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you have such an article at hand. The patient is to be moved about as little as possible. Unnecessary handling, moving, changing the clothes, etc., only tend to increase the exhaustion. Heat must be applied to the whole body if possible. Roll the patient up in hot blankets, or give him a hot bath if you have the conveniences at hand. Make use of bottles filled with hot water; in fact, anything productive of heat that can be gotten hold of. The two important points at which to apply heat are the region of the heart and the pit of the stomach. In making the application great care must be taken not to burn the patient, for in this condition he would not feel pain even were the amount of heat so great as to severely burn him. At the same time you may give him or her, as the case may be, hot drinks, with whisky or brandy added, but in small quantities, and repeated often. The proportions may be, say, a teaspoonful of brandy or whisky to a tablespoonful of hot water, which may be given every ten minutes. Or what I consider the best of all is aromatic spirits of ammonia; a teaspoonful to half a tumblerful of water and give a little at a time until the surgeon arrives.
A broken bone may be recognized by the occurrence of pain, of deformity, of bending where it ought not to bend, and of a sound and feeling of grating at the point of fracture. A fracture may be partial or complete, transverse, oblique or longitudinal; single, double or multiple; simple, comminuted, compound, compound and complicated. A partial fracture occurs when a bone breaks, or splinters on one side (its convex surface) and bends on the opposite (green stick fracture). A transverse fracture, or one in which the line of cleavage is, in general, at a right angle with the axis of the bone, is rare as compared with the oblique. A longitudinal fracture is a split in the long axis of a bone. It is frequently caused by penetrating wounds (gunshot), or may result from a fall with great violence upon the hands or feet when the cleavage commences in the articular surface. A single fracture is one break in one bone. A double fracture is a solution of normal continuity in two bones of one member, as the radius and ulna, the tibia and fibula. Multiple fracture is a term ap
plied to two or more separate breaks in one or several bones.
When a bone is broken in one direction, and at one point, without injury of any surrounding organ or perforation of the skin, it is termed a simple fracture. If there are more than two fragments it is a comminuted fracture. If any part of the fractured surface communicates with the atmosphere it is a compound fracture; and if it communicates with a joint, or involves in the fracture the wound of any important organ, as a large artery or vein, or as in the fracture of a rib, occasionally the pleura or lung is wounded, it is a complicated fracture. An impacted fracture is one in which the fragments are splintered and interlocked with more or less complete immobility.
A fracture may be caused by external violence, directly or indirectly applied, or by muscular action, or both factors may unite in the production of the lesion. As an example of direct violence in the effort to ward off a blow from the head, the ulna may be broken by the force of a cane immediately beneath the soft parts. A blow on the vertex which fractures the base of the skull or a fall on the foot which breaks the femur are common examples of fracture from indirect violence.
Contraction of the quadriceps extensor muscle may fracture the patella, or the same lesion may result from a fall on the knee, in which the direct violence and the action of this powerful muscle unite to cause the fracture. The bones of the aged break more readily and are slower in repair than those of the young and middle-aged. The bones of the right side are more frequently broken than those of the left. During childhood the frequency of fractures in males and females is about the same. During middle age it is ten times as great in males as in females. Between the ages of 50 and 70 years the difference is slight, and after the age of 70 years fractures are more common in females than in males, those most frequently met with at that age being fractures of the neck of the femur. Fractures are most numerous in children under 10 years of age.
Symptoms. The symptoms of fractures are loss of function or use, absence of normal contour and crepitus. A broken bone which is not impacted no longer acts as a support, or sustains muscular contraction. The natural
shape or outline is more or less distorted by displacement and overlapping of the fragments. Careful manipulation will determine the overriding, measurement will show shortening, while comparing it with the uninjured side will determine the degree of the injury. Crepitus, which is not always necessary to correct diagnosis, is the sensation imparted to the touch, and occasionally recognized by the ear, when the rough fragments are moved so as to grate upon each other. The diagnosis of the impacted fracture is more difficult, since crepitus and mobility are absent. Shortening must of necessity exist, which, with partial loss of function, and more or less pain and thickening at the point of fracture, will lead to the recognition of the lesion. A longitudinal fracture or fissure is often with difficulty recognized and may escape detection.
Process of Repair.-The first and immediate result of a fracture is hemorrhage, which occurs from the arteries, capillaries and veins. As a result of the irritation, determined by the accident and hemorrhage, inflammation follows. If the broken ends do not come in contact with the air, that is, if the fracture is not compound, the process of repair in bone after the injury is similar to the physiological process of development of this tissue, namely, the embryonic tissue is developed into cartilage. cells, and these undergoing proliferation develop into a secondary embryonic tissue which is formed directly into bone. If, however, air is admitted to a wound in a bone the process of ossification in the embryonic tissue is more rapid and direct, since the intermediate stage of cartilage cell formation does not occur.
A portion of this new formed issue, which results from irritation following a fracture, undergoes a process of calcification by the absorption of inorganic material from the blood, and is then known as callus.
That portion which lies around and on the outside is the ensheathing callus; between the fragments the intermediate.
In connection with this subject I wish to say a few words about fractures of the skull, injuries which so many railroad men receive by falling from the tops of cars, especially when the roofs are slippery and covered with ice. The bone of the skull may be fractured by direct or indirect violence. Direct when the bones give way immediately beneath the
point which is struck; indirect, as when by falling from a height and striking on the feet or buttocks the base of the skull is fractured by the force transmitted through the vertebral column. A number of years ago I had a case which is worthy of mention, and perhaps many of you may have heard of it. A night watchman was employed on the N. Y. C. & H. R. R. R. in the lower yard at Utica. His name was Christian Slaper. While going his rounds among the freight cars he suddenly came upon a party of tramps who were breaking into a freight car. They turned upon him and with a hatchet struck him on the head, crushing in the skull for a space of about two and one-half inches in diameter. He laid insensible for over an hour and finally was found by some of the yardmen about 2 o'clock in the morning. They placed him on a handcar and brought him to the depot. When I arrived I found him unconscious and bleeding very profusely. I took him to his home on Water street and washed out the wound with an antiseptic solution, after which I cut down and removed several pieces of the bone. In the course of a day or so he became conscious and related to me the whole affair up to the time he was struck on the head.
Strange to say, before the wound healed at least two or three tablespoonfuls of the brain substance sloughed out. He made a splendid recovery and is alive and well, or was the last time I heard from him, which was only a few days ago. He is now about 75 years old.
A sprain is a wrenching or twisting of a joint, associated with considerable stretching and even tearing of the tendons and ligaments of the affected parts. Sprains usually occur at the ankle or wrist. Pronounced swelling and pain rapidly follow and are characteristic of the injury, though it is often difficult to tell the difference between a sprain, dislocation or fracture. The proper relation of the ends of the bone composing the joint, and the absence of the principal signs of dislocation or fracture, indicate that a sprain exists. A sprain is always troublesome and may be followed by severe results, a common sequel being anchylosis or stiffness of the joint. Sprains are sometimes quite trifling injuries and require no treatment but a little rubbing or a little
rest. At other times sprains are more serious and require as careful treatment as do fractures. In all forms of sprains rest is the most important thing to be secured, and after this comes moist heat. To secure rest a bandage will sometimes do, or a sling, or both. The ankle or foot may be helped by having a neatly folded towel, folded again, so as to make a sort of a rough splint, and placed around it before the bandage is put on. Besides this mode of treating sprains, wooden or other splints may be used if necessary and convenient. In sprains of the wrist, the hand and the forearm, the injured part may be laid on a straight splint, covered with cotton, wool or waste, so as to make the surface soft, and be lightly secured to it by means of a soft bandage or broad strips of sticking plaster. One of the bandages should be around the hand and one or two around the forearm above the wrist, not over it. The bandage should cover all. Sprains of the ankle should never be treated lightly. Accompanying them there is not infrequently a fracture of the inner surface of one of the leg bones that form the ankle-joint. This complication gives rise to so much trouble and requires so much skillful and patient treatment that it has come to be believed that it is better to have a broken leg than a sprained ankle. The general principle, however, in the case of a sprained ankle is, first, to put the joint at complete rest, then to allay inflammation if it arises, and afterward to promote the absorption of inflammatory products. For the first a splint and bandage usually suffice; for the second, application of hot water; for the third, friction and kneading the joint, with careful motion of it, and alternating hot and cold douching. Nerves, too, are not infrequently bruised, the injury resulting in numbness and loss of power of the parts below the joint, and in obstinate neuralgia. The ankle and wrist joints are sprained most frequently, and this is due not only to the freedom of their movements, but chiefly to the relations which they hold to locomotion in one instance and to self-defense and protection in the other. The knee-joint is less frequently sprained than one would suppose from the knowledge of its relation to the weight of the body and to the leverage of the extremities, in which function it forms. a most important adjuvant.
A contusion is a surgical injury other than fractures or wounds proper in which the skin remains intact. If there be a solution of continuity of the skin also the termed contused wound is used. Contusions are what are usually known as bruises. They are sometimes very painful and are often followed by discoloration due to the escape of blood under the skin from the small vessels of a part. A "black eye" is a familiar example of an injury of this sort. Contusions of the chest or abdomen may be very serious; for, besides the external bruises, important internal organs may be injured. Evidence of this may be seen in the spitting of blood or vomiting, or the passage of blood from the bowels or bladder; or there may be great depression. In such cases little can be done by the non-professional man beyond securing complete rest and sustaining the strength of the sufferer by means of warmth applied externally and careful stimulation internally.
Many railways, and especially those throughout the western and southern country, have a case completely equipped with necessary instruments, needles, dressings, roller bandages and appliances, with printed directions as to the care of injured persons. These cases are generally placed in charge of the conductor or foreman, who keeps it in his train box and is held personally responsible for the same. The following list of articles would answer all purposes in almost any emergency case until the arrival of the surgeon, and the latter, if he comes, as many times he does, empty-handed, can use the same:
4 ounces whisky.
6 ounces ichthyol ointment.
I pyramid of pins.
I dozen large safety pins.
6 sizes silk thread.
The first thing to do in case of an accident is to place the injured person in as comfortable a position as possible. Loosen the clothing so that the breathing may be free and keep him
Dislocations will be known by the deformities about the joints; wait for the surgeon to come and he will set them.
Sprains. Apply either hot or cold water and keep the joint quiet.
Fractures can be readily known. Compare with corresponding limb of opposite side and place it in a position as nearly like it as possible. It can be held in place by a bandage, with strips of bark, pieces of shingle, or a blanket folded and rolled tightly around it and tied on with strips of cloth. Always place the fracture in a position to give the least pain.
For bleeding.-Raise the limb; wash clean; if the blood comes in bright red jets apply the straps above the bleeding points just tight enough to control the flow.
Caution. Do not draw the strap too tight, as it will cause useless pain. If the blood is dark colored apply cloths wrung out of hot water, or a firm bandage. Elevate the limb. You can use the fingers for compression in the wound if necessary.
Dressing.--Wash every break of the skin with hot water, if possible; then apply gauze or some other clean cloth in layers of three or four thicknesses, held by a bandage, and notify the nearest convenient company's surgeon. If the injured man feels faint and weak lay him with his head low and give him some hot drink. Coffee is one of the best; brandy or whisky if necessary, but do not give too much.
Dr. Samuel H. Pinkerton has been appointed chief surgeon of the Oregon Short Line, with headquarters at Salt Lake. Dr. Pinkerton is one of the leading physicians in Salt Lake City and a most excellent surgeon.
THE NURSING OF THE EYE AFTER INJURIES AND OPERATIONS.*
BY CASSIUS D. WESCOTT, M. D., CHICAGO. Instructor in Ophthalmology at Rush Medical College; Ophthalmologist for the C. M. & St. P Ry., etc.
It is often said that it is impossible to do an absolutely aseptic operation upon the eye, and this is true, because the conjunctival sac constantly contains numerous micro-organisms which it is impossible to completely remove or destroy with safety to the tissues of the eye. These facts, however, instead of relieving us from the necessity of observing any of the usual precautions in the treatment of wounds, make it even more important that we exercise most scrupulous care in regard to the surroundings, the instruments, the hands and the dressings, in order to limit as much as possible the number of germs which must necessarily come in contact with the eye and be taken care of by nature's own germicidal processes. As we are all obliged to act as nurses as well as physicians in the care of many of the eye patients which fall into our hands, and as we must always instruct even the most thoroughly trained nurse in the methods which we wish to have employed, I have thought it might be well to discuss together to-day some of the details of ophthalmic nursing.
There is probably no part of the body which will stand relatively more traumatism without loss of function than the eye, and yet the neglect of any detail in the management of an operated or diseased eye may result in infection and the loss or impairment of vision. We must never forget that corrosive sublimate, carbolic acid and other antiseptic agents, which are well borne by other tissues of the body, act as powerful irritants to the conjunctiva and cornea, exciting inflammation and destruction of these delicate tissues. In my own work I have practically discarded all antiseptics, save boric acid, in the preparation of the eye for operation, and in cleansing it at subsequent dressings. Possibly the thorough use of sterilized water would give me equally good results, but I believe that a saturated, sterilized and filtered solution of boric
Read by title at the fourth annual meeting of the C. M. & St. P. Railway Surgeons' Association, held in Chicago, Nov 12-15, 1896.
acid is less irritating to the eye than pure sterilized water.
In the preparation of the patient for operation, for cataract, for instance, I have the face thoroughly scrubbed with soap and hot water, especially the eyebrows and lids and the nose; I then have the patient wash the face again with plain water as hot as can be borne, and have the nurse pin a sterilized towel snugly over his hair. After he is upon the table I flush the conjunctival sac several times with boric acid solution, preferably at the temperature of the body. If, however, I am to dress an injury to the lids in a railroad man, for instance, who has fallen from a train and struck upon the face, filling the skin with cinders or dirt, mixed perhaps with oil and other things, it has been my custom to apply a hot fomentation, made by dissolving in boiling water borax or sodium carbonate in the strength of 1 or 2 per cent. After fomenting the parts for ten or fifteen minutes, it is usually possible to cleanse the skin thoroughly by gently scrubbing with the same solution, followed by a flushing with bichloride solution 1-5000. Instruments are best sterilized by boiling in a 2 per cent. solution of sodium carbonate, but I am content to sterilize the knives and scissors by simply pouring upon them boiling water, and then transferring them to alcohol, where they are allowed to remain several minutes, or until needed for the operation. It is certainly much safer to boil our forceps, needle-holders, specula and other complicated instruments, and we should certainly thoroughly scrub and boil all of these after they have been used about an infected
Even though our fingers do not come in contact with the parts operated upon, we should be as careful in cleansing the hands before operating or dressing an eye as if we were about to go into the abdominal cavity. I am content to thoroughly scrub my hands. with soap and very hot water, using a stiff brush before and after cleansing the nails with a knife, and then thoroughly rubbing the hands, and especially the fingers, with alcohol.
The bottles which are to contain my cocaine solution, the atropine solution and the saturated solution of boric acid are cleansed by boiling for fifteen minutes before being filled. The pipette, or dropping tube, is sterilized
with the instruments each time before being used in an operation, and in the subsequent dressings, and after a dressing is no longer needed, it is thoroughly cleansed with hot water each time before and after being used. In my office I keep a number of pipettes constantly immersed in a 1-1000 solution of formalin, a comparatively new antiseptic agent, which is acquiring such great favor that perhaps a few words in regard to its use in eye surgery may not be amiss.
It is unquestionably a safe and efficient agent if properly used, but like all other powerful antispetics it has its own disadvantages. It can safely be used upon the eye in a strength of I-1000, and in such a solution is more efficient, perhaps, than a saturated solution of boric acid, and less irritating than the bichloride solutions. In the strength of 1-100 it acts as a cautery, and is an efficient application for infected ulcers and suppurating wounds of the cornea, but its application must be limited to the exact spot where its effect is desired. If used for the sterilization of instruments, which, by the way, it does not tarnish or discolor, it may be used in a strength of 1-200 or 1-500. Personally I do not use it for the sterilization of instruments, for the reason that it is a very penetrating agent and quickly hardens the skin of the fingers, making them rough and less sensitive.
For sponges I use suitable pieces of lintine moistened with boric acid solution. Silk for sutures is sterilized by boiling and kept in strong alcohol. I prefer the "iron dyed" silk. Kangaroo tendon, which I have used a great deal, is sterilized in the manner so often described by Dr. Marcy, and preserved in alcohol.
In regard to the materials for dressing, I would say that I have found borated gauze, borated cotton and lintine, purchased in original packages from reliable manufacturers, and subsequently well cared for, to be perfectly reliable and sufficient for all our needs. After smoothly closing the lids over an operated eye, I am in the habit of covering them first with a single layer of lintine or borated gauze moistened with boric acid solution, and then applying over this sufficient fluffy borated cotton to fill the concavity of the orbit, and over this a bandage of white mosquito netting, saturated with hot water. Such a