NEW REGISTRATIONS.

Dr. John D. Milligan, Pittsburg, Pa., surgeon P. & L. E.

Dr. R. J. Stiver, Lena, Ill., local surgeon I. C. Dr. W. R. Hamilton, Pittsburg, Pa., surgeon Penna. Dr. G. Greaves, Herkimer, N. Y., surgeon A. & St. L. Dr. A. F. Walter, Gladbrook, Ia., local surgeon C. & N. W.

Dr. D. A. Stewart, Winona, Minn., local surgeon C., M. & St. P.

Dr. J. F. Robinson, Manchester, N. H., local surgeon B. & M.

Dr. A. L. Clark Elgin Ill., local surgeon C., M. & St. P. Dr. S. W. Spitler, Wellington, Kan., local surgeon S. Fe and C., R. I. & Pac.

Dr. Fermin Martinez, Monterey, Mex., division surgeon Mexican Central.

Dr. F. J. Lutz, St. Louis, Mo., consulting surgeon "Frisco."

Dr. John Isbell, Washington, Mo., local surgeon M. Pac.

Dr. Edward C. Rushmore, Tuxedo, N. Y., surgeon Erie.

Dr. John J. Buckley, Missoula, Mont., chief surgeon N. Pac. (W. Div.).

Dr. F. W. Robinson, Sturgis, Ind., division surgeon G. R. & I.

Dr. William M. Finley, Altoona, Pa., surgeon P., J. & E.

Dr. H. N. Street, Gloster, Miss., local surgeon Y. & M. V.

Dr. Owen E. McCarty, Niagara Falls, N. Y., local surgeon L. V.

Dr. Joseph Pogue, Edwardsville, Ill., local surgeon Wabash and C., P. & St. L.

Dr. S. A. Daniel, Welch, W. Va., division surgeon N. & W.

Dr. E. J. Morris, Philadelphia, Pa., local surgeon B. & O.

Dr. Jacob S. Kauffman, Blue Island, Ill., local surgeon C., R. I. & P.

Dr. Stephen T. Turner, El Paso, Tex., division surgeon S. Pac. and G., H. & S. A.

Dr. W. H. Magie, Duluth, Minn., chief surgeon D.. M. & N.

Dr. Jacob Schneck, Mt. Carmel, Ill., local surgeon Southern and Big Four.

Dr. E. R. Switzer, Salina, Kan., local surgeon M. Pac. Dr. B. W. Harris, Norwich, N. Y., surgeon N. Y., O. & W.

Dr. H. E. McNutt, Aberdeen, S. D., local surgeon C. & N. W.

Dr. D. Campbell, Butte, Mont., local surgeon N. Pac. Dr. J. W. Pettyjohn, Hoyt, Kan., local surgeon C., R. I. & P.

Dr. I. N. McNutt, Pevely, Mo., local surgeon St. L., I. M. & S.

Dr. J. D. Bedford, Honey Grove, Tex., G. C. & S. F. Dr. A. A. Deering, Boone, Ia., district surgeon C. & N. W.

Dr. William H. Palmer, Janesville, Wis., district surgeon C. & N. W.

Dr. E. S. Montgomery, Pittsburgh, Pa., surgeon B. & O.

Dr. C. T. Burchard, Falls City, Neb., local surgeon Mo. Pac. and C., B. & Q.

Dr. John Dennison, Litchfield, Ill., local surgeon Big Four, Wabash, I. C., J. S. E. and C., P. & St. Louis.

Dr. W. J. Cuddeback, Port Jervis, N. Y., local surgeon Erie.

Dr. Lester Keller, Ironton, O., local surgeon C. & O., C., H. D. & Iron Road.

Dr. Melvin Collins, Oxford, Kan., local surgeon S. Fe.

Dr. John W. Gordon, Belle Vernon, Pa., division surgeon P. & L. E.

Dr. B. F. Eads, Marshall, Tex., chief surgeon T. & Pac.

Dr. Henry Hatch, Quincy, Ill., local surgeon C., B. & Q. Dr. A. A. Bondurant, Cairo, Ill., district surgeon St. L. S. W., local surgeon M. & O.

Dr. N. E. Brundage, Delphos, O., local surgeon T., St. L. & W. and C., H. & D.

Dr. Harold W. Banks, Escanda, Mich., district surgeon C. & N. W., local surgeon C., M. & St. P. and E. & L. S. Dr. R. P. Malay, Whistler, Ala., local surgeon M. & D. Dr. H. P. Boardman, Oakes, N. D., local surgeon N. Pac., C. & N. W. and "Soo."

Dr. D. W. Crouse, Waterloo, Ia., district surgeon I. C. and C., R. I. & Pac.

Dr. L. K. Onsgard, Houston, Minn., local surgeon C., M. & St. P. and S. Minn.

Dr. Albert G. Ellinwood, Attica, N. Y., division surgeon Erie.

Dr. B. F. Fortner, Vinita, I. T., local surgeon M., K. & T. and Frisco.

Dr. Lucius Frenchy, Davenport, Ia., local surgeon C., M. & St. P.

Dr. Reginald W. Garstang, Indianapolis, Ind., surgeon C., C., C. & St. L.

Dr. R. Sumter Griffith, Basic City, Va., surgeon C. & O. and N. & W.

Dr. Gainor Jennings, West Milton, O., surgeon C., H. & D. C. and P. Traction Co.

Dr. John W. Lane, Linneus, Mo., local surgeon C., B. & K. C.

Dr. W. R. Chalker, Lake City, Fla., local surgeon S. A. L.

Dr. Oliver B. Quin, McComb, Miss., district surgeon I. C.

Dr. M. A. Gates, Ronceverte, W. Va., local surgeon C. & O.

Dr. David Gardner, Lehigh, I. T., local surgeon M., K. & T.

Dr. Milton Jay, Chicago, Ill., chief surgeon C. & E. I. Dr. J. D. Griffith, Kansas City, Mo.

Dr. A. Hayden, Shullsburg, Wis., local surgeon C., M. & St. P.

Dr. Geo. W. Johnson, Savanna, Ill., local surgeon C., M. & St. P. and C., B. & Q.

Dr. J. C. Adams, West Superior, Wis., local surgeon C., St. P., M. & O.

Dr. N. B. Breckenridge, Ada, I. T., local surgeon Frisco.

Dr. Thos. A. Hobson, Parkersburg, Ia., local surgeon

I. C.

Dr. Geo. Harvey Cole, Conneaut, O., surgeon L. S. & M. S.

Dr. Geo. W. Gabriel, Parsons, Kan., local surgeon Frisco.

Dr. F. J. Schaufelberger, Hastings, Neb., local surgeon St. J. & G. I.

Dr. D. E. Welsh, Grand Rapids, Mich., local surgeon G., R. & I.

Dr. John F. Pritchlow, Salt Lake, Utah, local surgeon R. G. W.

Dr. S. R. Hewett, Charles City, Ia., local surgeon C., M. & St. P.

Dr. D. F. Speicher, Elk Lick. Pa.

Dr. H. Logan, The Dalles, Ore., assistant surgeon O., R. & N. Co.

Dr. Samuel H. Pinkerton, Salt Lake City, Utah, chief surgeon O. S. L.

Dr. J. W. Tope, Oak Park, Ill., local surgeon C. & N. W.

Dr. J. D. Brazeel, Wagoner, I. T., local surgeon M., K. & T.

Dr. W. L. Dunn, Glade Spring, Va., surgeon N. & W.

Dr. B. G. Copeland, Birmingham, Mo., chief surgeon A., G., S. & B. S.

Dr. Arthur Jukes Johnson, Toronto, Can., chief surgeon Toronto Ry.

Dr. James A. Quinn, St. Paul, Minn., chief surgeon G. N.

Dr. W. C. Overstreet, Sedalia, Mo., consulting surgeon M., K. & T.

Dr. John Anderson Reed, Maysville, Ky., local surgeon C. & O.

Dr. Lloyd G. Hewitt, Northwood, Ia., local surgeon C., R. I. & Pac.

Dr. W. T. Mahon, Chamois. Mo., local surgeon Mo. Pac.

Dr. Wm. R. Patton, Charleston, Ill., division surgeon I., St. L. & W.

Dr. J. N. Steaby, Freeport, Ill., local surgeon C. & N. W. and C., M. & St. P.

Dr. R. G. Mendenhall, La Cygne, Kan., local surgeon Frisco.

Dr. Daniel A. Currie, Englewood, N. J., surgeon Nthn. R. R. of N. J.

Dr. M. H. Proudfoot, Rowlesburg, W. Va., local surgeon B. & O.

Dr. George W. Smith, Monongahela, W. Va., local surgeon B. & Ö.

Dr. W. T. Evans, Jewett, Tex., local surgeon Jewett,

Tex.

Dr. Henry T. Godfrey, Galena, Ill., district surgeon C. & N. W. and local surgeon I. C.

Dr. W. L. Smith, Streator, Ill., local surgeon Wabash, S. Fe and C., B. & Q.

Dr. F. W. Schmidt, Chicago, Ill., local surgeon I. C. Dr. P. A. Melick, Williams, Ariz., local surgeon S. Fe Pac.

Dr. James N. Richards, Fallsington, Pa., local surgeon Pennsylvania.

Dr. Edward E. Stonestreet, Rockville, Md., surgeon B. & O.

Dr. Manning Simmons, Charleston, S. C., local surgeon Southern.

Dr. Carleton M. McGuire, Walsenburg, Colo., local surgeon D. & R. G.

Dr. William B. Morrow, Walton, N. Y., surgeon N. Y., O. & W.

Dr. William T. Ingram, Murphysboro, Ill., local surgeon I. C.

Dr. T. C. Barnum, Pauls Valley, I. T., local surgeon G. C. & S. F. and A., T. & S. F.

Dr. Charles E. Robinson, Clarksville, Ark., local surgeon L. R. & F. S.

Dr. J. L. Jones, Jonesburg, Mo., local surgeon Wabash. Dr. H. K. Whitford, Elgin, Ill., local surgeon C., M. & St. P.

Dr. J. N. MacArthur, Winnipeg, Man., ex-surgeon N.

Pac.

Dr. S. E. Robinson, West Union, Ia., division surgeon C., M. & St. P. and Rock Island.

Dr. John P. Haller, Pocahontas, Va., surgeon N. & W. Dr. G. M. Pirtle, Carlisle, Ind., local surgeon E. &

T. H.

Dr. Daniel McL. Miller, Oconomowoc, Wis., local surgeon C., M. & St. P.

Dr. J. S. Hasemein, Los Angeles, Cal., local surgeon B. & M.

Dr. William Jepson, Sioux City, Ia., local surgeon I. C. Dr. A. F. King, Pueblo, Colo., local surgeon D. & R. G. and C. S.

Dr. Clayton Tiffin, Hamilton, Mo., local surgeon H. & St. J.

Dr. Louis E. Broughton, Andalusia, Ala., local surgeon C. of Ga.

Dr. George W. Crile, Cleveland, O., local surgeon Big Four and N., P. & E.

Extracts and Abstracts.

TREATMENT OF FRACTURES AND INJURIES TO THE ELBOW-JOINT.

BY ARTHUR J. GILLETTE, M. D., AND JOHN B. BRIMHALL, M. D., ST. PAUL.

It is obvious that a student of surgery must be extremely confused when he meets with a fracture or injury at or near the elbow-joint. When he reads of the possibility of "a separation of the whole epiphysis," "separation involving part of diaphysis at one side," "supra-condylar fractures," "T or Y fractures," "epiphyseal separation of the epitrochlea," "fracture of the internal condyle," "partial fracture of the capitellum," "fracture of the external epicondyle" or "fracture or epiphyseal separation of the external condyle." Then he has the various dislocations to consider. Dislocation backward of both ulna and radius, partial dislocation backward of ulna, dislocation forward of both ulna and radius, dislocation forward of ulna with fracture of olecranon, dislocation forward of radius, dislocation backward of radius; besides the injuries to the nerves of which the writers have seen two which produced a flexion at the wrist, and so-called "claw hand" which either resulted from the injury to the nerve at the time of the trauma, callus or from inflammatory adhesions. After one has mastered his case so far as to make a proper diagnosis, which is not easy, especially as a tremendous proportion of these cases occur in the young, even in very young children and from very slight injuries, he is still further embarrassed when he comes to treatment-first, by the position. It has been a very fertile source of discussion whether to put the arm in a rght angle splint or in extension or a changing angle or acutely flexed or a suspension of the flexed arm in a "Thomas wrist halter," etc. After the surgeon has decided this point then comes the question of mobilization, some advocating passive motion early, very early, before ten days, some ten days, some two weeks, three weeks, four weeks, six weeks, and we who have thirty cases to report advise no passive motion at all.

Our first case was seen in the country where we found a boy with the following history: May 2, 1891, H. R., 10 years old, was thrown from a horse and sustained a compound comminuted fracture of the lower end of left humerus, described as a T-fracture, in which both external and internal condyles are separated from the shaft and also from each other. The end of the shaft protruded through the wound in the skin and the joint was much

swollen and discolored.

From our impressions of the treatment of injuries and fractures about the elbow-joint our desire was to dress this arm in a flexed position, and although he was profoundly under an anesthetic the moment we attempted to flex the arm the fragments would be displaced, but every time we extended it and especially when we made complete extension and considerable traction, all of the fractured fragments were brought into their normal position. We were, therefore, much against our will, obliged to dress the arm in this way, using plaster of Paris, extending it from the fingers to the armpit, with the forearm

fully supinated and traction continued until the plaster was thoroughly hardened; then, by cutting windows in the plaster to dress the wound, it was left in this position for five weeks. When this cast was removed for inspection the arm was found to be in such excellent condition that the same cast was reapplied for two weeks longer, and an absolutely perfect arm was the result, and is the result to-day, and we do not believe, aside from the scars, that a surgeon would be able to tell which arm had been fractured. From that time to the present we have treated every form of fracture, dislocation, injury, even tuberculous joints in this position, and we have met with such uniform success that we believe we are justified in reporting it here and advocating it.

We have not reported here anything but fractures and dislocations because the term "injury" is vague and gives no exact lesion, and necessarily a slight injury, and therefore a good result would have very little weight as to the efficiency of this form of treatment.

In the tuberculous joints which we have treated in this way results are always considered relatively, neither is it easy to follow up the cases and get an exact report of the present condition.

Neither will we discuss in this paper the juxtaposition of the parts or the muscular action on the fragments in the various fractures, which arguments are sometimes used by various authors to justify their particular form of the position of the arms in dressing these fractures, as this ground has been thrashed over again and again with no conclusions, and we therefore present these cases as clinical facts to justify the position which we advocate, namely, that of full extension and supination with traction and no passive motion or massage.

Case No. 1. May 2, 1891.-H. R., 10 years old, was thrown from a horse and sustained a compound comminuted fracture of lower end of left humerus, described as a T-fracture, in which both external and internal condyles are separated from the shaft and from each other. The end of the shaft protruded through the wound in the skin and the joint was much swollen and discolored.

Treatment: Anesthetized, reduced as before described and dressed in complete extension with plaster cast from axilla to fingers, with the forearm fully supinated, and strong traction continued until the plaster was thoroughly hardened. This cast was left on for five weeks, then removed for inspection. The condition was found to be so satisfactory that the same cast was reapplied for another two weeks and an absolutely perfect arm was the result.

Case No. 2. April 27, 1892.-W. T., boy, 4 years old, fell from a ladder, sustaining a fracture of lower end of left humerus. External condyle separated.

Treatment: Anesthetized, reduced and plaster cast applied as in previous case, with the forearm fully extended for five weeks. The cast was then removed and a roller bandage applied. No passive motion was employed, but the child was encouraged to use the arm. When seen one week later the result was found to be perfect.

Case No. 3. July 2, 1892.-C. W. H., adult, sustained a fracture through inner condyle of right humerus. Treatment: Anesthetized, reduced and a plaster cast

applied, with forearm extended for six weeks. Active motion for less than one week, when motion in the joint was found to be perfect.

Case No. 4. September 16, 1892.-W. C., 10 years old, fell from balcony on second floor and fractured both bones of left forearm close to elbow-joint.

Treatment: Anesthetized, reduced and plaster cast applied, with the forearm fully extended and supinated for four weeks. The cast was then removed, a roller bandage applied and the boy was encouraged to use the arm. The result was found to be perfect when the arm was examined one week later. At the end of another week the boy met with an accident on the street, which resulted in fracturing the same arm above the elbow.

Case No. 5. October 29, 1892.-Same boy, supra-condylar fracture of left humerus.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm fully extended for six weeks. Active motion for another week brought a perfect result. Case No. 6. February 23, 1893.-H. C., 13 years old, comminuted fracture of lower end of left humerus, described as a T-fracture, in which both external and internal condyles were separated from the shaft and also from each other.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm fully extended for eight weeks. Motion at this time was absolutely perfect.

Note: The cast in this latter case was undisturbed for eight weeks and the result being such perfect motion, it tends to corroborate a previously advanced theory that long immobilization of fractures near a joint is very desirable. In this case the outline of the joint was normal when the cast was removed, and there was no perceptible callus at the seat of fracture. The redundant callus had evidently been absorbed, and in no way interfered with motion of the joint.

Case No. 7. July 8, 1893.-F. G., 11 years old, fracture near elbow-joint (exact condition not noted in our records).

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm extended for six weeks. Motion was practically perfect when cast was removed. (Never saw this patient afterward.)

Case No. 8. July 12, 1894.-H. B., 14 years old, fell from a tree, sustaining a complete backward dislocation of both radius and ulna. Joint was very much swollen and the skin much discolored from extravasation of blood, showing considerable laceration of soft parts at elbow.

Treatment: Anesthetized, reduced and a plaster cast applied with the forearm extended for four weeks. Result was then perfect.

Case No. 9. July 14, 1894.-D. H., 3 years old, fell from a table and sustained a fracture of radius and ulna near elbow.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm extended and supinated for four weeks. Result was then perfect.

Case No. 10. November 28, 1894.-C. H., 11 years old, by a fall, fractured radius and ulna near elbow.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm extended and supinated for four weeks. Result perfect.

Case No. II. April 6, 1895.-A. T., 13 years old. by falling downstairs fractured the lower end of left humerus, separating the external condyle.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm fully extended for six weeks. Result perfect.

joint was, however, still swollen, and we have received no report of the case since. (In this case an anesthetic was not used.)

Case No. 21. August 2, 1896.-J. D., 11 years old, fell from a turning pole and sustained a comminuted fracture of lower end of left humerus. This injury consisted

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm fully supinated and extended for four weeks. Result perfect.

of the internal epicondyle. The joint was very much swollen.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm extended for four weeks, at

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm fully supinated and extended for four weeks. Result perfect.

Case No. 14. September 13, 1897.-W. J., 12 years old, fell from a window of second story, sustaining a T-iracture of lower end of humerus, also a complete backward dislocation of both ulna and radius at the elbow. The joint was very much swollen and discolored.

Re

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm extended for eight weeks. sult perfect.

Case No. 15. April 7, 1898.—A. C., 7 years old, fell one flight of stairs, sustaining an oblique fracture of lower end of humerus, separating the internal condyle, and backward dislocation of ulna at the elbow. Marked deformity and swelling of the joint.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm fully extended for six weeks. Result perfect.

Case No. 16. September 18, 1898.-L. H., 7 years old, by a fall fractured left humerus through external condyle.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm fully extended for six weeks. Result perfect.

Case No. 17. April 20, 1898.-B. H., 1 year old, fell downstairs and fractured lower end of right humerus through the condyles. This was in all probability a separation of the whole epiphysis.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm fully extended for five weeks. Result perfect.

Case No. 18. November 11, 1897.-Boy, 14 years old, by a fall sustained an oblique fracture through lower end of humerus, separating the external condyle.

Treatment: Anesthetized, reduced and a plaster cast applied, with forearm extended for six weeks. Result perfect.

Case No. 19. December 4, 1898.-Boy, 10 years old, fractured radius and ulna near elbow-joint.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm extended for five weeks. Result perfect.

Case No. 20. March 14, 1898.-N. M., adult, transverse fracture of olecranon.

Treatment: Plaster cast, forearm extended.

This man removed the cast himself before the end of two weeks and reported that his arm was all right. The

removed. Motion was then limited to 45 degrees flexion, and after using the arm for a few days, with no dressing except a roller bandage, the boy returned to the office with the joint swollen, motion painful and less free than when the cast was removed.

The mother consented then to the application of another cast, which was worn for two weeks. Motion then was practically what it had been when the first cast was removed and passive motion was begun. The arm was occasionally flexed by using force, to a right angle, which caused the boy much pain, and for a few days following such treatment the motion was less free. After several weeks' treatment in this way we concluded that it was decidedly of no benefit to the joint and left the case to nature. At the present time all movements at the elbowjoint are free, with the exception of flexion, which is only a trifle less than to a right angle. For all working purposes this is practically a perfect arm, much more so than if fixed at a right angle.

Case No. 22. October 20, 1900.-B. L., 9 years old, fell from a fence and sustained a comminuted fracture of lower end of right humerus, both condyles being separated from each other and from the shaft of the humerus. Joint very much swollen.

Treatment: Anesthetized, reduced and a plaster cast applied, with the forearm extended for six weeks. Motion was then found to be limited to 45 degrees flexion. Passive motion was employed for two weeks, with the result of increased swelling and a lessened degree of flexion. A fixed dressing was then applied for two weeks with the arm flexed as much as it could be. After the removal of this dressing the treatment was left to nature, and at the present time all movements at the elbow-joint are free, except that flexion is limited to a little less than a right angle.

The arm is a useful one, there being practically nothing disabling about it, as she uses this arm on all occasions in preference to the other.

Cases Nos. 23, 24, 25, 26.-During the summer of 1896 there had been a circus in town, and some very alluring acrobatic feats were exhibited. As a result, we were called upon during the ten days following this circus to treat four boys who had sustained fractures of the lower end of the humerus, all being caused by falling in an attempt to duplicate the circus performance. These cases were treated as patients of the city and county, and we have not the definite records which are noted in the other cases. However, the same treatment was used in all, anesthetized, reduced, a plaster cast applied, with the forearm

extended from six to seven weeks, and the results were all perfect.

Case No. 27. Suppurating case. October, 1898.-Boy, 13 years old, charity case, came under treatment one week after injury to elbow, which consisted of a compound comminuted fracture of condyles of left humerus, described as a T-fracture. The joint was very much swollen, suppurating freely, and the tissues infiltrated with

pus.

Treatment: Irrigation, antiseptic dressings and plaster cast applied, with forearm extended for five weeks. Motion then was free in the elbow-joint, but flexion was imited to 45 degrees. Never seen afterward.

Case No. 28. October 15, 1901.-T., boy 9 years old, oblique fracture of lower end of humerus. Internal condyle separated, plaster cast applied in extension, removed at the end of five weeks. The day following removal of cast the boy fell from a chair on which he was standing, the arm going down between wall and radiator, producing a second separation of fragments. A similar dressing was reapplied and removed seven weeks later. Some stiffness of joint. Result now perfect motion.

Case No. 29. October 12, 1900.-G. F., aged 8 years, sustained a compound fracture of the lower end of the humerus "supracondyloid." The wound was very slight. It was thoroughly cleansed and dressed antiseptically. The child was anesthetized, arm fully extended, plaster cast applied from the fingers to the armpit, and the dressing was not removed for four weeks. Union seemed to be complete, but the cast was readjusted. No attempt at motion was made at the joint, and the child wore the cast four weeks longer. Result perfect.

Case No. 30. December 30, 1901.-L., aged 10 years. Fracture of the external condyle. Did not consult a physician for one week after the injury. The swelling about the joint was considerable, and was very tender. This child was not given an anesthetic, as it was easy to demonstrate a fracture of the external condyle, since he was very thin, and gradual extension and traction relieved the pain as it relieved the reflex muscular spasm. This cast was removed at the end of two weeks, as we were anxious as to the relation of the fragments, for in this case we attempted treatment without an anesthetic, but no motion was made at this time, and the straight position was continued for eight weeks, and then the child began to use the arm, and is now perfect in every respect.

The results obtained in cases Nos. 21 and 22, while being imperfect, are not really bad results as to usefulness. Physical examination of both these cases at the present time shows in each that the internal condyle was not properly replaced at the time of dressing, as in each the epicondyle can be felt displaced forward, outward and firmly ossified to the anterior surface of the lower end of the humerus. This was corroborated by the fluoroscope, and when flexing the arm this bony protuberance could plainly be seen to lock further flexion. The removal of these displaced condyles will undoubtedly be followed by much better flexion.

Conclusions. First, this is a dressing of easy application. Second, in most instances it is the most comfortable for the patient. Third, the circulation is less interfered with. Fourth, it is shown in our own cases and in those

of others that the fracture of the external or internal condyle is the most frequent fracture; that the muscles arising from these condyles have a tendency to draw the fractured portion toward the median line and in front of the elbow-joint, thus blocking flexion, and with the straight splint they are easily held in position. Fifth, if there is a great deal of callus there is no danger of the olecranon fossa becoming filled with it and thus blocking extension, and the olecranon process furnishes an admirable splint to keep in place the fragments when the condyles are fractured. Sixth, the traction which is made with extension and supination keeps the normal bony surfaces, with the exception of the epitrochlear surface and the olecranon, the furthest apart. Seventh, we have found that in fractures near a joint no motion whatever should be permitted until the fractures are thoroughly united, as the irritation naturally causes an increased amount of callus, which interferes with motion. Eighth, active motion is much better than passive, for in passive motion force is used and the joint is continually irritated, which keeps up a certain amount of inflammation and tenderness and the patient will therefore of himself refuse to use the elbow. Ninth, it is the tendency of all joints when injured or inflamed from any cause to flex, therefore if an arm is placed in a flexed position for repair, when it is restored it is necessary for some active measures to be taken in order to extend it; this is not necessary when the arm is fully extended. Tenth, ankylosis is rare from any cause; less frequent from injuries, and we have not seen one case of ankylosis of the elbow-joint from injury, fracture or dislocation in some twenty cases which were considered bad results from fractures which were treated in a flexed position and some which were not diagnosed or treated at all. Eleventh, an anesthetic should always be used in reducing these fractures, as they result from such slight causes in children that they might easily be overlooked, besides, under an anesthetic it is much easier to reduce the deformity, and anesthesia shouid be continued until the plaster is thoroughly hardened. Twelfth, this position gives the very best results, but it must be remembered that in order to get these results the fracture must be perfectly reduced, which was not the case in the only two imperfect results which we have treated by full extension and supination.-St. Paul M. J. ON THE

DANGERS OF THE ESMARCH
BANDAGE.

(1) A 70

Ledderhose relates the following cases: year-old patient with diabetic gangrene of the foot; amputation of the thigh after holding up the leg and constriction with the rubber tube. striction with the rubber tube. On the surface of the stump femoral vein and artery thrombosed. After loosening the tube, tissues filled well with blood; perfect consciousness after the operation, but breathing -somewhat labored. Sudden death a quarter of an hour after the return to bed. No post-mortem. Ledderhose believed that the application of the tube, together with the return of the circulation after its removal, ioosened a thrombus in the femoral vein. (2) A 16-year-old boy; necrotomy of the tibia; constriction of the thigh with elastic bandage after holding up the leg. On the com