In dealing witb fractures it should always ends of the bone. This is avoidable and be remembered that we are dealing with a care should be taken that it does not occur. wound—a wound of bone and as is the "The opinion of surgeons differ in regard case with wounds of the soft parts, the wider to the treatment of fracture. Some contend. the wound surfaces area part, the more lati. ing that all fractures, whether simple or not, tude of movement they have, the greater the should be treated by open operation. Some injury to lymph and blood vessels, and the bold that no simple fracture of long bone greater the amount of exudate and swelling should be treated by open operation. Some, The sooner the wound surfaces are approxi. who under ordinary conditions employ nonmated the less will be the swelling and the operative methods in fractures, in general, more perfect the result.

employ operative methods in some cases when Lotions containing opium and other drugs it seems necessary. for the reduction of the swelling have no This class of surgeons as a rule adopt one place in fracture-treatment.

of three methods of procedure: The results to be aimed at in fracture-treat. 1st. Immediate application of some form ment are, union without deformity, without of splints or apparatus. impairment of function of the part and with 2d. The applications of splints or appar. as little loss of time and usefulness as possi. atus which may be easily removed to admit ble. It is however, difficult to arrive at a of examination, of massage, and passive proper test of the efficiency of any special movements being applied to the parts. line of treatment in dealing with fractures. 3d. The lipited use of splints with their

“The amount of the deformity and degree early rejection entirely. to which function has been impaired are the In tbe treatment of simple fractures each final tests of the efficiency of the method em. case must be a rule unto itself, a great deal ployed in each case.

depending upon the nature of the fracture "Many surgeons have adopted the X-ray and its direction, whether it be transverse, as a final test of their work, and who hold oblique, longitudinal, dentate or spiral, or that if a set fracture does not show perfect whether important arteries, nerves and mus. approximation by the shadowgraph, just af. cles, with their attendant sequelae of paralyter the splints are applied, it should be out sis, atrophy and gangrene are involved. down on and means of internal fixation In both simple and compound and compli. adopted for the coaptation of the ends of the cated massage and passive movements have fractured bone."

proven themselves of great value when intel. I regret very much that a great many sur Jigently applied." geons are blunting their diagnostic sense By passive movements I do not refer to by a too great reliance on the X-ray; which, the old form of pump-handle movements while a valuable adjunct in the treatment which was applied many weeks after the in. of fractures, is by no means faultless.

jury, but that which is applied a few days It must be borne in mind that often a after injury, a few degrees at a time care be. fracture which has been exposed and united ing taken not to disturb the ends of the frac. by ligature or other means will not stand tured bone. this test, and for that reason the X-ray can. The application of passive morements and not be the sole test of our work, for we well massage to the sites of the fracture before know that absolutely perfect approximation the bones were thoroughly united is of recent of the ends of fractured bones is impossible time. There is at present a strong general except in the most simple transverse frac. tendency to put aside all forms of retentive tures.

apparatus which render the parts inacoessible While every legitimate means should be in favor of those forms which are easily mov. employed to obtain as perfect apposition of able and admit of easy access to the injured the parts as possible, yet it is amply proven parts, favoring the employment of massage by experience that slight displacement, unless and passive movements, whicb lessen the pain, it be of a rotatory nature, is not generally fol. prevents effusions, promote absorption of lowed by any disability of function if adhe. effused products; hastens callous formation, sion and interposition of soft parts be guarded prevents adhesions of soft parts, avoids wast. against by early massage and passive move. ing of muscle; prevents stiffening of tendons ments.

and joints, and increases the range of funo. That impaired funotion, which is the result tion of the parts. Thus all of the conditions of some fractures in which the position of the are prevented which are so frequent under ends of the broken bone is not ideal, is gen. the older forms of treatment. erally not due to imperfect bony apposition, Passive movements, according to Bickham, but to adhesions and changes in the soft are divided into three classes, namely, imme. parts due to their impaction between the diate, intermediate and remote.

Immediate when employed within the first study, experience and comparison of results two days.

of the new with the old methods have proven Intermediate when applied from the second their inefficiency. to the fourteenth day after injury.

Compound fractures have always received Remote wben applied at a later time. some form of operative treatment, if only to

Results are better and recoveries quicker the extent of cleaning the site and putting when these movements are instituted earliest. the parts into favorable position for repair.

Passive movements should be instituted at Comminuted and complicated fractures have first, and active movements as soon as the also often received such treatment, so that onion of the parts are strong enough to ad. the application of a somewhat more radical mit of it with safety. The use of passive operative treatment to those classes is not so movements and massage has shortened the distinctly new as is the operative treatment of period of repair one-third and restored the simple fractures (Bickhanı). function in one-half the time usually re. The treatment of compound fractures at quired.

various periods is one of the notable illustraThe use of continuously retentive splints, tions of conservative surgery. especially those of plaster of paris, tend to At cne period a very large number of com. retard union and prolong the disability of the pound fractures came to amputation; and part after its removal. For this reason mop. it was the rule in many hospitals to amputate able splints have, to a large extent, replaced all limbs above the site of a compound fracthe immovable ones.

ture involving a large joint. l be present state of fracture-treatment may Then followed a period when conservatism be said to be in a transitional stage; it is was shown by saving the part at the expense now in the process of passing from the rou. of shortening it by making an incision at the tine bard and fast, prolonged splinting in side of a compound fracture, including a joint common use until a short time ago, to tbe if necessary. At the present time still fur. more rational and exact methods of the pres. ther conservatism is being shown by neitber ent time, wbich includes the use of passive amputation nor excision, but by freely exmovement and massage in conjunction with posing the parts by operation, repairing the the movable splints and open incision in damage done to the neighboring soft parts, favorable cases.

thorougbly cleansing the part with antiseptio The operative treatment of simple fractures irrigation followed by aseptic douching treatis condemned by many as not to be used in ing the ends of the bone as the conditions any case just as there are many advocates found may indicate, resorting to some method of its employment as a routine practice. I of internal fixation of the broken ends, and am not in favor of total condemnation of its the putting of the part in an open splint. practice, nor do I wish to be put on record as As we cannot always be certain of asepsis, advocating it in all cases, and would consery. drainage should always be instituted at first. atively limit it to those cases which are It should be continued as long as it is nec. otherwise unmanageable, and such special essary, but can as a rule be dispensed with cases, as for example, certain spiral and ob- in about three to six days. This method of lique fractures, namely, of the tibia, and procedure applies with equal force to those some fractures near joints in adults, notably compound fractures with the smallest puncof the humerus at the elbow.

ture, as to those with large external wounds. The simple fractures most frequently oper. The temptation may be very great to disinfect ated upon, by open incision, even by those externally and to try to disinfect internally who do not otherwise adopt the method, as a an insignificant looking puncture of a comroutine procedure, are oblique fracture of the pound fracture, and seal it with collodion, tibia (which beads the list), fracture of the but subsequent septic infection will in opper part of the humerus, and of the hu. most cases cause regret. When the parts are merus ear the elbow; of tbe upper and lower thoroughly exposed, the extent and nature of part of the femur; of the patella; fractures the damage can be determined, and may indi. of the spine, and of the skulī. The most diffi. cate the advisability of excision. Where it is cult simple fractures to deal with are the necessary to bave free aucess to a wound of a spiral and comminuted fractures; fractures compound fracture for the purpose of irriga. whose fragments penetrate and lacerate soft tion and dressings, a method of protecting parts, and fractures associated with passive plaster casts and dressing from fluids has tension of muscles and fascia.

been devised by Crouse and introduced into The position in fracture treatment of sim; practice by Dr. Warren Stone Bickham. “It ple fractures by open inoision has not as yet is a semi-gelatinous paste made by making a been accurately defined, but as before said, solution of dental rubber No. 2 in commercial should not be condemned entirely until time, chloroform with enough loose absorbent wool

worked in to make a meshed mass.” “In

PRESIDENT'S ADDRESS. * planning the window of the cast we should so calculate that there shall be at least one

LOUIS H. BEHRENS, M.D. inch of healthy shaved, sterilized and dry, skin between the circumference of the open.

ST. LOUIS, MO. ing in the cast and the outer margin of the President of the Medical Society of City Hospital Alumni. wound. The paste, 18 then applied with a Gentlemen, and Fellow-members of the spatula and packed between the skin and the

Medical Society of City Hospital margin of the opening in the cast, filling all

Alumni: the opening and coming up and out upon the surface of the cast. The whole mass of paste

Words can hardly convey the sense of ap. and the plaster cast in the vicinity are then

preciation that I feel for the confidence that veneered with a plain chloroform solution of

has been shown, by electing me to the highthe rubber. The rest of the cast is then

est office within your gift, while I have exshellaced.” The opening around the wound

pressed a regret that I have been so chosen, is thus aseptic and waterproof, and may be

yet I wish to assure you that such expression, flushed and irrigated witbout damaging the

emanates from a recognition of my slight

ability to serve you as you should be served. cast.

But as the affliction is now on you, and perA word about comminuted fractures. baps difficult to eradicate, your humble serComminution in a fracture is often difficult vant can but say, that he will do the best to recognize by ordinary manipulation and he can, put every earpest effort forward, and is only demonstrated by the use of the X-ray. endeavor to make 1906 a creditable one, in Even where it is present, especially if it be the list of extremely successful years of the simple and not extensive, does not particu. past; in order to do this, it will require the larly complicate the fracture. In the ordin same hearty co-operation and aid, that has ary cases pon-operative treatment may be em. been extended to the officers in former years. ployed, but where it is more extensive or Our society had its first meeting in No. complicated, or when simple comminution verber, 1891, its parentage bode well for a prevents the acourate approximation and re. healthy and vigorous infant, with such names tention of the ends of the bone in the proper as, appearing on the roster of charter memposition it should be cut down and dealt with bers, viz: Barker, Boisliniere, Bond, Bryson, as the needs of the case may require.

Dalton, Dorsett, Falk, Friedman, Freis, In cases of extensive comminution, exoi. Frumson, Fry, Grant, Grindun, Hall, Ho. sion of the bone-ends may be called for, fol. man, Hurt, Hypes, Jacobson, Kohl, Lewis, lowed by internal fixation or bone grafting. Love, Mardorff, Meisenbach, Moore, Mudd, Lastly, complicated fractures. The strongest Mueller, Nowlin, Pierce, Reder, Rowland, argument for open operation in this class of Schleiffarth, Seibold, Sluder, Smith, Spore, fractures, followed by internal fixation, is that Taylor and Valle, representing its paternity, it gives free access to the fracture, and gives is there any wonder that the organization is full opportunity to treat and rectify any so successful, that its youth is so assertive special complication which may be more im. and making itself felt with such men still portant than the fracture itself.

among its most active workers ? One thing more I wish to impress upon

The Medioal Society of City Hospital you and that is, in compound and comminuted

Alumni stands for progress, in matters med. fractures, we are safor in enlarging the open

ical, in our city and state; among the most ing and clearing the surface and suturing the

prominent accomplishments I may mention, fragments under strict antiseptic precautions

was the demonstration of the practical utility and thorough drainage, together with intelli.

of school inspection; and, though that act gently applied massage and passive move.

received but slight recognition and encourments than under the older methods of treat.

agement at the time, nevertheless, the time is

rapidly approaching when the Board of Edu. ment.

cation of St. Louis, will awaken from its ap.

parent state of lethargy regarding health law International, System of Surgery.

requirements, and appreciate the necessity of

such important work, and institute its conStimson on Fractures. Scudder on Fractnres.

tinuation. Operative Treatment of Fractures by Warren. Stone Bickman, Post-Graduate, New York, pp 236, 237, 238,

Some four years ago, Dr. Homan pre.

sented a feasible plan, before this society, Wharton and Curtis, Surgery.

upon which to work and elioit interest in

the establishment of a State sanatorium for A. R. Mitchell, February number Railway Surgeon, "Frac

• Read at the annual meeting, January 6, 1906.

Bickham, Surgery.
Bryant, Surgery.

Von Bergman, Surgery.

247, 249, 251, 257, 268.

Wyeth, Surgery

Alfred Keyes, Jr., Reference Handbook American Medical Sciences.


the treatment of consumption; a committee iner's system of Massachusetts be substi. was appointed at once, the aid of other medi tuted. cal societies and influential medical men was 9. That the reform of the medical expert solicited; in due time a proper bill was question should be agitated and freely disframed, and presented to the proper commit. cussed, with a view of regulating same legally tees at our State Capital. It is needless to and professionally. add that hesitation was manifest; this bill The above appeals to all of us no doubt, it seemed did not appeal to the august assem. and I am pleased to state that the report has bly at Jefferson City, and seemingly found borne fruit indirectly, for within the week its way to the usual pigeon hole; persever- antispit agitation has begun and arrests are ance won the day, bowever, an intelligent being made, and our smoke inspector's office committee took the matter in charge, and in does not seem to be yet in a hopeless state due time the hopelessness of a few years be- of hibernation, as some activity there has fore turned to the hopeful. Fifty thousand become manifest, so reported, if not seen, as dollars bas been appropriated for such a san. yet. atorium by the State, the location purohased, Fellow members, we have much work beand work begun, so that Missouri is now in fore us, not confined alone to the simple disthe line of progression that other states oussion of matters medical, but it occurs to have shown, in the subject of educating and all that a greater activity must be shown by treating the poor and unfortunate consump- us in properly educationg the people to the tive. Time will show its gratitude and ap. baneful effects to health resulting from pro. preciation indirectly to this society for the miscuous expectoration, and the deleterious thought, ways, means and work in this ac. effects on the respiratory apparatus of these complishment.

ohunks of soot that are ever present in the Benevolence in act and feeling, has been atmosphere surrounding our city. The Civic our slogan; how could it be otherwise with Improvement League is doing its duty; unus, beginning our medical career as we have fortunately it is regarded as a society solely among those who represent the poorest of the for beautifying and making our city pleaspoor in most instances, and we are at all times antly habitable; no matter wbat else is uninterested in seeing that those so unfortunate dertaken by it, it is not apparently regarded are shown proper consideration as charges in a serious vein by our people. Be neat of our city.

about your person, morals, and surroundings, At our last regular meeting, the Com. just so you and our city will look and be mittee on Municipal Affairs and Public looked upon as being inodel, seems to be the Health made some recommendations for fu. way their mission is wrongly regarded; their ture work of our society, to which opinions work in sapitation and health law enforceexpressed we must heartily concur. An ab. ment is not accepted seriously, though it is stract of such recommendations bears repe- good, and their work is perfect in getting at tition tonight, and is as follows:

it, if not getting the results; honestly, and 1. That the crusade of Collier's Weekly and unfortunately for it being so, the term Civic Ladies' Home Journal against patent medi. Improvement League seems in the minds of cines be endorsed and resolutions of com. people as being solely identified with school mendation adopted.

gardens, potato and vegetable patches, boxes 2. That the policy of down-town druggists on the streets for depositing refuse, ash pits, beralding patent medicine departments, and garbage cans and matters generally esthetic. allowing quasi-medical practitioners to use Granted that this work is thoroughly comstores for headquarters, while at the same time mendable and a necessity and has in all of soliciting business from the profession, be our minds appruval and hearty approbation, severely censured.

but people in many instances, don't want to 3. Tbat the use of all utensils in common be nice, so to speak, just for niceness sake. be abolished, particularly, the cigar cutting They listen with attentive ear, to the various machine, in cigar and drug-stores, etc. lectures, forget in due time the teachings, and

4. That we insist in the enforcement of the the mission is lost in such work pertaining antispitting law.

to health when such a body is depended upon 5. That a city tuberculosis sanatorium be entirely to talk upon and instruct on health established,

subjects. 6. That the smoke inspector's office be It then falls in great part to such societies awakened by a resolution.

as this to bring about law enforcement of 7. That the over-crowded condition of the beatlh laws and affairs, and it can not be insane asylum be relieved.

again said that should we lend our aid as an 8. That the present coroner's system be organization, to see that the antispit and abolished in Missouri and the medical exam. antismoke ordinance is enforced, from a

standpoint of health injury, that much more on Broadway and Market; the old funnel might be accomplished than what has been works over time in impregnating the atmos. for people fear that something that will in. phere with its filth. I will say that the new jyre their precious selves,

City Hospital has smoke consumers. Who are the spitters that we must fear? The smoke abatement will never be solved The poor, ignorant fellow, that spits openly, on the talk of neatness. and I think we have at home, in street and publio places and con. the proper argument that will more quickly veyances alike? The one that is usually ar. lead to its solution, the health cudgel must rested, not altogether for expectorating. per: be intelligently and persistently used. haps half drunken, and knows no better, and

Many thousand tons of soft coal are

M upon whom the law inflicts its $1.00 fine, or

burned in St. Louis daily; to every 100 tons stays it, perhaps, without his understanding

of suob coal one ton of soot is thrown into the import of his arrest; he thinks no doubt

the atmosphere, so I have been informed. Is that the infiction was due to a lack of the

there any wonder that plant life does not finer senses on bis part; in other words, he

thrive in our down town section ? That has was caught, and arrested for not being nice,

been demonstrated time and again at our he will apit again, more often, just out of

city hall and court house gardens; trees and spite; look at the recent arrests and judge.

grass refuse to grow. Is then such an atNo, the man to be taught the lesson, is the

mosphere a proper one for human life, for one clothed as a gentleman, and to all ap

those beings that are forced to live in it? pearances sucb, or should be, who, in bis

It is not necessary to say more on this subown domicile knows his sense of duty, but

ject, but the smoke ordinance must be en. when in public places or on cars, seeks in the

forced on health lines if it is to meet with fascinating manner some dark corner, or per.

its intent. haps, with hand to side of mouth coughs and

A problem more serious and of greater im. uses the space between the car window and

port menaces this, as well as other large casing as a cuspidor. There is the danger

communities, and sooner or later cognizance ous one, and the proper subject for the law's

must be more generally taken of this vital vengeance; such would be an example worthy

subject, by the laity, and its appalling results of the law. That is the type of cattle we

be better understood. must reach, else the antispit ordinance be.

I refer to the immorality existing especially comes a farce.

among the young men and boys and the effect This ordinance had practically its birth in

of such that is becoming so commonplace. this society and I can say that it becanie a

A frightful prevalence of syphilis and gonor. law through the joint efforts of this society and the Civic Improvement League. We are

rhea among these youngsters, every one of us then in part responsible for its birth, and it

has seen too often in recent years. is our duty to see that education and mild It seems that in order to become the true means, at first, be tried to enforce it, and if sport, it is necossary to become so infected: that is not adequate the law's force wust be they regard gonorrhea as proper and simple. inflicted.

Syphilis causes but little more thought. We also have an anti-smoke ordinance and

Neither disease has ever been properly ex. a person, so-styled inspector, with many as.

plained until the persou becomes the patient, sistants, who are clothed with proper au.

and then the damage is done. thority to enforce the law to the letter; such Too often the physician is not sufficiently reads like a dream-it is nevertheless true. plain in his talk to these youngsters, and The lay press bas fought and fumed and they, to avoid further trouble, as they think, talked itself to proverbial blueness, in a marry-with the awful results that are appreseeming meaningless manner, of the smoke ciated later by all, in too many instances. nuisance; its work has borne no fruit, for What then are we to do as medical men, to today St. Louis sees more dark and dirty call a halt to this syphilizing our young men days, than ever before, due to that ever with and boys in which it means suffering to the us miserable blanket of soot, soiling every other sex also. The good minister's talks to thing and everybody, driving business men young men are wasted on barren soil, young almost to distraction by the damage done, men and boys won't be good, just for good's and the rest of us have long since ceased our sake; also the social evil law is a farce even attempts at personal cleanliness, in many in. where it is enforced. Take Vienna for instances it has created more scientifio cussers, stance, such a law exists and so near as I could and why? just because of lack of law enforce- learn, is enforced to the letter, but that city ment. But why should factories he expected seems a hot bed of venereal diseases; perhaps to comply with a law that our city does not it is not the so-called prostitute, but the coy, regard ? Take as example, the Court House “soft snap,” as we know them here.

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