of the same femur in the middle third, with poorly adjusted overlapping fragments.

CASE 3.-A. H-, eleven years of age, was riding on the sweep of a horse power in an elevator. While passing over the tumbling-rod, his trousers caught in the knuckle of the rod, his body thrown forward and his leg wound several times around the rod, when fortunately the horse was stopped. When he was taken out, his clothing was nearly torn from him, and his leg was frightfully mangled. The femur was broken twice in the middle third, and both the upper and lower fragments were protruding through the flesh. The tibia was broken into three fragments, with the middle fragment nearly separated from the soft parts of the leg. The fibula was broken only once in two, and like the tibia, was nearly bare of flesh. The soft parts of the leg were torn spirally from the upper end of the tibia, downward and outward nearly to the ankle, and both bones were nearly denuded. The entire wound was ground full of fine dirt of the horse power track. It was evident that the blood supply was seriously interfered with, and the possibility of saving the limb was seriously considered. I cleared it up as best I could and drew the torn fragments of tissue together, placing a large number of stitches, placing several strands of iodoform gauze at different points to insure drainage and dressed the member with loose gauze dressings wet with warm boric acid solution, held in place with the old fashioned many tailed bandage. I prepared a Hodgen's splint, using strips of bleached cotton flannel as above described, and placed the leg in it. I was unable to apply the plaster strips as is usual on account of the torn condition of the flesh and the poor condition of the circulation. I did, however, place a strip of plaster on each side of the ankle, including the malleoli, and wound the same with a roller, which I fastened to the crossbar of the splint as above directed. This served to steady the limb and while I could not apply any perceptible extension, I hung the splint up in the usual manner, giving very little, if any obliquity to the rope, still with the knee slightly flexed, and the weight of the

limb swinging in the basket, served to extend the femur sufficiently for all purposes. Let me mention here, that I believe that with this splint, less force is required to secure the proper extension, than with any other. After the dressing was fully applied, the case gave me very little trouble. The many-tailed bandage and padding under the limb had to be renewed only once, after a few days on account of the drainage. Very little suppuration occurred, and the case went on to a perfect and satisfactory recovery, and in a little less than two months, the lad was out on crutches, and to-day, it would puzzle the best of you to tell which leg was broken, except for the somewhat unsightly scars on the skin. It is now four or five years since the injury. The amount of shortening is almost imperceptible.

CASE 4-Mrs. R, over sixty years of age, very much of an invalid, while attempting to use the commode, lost her balance and fell, striking on her right hip, causing a well marked impacted fracture of the neck of the femur, with about an inch and a half flattening of the trochanter, and not more than about one half inch shortening of the limb. Patient was refractory, and because she could move the limb a little, and could not hear the bones grate, would not tolerate any dressing for fracture, for more than fortyeight hours. Finally, on account of the severe pain she endured, she consented to have it dressed, and I placed it in a Hogden splint. I gave her just extension enough to steady the limb, and she went on to a complete and satisfactory recovery. She wore the splint between five and six weeks, and by the end of ten weeks was about the house without crutches. The shortening does not exceed half an inch.

CASE 5.-I was called by a neighboring practitioner last December to assist in dressing a fracture of the upper third of the femur, caused by direct violence, in an old gentleman, Mr. S, over eighty years of age. I applied Hogden's splint after the manner above described for simple fractures, using a fair amount of extension. The old gentleman, who was suffering severely before the dressing was made. soon expressed a great amount of satisfaction with it, and became

free from pain. I am told by the attending physician that he made a marvelously good recovery and was released from the splint at the end of about five weeks after the injury. The doctor tells me that the patient subsequently died from some lung trouble, but the result of the fracture was perfect.

CASE 6. Mrs. K, thirty-five years of age, sustained a comminuted fracture of the middle third of the femur, by direct violence. There were two oblique fractures, the middle fragment as near as I could determine, being about two inches in length. I experienced considerable difficulty in adjusting the fragments, and while I could seemingly restore the length of the limb, I could not feel certain as to the adjustment. I dressed the limb with Buck's extension, using weight and pulley, and applied adjusting splints and sand bags to immobilize the limb. At the end of six weeks I made careful tests of the union. It seemed to be satisfactory, so I released the limb. After three days, the patient hurt the limb in the night, and when I saw her next day, I found that it had sprung outward to a very marked degree. I had very little difficulty in springing it back into line, reapplied the extension for six weeks more, after which my patient gradually got up on crutches. The shortening was not more than three-fourths of an inch, but the callus was large and at some points tender. The knee joint gave me a good deal of trouble from stiffness and tenderness. This fracture was sustained on the eighth of July, and on the sixteenth of November following, at which time my patient was getting around fairly well without crutches, she had the misfortune to slip and fall her length on the floor, and sustained another fracture of the same femur. This time there were also two fractures, one of them at the site of the lower former fracture, the other seemed to be in a new place farther up the limb, making the middle fragment, I should judge, measure about four inches. The amount of callus from the former fracture made it difficult to diagnose the case satisfactorily, and the possibility of sarcoma was suggested. I dressed the limb this time with Hodgen's splint,

and experienced much less difficulty in securing the adjustment and extension required, and it is safe to say that the amount of attention required of me was very much less than half that required the first time; besides my patient declares that there is no comparison between this and the former dressing. With the former she had a sense of being bound solidly to the bed, while with the latter, she felt free and could enjoy a good deal of change of position without any detriment to the limb. This time I kept her in the dressing nearly twelve weeks, and when I released her I had secured what seemed to be an excellent result. The tenderness and stiffness of the knee as the result of the first extension had not been relieved at the time of the last fracture, and consequently existed without much change after the dressings were finally removed. I gave her an anesthetic and forcibly flexed and extended the knee, and in a little while she had full use of the limb. I desire to note the fact that I have had much less trouble with tender knees after using Hodgen's splint, than any other form of extension.

A point of interest that deserves special mention in this last case, is that where there are two fractures close together in the middle of the femur, the middle fragment is apt to be quite destitute of blood supply, and by its lowered nutrition, must of necessity, make very slow and unsatisfactory repair, and much time must be allowed for the fracture to unite. I am satisfied that I acted unwisely in removing the dressings as early as I did, the first time, notwithstanding the fact that the union seemed good. I would call attention to the danger from too much extension in this class of fractures, for fear of separating the middle fragment from one or the other adjacent fragments, and interfering with the union.

Permit me to call attention also to the fact that the femur, with the patient in the dorsal decubitus, inscribes an arch, the convexity of which is upward, and too much extension, or neglect to properly arrange the foundation upon which the limb rests, is liable to cause a sagging of the center of the femur, and loss of proper contour of the limb. This is important whether Hodgen's splint or any other form of dressing is used.

PNEUMONIA

A SHORT REVIEW OF ITS TREATMENT FOR THE LAST FIFTY YEARS

BY A. T. CONLEY, M. D.

Cannon Falls

The prevention and treatment of pneumonia is our greatest problem in medicine today. The twelfth census (Bulletin of August, 1901) places pneumonia at the head of the death column, it having caused the death of 55,296 people during the year 1900, i. e., 191.9 persons died of pneumonia out of every 100,000.

The Bulletin of the Chicago Board of Health states that in that city there were 25,719 deaths from pulmonary tuberculosis between the years 1851 and 1890, and 16,577 deaths from pneumonia during the same period. But in the decade from 1891 to 1901 there were 22,957 deaths from pulmonary tuberculosis, and 25,228 deaths from pneumonia, making an excess of 9 per cent in favor of pneumonia.1 This report shows that while tuberculosis is decreasing, pneumonia is rapidly increasing. On this point French, using the State of Massachusetts for an example, shows, that in 1860 pneumonia caused 10.82 deaths in each 10,000, and in 1890 it caused 18.83 per 10,000, nearly double.

During the same period consumption fell off more than half. Between the years 1861 and 1871 pneumonia caused but 3 per cent of the deaths from all causes; in the following decade, 5 per cent; the next 6.7 per cent; but in the last decade, from 1891 to 1901, it rose to 10 per cent.2 N. S. Davis, Jr., places the mortality at the present time in Chicago at 12 per cents and says that each decade since 1850 shows a startling increase, beginning at that time with only 1.66 per cent mortality from all causes. And such well known