together. This case occurred more than thirty-five years ago. I treated it by the open method, and had to remove some pieces of bone. The femur of the other leg was broken at about the same time. I used precisely the same principle and method of treatment, massaging the parts, and the fragments grew together, although this leg was a little shorter than the other one.

I have been through the mill a good deal in the treatment of these cases, and I believe if you inspect the condition of the fragments frequently, using plenty of warm water, and gentle friction above the seat of fracture, you will have good results.

Dr. C. F. Larson: There are two points that impressed. me this afternoon in listening to this discussion. In discussing shock and the use of stimulants in shock, there was nothing stated as to whether there was an accident or not. There is nothing positive in the practice of medicine except surgery. All of you know of or have heard of "Uncle" Allen. Many of you had the pleasure of listening to him at Rush Medical College. I remember very well that he used to say, "Young men, when you start to practice medicine, I want you to remember one thing: You will meet with cases that you do not fully understand. But don't get scared; seven patients out of ten will live in spite of all you may do for them." When I heard a gentleman say this afternoon that he gave a man three pints of whiskey inside of two and a half hours, and the man recovered, it proves Uncle Allen's statement.

In medicine there is nothing positive; in surgery there is. For instance, a man sustains a fracture. If we bring the broken surfaces in perfect approximation, we expect to see the bones grow together and obtain a perfect result. On the other hand, if we leave a space between the broken surfaces, a bridge of callus will span it over, and while the bones will grow together, we will not get a perfect result. The broken surfaces must be brought in apposition in order to secure good results.

There is another point to be considered in treating fractures. The first thing is to get as perfect a result as possible, so far as approximation of the fragments is concerned. Furthermore, we should consider if the patient is going to be incapacitated for work. It is true, and I am sorry to say so, that too many surgeons look only to the question of getting a perfect result so far as approximation and perfect union of the broken surfaces are concerned, and they leave out the question of the time the man may be incapacitated from work. If you use massage as an adjunct in the treatment of fractures, you may not hasten the time of healing of the fracture, but I am sure you will shorten the time the man is laid up from work; and at the same time the fracture has healed, you prevent ankylosis.

When I speak of fracture of the patella, I am certain that the dressings that have been spoken of and described this afternoon will perhaps bring the broken surfaces in apposition, and keep them so until healing of the patella takes place. If you keep the bone that way, you will have ankylosis left to treat afterwards, and I saw in one textbook that if a man has been laid up in bed for three months it will take at least a year to break up the ankylosis. This is all very well, but I do not think it is right to look at it in that light. If we can so treat a fracture

that the patient is able to walk about the moment bony union takes place, it is our duty to do so.

I hope the members will try the use of the dressings I have described for cases of fracture. I believe there is considerable virtue in them over some of the others that have been mentioned.

Dr. T. W. Nuzum: There is one point that was not mentioned this afternoon which is important. Some years ago I saw Professor Senn operate on a child who had been repeatedly operated upon for non-union of the tibia, and he dovetailed one end into the other end, so as to get the surfaces in contact. That was a good idea.

In regard to massage in fractures, when we dress a fracture that has occurred some hours before, and there is much swelling and edema of the tissues, it is practically impossible to know just how well we have adjusted the fragments. If we remove our dressings in a few days, and rub gently over the site of fracture, and find the fragments are not properly adjusted, and the swelling has disappeared, it is an easy matter to get the fragments back to place more perfectly and easily than at the first dressing. I have never seen but one case of non-union, and this was an old one, but I have seen quite a number of cases of delayed union. Sometimes I believe nonunion occurs from not having perfectly adjusted the ends. of the bone; and tight dressings may have something to do with it. I think massage is a useful adjunct in these cases. We should strive for perfect adjustment of the fragments, and not too much motion. I have seen several cases where the dressings were not properly applied, so as to retain the fragments in place, but by applying a more efficient dressing and resorting to gentle massage, recovery soon ensued. I have never found it necessary to operate on a case. Dr. J. P. Crawford: I agree with all of you that there are many factors which enter into the process of nonunion of bones. Dyscrasia is a very general term. There may be lack of nerve force, nerve injury, and many other disturbances. But I believe, after all, there is a time for bones to unite, and if there be too much separation of these, as well as the granulations that are thrown out, we retard the process of union when we have a condition of this kind, plus dyscrasia or disturbances of nerve force. The

nutrition

is

tures.

Dr. D. S. Fairchild: In some of my remarks I had reference to the paper of Dr. Van Werden on simple fractures. I think we are obliged to confess really that we do not know what causes non-union. We have heard this one and that one say it was something connected with the treatment of the case which gave rise to non-union. Suppose any of us should have a case of non-union staring us in the face, and are sued for malpractice, it behooves us to be very careful what we say in regard to the cause of non-union. One man may say that the cause of nonunion was due to too tight bandaging; another may say that it is because the surfaces were not rubbed enough, and still others will say that it is due to this thing and that thing. If we really knew what caused non-union, then we would be in a position to speak positively. If we had a definite cause for it, we would know what to say, but since we have really no definite knowledge of nonunion, we should be very guarded in making statements. One may say that the cause of non-union is due to an error in the treatment of the case, and a physican consequently might be sued for malpractice. We cannot be too careful in what we say regarding the causes of nonunion, since we know nothing really definite about the subject.

Dr. W. Van Werden: Cases of simple fractures that call for wiring are very, very rare; but we will find it necessary to resort to wiring in some instances in order to get perfect results.

As to the particular case that Dr. MacRea spoke of, there is no doubt one can operate and wire the fragments, feeling that the wire will give him little trouble. Of course, if the surgeon leaves the point of wire sticking up or projecting, it will act as a foreign substance, irritate the part, so that there will be trouble, and he will be compelled to remove the wire. Supposing one should resort to wiring in a case and it becomes necessary to take the wire out, it can be done very easily, and yet there is nothing that is encapsulated as quickly, and I believe some of the unsatisfactory results from wiring are due to other wire having been used rather than silver wire. I am speaking in regard to silver wire absolutely. There is no tendon that compares with it, either kangaroo tendon or chromicized catgut. I spoke of cases that were adapted to wiring, of cases that should be wired to get results which could not be obtained in any other way.

In regard to the case described by Dr. Kester, some ten years ago a young girl, 9 years of age, was kicked by a mule, and sustained an oblique fracture of the jaw, also a fracture at the symphysis. It was with great difficulty that I could keep the parts in position with any dressings I could devise. I had to reset the fracture as many as three or four times in one day. Finally, I deemed it necessary to drill down and wire the fragments,

and the results were perfect. I do not believe I could have obtained a good result by any other method of

treatment.

Dr. J. H. Stealey: I want to make a few remarks, inasmuch as Dr. Macrea referred to me, I believe, as having had a great many cases of ununited fracture. I have practiced medicine for twenty years, and have only had one case of ununited fracture of my own in that length of time, the one which I referred to in the paper. I would like to have the gentleman understand that the majority of those cases (four of the five) were sent to me by other physicians for treatment.

Regarding the remarks made by Dr. Jenkins, in speaking about looking at his fractures every day, probably that is a very good thing for minor cases; but, it seems to me, if we are going to take the dressings off of the fracture, feel around every day, and massage it, there is great liability to non-union. That was the case in one instance which I reported that was brought to me. Massage in old people is undoubtedly a valuable adjunct to the treatment. A few years ago, when I was in Paris, I attended Championnière's clinic, and he showed me 50 cases he had treated. He treats all cases by practically massage without any support, unless support is absolutely necessary to keep the fragments coaptated. Nearly all of his cases were incomplete, and there was more or less deformity in nearly all the cases I saw.

The doctor (Dr. Nuzum), in speaking about dovetailing the tibia, did not say anything with regard to the fibula. I would like to ask him what Dr. Senn did with the fibula?

Dr. Nuzum: The fibula was undeveloped in that case.
Dr. Stealey: He did not make a section of it?
Dr. Nuzum: No.

Dr. Stealey: Dr. Crawford spoke about it being impossible to have non-union where the fragments were properly coaptated. One such case I reported.

Dr. Crawford: I did not say that exactly.

Dr. Stealey: As to dyscrasia, it is a term which is used a good deal the same as malaria. It may be due to dyscrasia or malaria. In one case we attributed the nonunion to dyscrasia, because the bone had been kept in place and the bandages were not put on too tight, yet we failed to get union. When I cut down and brought the parts close together, removed the granulation tissue with periosteal knife, scraped the bones so as to set up irritation, in three months afterwards we had perfect union. Dr. Fairchild spoke of non-union. These cases were not operated on inside of three months. We have delayed union from six to twelve weeks, in some cases, and in most of them there was non-union from three and a half to six months.

One of the speakers described a case in which there was atrophy of the upper arm. This may have been due to an injury of the musculo-spiral, spinal accessory, or some of the nerves at the time of the occurrence of the fracture, and In a case of that kind the use of electricity and proper massage should be resorted to to see whether the muscles cannot be restored, and if not, by this means, I can hardly see cause for making another attempt at union. I mentioned an atrophic condition of the muscles and nerves in my paper,

In regard to the use of the X-ray, all of my cases were ambulatory; they came to the office, were examined by the X-ray, and I kept a careful watch of them. I have never used kangaroo tendon in these cases.

Dr. Jenkins: I do not wish to be understood as advocating the use of massage every day in the treatment of fractures. I do not resort to it every day. I believe it is essential to inspect the condition of the part from time to time, in order to obtain good results.

Dr. A. I. Bouffleur: I hardly feel as though I am warranted in discussing this subject further. However, as I have been called upon to do so, there are one or two points I would like to mention. In the first place, I was glad to hear Dr. Stealey mention his observations with reference to the Championnière treatment of fractures. The late Dr. Caldwell, who was a former associate of Dr. Stealey's, and who attended so many meetings of this association, was quite an enthusiast on the subject of massage in the treatment of fractures. Having heard Dr. Caldwell, I was also interested in the remarks made by Dr. Stealey, and his observations on the subject.

I am very much interested in the subject of fractures, and I devote about three months each year to the teaching of this subject; therefore, I have been investigating it quite a bit. At the present time I have one of the best masseurs in the city who comes to the hospital every morning and gives massage to all my cases of fractures. I have done that because I have personally been employing massage in my own way for quite a while, and it was my desire to have some definite knowledge as to its value, when applied scientifically. Professor Oldenberg is an expert in administering massage, and has been employing it in my cases of fracture for two months or more. Some of the cases have done remarkably well; others have not shown any benefit from it at all, and in one or two instances I am inclined to think it was a positive detriment. I have never had the boldness to allow my patients to go without any support while he was applying his massage, and relying on that entirely, as Championnière does. We use splints in all of our fractures. I apply a circular splint, leaving it on for a short time, say from twentyfour to thirty-six hours, when two-fifths is cut out and the remainder then used as a mold. After the first week, we simply make a mold for one side of the limb, allowing that to be the means of support, and having massage applied to the exposed parts of the limb. I am a believer in massage, from the reason, first, as Dr. Larson stated, it favors union. It improves the circulation. There is no question about that. Secondly, it produces results, in that your patient gets well, and you do not have to treat the case for a similar length of time to remove the effects of quietude of the adjacent joints. I believe emphatically and unqualifiedly in the immobilization of both the proximal and distal joints for a few days. This has been brought to my mind several times within the past year or so, in which there has been considerable deformity following fracture a few inches below the knee, or just above the ankle, in which the joints were not immobilized, and perceptible permanent angular deformity ensued.

As to ununited or delayed fractures, it is strange how these cases run. One will probably see a number of

them, particularly cases referred to us, within a comparatively short period of time. I had in the past year at one time four cases of delayed union. It is an unusual thing. I have never had such an experience before, and I do not know of anyone else who has had. The cases were treated carefully; they were looked at frequently. In one case the patient, a man, had double fractures of both limbs. In two cases of fracture of both limbs, the patients were unable to be about, the circulation was interfered with, and general nutrition impaired. In another case, a healthy young man, who was able to be up and about on crutches in a few days, so that he could be out-ofdoors, had very marked inability to make callus, and it was only by prolonged massage that we were able to stimulate callus formation. In this connection I desire to say that about two years ago I recall a case in which massage, persisted in daily and thoroughly, did not result in the production of callus. If you use one of these hot air machines, generating superheated air at 350° for twenty to thirty minutes, accompanied by massage, you will get callus formed quickly. In two instances I recall, in which massage was given thoroughly for three or four weeks, in one case in particular no callus was formed at the end of three weeks. This patient was given careful and systematic massage for three weeks, without any callus formation, and yet in a single week by the daily application of superheated air, by means of the Betz Hot Air Apparatus and massage, the formation of callus was rapid. I believe superheated air has virtues, in that it stimulates the nutrition of the part and quickens the formation or production of callus.

I am very sorry the subject of Pott's fracture was not discussed. It occurs to me that this is a form of fracture that railroad surgeons have to treat quite frequently, and if you will remember that last year, or the year fore, we had this subject up for discussion at the clinic, and therefore I will not discuss it any further at this time.

ure.

be

Fracture of the patella is something all of us approach with a great deal of caution, perhaps dread, in a measI dislike to have fractures of the patella to deal with. I have two such cases on hand at the present time, both of them doing nicely, one an old case that was operated on a year ago. The physician used cervix silver wire in a man weighing 240 pounds. In this case the cervix wire proved useless as a retentive element. We had difficulty in overcoming the separation of 31⁄2 inches which existed for ten months. We did not resort to the application of small cervix wire, but to the use of wire sufficiently strong to hang a man with. If that wire

should give trouble, it can be removed just as readily as wire of smaller size, and we are sure that it will not give

way.

In speaking of a recent fracture, one four weeks old, one of the speakers said it was accompanied by great swelling of the joint. Great swelling of the joint is considered a favorable thing. It shows that the joint capsule is intact, and Fowler, of Brooklyn, years ago stated that it was one of the most favorable things in the ultimate union of bone that one could have. It is in those cases where the joint capsule has been broken, so that extravasation takes place into the tissues of the thigh, you must

keep your hands off. It is in those cases that infection occurs, and when it does occur, it is alarming. Given a case in which the joint is distended, then I know hemorrhage is confined to the joint, and within a few days, if there is contusion about it you wait to insure asepsis, you can then empty the joint and operate with comparative safety. If there is a rent in the capsule, which extends to the tissues of the thigh, you had better let the case alone, as the percentage of infection and the percentage of loss of limbs are great.

As to the means of suturing, that will depend entirely upon the operator. Personally, I like the subcutaneous suture for simple transverse fractures, as it can be used with a great degree of safety. It is what is called the Barker method, which consists in passing silver wire down into the joint underneath the patella, it being practically a subcutaneous operation. It is done with a heavy needle, such as is used for sewing the perineum, and it

will answer very well. You pass the needle underneath the patella up through the skin, and then withdraw the end anterior to the patella. If you have a multiple fracture, that method is not applicable. You may be able to operate subcutaneously even in multiple fracture or through three or four small openings. If you are going to open the joint, I do not see any particular reason for wiring the patella. Dr. Macrea thinks that suturing the fascia and periosteum is sufficient. That may be true, I am not going to question that statement. I see no disadvantage in wiring the patella if you can keep out of the joint cavity.

This is a subject which is fraught with a great deal of interest. I was pleased with the manner in which Dr. Van Werden presented his cases. He had three at one time, which is unusual, yet the results were uniformly good. I cannot say that I am an enthusiast on the subject of wiring simple fractures, because I am not. I very rarely wire one; but I appreciate the fact that in compound comminuted fractures it is an advisable and proper surgical procedure. I would like to call your attention to the modification of the title of his paper. He did not advise this method under all circumstances, but only when the conditions and circumstances are favorable. That is an important point.

FRACTURE OF THE CLAVICLE AND ITS TREATMENT.

According to Tillaux the clavicle may be fractured in three places in the center or at either end. Fractures at the inner end are so rare as to require little mention. Those at the outer end are nearly as rare, their distinguishing feature (contrary to Malgaigne's opinion) is the absence of deformity; pain on palpation limited to a small area enables us to make the diagnosis. The most common is fracture of the shaft, either direct by falls against furniture, etc., or indirect by a fall on the tip of the shoulder. There is a difference between fractures in the child and the adult. In the child, the periosteum is intact and there is no deformity, in the adult the contrary is the case.

The numberless apparatuses for fractured clavicle show that treatment is not always satisfactory. M.

Tillaux believes that the displacement in oblique fractures (indirect) is almost impossible to correct, and hence nearly always there will be a vicious callus.

The best apparatus as well as the simplest is the double sling of Gosselin, which is also excellent in all traumatisms of the shoulder. The forearm being placed in the sling, the two upper ends are knotted around the neck, the two lower around the waist, bandages connect the ends.-Rev. Int. de Ther. Phys.

TREATMENT OF FRACTURED PATELLA.

M. Jules Bridoux says when called on to treat a fractured patella, we find (1) a broken bone with the fragments more or less separated, with blood clots, fragments of fibrous tissue, or effusions, not only preventing coaptation but tending to increase the separation. (2) The joint is the seat of arthritis and effusion. (3) The quadriceps muscle has a tendency to atrophy.

To combat these conditions we must (1) bring the iragments together, or (2) at least remove the obstacles to coaptation, hemarthrosis, effusion, and fragments of fibrous tissue. (3) Improve the nutrition of the quadriceps.

By combining massage, compression and early mobilization, we have the treatment of choice, if separation is rot excessive. If the latter is important we may use the same measures, having suture in reserve; if this is necessary, it must not be delayed too long.

In compound fractures it is preferable to make use of hooping at once. In case of repeated fracture if mobilization and massage do not suffice hooping should be resorted to It is best to commence with non-operative During convalescence, use must be made of friction, room treatment, leaving operative intervention for the future. gymnastics and mechano-therapy.-Gaz. Med. Belge. ACCIDENT TO A PASSENGER RIDING ON A PASS.

In the United States Circuit Court for the District of Maine the court in Duncan v. Maine Central Railroad Company, held that a person riding over a railway on a pass given without consideration, and after assenting to the conditions that he should assume all risk of accident, and that the carrier should not be liable, cannot recover from the railway for injuries caused by the negligence of its servants. It was also decided in this case that it was immaterial that the giving of the pass was a breach of the act to regulate commerce.

re

RAILROAD EMPLOYES' EXAMINATIONS.-Murray ports the results of examination of something over 4,000 men for the Delaware, Lackawanna & Western Railroad for vision, hearing and color perception. He found about chromatic sense; 9.44 per cent 3.01 per cent were color blind; 2.58 per cent had weak were in need of glasses

or other means to improve their vision for distance. He suggests discouraging the use of tobacco and making frequent examinations on account of the dangers of acquired color blindness; that the employes should have at least eight hours of sleep, as loss of sleep leads to intemperance, smoking and nervous irritability.-Annals Ophthal. Jour., '03.

In regard to the use of the X-ray, all of my cases were ambulatory; they came to the office, were examined by the X-ray, and I kept a careful watch of them. I have never used kangaroo tendon in these cases.

Dr. Jenkins: I do not wish to be understood as advocating the use of massage every day in the treatment of fractures. I do not resort to it every day. I believe it is essential to inspect the condition of the part from time to time, in order to obtain good results.

Dr. A. I. Bouffleur: I hardly feel as though I am warranted in discussing this subject further. However, as I have been called upon to do so, there are one or two points I would like to mention. In the first place, I was glad to hear Dr. Stealey mention his observations with reference to the Championnière treatment of fractures. The late Dr. Caldwell, who was a former associate of Dr. Stealey's, and who attended so many meetings of this association, was quite an enthusiast on the subject of massage in the treatment of fractures. Having heard Dr. Caldwell, I was also interested in the remarks made by Dr. Stealey, and his observations on the subject.

I am very much interested in the subject of fractures, and I devote about three months each year to the teaching of this subject; therefore, I have been investigating it quite a bit. At the present time I have one of the best masseurs in the city who comes to the hospital every morning and gives massage to all my cases of fractures. I have done that because I have personally been employing massage in my own way for quite a while, and it was my desire to have some definite knowledge as to its value, when applied scientifically. Professor Oldenberg is an expert in administering massage, and has been employing it in my cases of fracture for two months or more. Some of the cases have done remarkably well; others have not shown any benefit from it at all, and in one or two instances I am inclined to think it was a positive detriment. I have never had the boldness to allow my patients to go without any support while he was applying his massage, and relying on that entirely, as Championnière does. We use splints in all of our fractures. I apply a circular splint, leaving it on for a short time, say from twentyfour to thirty-six hours, when two-fifths is cut out and the remainder then used as a mold. After the first week, we simply make a mold for one side of the limb, allowing that to be the means of support, and having massage applied to the exposed parts of the limb. I am a believer in massage, from the reason, first, as Dr. Larson stated, it favors union. It improves the circulation. There is no question about that. Secondly, it produces results, in that your patient gets well, and you do not have to treat the case for a similar length of time to remove the effects of quietude of the adjacent joints. I believe emphatically and unqualifiedly in the immobilization of both the proximal and distal joints for a few days. This has been brought to my mind several times within the past year or so, in which there has been considerable deformity following fracture a few inches below the knee, or just above the ankle, in which the joints were not immobilized, and perceptible permanent angular deformity ensued.

As to ununited or delayed fractures, it is strange how these cases run. One will probably see a number of

them, particularly cases referred to us, within a comparatively short period of time. I had in the past year at one time four cases of delayed union. It is an unusual thing. I have never had such an experience before, and I do not know of anyone else who has had. The cases were treated carefully; they were looked at frequently. In one case the patient, a man, had double fractures of both limbs. In two cases of fracture of both limbs, the patients. were unable to be about, the circulation was interfered with, and general nutrition impaired. In another case, a healthy young man, who was able to be up and about on crutches in a few days, so that he could be out-ofdoors, had very marked inability to make callus, and it was only by prolonged massage that we were able to stimulate callus formation. In this connection I desire to say that about two years ago I recall a case in which massage, persisted in daily and thoroughly, did not result in the production of callus. If you use one of these hot air machines, generating superheated air at 350° for twenty to thirty minutes, accompanied by massage, you will get callus formed quickly. In two instances I recall, in which massage was given thoroughly for three or four weeks, in one case in particular no callus was formed at the end of three weeks. This patient was given careful and systematic massage for three weeks, without any callus formation, and yet in a single week by the daily application of superheated air. by means of the Betz Hot Air Apparatus and massage, the formation of callus was rapid. I believe superheated air has virtues, in that it stimulates the nutrition of the part and quickens the formation or production of callus.

I am very sorry the subject of Pott's fracture was not discussed. It occurs to me that this is a form of fracture that railroad surgeons have to treat quite frequently, and if you will remember that last year, or the year before, we had this subject up for discussion at the clinic, and therefore I will not discuss it any further at this time.

Fracture of the patella is something all of us approach with a great deal of caution, perhaps dread, in a measure. I dislike to have fractures of the patella to deal with. I have two such cases on hand at the present time, both of them doing nicely, one an old case that was operated on a year ago. The physician used cervix silver wire in a man weighing 240 pounds. In this case the cervix wire proved useless as a retentive element. We had difficulty in overcoming the separation of 31⁄2 inches which existed for ten months. We did not resort to the application of small cervix wire, but to the use of wire sufficiently strong to hang a man with. If that wire should give trouble, it can be removed just as readily as wire of smaller size, and we are sure that it will not give

way.

In speaking of a recent fracture, one four weeks old, one of the speakers said it was accompanied by great swelling of the joint. Great swelling of the joint is considered a favorable thing. It shows that the joint capsule is intact, and Fowler, of Brooklyn, years ago stated that it was one of the most favorable things in the ultimate union of bone that one could have. It is in those cases where the joint capsule has been broken, so that extravasation takes place into the tissues of the thigh, you must