were loosened the nurse always held the fragments while massage was given until union took place. After four weeks union had progressed so far that the splint was loosened from the leg and slight passive motion attempted. December 4, seven weeks after the accident, the splint was removed altogether, and the patient allowed to stand on his leg. December 12, two months after the injury, the patient went to his home able to walk with the assistance of a cane, although when going out he used a pair of crutches for safety's sake. The patient was able to bend his knee to about 30 degrees without discomfort. The union is very firm, I purposely refrain from saying bony, as most writers seem to doubt that bony union ever takes place without wiring; in this case the union is certainly very firm, but undoubtedly too short a time has as yet elapsed to speak of positive results.

To recapitulate, I beg to call your attention to what I consider the advantage of the advocated dressing. 1. It can be very easily made and applied.

2. It holds the fragments firmly in place and the same can be gradually brought together as the swelling subsides.

3. It allows of frequent inspection and treatment of the fracture and knee-joint.

4. It does not interfere with the circulation and consequently with the process of repair.

COMPOUND FRACTURES OF THE FOOT.*

BY DR. G. G. COTTAM OF ROCK RAPIDS, IOWA.

The ordinary methods of treating open fractures as determined by the trend of modern enlightenment are now so fully set forth in the textbooks and have formed the basis for so many discussions in the societies that it is quite unnecessary to recapitulate them now. The object of this paper is only to lay stress upon a method of dealing with severe cases when the more commonly utilized procedures fail to control infection.

The great necessity of saving as much of the foot for a workingman as possible, and the fact that these injuries so often occur among the working classes, render it imperative that we make use of every method which seems to give promise of success, before resorting to amputation. The surprisingly good functional results which may follow severe crushing injuries when most of the foot is thus saved shows what can be done, but there is a disposition among surgeons to incline to the belief that a smooth, well-formed amputation stump of the foot is more useful to the patient than an entire extremity after a severe injury. Moreover, there remains, too, that traditional regard for classical forms which impels us to needlessly sacrifice tissue to make a pretty operation after the lines laid down by Lisfranc, Hey, Chopart and others, when the welfare of the patient would be much better subserved did we remove only the absolutely necessary. I trust that the time will soon arrive when the use of ready made methods of amputation will be as obsolete as the use of ready made splints is becoming. Especially does this apply to the foot, where cosmetic effect can be totally disregarded and all effort put forth in the direction of the salvation of the greatest amount of tissue.

* Read at the ninth annual meeting Iowa State Association of Railway Surgeons, Des Moines, October 22-23, 1902.

The greatest difficulty in the successful treatment of compound fractures of the foot is in the direction of the control of infection. I use the term "control" advisedly, for, as I have stated elsewhere, I look upon all accidental, open wounds as infected from the start, and drainage in some form or other cannot safely be dispensed with in any case. Generally it will be found that ordinary tubular drainage, using large caliber tubes, will satisfactorily answer the purpose, but if there has been extensive contusion of the tissues, offering the greatest facility possible to the development and propagation of infection, I have found the use of continuous irrigation with weak antiseptic solutions or even normal salt solution effective when previously an amputation had seemed imperative.

This is, of course, no new suggestion, but I find that few realize its utility in these cases and under these circumstances I trust that I may be pardoned for emphasizing its importance.

The technic is simple. To secure the best results the tube should pass entirely through the foot and be liberally provided with fenestra. The inlet end is connected with a large fountain syringe or irrigator containing permanganat solution 1-10,000 and the tube partly compressed so as to cause the solution to flow very slowly. The foot can rest on a rubber sheet or a Kelly pad, to permit the solution, after flowing through the foot, to be conducted to a basin on the floor without soiling the bedding. In this way the irrigation can be continued for

hours at a time.

The accompanying photographs, which I shall pass around, will show a recent case treated in this manner. They are both taken from the same case on the same day, twelve days after the receipt of the injury.

DISCUSSION.

Dr. Babcock: I am very much interested in this paper of Dr. Cottam's, and while the remarks I would offer upon it would perhaps be more germane to Doctor Knott's

grene. I found an old alcoholic, who had had his foot badly crushed and cut off by the train. The doctors had amputated it just below the knee, but he had gangrene and they then operated above the knee. When I arrived. I saw that the edges of the flaps were badly discolored and it looked as though the whole was going to slough out. In fact, it was so bad I would have felt justified in a third operation had the man had sufficient vitality. But it was painfully evident the old drunkard could not stand any more surgical intervention-and then it was in a

terribly unsanitary place-and we rigged up just such an affair as Dr. Cottam suggests and kept up continual irrigation for about six days and got good results. As I say, I offer this, because I understood Dr. Knott took the ground that we should not be applying solutions to these wounds. As an antiseptic we used permanganat of potash most of the time.

Dr. Knott: I did not intend to discuss this paper, but I suppose I have to now, Dr. Babcock misunderstood me. The impression I tried to convey was that we should not apply chemicals. I believe the effect secured from irrigation is mechanical. I believe that the benefit we get from the use of permanganat of potash, bi-chlorid of mercury, or any other solution in these wounds, is from the water. As I have stated, it is an absolutely well-known fact that there is no solution which you can introduce in tissue which does not create superficial cell necrosis. We also know that these solutions act under laboratory conditions much more satisfactorily than they do in the wound.

I believe as fully as Doctor Cottam or Doctor Babcock in irrigating and washing out infected wounds, but the difference between us is the nature of material, or irrigating fluid to be used. When we douche these wounds with chemical solutions, we lower the resistance, and believing that the benefit of irrigation is mechanical, I use the salt solution as the ideal.

Dr. Cottam: I have not much to say in regard to the point brought out by Dr. Knott. I never knew a wound. yet that did not have some superficial cell necrosis; the trauma in the first place produces cell necrosis. Of course, I can understand his reasoning, and I am very much opposed to bi-chlorid or any of these chemicals; I have always been against the use of strong antiseptic solutions upon denuded tissues. I cannot, however, admit that any possible harm can accrue from the use of normal salt solution, or weak permanganat and the results I have obtained encourages me to believe that great good can be accomplished thereby.

POTT'S FRACTURE.*

BY E. C. MC MEEL, M. D., OF DELLMAR, IOWA.

This is one of the classes of cases we are very often called upon to attend, as it frequently happens from jumping off the cars or other ways.

On Sept. 29, 1902, I was called to see W. H. R., age 30, who was driving home when his team became frightened, and ran away. Seeing he could not control them, he jumped. It was dark, and he could not see where he was going to alight, just as in jumping from the cars.

I found him suffering a great deal of pain. He said he had lit on something, and his foot turned with him. I wanted to give an anesthetic, but he said he would not take any. I told him unless he did I would not be responsible for the results, but he said, No! I proceeded to make my examination, and found the ankle badly swollen and dislocated, with fracture of the external malleolus and eversion of the foot. I could not satisfy myself as much as I wished, as we cannot be too careful in these cases. I proceeded by grasping the toes with my *Read by title at the tenth annual meeting C.. M. & St. P. Ry.. Surgical Association, Chicago, December 18-19, 1902.

right hand and the heel with my left, and made extension, while one of the bystanders made counter extension. I reduced the dislocation and brought the bones in apposition. Perforated tin splints padded with cotton were then applied, which held the parts in position for several days. After the swelling had subsided I applied a plaster-ofParis bandage, which was left on for three or four days, when it was removed, as he complained of pain and burning.

I found nothing wrong, so it was replaced with another, which was left on for four weeks, and then left off with good results. There is very little impairment of motion. The parts were supported with a roller bandage for several weeks after. He is now walking without a cane.

REMARKS ON INJURIES OF THE SPINE AND CORD.*

BY HUGO PHILLER, M. D., OF WAUKESHA, WIS.

When I selected "Injuries of the Spine and Cord" as the subject of a paper for this association, I had a double object in my mind; first, that I knew mighty little about it, compelling me to read up, and second, that as a railway surgeon I may at any time be called before the courts to give evidence in damage cases, and that it behooves us all to be well posted in the matter. I hope that by an extended discussion the defects of my feeble efforts will be duly criticized and that by such criticisms we all may learn lessons of untold value. Even Thomas H. Manley, in his valuable essay, read before the Mississippi Valley Medical Association, October 15, 1902, says:

"No serious effort has yet been made by an American author to classify the pathology, to elucidate symptoms, or establish differential diagnosis in this important group of traumatisms."

Time will not permit me to give the histologic anatomy of the cord and its envelopes. There are, however, some features of the gross anatomy, and of the relations of the cord and its investments, which are of importance in the consideration of the subject and I beg leave to describe them briefly:

The spinal cord, with its investing membranes, is situated in and protected by a canal in the vetebral column. This spinal canal is made up of 26 rings, which when articulated together and firmly connected by the various. vertebral ligaments, form the osseo-ligamentous canal extending from the foramen magnum to the sacrum. The walls of the canal are formed by the bodies of the vertebræ in front, the pedicles, transverse and articular processes laterally and the laminæ and spinous processes behind. The bodies form the principal bulk of the vertebral column and are united by the intervertebral fibrocartilages, the anterior and posterior ligaments. neural arch, which completes the circumference, is formed by the pedicles and laminæ. The posterior aspect of the canal (neural arch) is in addition covered and protected by the layers of the thick dorsal muscles, so that only the spinous processes are subcutaneous. The vascular supply of the cord and its envelopes is abundant. In connection with the veins of the cord two points must be mentioned; first, that the spinal veins have no valves, and hence, readily dispose to congestion: second, that many of these veins are in close relation to the vertebral liga

The

*Read at the tenth annual meeting C. M. & St. P. Ry. Surgical Association, Chicago, December 18-19, 1902.

ments, and injury to the latter is liable to be attended by more or less venous hemorrhage.

From these anatomic outlines the following conclusions must be drawn:

1. That the cord is enclosed in a complete osseo-ligamentous canal.

2. That the canal is deeply situated and protected by several overlying structures.

3. That the cord does not by any means fill the cavity of this canal, either transversely or longitudinally, but lies loosely in its interior with considerable surrounding space.

4. That the cord is not connected with the walls of the canal, except where the spinal nerves make their exit and these connections are extremely loose.

5. That between each of the investing membranes, dura, arachnoid and pia, there is a quantity of cerebro-spinal fluid, so that the cord is not only surrounded by, but actually floats in fluid.

6. That there is no organ in our body more thoroughly protected from violence than the spinal cord and that injuries of it, without lesions of the surrounding bony elements, seem to be an anatomic impossibility. It is now known to us that the spinal cord consists of four different portions, viz.: (a) Processes from cerebral cells; (b) processes from cells which are present in the spinal ganglia and, perhaps, also in the periphery; (c) cells whose processes extend into the peripheral nerves, and (d) cells which, together with their processes, lie in the spinal cord. (L. Bruns, Hannover.)

It is, therefore, conceivable, that no boundary can be drawn either between the lesions of the spinal cord and those of the brain, or between the latter and those of the peripheral nerves.

The spinal cord itself, although only about the size. of an ordinary lead pencil, is composed of millions of nerve cells and distinct bundles of nerves. Some of these herves pass through it to reach the brain above, while others become united to the spinal cells and pass no further. The cells of both the brain and the spinal cord are practically electric batteries (as Ranney in his "Lectures on Nervous Diseases" designates them), and the nerve-fibres are the wires by which they are connected with the different organs of the body, the muscles, skin, joints and viscera. This wonderfully constructed organ is under the control of the brain, but is capable of exerting under certain circumstances a control over all acts, called "reflex acts, because they are to a greater or less extent" independent of the will. Prof. Austin Flint, in summing up the physiologic functions of the cord as a conductor of motor and sensory impressions says:

"The antero-lateral columns are insensible to direct irritation and serve as conductors of the motor stimulus from the brain to the anterior roots of the nerves. If these columns be divided, voluntary motion is lost in all parts below the section. If the rest of the cord be divided, icaving the antero-lateral columns intact, the power of voluntary motion remains. Throughout the greater part of the cord, this action is direct and division of the antero-lateral columns on one side produces paralysis of motion on the corresponding side of the body. There is a decussation of the motor-fibres in the medulla oblongata and a partial decussation in the cord itself in the upper cervical region. In the dorsal region and below, the

motor-conducting fibres are situated chiefly in the anterior columns, but in the cervical region these fibres pass to the sides and are contained chiefly in the lateral columns. The gray substance of the cord serves as a medium of transmission of sensory impressions to the brain. This is effected chiefly by the gray matter surrounding the central canal, but it may take place to some extent in other portions. If the entire gray matter is divided with but slight injury to the white substance, sensation is lost in all parts situated below the section. The white substance does not conduct sensory impressions to the brain, either in the antero-lateral or the posterior columns. The most probable function of the white substance of the posterior columns is to unite the different segments of the cord together by longitudinal commissural fibres, and this portion of the cord has an important influence in co-ordinating the muscular movements.

The sensitive nerve fibres from the posterior roots of the spinal nerves pass in the cord for a short distance upward and downward. They then penetrate the gray matter and decussate throughout the entire length of the cord. Division of one lateral half of the cord is followed by complete paralysis of motion on the corresponding side of the body in all parts below the section, anesthesia in all parts below the section on the opposite side of the body, and hyperesthesia in the parts below the section upon the corresponding side of the body."

Injuries of the spine according to Roswell Park and Dennis may be divided into fractures, dislocations, fracture and dislocation combined, strains (sprains), and

traumatic neuroses.

The degree of force necessary to produce a fracture or dislocate a vertebræ, well cushioned as it is, must by all means be very great; as falling from a height and striking a hard object, or falling across some object so as sharply and forcibly to bend the back. Such and similar forces come into play in railway accidents, when persons are violently thrown across the tops of seats in a passenger coach in consequence of a collision, or when they are thrown or fall from a car in motion, against some hard object with sufficient violence to double up the body, or when cars are derailed, topple over and throw the passengers violently about the inside of the In all such cases certain external signs will be found at the site of the injury, to wit: discoloration of skin, ecchymoses, and an irregularity in the spinous processes. Crepitation on careful palpation may also be detected. The effect upon the cord itself will be laceration, due to compression by impinging bone splinters, or hemorrhage into the envelopes or its canal. The structure of the cord itself, being rather firm, will, however, often resist a blood clot, due to hemorrhage, which will under pressure take the direction of the least resistance, i. e.. along the line of the canal.

car.

According to Thomas H. Manley (in the paper before mentioned, October 15, 1902), "the most confused ideas prevail in relation to spinal hemorrhage, the prevailing impression being that the blood escapes into the meninges or the medullary elements of the cord, hematomeningia, while quite invariably the blood leak is into the spinal canal-hematorachis. This latter is of itself rarely a cause for serious apprehension, but when complicated it becomes an aggravating factor in provoking pathologic changes, tending to meningitis or myelitis, ascending or descending. The gravity of the hemorrhage depends on its site, volume and complications.”

It is generally not very severe, simply an oozing from small branches and is quickly arrested, hence hemorrhage into the cord or its envelopes does not produce subsequent symptoms of a true laceration of the cord, the pressure being only of such degree as to produce a blunting of some of the sensory or motor functions of the cord, and which generally cease after absorption has taken place.

The principal symptoms of a genuine true lesion of the cord can be expressed in one word, to-wit: Paralysis, which comes on at once, before psychic elements have an opportunity to figure in the case, and which is according to the amount of pressure, either absolute or partial and entirely beyond the will of the injured party. Other symptoms will sooner or later make their appearance, retention of urine (excepting in fractures or dislocations of the lower lumbar segments, where incontinence of urine and feces is the immediate result), and atony of the bowels. Cystitis, purulent nephritis are common sequels, and later on bedsores will complicate the grave conditions, as evidence of impoverished nutrition. Atrophy of muscles in the affected region will result; sensation and motion are absent, but at times the several tests, if they can be applied at all, will exhibit reflexes. To recapitulate, the best guide for making the diagnosis of a true severe lesion of the cord are—in the absence of other signs beyond the will of the patientparalysis, retention of the contents of bladder and bowels,

and bedsores.

Even the most careful palpation will not always reveal a fracture of the spine. In the lumbar region the diagnosis of such lesion is impossible by the sense of touch aione. A fracture of any of the spinous processes of either the cervical or dorsal vertebræ is simple, when there is displacement, but with the transverse processes of the cervical vertebræ, owing to their depth the recognition of a fracture of one of them is rather difficult, if at all possible. Congestion or inflammation of the meninges or the cord, as stated before, is a common sequel of severe

are not

has recently shown that such young nerve fibres, running into the adventitia of the vessels, reach by a very complicated route the surface of the cord, and hence reach

offers no exception, the cord has been sutured successfully after injury from fracture, as reported by Stewart and Harte (Phila. Medical Journal, June 7, 1902, p.

As to the prognosis of lesions of the spinal cord due to laceration or impaction from a fractured or dislocated vertebra, it must necessarily be very adverse. All such lesions invariably manifest themselves by gradually increasing symptoms which undermine the general strength of the patient, the existing cystitis, due often to the repeated introduction of the catheter, the subsequent pyelonephritis, the retention of feces and urine produce toxemia, bed-sores and muscular atrophy are evidences of decreasing nutrition, and death from exhaustion generally closes the scene.

In less serious lesions, as hemorrhage into the cord or its envelopes, recovery generally takes place and with the absorption of the blood-clot all symptoms cease. In cases, complicated with other conditions, no matter how slight the injury may be, it is wise to delay rendering a prognosis at the first examination and rather wait for developments. It may, however, be laid down as a rule, never to give an unfavorable prognosis as to the outcome of a case of spinal cord injury, unless it is ascertained beyond doubt that the case is one of true cord lesion, caused by dislocated or fractured vertebræ, when a grave prediction with safety can be rendered.

In regard to strains or sprains of the spine, it is a fact that a genuine, complete luxation without simultaneous destruction of the cord can never occur. A displaced vertebra is a diastasis and not a dislocation, because the intervertebral junctions are not true joints. Luxation of the apophyses can only occur with co-existing fracture of an arch or pedicle, except in the cervical region. The differentiation between fracture and luxation is at times very difficult and errors have been committed even by prominent surgeons.

Very little need be said about the treatment of these serious lesions of spine and cord. Our first attention will be called to subdue "shock" by hot applications and hypodermatic stimulation, and to produce absolute mental and physical rest and tranquility by full doses of morphia with strychnia. Careful palpation must be done from neck to coccyx (if possible); any bruises on skin, crepitus and irregularity in the lines of the vertebræ must be carefully considered. Under such conditions, with co-existing paralysis beneath the seat of the trauma, the surgeon would commit an act of criminal omission of duty in not immediately performing the operation of laminectomy, necessary for the removal of impacted fragments of bone, blood clots, etc., it being a fact that the mischief to the cord is done in the moment of receiving the injury, and from this moment the cord must necessarily be damaged beyond repair if not released from compressing elements by an immediate operation.

There is no cavity, no organ in the human make-up which has not been entered by the surgeon's knife successfully, thanks to the aseptic precautions and measures at our command at the present time; the spinal canal

century affirmed, that exposing the cord is not dangerous, "that deaths after fracture were usually the result of pressure with continued irritation of the cord by fragments of bone, and not the result of partial or complete destruction of the cord, and that reunion can take place after laceration of the cord."

I come now to the consideration of a condition which so often will baffle the judgment of the practitioner, when examining a patient for alleged injury of the spine, or when giving evidence in a case of litigation for damages, and being cross-examined by an astute attorney; a condition which we find yet in our textbooks of surgery described under the name "Spinal Concussion."

Erichsen, the parent of the term "railway spine," argued that certain cellular and molecular pathologic changes often follow injuries, which do not involve extensive organic disintegration of the medulla spinalis or its bony envelope.

Roswell Park in the last edition of “A Treatise on Surgery by American Authors" (1901) has an article by E. H. Bradford, an American surgeon, from which I quote: "There is apparently no doubt that a severe lesion may take place in the cord without any external evidence of injury. It is difficult to explain the physical law by which such injuries are inflicted but the facts cited seem beyond question."

By

C. H. Golding Bird ("International Textbook of Surgery," 1900), says: "The question of spinal concussion is a vexed one. While some surgeons practically deny its existence, others class under the name conditions which are now known to bear a different interpretation. concussion of the spine is meant a more or less complete annihilation of the functions of the spinal cord immediately following an injury, temporary in character and unattended by any discoverable gross lesion. The term concussion must be regarded as provisional, for after all, the idea that a molecular disturbance of nerve matter constitutes concussion is only a good working hypothesis." I find in the "Medical and Surgical History of the War," (Part III.) over the signatures of S. Weir Mitchell, Geo. R. Morehouse and I'. I'. Keen, Jr., the following statement, which I insert as a historical relic: "Another class of nerve affections demands some notice, before we discuss the undoubted instances of reflex paralysis from wounds which have fallen under our notice. These are what the French writers call cases of injury from commotion. They differ from those we have described in being due to the mere mechanical effect, produced upon the neighboring parts. If, for example, a cannon ball passes near the spinal column, it is conceivable that the roll of its motion and the resistance of the tissues may determine in the spine a brusque and sudden oscillation of the contents sufficient to cause very grave results."

According to Clinton B. Herrick ("Railway Surgery," 1899), concussion or traumatic neurasthenia may be defined "as a state, resulting in a person from being in a severe accident or shake-up, in which the more or less tossing about, coupled with the fright and terror of impending bodily injury or death has brought on a condition of neurosis, in which the individual actually believes, or can by suggeston be made to believe, that he is the victim of and suffers from the pangs of a severe injury,