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J. A. (Joel Asaph) Allen.

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nation may be made without causing suffering to the patient or
injury to the surrounding parts. While the muscles are thus
relaxed and the patient is oblivious to pain, the fracture should, of
course, be reduced.

Fractures near the joints are at the present day often mistaken
for sprains or wreuchcR, especially near the wrist or ankle. Before
the days of Dr. Colles, of Dublin, what is now known as OoUes'
fractures were treated as sprains, and the deformities resulting
were very great and as numerous as the cases thus treated. After
the investigation of Colles, Smith and others, this form of fracture
was treated properly by those who studied and followed their
methods.

To diagnosticate a fracture near the wrist, it is only necessary
to place the forearms parallel to one another with the palms in



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apposition aad compare the oatlines of each. It is unnecessary
and worse than nseless to look for diagnostic crepitation, and in
some cases it woaid be impossible to get it.

Many patients after being injured imagine, if power is left
them for volantary motion of the extremities, that there can
be no possibility of a fracture. This unfortunate error has been
the additional cause of many deformed and crippled limbs. People
should know and remember that the extremities do not depend on
the bones for their motion. Whole sections of bone may be absent
in an arm without destroying the power of the hand or its useful-
ness. I have deen cases where large portions of the bony structure
of the arm, even including the elbow joint, were absent without
seriously eurtailing the use of the hand. Many similar cases are
reported in the surgical history of our late war.

At a recent meeting of the Imperio-Royal Society of Vienna, Prof.
Billroth showed a man thirty-four years old, who, in spite of the entire
absence of the shaft of the humerus, was able to perform his duties as
a coachman. At the a^e of five years he had been thrown down by a
carriage which passed over his arm, and protracted suppuration fol-
lowed. At the time the patient was shown, the humerus was found to
have been replaced by a hard cord as large as the thumb, probably
containing the blood-vessels and nerves of the arm and perhaps some of
its muscles. There were no trophic disturbances of either the forearm
or hand.

On a late occasion I treated a very severe Colles' fracture in
which existed great deformity. I felt diffident in assuming the
case, as the outlook for a good result was not encouraging. How-
ever, after careful treatment and assiduous attention, it proved one
of the best results I had ever obtained; the member was restored
to usefulness without deformity.

When I sought the patient to grant me pecuniary acknowledg-
ment, she utterly refused to do so, as the neighbors told her the arm
was not broken at all, since she had suffered no pai|i after the first
dressing and could move her fingers during the whole time. If the
fracture had not been properly reduced, she would have suffered
continuous pain, and if her fingers had been fastened to a palmar
splint, as in the old manner of treatment, she could not have
moved them at will. She and her neighbors Would probably then
feel they were getting an equivalent for the fees requested.

To facilitate the diagnosis of a fracture, it is necessary to learn
the cause and conditions under which the injury was sustained.



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This knowledge will often prove an invalaable aid in diagnosis
and treatment.

There are certain well-known rales for the treatment of frac-
tures which cannot be wholly ignored, bat may be modified accord-
ing to the exigencies of the case.

To attain the maximam of success, the surgeon must be fortified
with a thorough knowledge of his duties and a natural taste or
genius for his art. He must be endowed with the natural gifts of
invention and construction. Otherwise he will prove a dismal
failure, and the results of his work will prove a plague to him and
a source of misery to his patient. Persons who are not naturally
gifted with a taste for music or art could not attempt to sing a
song or paint a picture without incurring the ridicule of their
neighbors, but might not inflict serious injury to any one. Not
so with the man of clumsy hands and untutored brain, who *^ rushes
in where angels fear to tread," in his attempt to do the work of
the skilful surgeon. Ugly deformities, life-long misery and
expensive lawsuits are often the fruits of such overweening self-
confidence.

It is better that a broken bone be reduced or set as soon as
practical after the injury, as it is easier to adjust the fragments
before much swelling occurs. If, however, a surgeon cannot be
immediately had, the friends should place the limb in an easy
position and apply warm water dressings until the arrival of some
one duly qualified to attend to the case.

An accident generally produces much excitement among the
neighbors, and perhaps five or six will rush to difiPerent telephones
and hastily summon as many doctors. The first one that arrives,
whether surgically qualified or not, stakes out the claim, as the
miners would say, and holds the ground against all comers, even
the family physician. As the proper treatment of a fracture is to
the patient a matter of a life-time, he or his friends should calmly
and without fear of offending any one, select some person of well-
known surgical ability, even if a few hours were necessary in which
to find him, as the patient will not suffer as much by a short or
even tedious delay as he would at the hands of an unskilful or
inexperienced operator. Dr. Samuel D. Gross says:

There is no class of in juries which a practitioner approaches with
more doubt and misgiving than fractures, or one which demands a
greater amount of ready knowledge, self-reliance and consummate skill.
If I were called upon to testify what branch of surgery I regarded as



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DOYLB : FBACTUBBS AND THBIB TBBATMBNT. 469

the most trying and difftoult to practise succesefuUy and creditably, I
should unhesitatingly assert that it was that which relates to fractures.
As to myself. I never treat a case of fracture, however simple, without
a feeling of the deepest anxiety in regard to its ultimate issue. I cer-
tainly know none which requires a more thorough knowledge of topo-
graphical anatomy, a nicer sense of discrimination, a clearer judg-
ment, a more enlarged experience or a greater share of vigilance and
attention — in a word, which requires a higher combination of surgical
tact and power.

Such impressive language from one of the most illastrious
fathers of American surgery ought to dispel any cherished ideas
of the simplicity and ease with which broken bones may be
repaired.

After dressing a recent fracture, the patient should in a short
time feel mnoh relieved. If not, it is very evident that the frac-
tured surfaces have not been placed in apposition, and the surgeon
should not feel that bis duty is properly done until the patient is
made comparatively comfortable, even if he has to undo the dress-
ings and make a thorough examination and a readjustment if
necessary.

Advance in the mechanical treatment of fractures has kept
pace with the improvement of the age. New appliances and
methods have replaced the old, less restriction is placed upon the
sufferer, he is not imprisoned in cumbersome splints or manacled
down, as it were, to his bed for weeks and months with strict
orders not to move limb or muscle. As a result of intelligent
observation and practical experience, it is now found proper to
allow a patient liberties with his broken limbs that would utterly
shock sticklers for old-time methods. The pistol splint has been
fired into oblivion and the saw-dust box is relegated to the dark-
ness of the lumber-room to give place to the results of cumulative
experience.

The common practice of applying cold water dressings to
injured or fractured limbs cannot be too strongly deprecated,
although sanctioned by many surgical authors. Cold applications
may, while in actual contact, keep down the temperature, but on
their removal an injurious reaction is very apt to occur. Without
minutely entering into this interesting subject, I would say that a
surgical experience of nearly thirty years has taught me that
warm applications only should be used in the treatment of local
inflammations.



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It may seem paradoxical that heat will expel heat or prevent
its occarrence, bat whea applied to an injured surface it will pre-
vent inflammatory action or reduce it much more effectually than
cold. The moist warm poultices of our grandmothers have
relieved more suffering than the ice bag fad of the present day.
The industrious housewife who has been up to her elbows all day
in the hot suds of the wash tub will find when her task is done at
night that her hands are cool, white and comfortable, while her
husband, who has been cutting ice on tjie lake, will, after the even-
ing meal, display in sharp contrast a pair of inflamed hands,
swollen to the size of boxing gloves, red as lobsters, and painful
as aristocratic gout.

Warm water applied to the surface of a bleeding stump is seen
to contract the fibers of the exposed muscles, and render them
pale, while it arrests the bleeding. The elastic reticulated coats
of the small arteries no doubt undergo the same contraction and
thereby lessen or entirely close the mouths of the vessels. Chilly
applications may do for the amphibious toad or the cold-blooded
porpoise, but never for the warm heart's blood of the human
biped.

As to the outcome and treatment of fractures, much, of course,
depends on the character of the injury and the physical condition
of the patient. In simple fractures it is to be expected that proper
treatment will produce good results. There are, however, forms
and degrees of fracture in which it is impossible to restore the
limb to its former shape and usefulness, but often much may be
accomplished in apparently hopeless cases. In these days of
aseptic surgery, many crushed and mangled limbs may be saved
that were formerly doomed to amputation.

In this most difficult branch of the healing art, surgeons are
often blamed for deformed or shortened limbs. The faultfinder
does not perhaps consider the history and extent of the injury, or
if he does he expects something bordering on the miraculous. In
many cases of simple fracture, especially of the femur, it is impos-
sible to prevent more or less shortening, due, no doubt, to absorp-
tion of bone.

Many medical men, I am sorry to say, are prone to flippantly
criticise the work of their brother practitioners without even
enquiring into the history of the case or the extent of the injury.
When invited to examine fractures that have been treated by my
neighbors, I make it an invariable rule to acquaint the doctor in



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THB MICB08C0PB IK EXAMINATION FOB GONOBBHBA. 471

qaestion before expressing an opinion, that is, when any deformi-
ties exist, and often find on investigation that the result is a very
good one when the extent of the injary is taken into considera-
tion.

The responsible duties of our exacting and laborioas profes-
sion are often ameliorated by the kind words and deeds of profes-
sional brethren who are qualified to pass judgment on the results
of our work. If we perform our duty properly, no unjust oriticism
of false friend or open foe need cause any concern.

70 West Genbsbb Stbbbt.



©FranAPailoa*



WHAT VALUE HAS THE MICROSCOPE IN EXAMINA-
TIONS FOR GONORRHEA ?i

Bt prof. A. NEISSEB, Breelau.

(TransUted from the Deutsche Medicinische Wocheneehtift, Nos. 90-SO, 1893.)

Bt G. a. HIMMELSBACH, M. D., Buffalo, N. Y.,

Clinical Instructor in Medicine, University Dispensary, Buffalo, N. Y.

Dr. Bbobsb (Berlin), in bis lecture before tbe Society of Obstetrics
and Gynecology, at Berlin, upon The Etiology, Diagnosis and
Therapy of Gonorrhea in Women, made certain statements which
I consider should not be allowed to pass unanswered, particularly
so because none of those who took part in the discussion opposed
him. Such views, even though supported by other eminent men —
for instance, B. Sanger — are entirely contrary to those entertained
by me and my friends for several years past. Their views appear
to me, in every respect, to be so very poorly grounded and proven,
that their general acceptance hereafter will prove dangerous to all
questions concerning gonorrhea, especially as regards its prophy-
laxis and therapeutics.

I, therefore, feel myself called upon to illustrate once more
our principles of treating gonorrhea, in opposition to those advo-
cated by Dr. Broese. The differences are briefly stated as follows :
A general use of the microscope, to prove the presence or absence
of the gonococcus, is unquestionably the best and, undoubtedly,
the most efficient means at our command. He who does not use
this method is not only making a great mistake, but also deprives
himself of important advantages. In view of the fact that this

1. Bead before the Journal Club, January 96, 1894.



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472 TBANSLATION.

method is often both diffionlt and imperfect, it reqaires repeated
examinations, and those who make use of this means reqaire con-
siderable experience.

What do our opponents say ?

This method of the ase of the microscope to detect the gono-
coccas is of positive value only in case of doubt (or error), besides
we have other methods in abundance ; then, too, it is so little
to be depended upon that we prefer to do away with it entirely.

Such a standpoint as this ought to be fought against. It is
most astonishing to hear Dr. Broese clearly express his conviction
that the gonococcus is the cause of all gonorrheal processes.

If that is the case, then we must admit the practical value of
the microscope in order to study the many characteristics and
properties of the bacteria, and also its practical use in the diagnosis
and treatment, besides the satisfaction of a surer therapeutic suc-
cess in all the stages of treatment. If there exists any difference
of opinion as regards its usefulness, it is mainly in the methods of
examination.

Now, then, wherein does my acknowledgment of the usefulness
and the necessity of examining for the gonococcus consist ?

In innumerable instances, in which we could neither by macro-
scopic inspection nor a most careful clinical investigation state
with absolute certainty whether the discharge from the mucous
membrane is a specific gonorrhea, due to the presence of the gono-
coccus, or whether it is nothing but the result of an inflamma-
tion, due to other causes, the microscope will detect the presence
of the gonococcus, and then a positive diagnosis is established.
With a positive diagnosis, we are enabled to undertake the proper
treatment of our patients, with due regard as to etiology.
Instances without number in which men, who are about to enter
matrimony, present themselves at my office, brought there by a
delicate feeling of foresight. A thorough, day after day, micro-
scopic examination of the urethral mucus, the urinary shreds, and
the prostatic secretions, etc., generally results in the proof of the
existence of the gonococcus.

The diagnosis in women is, undoubtedly, much more difficult ;
nevertheless, a great many cases have been successfully examined
and a positive diagnosis arrived at. Hundreds of prostitutes are
annually snatched from their disorderly, vagabond life, and placed
in a hospital for the care of such cases, although regularly exam-
ined by one of the district physicians and pronounced sound in



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THB MICBOSCOPE IN BXAMINATION FOR GONOBBHBA. 47S

body. These very women would have diseased all those who had
intercoarse with them. Furthermore, how •ften do we discover,.
by means of the microscope, even in married women, the undoubted
existence of gonorrhea, and thereby establish a foundation for fur-
ther therapy?

We should always be loth to set aside a microscopic investiga-
tion for the gonococcuB, which is conclusive, even though the
discharge is so diminutive that it is hardly noticed, or even if the
objective symptoms of the disease are wanting; or, again, even in
quite simple cases, where the urethral discharge is profuse.

In the first place, there is the fact (all mechanical causes
excluded) that there are cases of urethritis procreated by other
bacteria. It is true that such cases are rare, but, nevertheless^
they are sometimes met with. The positive diagnosis, in such
caaeSy will materially influence the prognosis and therapeutics. I
am treating, at the present time, a gentleman (county judge), mar-
ried for the past nine years, who under oath declares that during
this time he has not had coitus with any woman except his wife.
He first consulted me in February of this year, and, upon inspec-
tion, discovered what I took to be simple gonorrhea ; but, upon
repeated inspection and examination, I was unable to find the
gonococcus,^ yet found the discharge mingled with immense
quantities of diplococci, presenting themselves intra- and extra-
cellular, apparently arranged in one long string. Under treatment
this condition disappeared quite rapidly. Since then my patient
has had a recurrence of the same soon after intercourse with his
wife. I regret to say that I have not yet had an opportunity to^
examine his wife, to prove whether every new infection comes
through her.

A second but more common appearance of gonorrhea, in men
and women, is where they have previously had an undisputed
attack of the disease and had apparently been cured ; then, subse-
quently, through cohabitation, contracted the same disease, or, at
least, set up an acute purulent discharge. In all such cases, micro-
scopic examinations will result in the following conclusions : (1)
Has there entered a fresh (new) infection ? Or (2) is it a recrudes-
cence of an old, latent, inflammatory process of a gonorrheal
nature, even though all traces of gonorrhea had long since been
removed ?

Now, then, the question is : Is there a fresh infection or a revival
of the old gonorrheal processes ? This cannot be decided with cer-



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474 TRANSLATION.

tainty, because the difference in the namber of gonococci in both
cases is not so strikingly great that a safe decision is warranted.
Very often, however, we have to do with cases where there is con-
siderable pas withoat the presence of the gonococcas. This con-
dition usually subsides in a few days by a simple, mild, non-
specific, that is to say, non-parasitic treatment, while newly con-
tracted infections will take on a chronic course. Again, there are
<^ases of exacerbations of gonorrhea (gonococcus) in which the
olinical phenomena disappear very early. In these instances, a
differential diagnosis cannot be made with surety, from the pro-
gress of the disease alone, without an examination for the gono-
ooccus.

Further explanation is unnecessary as to the importance of
fixing this differential diagnosis at once, both as regards its rela-
tion to prognosis and therapeutics, besides, also, from a humanita-
rian standpoint. I must not omit to report the following case
which I had an opportunity of seeing a year ago :

The patient, an officer, consulted me first in August, 1888 ;
eleven months prior to that time he suffered from acute gonorrhea,
accompanied by left epididymitis. At a more previous date than
that he is said to have suffered pain in his right epididymis. Still,
at the time of his consultation, there were no manifest changes
present.

Often repeated examinations did not reveal any sign of secre-
tion or any flakes ; all subjective symptoms were wanting. In
February, 1890, t.his patient, who had then been married eighteen
months, returned to me. Both he and his wife felt perfectly well.
His wife was examined gynecologically and pronounced healthy ;
still he wished to be informed whether his former troubles
accounted for the barrenness.

Closer examinations showed a well-preserved potentia oOeundi.
He said his wife was very easily excited and very often wanted
<3oitus, which he promptly satisfied. The examinations brought
to light the following facts : Besides a small varicocele, which
was discovered very early, were found nodules attached to a
thickened epididymis. Examination of the spermatic fluid
showed the spermatozoa completely wanting. I saw the patient
^uite often after that. I made some effort to remove these
nodules and thickening, but without any beneficial result
In June, 1891, my patient came to me in despair, stating that
his wife had been off on a visit for two weeks, and when she



\



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THB MICB08C0PB IN EXAMINATION FOB GONOBBHBA. 475

returned he foand himself sick again with gonorrhea, and only
after several copulations with her. He said his wife could hardly
go a day without several copulations and that she must have
become diseased during her absence. He was convinced that
divorce proceedings had to follow. The examination disclosed a
profuse purulent discharge, which appeared two days after copula-
tion, and he firmly asserted that he had not had intercourse with
another woman. I was persuaded that his present attack must
have been contracted from his wife. An acquaintance with the
oase for three years, strengthened by repeated examinations, led
me to exclude urethritis.

For the sake of protection and as an expert to have the neces-
sary proofs at hand in view of the divorce proceedings about to
be instituted, I made microscopic examinations and preparations.
The examinations, however, disclosed great quantities of pus cor-
puscles, together with a few epithelinl cells, bVit allfN>lutely no gono-
cocci, and, indeed, there was an absence of any bacteria. This investi-
gation was continued daily for two months ; the discharge gradually
grew less, though again and again it was examined, but always with
the tame result, until at last all investigation was stopped by the
absence of any flakes. One of my friends and colleagues who
generally treated the patient, also saw the discharge and he was
just as firmly convinced as myself that it was a typical case of
gonorrhea. Our diagnosis, however, was at once rectified upon a
microscopic examination. This procedure was also necessary on
account of the psychical condition of the patient. It can be
safely said that without the use of the microscope the diagnosis
of gonorrhea would have been made. The progress of the case
was somewhat tedious and accompanied by a mild cystitis ; the
latter symptom would also tend to strengthen the diagnosis of
gonorrhea. The causes of this acute suppuration I am at a loss
to account for, because I could find no other bacteria ; but gonor-
rhea or any other infection of that man by his wife was all out of
the question.

To be sure, not every case we meet presents such dramatic
results as the one before us ; but he who meets with many cases
of gonorrhea, accompanied by other complications, particularly so
when from the better class of society suffering from chronic
gonorrhea, must confess how complicated these important and
responsible steps become. We must also admit the inestimable
value to the physician when he can say that the microscope has



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476 TBANSLATION.

shown him the presence of the gonocoooas when none were
expected ; then, again, when an apparently serious discharge has
been found to be a harmless non-infectious material.

With women, the diagnosis of all these conditions is much
more difficult than with men, and false conclusions with the micro-
scope will happen more often ; nevertheless a goodly proportion
of cases will present negative symptoms of the disease sufficient to
guide him in a correct prognosis and therapy. But gynecologists
(£. FrUnkel and Sanger), two of my respected friends, oppose me
in the following words : << How seldom you andrologists are able to
find any gonococci in the husband who contracts the disease from
his wife, who suffers from gonorrhea.^' Well, I concede that not
in all cases where there exists these conditions between man and
wife do we find a satisfactory explanation ; but, again, we must
consider how many unknown points will spring up in cases of this
kind.

Is gonorrhea in women always a fact — that is to say, a bacterio-



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 47 of 78)