more water, quick!" Again emesis occurs. "My God, I will die unless can turn over, lift that leg, oh, that does not do any good, give me some more water! Oh, my God, how that leg hurts, raise me up, more water please!" And then emesis again. And now suddenly an almost instantaneous change comes over him, his bright and brilliant eye, profoundly intense in expression, seems dull and the alæ of the nose move with rapidity, when a sudden spasm seizes the injured man. He slowly turns his head, with tense and rigid muscles, to one side, his breathing becomes shallow and rapid, and the pulse has stopped. With a long, deep gasping breath, death has ended his life, his face partially buried in the pillow.

Delirium, or no delirium, we certainly believe that a great majority of these cases, under the influence of profound shock or call it, if you will, traumatic delirium, have the full, free and unruffled use of good sense, and are competent to decide any question influencing their material interests or regarding the disposition of their material effects. We have truly an exaltation of mentality, but the brain still lives, seemingly superior and paramount to the physical condition, and acts with lightning-like celerity, glowing with an intense excitement. Again, we not infrequently find in grave and severe injuries that a plainly manifest condition of delirium does exist, verging upon insanity. In one case where a truely religious catholic was hurt, immediately following his injury, a wild traumatic delirium made itself manifest. He acted entirely different from what his nature and habits would have indicated. He not only cursed doctors and attendants, and used the most foul and profane language, but cursed and damned the priest who sought to give him consolation. Again, we have seen them under the influence of shock in almost a maudlin condition. A man who had both of his thighs crushed was full of laugh and inanity; he leeringly, foolishly and idiotically laughed at the doctors and when the priest came he said to him: "I'm a railroad man, won't you forgive me?" This was the only sentence he would utter. He would laugh and wildly turn his eyes and repeated as long as he could see the priest, the words just quoted. Again, in one case we have seen almost complete and perfect placidity of mind, no excitement, no unusual appearance of the countenance, and had a sheet

been so placed as to cover him from his neck down, one surely would have thought that the patient was simply comfortably resting and not a fatally injured and dying man. Both of the man's lower limbs had been crushed, nearly up to the pelvis. When we came to his side he said with the utmost coolness and in an unruffled voice: "Doctor, what do you think? Will I get well or not?" We were compelled to say that we thought he would die, shortly after which he turned his head and coolly viewed the attendants and said: "I asked this question of the doctor, because I knew that he would not lie to a dying man; now I know that I am bound to die." And he did not survive fifteen minutes after the announcement was made to him. From our earliest experience in treating railway men, with grave and fatal injuries, we formulated this opinion: That in spite of traumatic delirium or intense shock, almost every man (unless his brain be injured), who dies under these conditions, shows a pronounced individuality, constantly present, the peculiarities of the individual ever manifest. There is no classical description which will hold in all cases of either so-called traumatic delirium or profound shock. The brave man, the sensible man is manifest as such in shock; the coward, the fool and the villain almost always indicate the peculiarities of their mental condition (with an uninjured brain), according to the predominating characteristics of mind. We have seen all the philosophy manifest that man is capable of manifesting, and that where we would never have suspected its existence. We have seen the dread and terror manifested among the culpable and guilty, the placid death of the believing Christian, and the uncertain mental elements of the superstitious. Death to the surgeon upon the railway always presents the predominant characteristics of the individual, just as in life, with the exception of a higher moral tone which is almost invariably manifest in the presence of death.

An Englishman, who had been noted for his cool, calm, clear judgment and non-combative disposition, even under the influences of stimulants, was caught between the draw-heads of passenger cars, prior to the introduction of the Miller platform and coupler; after the accident he spat up a mouthful or two of scarlet arterial blood, and was conveyed to his home in a dying condition. Everything indicated the near

approach of death and his wife was so informed. She implored us to announce the fact to the dying man and to ask him whether or not he did not desire the presence of a priest or minister. So accordingly, we approached the patient and detailed the message as requested by his wife. He turned slowly and looked up, and after a moment or two of thought said: "Doc, tell the Missus to come in here." She was summoned and he then said: "Missus, have I not always followed out my religion?" "Why, yes, you have," she said, "but in your own peculiar way of believing. Why, Doctor, he believes in the Golden Rule, that is to do unto others as you would have them do unto you. He has invited into this very house mean, low and dirty dogs, who have shamefully wronged him, as though these men were good as angels, simply to return good for evil." "Ah, there, Missus," said the dying man, "that is neither here nor there, I have clearly done my duty. Now, Doc, I would like to ask you this question: If you had a business transaction and you could settle it with yourself and the other party better than in any other way, would you call in a third party? Well then, Doc, and you, too, Missus, what is the use of my calling in either priest of preacher when God Almighty and I can arrange our differences better than anybody else?" And with this opinion he died.

Again, there was a kind of nondescript character, who was a brakeman. He had red hair, a freckled, dingy face and a divergent strabismus, yet a head full of brains. When at work he was all work, devoted to discipline and very industrious until pay day came. When he had the accumulations of a month in his hand life to him became a continuous spree. When he again returned to duty, no one was more intelligent and effective than he. Being pleased with his bright, cheery, witty and intelligent character and his quaint, unique looks, we took a fancy to him and employed him upon one occasion to act as nurse to an injured man. At that time prescriptions were given upon a neighboring druggist. Being much engaged in attention to other cases, we neglected to notice the case in question and sent an assistant, and we both neglected to ascertain the quantity of brandy which was being used. Upon calling at the drug store, the druggist said: "Doctor, you certainly have not ordered all the

brandy which this injured man is using." We then casually asked him how much brandy they had obtained within the past thirty-six hours. "Why, sir," said he, "they have used nearly $18 worth of brandy, and your-red-headed nurse is thoroughly soaked with good drink." Upon going to see the patient, we found that both patient and nurse were thoroughly drunk, and in rather severe and forcible language dismissed the nurse and employed a new man. One day in going through the hospital, after having been absent for some six or eight days, whom should we seen in a bed in the ward, but the pale, pained and wan face of our old and illbehaving nurse. Looking up plaintively, he said: "Doctor, I have prayed for you to come, they don't seem to know what is the matter with me, and I believe that I am near unto death." In reply to inquiries he said: "I was standing in the L yard close to the platform, not thinking, when the engine struck me. I was caught between the platform and the engine. I felt my hip bones crush in. I dropped down in a dead faint. I know that something is wrong here, Doctor, I can hear the grating myself when I move." Upon examination it was found that he had sustained a fracture of the pelvis, with laceration and rupture of the urethra and urinary infiltration had already taken place. He was told that his recovery was doubtful and asked if he had not some friend or near relative whom he desired to see. He said: "Doctor, I came from a good and respectable family. I am what you call the black sheep of that family, but I have a sister who lives in Maine. She is as good and pure as an angel, and as sensible as Solomon--send for her." She was accordingly sent for, and when she came we found a real pleasant, common-sense, good woman. The patient was now approaching his end, and she was so informed, when she earnestly begged us to ask him whether or not he desired religious consolation. We asked him in her presence. He turned his head and looked up at her and said: "Sis, whatever Doc orders, by God, I will take."

Dr. C. A. Smith, chief surgeon of the St. Louis & Southwestern Railway, with headquarters at Tyler, Texas, has commenced a rather extended scale of bacteriological investigations concerning the plasmodium malariæ. His department is thoroughly well equipped for such work.

Extracts and Abstracts.

The Question of Position in the Treatment of Fractures of the Lower End of the Humerus.

The following paper, by Charles A. Powers, M. D., of Denver, Colo., surgeon to the Arapahoe County Hospital and consulting surgeon to St. Luke's Hospital, was read at a meeting of the Denver and Arapahoe Medical Society, March 10, 1896. It is such an important clinical contribution that we reproduce it entire:

Until recent years there was but little difference of opinion regarding the position in which the elbow should be placed in fractures at the lower end of the humerus; the right angle was unanimously advised and employed, and this for the reason that the arm was in the most useful condition possible in case ankylosis ensued. The position was classic, and the injunction to begin passive motion at an early date in order to prevent ankylosis was faithfully followed. In 1880, however, Dr. Oscar H. Allis of Philadelphia, in a most careful and scientific essay, called attention to the change in the axes of the arm and forearm which may take place when the outer condyle slips down or the

internal condyle is displaced upward, resulting

992

in a deformity to which the term "gunstock' is applied. For the avoidance of this Dr. Allis recommended that the forearm be placed in a position of extension. He also strongly emphasized the important principle that no passive motion be made at the elbow until union should be complete. This latter proposition, I believe, admits of no debate in the average case; passive motion before consolidation of the fragments leads to rather than avoids. ankylosis. But to the contention that the position of complete or nearly complete extension should be employed in fractures entering the joint, I shall ask your attention, and I shall endeavor to demonstrate to you that the position of safety is that of flexion and that this position is attended with sufficiently satisfactory results to warrant its being retained by the average practitioner of medicine.

In order to bring before you the arguments of those who favor complete or nearly complete extension I quote from a valuable paper read by Dr. John B. Roberts of Philadelphia before the American Surgical Association in 1892. Dr. Roberts said: "A surgeon who fully realizes the probability of impairment of the carrying-function in these fractures can, without doubt, treat them equally well in either. the flexed or the extended position. Accurate readjustment of the fragments and provision

* In a recent communication Dr. Allis writes that the success attained in treating these features with plastic dressings convinces him that manufactured splints held in place by roller bandages are largely responsible for this deformity. Annals of Surgery, July, 1892.

for careful maintenance of the coaptation will usually produce good results. Practitioners who have comparatively few cases are, however, less liable than surgeons to appreciate the probability of a 'gunstock' deformity. In the flexed position of the elbow, moreover, the deviation of the axes of the arm and forearm does not exist; hence, in this position a slight displacement of the plane of the articular surface of the humerus is easily overlooked. For these reasons the extended position is the better for general adoption, since the angularity of the unbroken arm is then noticeable, and any interference with the normal deviation is very apparent." I fully agree with Dr. Roberts in thinking that the surgeon who sees many of these fractures will obtain satisfactory results under any form of treatment which his experience and judgment may lead him to adopt, but for the general practitioner, who sees these cases but seldom, to treat them in extension seems to me unwise, and I am led to this thought by the recollection of the following

cases:

Case I. In July, 1893, a boy of nine years was admitted to my service at St. Luke's Hospital, New York, with the following history: Some six weeks previously he had fallen, injuring the left elbow. Immediately thereafter he was

seen by a physician, who told the parents that the elbow was broken. He put the limb up in complete extension, and applied splints, which were changed from time to time and which were finally removed at the expiration of five weeks. At this time there was little or no motion at the elbow and despite vigorous measures, the range did not increase. Six weeks after the injury, as I have said, the lad came under my care. Examination revealed the following condition: The elbow-joint was considerably thickened, especially in the region of the external condyle; the forearm was completely extended upon the arm, and could be fixed but 10°. Under an anæsthetic attempts to flex the elbow proved unsuccessful, whereupon a four-inch incision was made over the external condyle and the joint entered. The coronoid process of the ulna was found to be broken off and displaced upward and backward, lying posterior to the articular surface of the humerus, thus completely locking the joint. The fragment was removed. The external condyle was the seat of a fracture running downward and inward through the articular surface, the fragment being displaced anteriorly. The anterior surface of this fragment was chiselled away, whereupon the elbow could be completely flexed. The wound was sewn up without drainage, the elbow put up at a little more than a right angle, and an ordinary aseptic dressing applied. Complete primary union resulting, motion was begun at the end of four weeks. The arc rapidly increased and

three months later the use of the elbow was very nearly normal.

Case II. One month after the foregoing case came under my observation, I was asked to see a boy of twelve years whose physician told me that some four months previously the patient had sustained an injury to the lower end of the humerus, the exact nature of which he was unable to make out, because of the swelling. He had applied splints in the extended position, removing them from time to time for the purpose of making gentle passive motion. The straight splints were not discarded until union was thought to be complete. At this time, however, the range of motion was very slight and could not be increased. When I saw the lad there was fibrous ankylosis, the Unforearm being extended upon the arm. der ether the adhesions were broken up, the forearm brought up to 135°, and a plaster-ofParis splint applied. Ten days later ether was again administered and the remaining adhesions were so far ruptured as to admit of nearly complete flexion. Plaster of Paris was applied with the elbow at a little less than a right angle, and two weeks later active motion begun.

A useful limb resulted.

Case III. In March or April of 1891 a young man of twenty years was admitted to my service in the out-patient department of the New York Hospital. He said that he had broken his elbow four months or so before and that it had been treated in one of the metropolitan hospitals in the position of extension. Complete ankylosis resulted. When he came under my observation there was no motion at the elbow, the forearm being completely extended upon the arm. Operation was advised but refused, and I did not see him again.

Cases IV and V are similar to Case III. Each came under my observation in the New York Hospital. In each there was complete ankylosis in the extended position. In both instances the elbow-joint was excised in narrow limits by the attending surgeon on duty-in one case by Dr. R. F. Weir, in the other by Dr. W. T. Bull. Both patients returned to the out-patient department for after-treatment. Each regained good use of the limb; the functions were excellent, considering that the joint had been excised.

These are cases which have been under my own observation, and I am sure that other surgeons can cite additional instances. I am far from saying that the ankylosis was due to the method of treatment; it might have occurred under other forms of management. In the first case the fractured coronoid would have prevented flexion and an operation at the time of injury was demanded; but if ankylosis were inevitable in either case extension was the worst possible position for it. We cannot say in any individual case of fracture entering the elbow

joint that a greater or less degree of ankylosis will not ensue, especially in people at or beyond middle life and in the gouty or rheumatic, and it is precisely for this reason that we should place the limb in the position best suited to its use in case of stiffening, provided that we do not hazard a deformity which will be of greater moment than can be compensated for by this position of election. I have myself long been convinced that the results are sufficiently good when the elbow is treated at or nearly at a right angle. In 1888 I read a paper before the New York Academy of Medicine based on the analysis of fifty cases which had been under my own care. The position adopted was that of 90° or thereabouts. Each case was carefully followed to the end and the result is noted as satisfactory in forty-eight cases out of the fifty. Since the publication of this paper I have treated some seventy additional cases, and while the management has been varied in some details, its principle remains that of immobilization at or near a right angle and the results. are sufficiently good to warrant its continuance.

As I have said, the advocates of the position of extension argue that better coaptation of the fragments is thereby obtained, and experiments on the cadaver seem to support their views. But it is interesting to note that a series of very careful experiments on the dead body recently conducted by Dr. H. L. Smith of Boston, tends to prove the exact opposite, and that better coaptation is made by complete flexion. Obviously, both of these views cannot be right, and, further, I do not think that this is a matter in which we can reason definitely from experiments made after death. These tests. cannot take into account muscular action, which is a most important factor in the production of the deformity accompanying fracture, and we cannot transmit on the cadaver the exact violence which produces these fractures in the living. In view of these conflicting conclusions, and in the absence of any considerable number of cases supporting either, I have felt that it might be of interest to bring forward clinical evidence in substantiation of the claim that the position of safety, viz., at or nearly at a right angle, yields sufficiently good results to warrant its employment by the general practitioner.

In our largest cities the out-patient surgeonssee the greatest number of these cases, and in order to supplement my own views I have communicated with three of my former colleagues. in the city of New York, Drs. Frank Hartley, B. Farquhar Curtis, and W. W. Van Arsdale, each of whom is in charge of large dispensary and hospital services, and the name of each of whom is a sufficient guarantee for the sound

1 Medical Record, December 22, 1888.

2 Berthomier: These de Paris, 1875.

Boston Medical and Surgical Journal, October 18, 1894.

The question which I asked each of the gentlemen was as follows: "What position do you consider best adapted to the treatment of fractures of either condyle of the humerus, or of the transverse fracture above the condyles, or of the so-called T-shaped fracture?" Their answers are as follows:

Hartley and Woodbury: (a) Internal condyle-gypsum splints from fingers to shoulder, forearm semiprone, elbow at right angle. (b) External condyle the same as the internal, except that the forearm is supinated. (c) Transverse or T-shaped-gypsum splint from fingers to shoulder or with shoulder spica, forearm supine, elbow at less than a right angle.

Curtis: Plaster-of-Paris bandage from fingers to axilla in most cases; occasionally when the superficial soft parts are impaired and need watching, a removable dressing with a wooden or tin splint. In the great majority of cases the limb is put up with the elbow inside of a right angle, but not actually flexed, as the latter position would be less comfortable. The hand is in semipronation. When the "carrying-point" is lost and it is difficult to restore it owing to the slipping of the fragments, as usually occurs in fractures of the internal condyle, the limb is put up in full extension and supination with particular attention to the "carryingpoint" for about two weeks, by which time the liability to lateral angular deformity has disappeared and yet union is not so solid as to render it impossible to correct any outer displacement which might interfere with flexion. Then ether is again given, the elbow flexed inside of 90°, and a plaster splint applied with careful attention to the position of the fragments. This splint is left in place until consolidation is complete.

Van Arsdale: In all cases flexion to 90° or to 80°; starch or pasteboard dressing until the swelling abates; then the same or plaster-ofParis for three or four weeks, according to age (until union is complete).

In my own recent cases I have put the limb up in plaster-of-Paris at about 90° when first seen, except in those cases in which a tendency to "gunstock" deformity was apparent. In

In each instance the number represents the surgeon's approximate estimate of his own cases.

Dr. Hartley having charge of the service, the immediate treatment being carried out in all cases by Dr. J. McG. Woodbury.

these latter instances I have made the angle 135° for ten days or two weeks, reduction being made under an anæsthetic with careful attention to the "carrying-point," and then changing the angle to 90° or to 80°. I am convinced that the extended position is not necessary to the obtaining of suitable coaptation of the fragments, and I am by no means sure that a moderate degree of cubitus varus is prejudicial to the usefulness of the limb; though I do not know that I am prepared to go quite so far as does Mr. Robert Jones of Liverpool, who says that neither it nor cubitus valgus is of any consequence from either an æsthetic or a functional aspect.

Of my last seventy cases the result has been satisfactory in all but one. This was a young lady of twenty-four years, who came to me one week after an elbow-joint injury. Examination under ether revealed a V-shaped fracture, each condyle being separated and the lines running to a common point at the trochlear surface. Despite all care the arc of motion was limited to between 90° and 135°.

With forced flexion as advised by Smith' of Boston, and Jones' of Liverpool, I have had but little experience, not enough to warrant an expression as to its real value.

I have not presented in detail the cases of the men whose opinions I cite, nor my own. What I want to say is simply this: That after having actively managed this number of cases, six hundred and fifty, it is our opinion that the best results are obtained by treating the limb in the flexed position, and that the general practitioner will find the greatest degree of satisfaction in following this form of management.-Medical Record.

Color Vision.

W. G. Laws, M. B. Edin., F. R. C. S. Eng., surgeon to the Nottingham and Midland Eye Infirmary, in a paper read before the Nottingham Medico-Chirurgical Society on April 15, 1896, pointed out that the subject lay in the debatable region between mental states and physical processes, where so many interesting problems remained unsolved. The eye was the end organ which brought us into direct relation with the ether, that ultimate form of matter as to which it became possible to doubt whether it was material at all, and which probably entered closely into the processes of thought itself. Before speaking of the theories of color vision it might be asked what was there in color vision that so many scientific minds had felt required explanation. It would be noticed that every theory contained the same fundamental idea that there must be a certain number of colors, varying with different ob

1 Boston Medical and Surgical Journal, January 4, 1895.

2 Provincial Medical Journal, December 1894.