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the signals are to be used throughout the entire railway system of any certain geographical section; and to perform the tests under the same conditions as the candidate is to be placed when it becomes necessary for him to determine quickly and promptly the colors of the signals in actual use. The signal-colors fixed and certain, nothing further remains necessary than to make the test-colors as nearly as possible identical with them.
Knowing from experience that loose colorselection at a distance is the only way to accomplish the purpose properly, simply and quickly, by those who are adequately trained in its performance, some such plan as shown and described by the writer in a paper read before the 1888 meeting of the American Ophthalmological Society can be used as the general method. By this means the numerous other and more complex plans can be reserved for a Chief Ophthalmic Expert of the road and his Assistant. To them all doubtful cases, and those where medico-legal questions may arise, may be given, so that less error in reasoning and fewer flaws in judgment can be established in any given case.
In conclusion, it must be understood that the present paper is merely a fragmentary and meagerly written effort to supplement what the writer has time and again personally endeavored to accomplish in other ways: that is, to protect the traveling public and their property from one of the greatest of special dangers known in railway service-subnormal color-perception (so-called "color-blindness")."
FOUR CASES OF FRACTURE OF THE FEMUR.*
BY DR. E. J. MILLER, MARION JUNCTION, S. D.
It was after considerable hesitation that I consented to present my first paper before such a learned and experienced body of surgeons. Medical men, and particularly surgeons, do not care for long-drawn-out introductions, nor do they attach as much importance to minutely detailed histories of
All that has been written here is equally as true for the socalled traction trolleys which run at such high rates of speed, especially in suburban districts, and so rapidly and frequently change passengers. In this class of employes, as a rule, applicants are selected for duty as both motormen and conductors, with an utter disregard not only as to their color-vision but as to their other visual functions.
* Read at the fourth annual meeting of the C. M. & St. P. Railway Surgeons' Association at Chicago, Nov. 12 and 13, 1896.
cases as they formerly did. If I have here committed that error I beg your pardon, and will endeavor to do better next time. It matters but little to us whether a man fell from a church steeple, a box car, or a door step, except for the mental effect it may have on the patient; what we want to know is, how and where our patient is injured, so that we may come to an immediate decision as to the injury we have to deal with.
After knowing the nature of an injury, the next question is, what should be done that will bring about the best results for the patient with as little pain and inconvenience as possible, and how should it be done?
I am on the "great prairies," in a small town ten miles from any other physician, hundreds of miles from a medical center and surgical instrument stores. I have no county medical society, no discussion about this or that surgeon's operation, this or that surgeon's system of setting fractured limbs. There is little to stimulate and encourage one on, and to keep one posted, except one's own personal ambition and energy.
Being surrounded by such conditions, what more can we do? We should attend every meeting possible. No surgeon can help gaining some valuable information from listening to the discussion of papers read, or cases and personal experience related. We should also attend clinics and take post-graduate courses as often as our means will permit-which is oftener than we will allow ourselves to believe.
We who are surgeons for railway companies should familiarize ourselves with the mechanism of engines and with the construction of freight and passenger cars for reasons that must be potent to all.
We should also be familiar with the principles of how this or that operation is performed by our leading masters.
We should be self-reliant, not egotistical, have some mechanical skill, and be not afraid to use a little originality for fear of criticism, where such can be done without being detrimental to our patient or employer.
Personally, I take as much pride in my shop, with its bench and tools, as I do in the use of my surgical instruments. In using tools in a shop we cannot help becoming more proficient in using our surgical instruments on a fellowIt is a sorrowful sight to see a surgeon
sawing off a femur, or any other bone, begin with the point of the saw instead of the heel, or hitting his fingers or hand instead of the head of the chisel, or tying an old woman's knot instead of a square or surgeon's knot!
In presenting the following four cases of fracture to the femur I have selected cases which give a range of ages and that happened under somewhat different circumstances.
Case No. I.-Jan. 11, 1894, I was called to see J. B., a German, aged 18 years, eight miles in the country. The message was: "Henry has fell and broke his leg; come quick." Not knowing just what I had to deal with, I put a few few extra bandages in my grip and was off, arriving there about two hours and a half after the accident. I learned that while the patient was coming from the barn, in scuffling with the boys he had slipped on the ice, and at the same time one of his companions had fallen on his leg. They heard it crack and he was unable to get up or stand. On examination I found that he suffered a simple oblique fracture in the upper third of the right femur, the upper end of the fracture being about two inches below the lesser trochanter, the lower about four and onehalf inches below the greater trochanter. As the treatment was the same in all four cases, I will endeavor to describe it here. Bear in mind it is in the country, where it is not, "Get what you want," but "Take what you can get." Yet, if I were where I could get what I wanted it would be the same, simply finished a little better.
From an old piece of siding I made an outer splint long enough to extend from the axilla to three inches below the foot. Another splint was made of an old lath to extend from the perineum to three inches below the foot, well padded in the crotch. About eight inches from the lower end of the splints I tied a piece of bandage ten or twelve inches long with a "clove hitch," the ends being on the outside. I then tied two bandages of the same length on the opposite sides of the ankle in the same way. With the patient on a bed, floor or lounge, having my splints, bandages and cotton ready, I reduce the fracture, having whoever chances to be present, hold the leg and pull on the foot, keeping it turned out at about an angle of 40 degrees. I then pad the leg, and place the inner splint in posi
tion, pushing it well up in the perineum; then I place the outer one into position, pushing it well up into the axilla. I then make all fast with separate bandages around the splints, one above the knee, one around the chest, one about the abdomen and pelvis, and one below the knee, well down. I then bring down the inner bandage that has been made fast above the ankle, passing it over the end of the inside splint; I do the same with the outside splint and ankle bandage, making them fast. I then put a block of wood three and one-half to five inches long between the two splints to keep them from pressing on the inner and outer malleoli. I then put on eight or ten more separate bandages at different parts of the leg, tying all in a square bow knot.
With such a dressing the leg is easily examined at all times. The entire operation, including the making of the splints, does not take more than thirty minutes.
The patient rests comfortably-at least my patients have and I have never found it necessary to give an anæsthetic in reducing a fracture of the femur except in one case.
In from eight to fourteen days I take off the splints and put on a plaster of Paris bandage, the whole length of the leg well up on the outside.
In some cases I put thin cottonwood splints, such as are used in making egg cases, soaked in hot water so as to form to the leg, between the cotton and plaster of Paris. I then give the patient a pair of crutches and have him. up and walking around from that time on; allowing him to eat and drink anything he wants, excepting liquor.
The case already alluded to made a good recovery. In eight weeks I removed the plaster of Paris bandage and found no perceptible shortening. I saw him again on the 20th of October, 1896; there was no shortening then.
Case No. II.-Mrs. S., German, aged 33, March 13, 1893, slipped and fell from her doorstep to the ground-about 22 inches. I arrived about four hours after the accident and found a simple transverse fracture in the upper third of the left femur, three inches below the great trochanter. With an old saw, hatchet and a pocket knife I made the splints, reduced the fracture and put the splints on as in Case 1. In fourteen days I put on a plaster
of Paris bandage; a few days later she got up, began walking around on crutches, and in ten weeks I removed the bandage. She used the crutch for three weeks longer, when she came in to see me; there was not then and is not now over one-quarter of an inch shortening.
Case No. III.-D. R., American, aged 54. August 15, 1896, while crossing the railroad track was thrown from a load of oats; several sacks fell on him. About one-half hour after the accident the sectionmen heard him calling help; they put him on a hand-car and brought him to the station, one-half mile south. I chanced to be passing through the town, being out chicken hunting, and was hailed. This was four and one-half hours after the accident. I examined the man and found a simple oblique fracture of the right femur, in the upper third; he was in great pain, though pretty full of whisky, which had been given him by kind friends. Having nothing with me but my gun-which was, of course, of no use in this case-I went to the track where they were building an elevator. There the carpenters kindly loaned me a saw and a hammer and gave me some nails and boards. I soon had the splints made, tore up a sheet for bandages, reduced the fracture, and applied the splints as I have described. I then loaded the patient into a spring wagon and sent him home, three and one-half miles north. I saw him again the next morning and every day thereafter for fourteen days, as I had to draw the urine.
On the 29th, fourteen days after the injury, I put on a plaster of Paris bandage and gave him crutches. On the 30th he was up, and more or less every day thereafter until the 6th of September; he was up all the time by the 15th, out about the yard. On the 17th of October I removed the bandage. I saw him November I and he has a shortening of threeeighths of an inch.
Case No. IV.-J. B., a German farmer, aged 62. July 7, 1892, while returning from Freeman on a load of hay--also having quite a load of "spirits"--was thrown off the load just in the edge of Marion. He was brought to my office at 9 p. m., and laid on a table. On examination I found a simple oblique fracture in the upper third of the right femur. The upper anterior end of the fracture being three
inches below the great trochanter, the posterior one six and one-half inches.
I soon had the splints made in my shop. After reducing the fracture and padding the leg with cotton, I applied an extra lath for an anterior splint, extending from the groin to within four inches of the patella, and a posterior splint five inches above the center of the popliteal space. Then I put the other splints on and bandaged as I have described. He was then removed to the hotel.
Three days later he was taken home, nine miles east. I saw him three days later, and again in three days. On the 28th, three weeks after the accident, I put on a plaster of Paris bandage, with light anterior and posterior splints. He was up and around with crutches in a few days. September 25 I removed the bandage. I saw him last August. I was unable to find a shortening of more than one-half inch in any position of measure
If I have said or presented anything worthy of your consideration, I beg your criticism and hope my seniors and more fortunate city brethren will feel justified in extending the hand of professional fellowship and give words of encouragement to the country doctor.
DISCUSSION OF DR. E. J. MILLER'S PAPER. Dr. Binnie: It is a dangerous thing to say very much about the question of fractures. I have been treating fractures in a manner similar to that described by the doctor for a good while, with the exception of the hitching below. I have used much wider splints than the doctor in the treatment of these fractures. I thought by dressing my fractures in that way I would have no accidents, but occasionally we do have them in spite of any form of splint that we may use. I have used pump-log, and recently I have been purchasing elm splints, put up and sold in Madison. I can get them to fit nicely. But with the best of splints the physician will not save himself from encountering difficulties at times, whether due to the form of splint or the peculiar form of the fracture.
Dr. Johnson: In the treatment of fractures of the thigh the essential point is extension. I think splints have comparatively little to do with the results obtained. In making extension I should use for this purpose adhesive plaster. Within the past two years I was
hastily called to an accident from the caving in of a bluff, during which one man was killed and another had his thigh broken above the knee and leg broken below the knee. These men were taken to a camp. There was the dead man on one side of me, and the living, but badly injured, man on the other in a semiconscious condition. (Here Dr. Johnson. demonstrated the manner in which he improvised a splint and applied extension in this case.) After we got the man fixed up we put him aboard a steamboat and he was taken to his home, a distance of 20 miles. I afterward heard from the doctor there, saying that the splint I applied was not taken off until it was left off permanently.
With reference to fractures of the thigh in children, I have had three such cases within a comparatively short time. I was somewhat at a loss to know how to manage this fracture, but I applied a plaster cast to the entire limb and lower half of the body on that side, and I would mention that the mode of making extension was to slip the plaster cast on the limb, then when I had it about half applied I took a piece of light hoop iron and put it down on both sides of the leg, making it three inches below the foot, reaching afterward the other side and across and fastened by means of a rubber band. Under this method of treatment these three cases did so nicely that I never want to use anything else. It is true, I may not have such gratifying success again.
Dr. Hemenway: I wish to make one protest against the implication that was given by Dr. Miller, and it is one that is very common and, I think, harmful, namely, that the city physician is to be regarded as generally more proficient than the country doctor. I do not believe it. I say what I say from a full knowledge on the two sides. I have seen the country doctor, and mind you, I believe in the science of medicine rather than empirical practice I believe a man should be thoroughly posted and know all of the latest improvements so far as possible. But it has been my observation that the country doctor as a rule works things out for himself. He considers them. and applies them; whereas the city physician, as a rule, as soon as he comes in contact with a difficult case, turns it over to somebody else. The change may be a benefit for the patient, but generally I do not believe it. Except in
the case of a few who are favored with hospital positions and facilities, the average city physician is not as ingenious as the country doctor, and the idea so prevalent that the city physician is to be regarded as much superior has a detrimental effect upon the younger members in country practice. They have a feeling of despair at the outset, which is oftentimes harmful.
Dr. Mitchell: My plan is similar to that of Dr. Johnson's. When I want extension I use a pair of spring scales instead of rubber extension, so that I can weight my extension each day and know how much I use.
Dr. Lincoln: I would ask whether the use of wide adhesive strips in treating fractures of the thigh is considered good surgery at present.
Dr. Cool: I desire to make an inquiry in reference to this transverse fracture. The doctor employed his improvised splint. Was there any necessity for that? Would not coaptation splints applied around the thigh keep the fragments in apposition? Was there any necessity for extension or counterextension? Another thing. Is the splint the doctor has exhibited any better than the old splints? I do not criticize the doctor's splint at all, but I want to know if, whenever I have a transverse fracture of the bone of either the leg or the thigh and treat it with coaptation splints, it is not sufficient.
A Member: How often do we see a transverse fracture?
Dr. Cool: I do not know. Here is one, you can look at that.
Dr. Johnson: Why not apply a plaster bandage at once, or within 24 hours. Would not that be considered good treatment?
Dr. Thompson: I think not. I do not think it is proper to cover a fracture of the femur until partial repair has taken place at least, and I do not think the criticism the doctor made on this point is quite fair. The doctor told us he did not have any splints, that he made his own. There are many of us who live in the country that make our own splints, and I think the doctor has improvised a very good dressing for fracture of the femur. Again, his dressing was proper if he had a transverse fracture. I do not think, however, we ever get a decided transverse fracture in which it is not necessary to apply extension to hold the bone
in position. I think the splint, with the exception of the hitch around the ankle, is a good one. I make my extension with plaster and a rubber band, but I do not think it is good practice to cover up a fracture of the femur until we get partial repair. We want to see it from time to time.
Dr. Townsend: The question of plaster of Paris splints has come up. The splint I use will perfectly fit every fracture. It prevents the fragments from slipping, and any man can use it. I buy in any store a piece of heavy flannel, as heavy as can be obtained-what we call Mackinaw flannel. If a femur is broken I use the well limb for a pattern and make a splint which reaches from the ankle up into the groin. I have a splint to fit about the knee, the calf of the leg and thigh. I cut it out of this heavy Mackinaw flannel. I have a splint
so that it will not close within one-half or threequarters of an inch around the limb. take the flannel and put it in plaster of Paris, about the consistency of cream. After I have done that I take some sheeted wadding and line the splint and apply it to the limb, placing around it a roller bandage. If the limb is swollen, I can spring it apart, and after the swelling has gone out of the limb I can bring it together; I can put a roller bandage on it and if I have a fracture of the femur, tibia, humerus or of the ulna, I can look at the limb at any time. The splint is elastic; the plaster of Paris is incorporated in the flannel, and you can make a splint large or small. Such a splint as I have described works admirably. I have used it in fracture of the femur, in Colles' fracture, Pott's fracture, and invariably have good results from its use.
Dr. Bell: I would like to inquire of the essayist whether he has met with any difficulty from the tilting of the upper fragments in either of the cases reported?
Dr. Miller: No. In case No. 4 I applied an antero-posterior splint, as well as two lateral splints, and had no trouble whatever.
Dr. Binnie: In regard to plaster of Paris, I have seen some bad results following its use. I recall one case where a man received a fracture of the femur one afternoon, which was put up in a plaster of Paris cast, and the patient sent to Southern Wisconsin the next day. I was sent for after three or four days to come and see the patient. The man had been kicked
by a horse and there was quite a wound. I cut down, ran my finger all around, uncovered the limb, and found the man had an inch and threequarters shortening. I told him I did not want to interfere with it. It was something like five or six days after the fracture had occurred. The limb, which had been greatly swollen, diminished in size, but was shortened to the extent referred to. I believe it to have been due to the plaster of Paris cast. But I arose to speak particularly of the question of shortening. I have seen cases at the end of six weeks that had no shortening, or none to speak of, but let the individual commence to walk and put a little weight on the limb, oedema takes place, and there is shortening. One of the ways to prevent shortening is to keep the individual from bearing too much weight on the injured limb until the callus is sufficiently hard that it will not sink with pressure, nor allow it to bend laterally. That is a caution I feel like advocating strongly. Keep the plaster on long enough, change it occasionally and keep the man on crutches; the weight of the legs is all the extension it needs.
Dr. Roth said that when he encountered a case of fracture, such as that under discussion, the first thing he did was to see what kind of a bed he had to put the patient in. He thought this was a very important point. If the physician did not secure a suitable bed in which to place his patient after the application of splints, he could not expect a good result.
Dr. Jackson: I have had good results in fracture of the femur in making my splints of bent iron, cut to the size to fit, using four strips. I keep up extension with weight and pulley. I had a young man who was kicked by a horse and sustained a fracture of the femur, the bone being broken just above the condyles at the knee. I do not think it was more than two or three inches. I tried one thing and another and found it was extremely difficult to hold the fractured ends in place until I got four pieces of bent iron and fitted them over the well leg, then putting up the fractured leg in that I had no further trouble. I only saw the leg once after that. It stayed in its place beautifully; there was no shortening. With the bent iron I have had usually good results.
Dr. Miller (closing): I am not only surprised, but pleased that my paper should have elicited so much discussion on the subject of