ture of the upper third of the femur and is a lateral view of the first case reported by Dr. Perkins. The lower fragment is usually drawn up behind the upper by the action of the hamstrings, rectus, tensor vaginae femoris and the adductors, the latter group being chiefly instrumental in carrying it to the inner side. The lower end

C. W., aged 7. Fracture of Right Femur. Firm union. Skiagraph taken ten months after injury. Antero-posterior view.

of the upper fragment is tilted forward and outward by the pushing up of the lower fragment assisted by the action of the iliopsoas muscle, thus producing an angular deformity. The angular deformity in this case is well marked. We notice that the intervening space between the fragments is filled by a shadow of less density than the bones but greater than that of the muscles.

and in this shadow we see several much lighter spots. The first shadow referred to represents the callus which nature had so lavishly poured out for the repair of the bones, and the lighter spots represent the solution of continuity of the same, produced by movements of the fragments; so that at the time of taking the

picture, eight weeks after the reception of the original injury, despite the liberal amount of callus the fracture was still ununited.

Number II was taken a few minutes later than number I, the X-Ray tube maintaining the same relative position and represents the appearance of the fragments after reduction had been attempted by extension and manipulation under complete anaes

thesia and the leg had been put up in a firm plaster Paris cast. The angular displacement had been considerably reduced but the wedge of callus which can be seen between the fragments prevented their complete approximation.

Numbers III and IV represent the condition of the bones at the present time, eight months after the first skiagraphs were taken, number III being the lateral and IV the antero-posterior view. By tracing the lighter shading of the medullary canal in number III we can see approximately the ends of our fragments, but the intervening space is filled by a dense shadow without the medullary canal and represents the permanent callus which has so firmly united the bones and by spanning the gap has prevented the shortening which is apt to follow a fracture in this locality.

Number IV shows a good lateral approximation of the fragments, although the slight inner displacement of the lower and the outer displacement of the upper can be perceived. This last skiagraph gives no intimation of the angular position at which union has taken place and illustrates in a very practical manner the advisability of inspecting both the lateral and antero-posterior axis in all cases in which an X-Ray examination is made.

Number V is a lateral view of the thigh described in the second case reported and represents the condition of the femur seven months after the operation of wiring the fragments, the silver wires being plainly visible and the vertical axis of the shaft of the bone apparently normal. We can see the medullary canal in the upper and lower part of the bone and notice the denser shadow of the bridge of permanent callus.

The X-Ray has established itself as a necessity in making an accurate and positive diagnosis in many of the lesions of the body, especially the localization of foreign bodies and obscure fractures. By the aid of the rays the surgeon is enabled to inspect the position of the fragments after the application of a temporary or permanent dressing, for the ordinary materials used in these dressings, such as wood or plaster, afford no barrier to the penetration of the rays. It saves the patient from the pain and discomfort incident to undue manipulation of structures which have already been contused and lacerated and especially enables a correct diagnosis to be made in the oedematous condition which soon supervenes upon some fractures and which excludes a positive diagnosis by the ordinary methods until after a considerable lapse of time.

The more the X-Ray is used in diagnosis in injuries in the neighborhood of joints the more rare will become the bad results from so-called sprains and the less often will the attending physician or surgeon fail to notify the patient or the family that an apparently trifling injury may result in permanent crippling of the joint.

PRESIDENT'S ADDRESS.

Delivered Before the Annual Meeting of the Denver and Arapahoe County Medical Society.

By LEONARD FREEMAN, M.D.,
Denver, Colo.

Recent years have seen the conception and development of many new ideas in medicine and surgery, some of which have been little short of revolutionary. I was tempted to review these advances, as is customary in presidential addresses, but it occurred to me that in our enthusiasm for our achievements we were apt to go too far, thus inflating values and exaggerating conclusions, and that it might be of interest to call attention to some of our limitations rather than our triumphs.

A physician who is not optimistic is but a poor physician; and yet, in spite of this, a great fault of the profession has been that it has claimed too much, notwithstanding the fact that our position is such that this is unnecessary. For instance, we often speak of "curing" various diseases, such as typhoid fever and measles, while in reality our services are confined to a watchful care of the patent's interests and a somewhat limited assistance of his natural resisting powers. It should never be lost sight of that the boomerang of boastful pretense is apt to injure us upon its return, and return it always does. The phenomenal growth of many fads and cults is no doubt stimulated to a certain degree by the distrust engendered in the minds of those who have observed the shortcomings of medicine in the face of extravagant claims. But it should in justice be said that these claims are much more often made by the weaker members of the fraternity than by the stronger.

Our more or less unconscious deceptions are not limited to others. We often deceive ourselves. In this connection witness

the long list of remedies and theories which have come and gone in times past. It is, therefore, well to occasionally pause and look about us, to consider whether we are not laying too much stress upon this or upon that, or carrying some theory or practice to an unwarrantable extreme. Although this may be a natural outcome of healthy enthusiasm, we should nevertheless endeavor, as far as possible, to see things as they really are and not as we should like to have them.

Let us consider the question for a few moments from a surgical standpoint. Take, for instance, the subject of asepsis. Nothing, with the exception of anaesthesia, has done so much for surgery; and yet we are in constant danger of going to extremes and regarding as essential things which have but little bearing upon our results. It is beautiful and imposing, without doubt, to have an operating room filled with plate glass and white enameled furniture; and yet equally good work can be achieved without these costly adjuncts. This so-called "aseptic furniture,” which is not aseptic, was largely forced upon us by enterprising dealers hungry for profits. Some of the cleanest work in the world is done by Halstead, of Johns Hopkins, upon a simple wooden table protected by a sterile sheet.

It is not essential that an operating room be lined with marble or glass or lead or even tiles. Just as many infections take place in such rooms as in those whose floors are of linoleum or of wood, provided that reasonable care be used in the latter class. Infections do not arise from floors and walls, but from the hands of the operator and from other things coming in actual contact with the wound. In this connection, if we stop to think, we will all admit that an efficient nurse is infinitely more important than an elaborate room, and yet this is often overlooked. It has long ago been shown that infection from the atmosphere is but a remote possibility, and that it may be avoided by not talking into wounds and by keeping the operating room moist—a little water on the floor, and especially a little steam in the air.

All this does not mean, however, that we should not have fine operating rooms. It simply means that we should view things in the proper perspective.