway surgeon cannot practice aseptic surgery. Soap and water, the saline solution, sterilized water, etc., will possibly be all sufficient in some clean cases; but where we have a contused, lacerated wound, with the parts begrimed with grease and dirt and cinders. ground into its innermost recesses, to insure against suppuration and secure primary union. we must not only scrub thoroughly with green soap and water but should use carbolic acid and bichloride freely. Consider the paramount importance of absolute asepsis in cases of conservative surgery where doubtful tissues finally diappoint us by sloughing.
If asepsis is complete a line of demarkation will form and the slough be exfoliated without any injury to the general wound; while if incomplete and a pus infection is mixed with the decomposition of the necrotic tissue the whole wound is in a most deplorable condition. Along those lines of sutures, where, at our first dressing, we saw such kindly primary union, at our second or third dressing we find a profuse suppurative discharge, with gaping of the wound and a subsequent pulling out of sutures-a condition remedied only
Read at the fourth annual meeting of the C., M. & St. P. Railway Surgeon's Association, at Chicago, November, 1896.
by a complicated system of adhesive straps, giving a long, tedious recovery, or necessitating a secondary operation.
I wish to speak particularly to-day of the case of a freight conductor, 33 years of age, who was injured in the Savanna yard April 23, 1896, while making a coupling. He had a severe contusion and laceration of the left hand through the metacarpus. The skin and subcutaneous tissues were torn from almost the entire area of the back of the hand, completely baring all of the extensor tendons. The wound in the integument reaching from the wrist joint down between the ring and middle fingers, was draged open the whole width of the hand. But the part which sustained the greatest crushing force was that between the thumb and the metacarpal bone of the middle finger. The thumb happily escaped much severe bony lesion by being dislocated outward from the carpo-metacarpal joint. The metacarpal bone of the index finger was literally crushed to fragments, while the skin, which was lacerated transversely from the longitudinal tear, down onto the index finger, was pushed toward its extremity as a cover would be pushed off an umbrella, if you will allow the comparison. A drop wrist in the opposite arm, from a former injury, very much impaired the function of that hand and extra effort was made to get as good a recovery as possible. After thorough preparation the index finger was amputated and its metacarpal removed; the thumb was then crowded over into the space made vacant by the removal of the metacarpal, reducing the area necessary to cover with flaps. Notwithstanding this fact, however, it was found that great tension was required to draw the skin surfaces into apposition. To reduce tension as much as possible the hand was dressed in a position of hyper-extension at the wrist. A large aseptic dressing was applied, moistened with a warm borolyptol solution and the patient sent to his home in Dubuque. At this time I really expected a great deal of sloughing of those contused flaps. Dr. Staples of Dubuque dressed the hand soon and, as everything was doing well, put on a dry dressing. Dr. Staples I think, dressed about once a week. There was no discharge but the margins of the flaps were necrotic. I next saw the hand two weeks after the injury; the sutures still remained and
were not disturbed; the wound was entirely dry and I redressed with boric acid powder. Now comes what I consider the most peculiar feature of this case; from the first with that line of sloughing along the wound there was no pain, no suppuration, nor any untoward symptom. The necrosed area seemed to undergo a sort of mummification and shrunk up with the sutures, still remaining from April 23 until June 8, over seven weeks, when the man come down to Savanna, and I saw that the dead tissue could be easily removed. This I did, revealing a nicely granulating surface beneath, which I dusted with protonuclein (special powder) and it healed rapidly. The man went to his work August I with a hand which will be very serviceable and in which, with the exception of one small point, there are no adherent tendons.
This case, I think, shows exclusively what can be done with integument, even when every indication is toward extensive sloughing. I believe that when an endeavor is made to save a portion of a member we should not remove anything which has the minutest chance of regaining its vitality, but should put on moist warm dressings and give it an opportunity to take advantage of that chance; and further, when amputation is necessary about the fingers or hand make such amputation without the slightest regard for methods if need be to secure for the patient the best result.
How often scraggling pieces of tissue that have escaped or withstood the severest part of the traumatism, and that the surgeon is tempted to trim off with the scissors, can be folded over, adjusted one with the other and make an astonishingly good flap to cover the end of a protruding bone, thereby lessening the patient's loss. I remember a case in which I amputated the thumb and index finger through their metacarpals and made an attempt to save the middle finger, but failed and was obliged to amputate on the second day, but that delay was invaluable as it not only showed the certain loss of the middle finger but enabled me to save the integument of the outer side of the finger from base to tip, which I lapped over to take the place of a large portion of the flaps covering the thumb and index stumps, lost by unexpected sloughing. The patient after recovery having sensation as in the tip
of middle finger when stimulation was made over the thumb stump. While I advise not to trim off scraggling pieces of flaps it is most essential to trim the edges of all retained integument thoroughly, thereby converting a contused and lacerated wound as much as possible into one of an incised nature.
Skin grafting, I think, may be employed much more commonly than at present and oftentimes the pedunculated skin-flap from the chest or other accessible part will render a hand useful which, without it, would be hopelessly crippled by cicatricial contraction. I think that if we cannot save a hand we should try to retain any part of it; even if it is no more than a portion of a finger on the end of a stump it is worth a great deal to its possessor. Everything considered, I believe that, in the hand, where every inch is so valuable, we should always take advantage of the doubt, if it exists, and a reasonable amount of waiting and moist dressings will often bring forth wonderfully satisfactory results, although requiring more work and care on the part of the attendant.
DISCUSSION OF THE PAPERS OF DOCTORS JOHNSON
Dr. Marks: Both papers, I think, are very important and very interesting. I am very much pleased when I can save a hand. A case came under my observation about ten years since, where a little boy was playing with a lawn mower, and had his finger cut off. The mother went out and picked it up. By the time I got there, of course it was pretty cold. I put it in warm water and put it on as soon as possible and to my surprise it held. That shows something of what we can do with the hand. I am glad to see that conservative surgery is a thing that is receiving attention at the present time. As has been stated, every particle, every eighth of an inch that can be saved, is of great benefit to the possessor.
Dr. Garlock: Conservative surgery is one of the finest things, possibly, that railway surgeons can adopt, but there is such a thing as carrying conservative surgery too far; that is, great judgment is necessary in knowing what conservative surgery consists in. A couple of years since I had a case of a brakeman in the yard at Racine who, instead of setting the brake, attempted to stop the car by pulling a