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THE DIFFERENCE BETWEEN
(Sat. sol. Nucleo-(proteid et albumen cum enzymes) R. & C.)
and the ordinary liquid foods is that Trophonine is a saturated solution of nucleo-proteids and nucleo-albumens, which are considered by Hammarsten as "complex phosphorized bodies and the nutritive materials for the cells" together with the enzymes (nucleo-enzymes) in a menstruum of pancreatized gluten and peptone with less than 14 per cent of alcohol by weight. Do not confuse Trophonine with the ordinary liquid foods. Remember it is a direct cell nutrient and builder.
REED & CARNRICK,
Do not jeopardize your patient's life by patronizing a druggist who will substitute.
42-44-46 Germania Ave., JERSEY CITY, N. J.
ST. LOUIS, FEBRUARY 26, 1906.
Papers for the original department must be contributed exclusively to th's magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted.
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ALBERT ABRAMS, M. D., San Francisco.
ARTHUR R EDWARDS, M. D., Chicago, Ill.
Mr. REGINALD HARRISON, London, England.
HOBART A. HARE, M. D., Philadelphia.
FERD C. VALENTINE, M. D., New York.
THE TREATMENT OF FRACTURES IN GENERAL.
EDWIN A. WEIMER, M. D.
Chief Surgeon G. S R. Co.: Chief Surgeon I. B. V. R. R.;
IN coming before you today with my subject I do so fully realizing that it is not a new one, but although old, and upon which much has been written, is fraught with never varying interest to both the physician and surgeon.
There is no class of cases that are the cause of so much anxiety to surgeon as fractures. It has been well said that the recovery from fractures has two phases: the surgical recovery and the legal recovery. The first depending upon the skill of the surgeon, the constituional condition of the patient, and the nature of the injury; the latter upon the financial condition of the surgeon and the mental constitution of the patient.
The study of the treatment of fractures has
Read by title before the Brainard District Medical Society at Bloomington, Ill., October 27, 1905.
been somewhat neglected because of the greater advance in more fascinating branches of surgery, I will, therefore, as briefly as possible present for your consideration some observations based upon experience, and which touch upon the most important points in fracture treatment. Those of us who do railroad work well know that the fractures that occur there are usually of the worst degree, and differ from the traumatism of the same class, as jars, contusions, lacerations, nervous shocks or traumatic neurasthenia, differ from the injuries received in the ordinary walks of life.
The first and most important thing in fractures is that the surgeon should have in mind a clear and accurate conception of the condition of the bone he is treating, so that he may arrive at a satisfactory and correct diagnosis, as nothing contributes so much to the successful treatment of fractures, and peace of mind of the surgeon, as a correct diagno. sis. This is, in some instances, made without difficulty but occasionally there is the greatest difficulty in establishing it. It is apparent then that, to accomplish this successfully, a most careful and systematic examination should be made in each and every case; not only of the part known to be fractured, but of the entire body; care being taken to note carefully the condition of the heart and respiration, and the condition of the pupils.
Beginning at the head go carefully over every bone and joint, not forgetting the spine. After having established the diagnosis and adjusted the principal injury look to the condition of the bladder, and take notice of any graver injury. There is no more common error in the diagnosis and treatment of smaller injuries than those injuries of the fingers requiring amputation than to overlook a fracture of the phalanges.
At this point I wish to call your attention to the diagnostic importance of crepitus, which is much overdrawn
Localized pain and tenderness are signs to which often too little importance is attached. There are a great many conditions, such as interposition of blood clot or soft parts which interfere with and entirely abol. ish crepitus, but pain and tenderness are almost always present. In the long bones especially, pain at the seat of fracture can be elicited by making pressure at a point remote from it.
In dealing with fractures it should always be remembered that we are dealing with a wound-a wound of bone-and as is the case with wounds of the soft parts, the wider the wound surfaces area part, the more latitude of movement they have, the greater the injury to lymph and blood vessels, and the greater the amount of exudate and swelling. The sooner the wound surfaces are approximated the less will be the swelling and the more perfect the result.
Lotions containing opium and other drugs for the reduction of the swelling have no place in fracture-treatment.
The results to be aimed at in fracture-treatment are, union without deformity, without impairment of function of the part and with as little loss of time and usefulness as possible. It is however, difficult to arrive at a proper test of the efficiency of any special line of treatment in dealing with fractures.
"The amount of the deformity and degree to which function has been impaired are the final tests of the efficiency of the method employed in each case.
"Many surgeons have adopted the X-ray as a final test of their work, and who hold that if a set fracture does not show perfect. approximation by the shadowgraph, just after the splints are applied, it should be cut down on and means of internal fixation adopted for the coaptation of the ends of the fractured bone."
ends of the bone. This is avoidable and care should be taken that it does not occur.
"The opinion of surgeons differ in regard to the treatment of fracture. Some contending that all fractures, whether simple or not, should be treated by open operation. Some hold that no simple fracture of long bone should be treated by open operation. Some, who under ordinary conditions employ nonoperative methods in fractures, in general, employ operative methods in some cases when it seems necessary.
This class of surgeons as a rule adopt one of three methods of procedure:
1st. Immediate application of some form of splints or apparatus.
2d. The applications of splints or apparatus which may be easily removed to admit of examination, of massage, and passive movements being applied to the parts.
3d. The limited use of splints with their early rejection entirely.
In the treatment of simple fractures each case must be a rule unto itself, a great deal depending upon the nature of the fracture and its direction, whether it be transverse, oblique, longitudinal, dentate or spiral, or whether important arteries, nerves and muscles, with their attendant sequelae of paralysis, atrophy and gangrene are involved.
In both simple and compound and complicated massage and passive movements have proven themselves of great value when intelligently applied.
By passive movements I do not refer to the old form of pump-handle movements which was applied many weeks after the injury, but that which is applied a few days after injury, a few degrees at a time care being taken not to disturb the ends of the fractured bone.
The application of passive movements and massage to the sites of the fracture before the bones were thoroughly united is of recent time. There is at present a strong general tendency to put aside all forms of retentive apparatus which render the parts inaccessible in favor of those forms which are easily movable and admit of easy access to the injured parts, favoring the employment of massage and passive movements, which lessen the pain, prevents effusions, promote absorption of effused products; hastens callous formation, prevents adhesions of soft parts, avoids wasting of muscle; prevents stiffening of tendons and joints, and increases the range of funotion of the parts. Thus all of the conditions are prevented which are so frequent under the older forms of treatment.
Passive movements, according to Bickham, are divided into three classes, namely, immediate, intermediate and remote.
Immediate when employed within the first two days.
Intermediate when applied from the second to the fourteenth day after injury.
Remote when applied at a later time. Results are better and recoveries quicker when these movements are instituted earliest. Passive movements should be instituted at first, and active movements as soon as the union of the parts are strong enough to ad. mit of it with safety. The use of passive movements and massage has shortened the period of repair one-third and restored the function in one-half the time usually required.
The use of continuously retentive splints, especially those of plaster of paris, tend to retard union and prolong the disability of the part after its removal. For this reason movable splints have, to a large extent, replaced the immovable ones.
The present state of fracture-treatment may be said to be in a transitional stage; it is now in the process of passing from the routine hard and fast, prolonged splinting in common use until a short time ago, to the more rational and exact methods of the present time, which includes the use of passive movement and massage in conjunction with the movable splints and open incision in favorable cases.
The operative treatment of simple fractures is condemned by many as not to be used in any case just as there are many advocates of its employment as a routine practice. am not in favor of total condemnation of its practice, nor do I wish to be put on record as advocating it in all cases, and would conservatively limit it to those cases which otherwise unmanageable, and such special cases, as for example, certain spiral and oblique fractures, namely, of the tibia, and some fractures near joints in adults, notably of the humerus at the elbow.
The simple fractures most frequently operated upon, by open incision, even by those who do not otherwise adopt the method, as a routine procedure, are oblique fracture of the tibia (which heads the list), fracture of the upper part of the humerus, and of the humerus ear the elbow; of the upper and lower part of the femur; of the patella; fractures of the spine, and of the skull. The most difficult simple fractures to deal with are the spiral and comminuted fractures; fractures whose fragments penetrate and lacerate soft parts, and fractures associated with passive tension of muscles and fascia.
The position in fracture treatment of simple fractures by open incision has not as yet been accurately defined, but as before said, should not be condemned entirely until time,
study, experience and comparison of results of the new with the old methods have proven their inefficiency.
Compound fractures have always received some form of operative treatment, if only to the extent of cleaning the site and putting the parts into favorable position for repair. Comminuted and complicated fractures have also often received such treatment, so that the application of a somewhat more radical operative treatment to these classes is not so distinctly new as is the operative treatment of simple fractures (Bickhamı).
The treatment of compound fractures at various periods is one of the notable illustrations of conservative surgery.
At cne period a very large number of compound fractures came to amputation; and it was the rule in many hospitals to amputate all limbs above the site of a compound fracture involving a large joint.
Then followed a period when conservatism was shown by saving the part at the expense of shortening it by making an incision at the side of a compound fracture, including a joint if necessary. At the present time still further conservatism is being shown by neither amputation nor excision, but by freely exposing the parts by operation, repairing the damage done to the neighboring soft parts, thoroughly cleansing the part with antiseptic irrigation followed by aseptic douching treating the ends of the bone as the conditions found may indicate, resorting to some method of internal fixation of the broken ends, and the putting of the part in an open splint.
As we cannot always be certain of asepsis, drainage should always be instituted at first. It should be continued as long as it is necessary, but can as a rule be dispensed with in about three to six days. This method of procedure applies with equal force to those compound fractures with the smallest puncture, as to those with large external wounds. The temptation may be very great to disinfect externally and to try to disinfect internally an insignificant looking puncture of a compound fracture, and seal it with collodion, but subsequent septic infection will in most cases cause regret. When the parts are thoroughly exposed, the extent and nature of the damage can be determined, and may indicate the advisability of excision. Where it is necessary to have free access to a wound of a compound fracture for the purpose of irrigation and dressings, a method of protecting plaster casts and dressing from fluids has been devised by Crouse and introduced into practice by Dr. Warren Stone Bickham. "It is a semi-gelatinous paste made by making a solution of dental rubber No. 2 in commercial chloroform with enough loose absorbent wool
worked in to make a meshed mass. 99 "In planning the window of the cast we should so calculate that there shall be at least one inch of healthy shaved, sterilized and dry, skin between the circumference of the opening in the cast and the outer margin of the wound. The paste is then applied with a spatula and packed between the skin and the margin of the opening in the cast, filling all the opening and coming up and out upon the surface of the cast. The whole mass of paste and the plaster cast in the vicinity are then veneered with a plain chloroform solution of the rubber. The rest of the cast is then
shellaced." The opening around the wound is thus aseptic and waterproof, and may be flushed and irrigated without damaging the
A word about comminuted fractures. Comminution in a fracture is often difficult to recognize by ordinary manipulation and is only demonstrated by the use of the X-ray. Even where it is present, especially if it be simple and not extensive, does not particularly complicate the fracture. In the ordinary cases non-operative treatment may be em. ployed, but where it is more extensive or complicated, or when simple comminution prevents the accurate approximation and retention of the ends of the bone in the proper position it should be cut down and dealt with as the needs of the case may require.
In cases of extensive comminution, excision of the bone-ends may be called for, followed by internal fixation or bone grafting. Lastly, complicated fractures. The strongest argument for open operation in this class of fractures, followed by internal fixation, is that it gives free access to the fracture, and gives full opportunity to treat and rectify any special complication which may be more important than the fracture itself.
LOUIS H. BEHRENS, M.D.
ST. LOUIS, MO.
President of the Medical Society of City Hospital Alumni.
Gentlemen, and Fellow-members of the Medical Society of City Hospital Alumni:
Words can hardly convey the sense of appreciation that I feel for the confidence that has been shown, by electing me to the highest office within your gift, while I have expressed a regret that I have been so chosen, yet I wish to assure you that such expression, ability to serve you as you should be served. emanates from a recognition of my slight But as the affliction is now on you, and perhaps difficult to eradicate, your humble servant can but say, that he will do the best he can, put every earnest effort forward, and endeavor to make 1906 a creditable one, in the list of extremely successful years of the past; in order to do this, it will require the same hearty co-operation and aid, that has been extended to the officers in former years.
Our society had its first meeting in November, 1891, its parentage bode well for a healthy and vigorous infant, with such names as, appearing on the roster of charter members, viz: Barker, Boisliniere, Bond, Bryson, Dalton, Dorsett, Falk, Friedman, Freis, Frumson, Fry, Grant, Grindon, Hall, Homan, Hurt, Hypes, Jacobson, Kohl, Lewis, Love, Mardorff, Meisenbach, Moore, Mudd, Mueller, Nowlin, Pierce, Reder, Rowland, Schleiffarth, Seibold, Sluder, Smith, Spore, Taylor and Valle, representing its paternity, is there any wonder that the organization is so successful, that its youth is so assertive and making itself felt with such men still among its most active workers?
The Medical Society of City Hospital Alumni stands for progress, in matters medical, in our city and state; among the most prominent accomplishments I may mention," was the demonstration of the practical utility of school inspection; and, though that act received but slight recognition and encouragement at the time, nevertheless, the time is rapidly approaching when the Board of Education of St. Louis, will awaken from its apparent state of lethargy regarding health law requirements, and appreciate the necessity of such important work, and institute its continuation.
Some four years ago, Dr. Homan presented a feasible plan, before this society, upon which to work and elicit interest in the establishment of a State sanatorium for
Read at the annual meeting, January 6, 1906.