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A Summary of Second Day's Proceedings of the Tenth Annual Convention.
The convention was called to order yesterday by the president at 9:37 a. m. The minutes of the previous session were read by the secretary, and on motion declared approved. Dr. Bouffleur reported that the Association. has received a request fom the Commissioner General of the Tennessee Centennial to hold the present meeting there, but this, unfor
CASSIUS D. WESCOTT, M. D., CHICAGO, ILL.
tunately, came in too late to receive consideration by the Executive Committee.
For the Committee of Arrangements, Dr. Bouffleur reported that sleeping car transportation had been secured from both the Wagner and Pullman companies.
The action in the revision of the constitution, taken at the last meeting, was read from the minutes by the secretary. The president then referred the matter to the Judiciary Committee.
Reading and Discussion of Papers.
The first paper of the day was entitled, "Observation Upon and Reasons for a More Complete Physical Examination of Railway Em
ployes," by Dr. Henry F. Hoyt, St. Paul, Minn., who said:
ABSTRACT OF DR. HOYT'S PAPER.
A large majority of railways now operated require tests to be made of the eyes and ears of employes, but this is often left to laymen, and no doubt soketimes imperfectly done. It was a long time before railway managers realized the importance of having men with normal eyes and ears, but they do now, and this part of the examination has come to stay. As nearly as I can ascertain, there are from twenty to thirty trunk lines and over a thousand smaller operated railway corporations or systems in the United States, altogether employing about seven hundred and fifty thousand men. Out of this vast number I believe there are at this time only six system that require what would be termed a complete physical examination of their employes. These are the Baltimore & Ohio, the Pennsylvania East, the Reading, the Burlington, the Pennsylvania West and Plant Systems.
These corporations, as I understand it, only require those employes to undergo examination who desire to become members of their respective relief associations, and doubtless the examination is to a large extent due to the fact that there is a relief fund or insurance benefit feature connected with these associations. There are other reasons, however, why every railway corporation should pay more attention to this question. With very few exceptions a man cannot enter into any department of the civil, military or naval service of the government without first demonstrating that he is physically sound and free from disease or its effects, and unless he can do so he is promptly rejected, no matter what his mental attainments may be. Yet how slight is their physical responsibility as a rule compared with that of the average train man on a railway, who can get employment with hardly a thought of his physical condition, be at once put in charge of human lives and property, where in discharge of his duty a pathological or congenital defect may cause great loss of both. After an accident railway companies are prompt in getting and often in damage suits take the ground that reports of the condition of an injured employe, injuries presented existed before accident occurred, but this position is rarely sustained for obvious reasons. A careful, complete physical examination of every man employed in the train or mechanical railway service made and recorded by a competent surgeon will not only elevate the present standard of manhood, strength and physical excellence among employes, but it may often prevent great loss of life and property. A physical defect does not necessarily bar a man from earning his living by railroad work, but these conditions should
be known and the unfortunate possessor of defective or diseased eyes, ears or heart, should be absolutely prohibited from filling any position where, in the discharge of his duty, he is, or may in anyway become, responsible for human life. In the way of protection of the traveling public, a physically perfect train crew will certainly minimize the danger in emergencies when compared with an imperfect one.
Another reason I advocate physical examination of employes is to protect the corporation against a certain class of unjust claimsfor damages for alleged personal injury sustained while on duty by employes. Some are perhaps made honestly through ignorance, but the majority made by the class I refer to are fraudulent. A man has some form of hernia, a spinal deformity or other pathological or congenital defect. He engages to work for a railway company where there is no physical examination. By watching his opportunity something soon occurs that he can adapt to his case and he is apparently injured. He keeps his bed, has the usual tedious recovery, exasperates the surgeon almost beyond endurance by his unreasonable demands and general cussedness, finally exhibiting the milk in the cocoanut by making an exorbitant demand to the company for his permanent disability, alleged to have been incurred in their service. The claim agent to whom you now cheerfully shift the burden of responsibility, recognizing or suspecting the injustice of his modest request, refuses to settle. He brings suit. The company have now got to prove that he had the infirmity prior to the time of the alleged accident. Under the existing circumstances this proof is next to impossible, and if the company is what is termed in legal phraseology "liable," the result is generally a fat verdict in favor of plaintiff.
Dr. Hoyt's paper was not discussed.
The next paper was by Dr. H. L. Getz of Marshalltown, Iowa, who gave some "Hints On the Treatment of Fractures of the Humerus, Radius and Ulna, with Complication of the Elbow-Joint."
ABSTRACT OF PAPER BY DR. GETZ.
I desire to call attention in this paper more especially to the importance and value of early manipulation in the treatment of the injuries named in title, and also to offer suggestions as aids in accomplishing the results most desirable. Three weeks, in what may be termed modern surgery, was regarded as an early date, after time of sustaining injury, to begin even passive movement of a joint involved by fracture, and while the value and importance of early manipulation was then appreciated, there seems to have existed in the minds of surgeons, as it does now doubtless with many,
that an earlier manipulation would result in the displacement of the fragments of the injured bones and so interfere with their union. While in the majority of fractures three to four weeks are required to insure a firm union, yet observation and experience have convinced the writer that most of these fractures are sufficiently firm in a week, and some in even less time, to bear reasonable manipulation and motion of the part when protected by the hand of the surgeon over the seat of fracture. many years it has been my custom in the treatment of these injuries to most carefully note, while reducing the same, the exact seat and character of the fracture, so that in the subse
HENRY F. HOYT, M. D., ST. PAUL, MINN.
quent early manipulation of the injured member support may be given at the exact point of injury, by the hand of the operator. It is by no means always necessary to use the entire hand in giving the necessary support at the seat of fracture; in fact, the thumb and one or two fingers are usually preferable, in as much as a finer sense of touch is thus obtained and any tendency to displacement of fracture, thus noted and more easily and readily averted; support so made also allows of more freedom of movement of muscles and tendons over the seat of injury than when the full hand is made to grasp the member at point where support is required. In the primary treatment of these injuries it is usually best, especially in children, and in adults where there is perhaps considerable swelling, as is so apt to occur in a short time after receipt of injury
at the elbow-joint, so that as already noted above, the exact location and character of the injury may be thoroughly defined; even in the after-treatment by passive motion it is well, especially in children, to use chloroform. I have frequently given a child a comparatively small quantity of chloroform, removed the dressings, manipulated and massaged the parts, reapplied the splints just in time to have the patient awaken and not realize what had transpired; another advantage in the use of an anæsthetic is the relaxation of the muscles and also the avoidance of contraction of muscles from fear of pain.
In fracture of the olecranon or of coronoid process, movement, flexion and extension of forearm is best deferred for from ten to fourteen days and then it is necessary to protect carefully the parts, so that separation of surfaces of the broken bone are held in close apposition. In Colles' fracture massage is of much less value and importance, or, in fact, less required than in elbow injuries, because there is a less amount of tissue here liable to inflammation and resulting deposits when movement is commenced. The thumb of one of the surgeon's hands should be placed immediately below inner surface of fracture, and usually the index or middle finger, and sometimes both, over the dorsal surface of wrist or lower part of forearm over the fracture; this done, the fracture is carefully protected and held in place, while the surgeon's other hand grasps the hand of the patient and gently moves the hand upon the forearm once in each direction. This movement, is, however, not of so much value as a full flexion and extension of the fingers and thumb of the hand; that is, flexion and extension of the fingers should be done as far as possible by effort on part of the patient, and should only be aided by the surgeon when the patient is not able to fully flex and extend. It is surprising, indeed, how little support is necessary to hold in position the ends of broken bone while the extension and flexion of the hands and fingers are made; if there coexists Colles' fracture and fracture of the ulna about opposite the seat of Colles' fracture, the fracture in the ulna may be supported by the same hand with which he supports the Colles' fracture, if, however, the seat of fracture in the ulna is higher up, the hand of an assistant may become necessary to give proper support to the ulna. Better than this, however, is the application, temporarily, of a light, short splint to upper and lower side of the arm, which should be held in place by bandage, thus giving the part to be manipulated into the hands of one person. By this method there is less liability of disturbing the broken ends of bone. This movement of the hand and wrist may, with advantage, be commenced in from four to five days after the
original treatment (the adjustment of the fracture) and should be repeated every few days for three to four weeks. This plan pursued will give the patient a useful hand and arm in from three to four weeks in many instances, and splints may then be discarded. One manipulation, as I have here suggested, say, even within the first week after receipt of injury, is worth ten or more commenced three weeks or a month after the injury. Summing up, give an anææsthetic, especially in children or timid and sensitive persons, so that you may satisfy yourself of the full nature and location of the fracture, and also that you may completely and properly reduce dislocation, if existing, and adjust the fracture to a nicety. Dress these injuries in such a way that they may be easily examined and manipulated, take them out of these dressing and institute passive and encourage active motion; be not afraid to make these movements. Always tell your patient how much danger there is of a stiff elbow or wrist or impaired use of hand, even under the best of surgical care and treatment, just as you see in most, if not all, of the surgical works to date. If you will practice that which I have suggested in this paper in general and detailed method you will surprise the patient and friends, and, in fact, yourselves, when you compare results with the old methods of treating these injuries, and they will wonder why you ever made such a statement. They will be contented, however, to drop the query at having a good and useful arm or hand, as the case may be, and will accord you a good and skillful surgeon. In conclusion I can assure you that if you will follow these suggestions you will materially reduce the number of malpractice suits.
The discussion was opened by Dr. D. S. Fairchild, who said:
Fractures of the humerus, or of the radius, or ulna, near or into the elbow-joint, simple, or simple and comminuted, involve propositions of great interest to the general surgeon on account of the deformity and impaired motion which may follow. All the facts connected with these cases are well known and nothing new or specially important can be offered. However, it may be helpful to use to review our present knowledge and experience with the hope of being able to avail ourselves of the best methods employed by those having the largest and best experience in the treatment of these injuries.
So much depends upon the care and skill employed in the management of these cases, and so important are the ultimate results to the patient, that no apology need be offered for the time employed in the consideration of fractures of any kind involving important joints.
There are at least three important pathological facts which may be considered, first, the comminution of bones very near the joint, which, by their vicious position, may create deformity and interfere with the movement of the joint; second, the formation of a callus which may interfere mechanically with the joint action; third, the adhesions which may form in consequence of an inflammation in or near the joint and thus limit the movement of the joint. The first and extremely important consideration is an exact diagnosis of the nature and extent of the fracture. The examination should be carefully made under the influence of an anæsthetic and should be prolonged sufficiently to enable the surgeon to reach a satisfactory conclusion as to all the facts involved. When the fragments are correctly reduced the question of retaining them in position is worthy of the most careful consideration. If they are retained by means of absolute fixation of the joint a degree of temporary or permanent ankylosis is almost certain to follow. If the joint is not so fixed the fragments are almost certain to become displaced and deformity occurs with even greater impairment of joint function. It therefore follows that the application of an immobilizing apparatus furnishes the best results, with employment of motion as soon as the fragments are united. Differences of opinion exist as to the position in which the arm should be placed in the treatment of fractures involving the joint occurring very near the joint. I do not think any absolute rule can be adopted. It has been my practice to fix the arm in the position which gave the best line and which succeeded in most thoroughly and easily bringing the fragments into the best possible relations. If the line of fracture is such as to admit of shortening I would attach a weight for a few days in order to obtain extension in the line of the axis of the bone. As a permanent dressing nothing serves better than a gutterlike plaster-of-Paris bandage, with the arm-as before mentioned-in the position. which most completely reduces the fracture. I think the same general proposition is true, whatever may be the location of the fracture, whether the fracture is in the humerus or in the ulna or radius. Motion and massage should be commenced as early as possible consistant with a safe union of the bones.
Compound fractures of the arm or forearm involving the wrists or elbow-joints, and particularly crushing injuries to the elbow-joint offer a strong temptation to the inexperienced surgeon to amputate, but he should be constantly on his guard against giving way to such temptations, for it must be a very desperate condition, indeed, which would warrant any such procedure.
If, however, the immediate treatment of such
injuries is not conducted on the most approved surgical methods serious results are almost certain to follow. Injuries of this character generally occur under the most unfavorable circumstances. In addition to the violence itself, foreign matter is very liable to be driven into the wound and a degree of infection is almost certain to occur, hence the most diligent and cleanly treatment should be at once employed. A large amount of sterilized water should be at hand, dirt, shreds of clothing, etc., together with detached pieces of bone shreds of devitalized or suspicious tissue trimmed away and careful washing, irrigation and wiping of the exposed and damaged parts should be employed until the surgeon is satisfied that the surfaces are as nearly surgically clean as possible; after this is accomplished careful drainage should be provided for either by rubber tubes or by pieces of folded sterilized rubber tissue surrounded by a layer of iodoform gauze and so arranged as to give thorough drainage, for it can scarcely be hoped that a perfectly aseptic condition can be obtained under the circumstances surrounding these cases.
A copious sterilized gauze dressing should be now applied and the parts fixed in a position which will most thoroughly reduce the fragments of bone and give the best position for a useful arm if ankylosis should occur, and the parts retained by means of a light plaster-ofParis bandage.
We cannot too strongly emphasize the necessity of great care in the early treatment of these cases, for the results will be largely determined by the thoroughness of the surgical methods employed. Amputation should never be considered except in cases in which the tissues are hopelessly destroyed. If any doubt exist as to this fact the injured parts should be enveloped in copious sterilized gauze saturated with a boric acid or weak bichloride solution and wait for results. If the accident occurs under such circumstances as to prevent the employment of proper treatment, the above wet dressings should be employed until the patient can be transported to a proper place, preferably a hospital.
Dr. P. Doughtery of Junction City, Kan., also discussed the paper. He rather criticised the splint which Dr Getz uses and described his own method of dressing Colles' fracture. He prepares two small compresses from roller bandage two inches in width and about the thickness of the little finger. After reducing the fracture he places one compress along the anterior and outer aspect of the radius, the other parallel with this over the ulna. He then applies a strip of adhesive plaster about two inches wide around the wrist, including the compresses. He then puts the forearm in
a narrow sling, using the weight of the hand for extension.
Dr. Getz closed the discussion by saying that he did not insist upon any particular form of dressing, but urged that massage and passive motion be resorted to early. He prefers, however, to have the patient wear a secure dressing and to make all movements himself under anæsthesia, if necessary.
"A Case of Intercondyloid Fracture of the Femur," was then reported, and skiagraphs exhibited, by Dr. F. W. Schmidt of Riverdale, Ill.
ABSTRACT OF PAPER BY DR. SCHMIDT.
The patient, a male, aet. 15 years, was tall, slim and anæmic. He was a machine hand, and was seen four hours after the injury. fell, doubling his leg under him and forcing the weight of his body upon it. He was placed upon a double inclined plane splint, which was removed on the second day, the limb extended gently and a long sand bag placed on each side. This was done to get time for swelling to subside in order to make diagnosis. Three days afterward a plaster-of-Paris dressing was applied from heel to hip with counter-extension. This had to be discontinued on account of intense pain. Passive motion was resorted to under anæsthesia five weeks after the injury. The limb could then be flexed about one-half. The patient was instructed to attempt passive motion himself and use massage. He walked about with cane in four months. Has worked for last nine months. Result-shortening one inch; can flex limb about one-half.
The discussion was opened by Dr. A. I. Bouffleur of Chicago, who called attention to the seriousness of these injuries and said that the skiagraph showed the condition of the joint, which could otherwise only be guessed at. He further said that the treatment must always depend upon the necessities of the individual case.
Dr. A. L. Cory of Chicago said that the chief difficulty in these cases was one of accurate diagnosis. He said that the usual method of dressing such cases was upon the double inclined plane, but he favored the dressing which Dr. Schmidt had applied. He also believed in massage and passive motion, but would defer such treatment till after union had taken place.
Dr. Schmidt, in closing, said that he had been censured for not using a double inclined plane in his case, but his result justified his
A paper on "Wounds of the Neck" was read by Dr. F. W. Thomas of Marion, Ohio, who said:
ABSTRACT OF PAPER BY DR. THOMAS.
In addition to the ordinary features, wounds of the neck have characteristics and dangers peculiarly their own. This is true on account of blood vessels, air passages and nerves that are so frequently injured to a serious extent, even though the wound in itself may not be a large one. Wounds in the cervical region are modified in their severity by the situation, the direction of the force and the depth to which they penetrate. We have the accidental, the homicidal and the suicidal wounds to consider
L. GETZ, M. D., MARSHALLTOWN, IA.
in this connection, each one having its peculiarities, which often have special significance from a medico-legal standpoint. The suicidal wounds are generally more lacerated and irregular than those made by another hand, and are either transverse or obliquely downward, the larger portion being on the left of the median line, and not as a rule deep enough to seriously injure the deep vessels.
Wounds which open the air passage, although trivial in size, and far enough away from the carotids and jugulars, sometimes do great mischief by interfering with respiration.
Hemorrhage from wounds in the cervical region is one of the most important points about these injuries. Blood may be drawn from a small wound into the air passage faster than the patient can expel it, and asphyxia