so covered by soft material or so located as to fail to make the expected marks. With an alkaline urine and good X-ray technie all ureteral stones will show; with an acid urine we may have stones which cast no shadow. These may be demonstrated after the opaque sol., used in making the ureterogram has been washed out by the flow of urine. Usually a plate is made two days following the ureterogram and the deposit on the previously nonopaque stone will now show a shadow. The shadows apt to confuse in the ordinary X-ray examination, i. e. without the shadowgraph catheter or ureterography, are those due to phleboliths, calcification of the pelvic ligaments, plaques in blood-vessel walls, calcareous areas in lymph-glands and foreign bodies and fecoliths in intestine or appendix. Ureteral calculi are usually oval-oblong in shape and irregular in outline; phleboliths are round with smooth outline; the shadows made by calcification of the pelvic ligaments, calcareous areas in glands or fecoliths and foreign bodies may be of any shape and indeterminate in outline. Kretschmer has recently emphasized the value of making a double exposure, each at a different angle, with the shadowgraph catheter in the ureter. This exposure is made on one plate and serves to absolutely demonstrate the relation of the two shadows. The shape and position of the shadow together with orientation by means of the ureterogram or opaque catheter serves to assure one of the condition. The present day treatment of ureteral stone tends to the conservative side. When we consider that 70 to 80 per cent. of these stones will pass spontaneously; that perhaps 10 to 15 per cent. can be made to pass by certain conservative measures, one should hesitate about doing ureterotomy till other means had failed or the complications demanded relief to save the kidnev function. These conservative measures are the dislodging of the stone by means of the sound, the injection of sterile oil both above and below the site of the stone and the stretching of the ureter below the stone with bougies or ureteral dilator. These measures are repeated according to conditions. The use of sterile oil helps to distend the ureter and lubricate the tract. The use of gradually increased sizes of ureteral bougies aid in enlarging the ureter below the stone and both probably set up increased peris Fig. I. To show shadow of stone, indicated by arrow. be the only means of relieving the condition, but it should not be done unless other (conservative) measures have failed or the complications are such as demand early relief to conserve kidney function. The cases for which ureterolithotomy is most cften necessary are those in which the stones are of large size and those embedded in the ureteral wall. CASE 1. June 12, 1918, J. M., age 42, American married; farmer. Family and previous personal history, negative. While working, a year and a half ago, he was taken with a sudden, sharp pain in the right lower abdomen; this pain radiated to right inguinal region and penis and toward the navel. He was nauseated but did not vomit. He had some fever; no macroscopic haematuria; no jaundice. He was sore in the right lower abdomen for about a week. This condition gradually righted itself and he had no more symptoms for eleven weeks when he had another similår attack. Since then he has had four more; the last one, two weeks ago. He states that he has seen no blood in his urine during or after any of the attacks. General examination negative. Wassermann negative. Blood; white and red count and hemoglobin, normal. Urine; negative, except a few blood cells. Slight tenderness over right costovertebral angle. Cystoscopic; slight edema about the right ureteral meatus, otherwise negative. Left ureteral catheter introduced to the kidney pelvis with apparently normal urinary output. Right catheter met with an obstruction eighteen centimeters from the meatus. X-1ay plate showed a shadow opposite the third lumbar vertebra in contact with the tip of the shadowgraph catheter. An unsuccessful attempt was made to pass the catheter higher after which, fifteen co. of sterile oil was injected into the right ureter. The patient had a chill, fever and pain for the eighteen hours following. On June 20, (eight days later) a number five catheter was introduced 24 cm. in the right ureter. An X-ray plate showed the shadow in the lower sacral region. Twenty cc. of oil was injected as the catheter was being withdrawn from the ureter. After this injection he had quite a severe reaction; tenderness over the right kidney and ureter; chills and fever and blood and pus in the urine for his stay in the hospital, (five days). Due to the severe reaction, a period of sixteen days elapsed until the patient returned for treatment. An X-ray plate made on July 6th, showed the stone well down on the pelvic floor. On this date, numbers eight and ten bougies were introduced into the right ureteral meatus and 20 cc. of oil was injected through the catheter above the stone. This was followed by moderately severe pain, more or less continuous for five days when on the 11th he passed an oval irregular, mixed stone, roughly three-sixteenths by three-eighths inches in size. CASE 2. C. N., Swede, age 37, married, electrical worker. One maternal uncle died of pulmonary tuberculosis, the family history is otherwise negative. Personal; always well till two years ago, when he had an attack of severe, colicy pa'n in the lower left abdominal quadrant. The attack came on in the evening and was accompanied by nausea, vomiting and distention of the abdomen with marked constipation. Always two or three days without a bowel movement with each attack. The pain has always been localized in the lower left quadrant without radiation. Attacks similar, but varying in severity and length, but always accompanied by vomiting and distension have occurred at intervals to date. Patient states he has had about a dozen; the longest period of freedom from pain was three months; last attack ten days ago. always needs morphine for relief. He thinks his attacks are due to indigestion as he overeats when feeling well, has some sour stomach and belches gas between his attacks of sickness. He has never noticed blood in the urine during or 'after the attacks. General examination, including Wassermann, stool and three different urinary examinations all negative. Regional examination negative. After intestinal emptying, an X-ray examination showed a dense shadow in the left side of the pelvis at about the level of the second sacral foramen of such shape, size and position that it could well be a ureteral stone. Three days later a cystoscopic examination revealed a normal appearing bladder with normal peristaltic action of both ureters. The left ureteral catheter (size 6) met with an obstruction 11 cm. from the ureteral meatus but by manipulation was made to pass to the kidney pelvis. A uretera-pyelogram showed only a slight dilation of pelvis and ureter above the stone and a narrowing of the ureter below the stone. After an hour 15 cc. of oil was injected in the ureter above the stone. This set up one of his attacks of pain which lasted three days. At the end of a ten day period an X-ray plate showed no change in the position of the stone and 20 cc. of oil was injected. Two weeks follewing this, another X-ray examination show Fig. III. Shows kidney, pelvis and upper ureter. ing the stone in the same position, a left rectus (Battle) incision was made down to the peritoneum; this bluntly separated down to the left ureter which was opened above the pelvic brim, the stone milked upward and removed, extraperitoneally. The ureter was sounded and stretched with a No. 9 bougie from above; the incision repaired with 00 chromic gut; a small cigarette drain was led out of the incision from the cut in the ureter and this was left in 24 hours. No drainage. Uncomplicated recovery. The stone removed was a mixed oxalate, oblong, one-fourth by one-half inches in size. CASE 3. April 2, 1918. C. J., age 42, sedentary occupation. Family history, negative; personal history, two attacks of appendicitis in 1911; appendix removed in 1912. While on a fishing trip in May, 1917, he had an attack of pain in the right lower abdominal quadrant. This lasted only about an hour, and he noticed no particular tenderness afterward. History otherwise negative. One week ago, while about, he was taken with a very intense, colicy righ-sided, lower abdominal pain which radiated to the penis and right lumbar region. The character of the pain gradually changed to a constant severe ache and tenderness. The pain was accompanied by nausea and vomiting at the beginning of the attack. General examination: Temperature, 101 F.; pulse, 91; white cell count, 13,000; Wassermann negative. Urine had a moderate amount of pus and blood. No visible hematuria, otherwise negative. Examination shows the right side of the. abdomen, especially the umbilical right semicircle, to be very sensitive. Fist percussion of the left costovertebral angle, negative; on the right side, it produces a very intense pain, radiating downward. Percussion dullness increased in the right lumbar region. Cystoscopic examination showed some redness and edema about the right ureteral meatus; otherwise negative. Catheter in the right ureter met an obstruction 9 cm. up; but by manipulation was made to pass to the kidney pelvis. Fifty-four cc. of cloudy urine ran by continuous drop from this side, showing very clearly the pyonephrosis. X-ray plate showed a small, round-oval, smooth shadow at the lower level of the right sacro-illiac joint. Injection of 40 cc. of thorium solution covered this shadow and demonstrated graphically the stricture below the stone and dilitation of ureter and kidney pelvis above the stone. Figure 1 is the shadow of the stone; Fig. 2 shows the stricture in the ureter and the dilatation of the ureter in the true pelvis with the stone shadow covered; and Fig. 3 shows the dilated condition of upper ureter and kidney pelvis. Catheterization of the other side showed a normal peristaltic urinary output, and the urine collected was normal. Functional: Phthalein used, intravenous injection; left side, 1st hour, 30 per cent; 2nd hour, 25 per cent. Dye appeared in 2 minutes. Right side, 1st hour, 9 per cent; 2nd hour, 15 per cent. Dye appeared after 18 minutes. X-ray examination of the rest of the urinary tracts, both sides gave no evidence of other stones. Only one injection of oil was given in this case as a plate made later showed no change in . the position of the stone and as the complicating conditions seemed of too much consequence to delay relief. On April 12, 1918, an oblique incision was made above and parallel to Pouparts ligament, the ureter opened at the brim of the pelvis and the stone removed extraperitoneally. The stone was embedded in the wall of the ureter and adherent to it. Below the stone was a strictured place in the ureter, demonstrated by bougies passed through the incision in the ureter after removal of the stone. The incision (in ureter) was repaired with fine chromic gut, with a cigarrette drain leading out. Urine drained along the track for ten days and then the incision closed on removal of the drain and farther convalescence was uninterrupted; the patient leaving the hospital twenty-six days after operation and has had no return of any urinary symptoms. ABSTRACT OF PAPER ON FRACTURES AND THE APPLICATION OF ARMY SPLINTS. CAPT. MERCER. Captain Mercer's talk was largely one of demonstration and it is impossible to abstract it to any degree of satisfaction. It was a very important subject and one handled in a way which every man dealing with fractures should have heard. Various splints as used in the army were demonstrated. At first the Army used various splints, then limited itself to the standard splints. America only uses seven kinds, two or three of these are capable of many modifications. The field coaptation splint is capable of being broken along several lines and may be moulded. Every man in the ambulance corps was taught the use of these splints. All of the splints used in the Army are adaptable to civil life. The Jones foot splint was used more in the English army, but not so much in the American army. The Jones hand splint can be moulded as was demonstrated. The Jones humerus extension splint fits over the body as demonstrated. It is necessary to abduct, externally rotate and approximate the lower fragments to the upper as demonstrated. Plaster may be used with these splints. The Hodgen splint is covered with canvas and can be variously modified. Considers the Thomas splint one of importance. The pressure is brought on the tuberosity of the ischium and demonstrated how it should be applied. Instead of using adhesive plaster the following formula was recommended in its place: Resin 50 per cent., Alcohol 50 per cent., Benzine (pure) 25 per cent., Venice turpentine 5 per cent. Also uses a short Thomas splint as demonstrated. They are light, comfortable and dressings may be done with them in place. In seven cases of patellar fracture used the expectant treatment with good results, no operations. The various phases connected with flat foot were discussed and demonstrated. One definition of flat foot given was: 'flattening of the arch with twisting of the foot.' Raises the inner border of the shoe one-fourth inch, that raises and throws the weight bearing line back where it should go. Illustrated the old Thomas heel which he said was used as an advertising scheme by some. In treating fractures he used one-fourth gr. morphine, then after a few minutes put them under screen and fracture was then reduced without the necessity of a general anesthetic. Demonstrated that one reason why sprains were so long in healing, was because small spicula of bone broken off with the ligament. It is hard to say which gives the best results in fracture of the patella, expectant treatment or operative. Uses expectant treatment largely. Capt. Mercer demonstrated that in many cases often where anatomical results were apparently not what one would like, yet functional results were good, this often is most important to the patient. DISCUSSION. Capt. Shackleton: Capt. Mercer is a man after my own heart. Speaks in terms of function. He does not make a compound fracture out of a simple fracture. Has been in orthopedic service. not from choice, but from necessity. Lovetts three points to be considered in orthopedic surgery are: What are you doing, is it worth while, and are you doing it? Formerly a fracture of the patella meant operation, now does it less. Related cases showing result of fibrous union of the patella which proved satisfactory. We should realize that the X-ray shows up the doctor in a bad light, and the shyster lawyer makes use of the exaggeration of the X-ray. When we analyze in terms of function rather than terms of X-ray we get a different view of fractures entirely. Discussed the various shoes demonstrated by Capt. Mercer. He agrees with Capt. Mercer in regard to the metatarsal wedge. Believes results can be brought about by felt pad and inner sole, Thomas heel is of great aid in correction. Position we get is that of bridge on the inner side of the foot, making the patient toe in. Standard in military splints will be of great value in civil life. The Thomas splint cannot be improved. Demonstrated how they held for long periods of time when applied on the battle fields. They are simple in application and anyone can apply them effectively. The only one not of practical use is the airplane splint. It gives incorrect posture and will gradually crawl out of position. Described another splint given by Capt. Clare, which is more satisfactory. Work of the medical department abroad was excellent. Most of the fracture cases coming back show excellent work. Did not operate on ununited fractures for three months, then if there was no evidence of tenderness or other evidence of infection, was massaged for three days then anti-tetanus serum given and they were operated. Dr. Dan H. Eaton: Used the regular splints which Cap. Mercer has demonstrated in the 83rd Division. Each man in the sanitary detachment had several weeks training in their use, and then had to pass an examination. The men who handled these fractures did good work. There were many cases of compound fracture. In the French hospitals they used plaster of Paris, which was left on for a long time, some as long as 16 or 17 weeks: some of these when received were frightful condition. They were put in Thomas or Hodgen splints, used Dakin's solution and it was surprising how the wounds healed up, by the use of splints they were easy to irrigate and dress. in Enjoyed Capt. Mercer's paper very much. Capt. Shackleton: The Thomas splint is very comfortable, area of pressure only about the size of a dollar. Dr. Goodrich: Asked if the Thomas splint is used in fracture of the hip. Saw one used in Chicago. Dr. L. H. Stewart: Has had few fractures. Never attempted to wire any sort of compound fracture, uses extension. Dr. Boys: In patellar fractures it has been his practice to wait a few days to be sure the hemorrhage has been stopped and then do the open operation with suture of the fascia with catgut. This has been very satisfactory in a limited number of cases which he has had. However, we should not be too ready to draw final conclusions from a limited number of cases. He then reported case of fracture of the humerus, combined with a very open lacerated wound over the inner half of the elbow joint. The wound was so extensive that this was treated first by debridement. almost entirely disregarding the fracture until ten days later when the wound was healed. When attention was directed to the fracture it was found to be in satisfactory position, so that nothing further was necessary in the way of reduction. Good recovery was made in all respects in this case. He expressed the belief that the average civil hospital was not sufficiently equipped with such splints as the doctor has described and states that these should be always ready and that perhaps the reason they were not was due to the infrequency of fractures as they occur in the hands of any physician in civil practice. Lieut. Crutchfield: Subject has been we'l covered. In treatment of fractures first immobilize, X-ray, give morphine and reduce under the screen. then screen again after splint is applied. Very few cases require general anesthetic, less than 5 per cent. of them do, as most of them are received early. Every case of fracture is a law unto itself. One rule will not apply to all fractures. Remember the mechanics of the part, relax and rest. The bones should be put in apposition, the splint applied and then studied under the X-ray at intervals. It is not the anatomical results, but the functional results that we are looking for. Dr. Boys asked Lieut. Crutchfield, if he gave morphine to young children. Lieut. Crutchfield: Makes exception in children, gives them general anesthetic because of fright. Cannot reduce fracture under the screen in every child. Dr. Tomkinson: About six years ago broke os calcis of left heel, had flat foot as result. Tried various methods, then started to toe in, which gave him good results. Capt. Mercer: Glad to hear about the case of fracture of os calcis, and the toeing in, which brings the line of weight to its proper relation All flat feet are abducted feet. Tibialis anticus muscle is put out of use and when we toe in it brings it back. If we will stroke the muscle in and about the joints 10 or 15 times. they will often relax and they can be reduced without anesthetic. These splints which have been demonstrated can be adapted to any case. In the A. M. A. Journal often find advertisements of some of the pneumatic ambulatory splints. A new army manual of splints is just off the press and gives all these splints and appliances. ABSTRACT OF PAPER ON REMARKS ON ANGUS MCLEAN, M.D. DETROIT, MICH. War has broadened surgery. Different angles have been seen by men of the different branches of service, but yet reports of all agree. Impressions from a base hospital of 3,000 beds compared with ordinary civil hospitals give one good advantages for drawing conclusions. Four-fifths of the cases were battle casualties. The preponderance of the different wounds varied according to the nature of the engagement. Did not look upon machine gun or bullet wounds, that did not hit the ground as seriously as they did the shell or shrapnel which often took a piece of earth with it. Those of the medical profession who went into the service early were lucky as they had opportunity to see all phases from the trenches to the Base Hospital. If there is one thing that did more than others for humanity it was the X-ray. Some |