ister alcoholics, and it is to be had in some form almost everywhere. In the shock of trauma, alcohol usually exercises, a dual action of simultaneously sustaining the vital powers, while it modifies or suppresses pain.-St. Louis Med. and Sur. Jour. PROGNOSIS OF FRACTURES OF THE SKULL. At a recent meeting of the Berlin Surgical Society, H. Graf spoke upon this subject. The material for the address was furnished by ninety cases treated at the Charity Hospital. Seventy-seven of the cases were men and thirteen women. Concussion of the brain was present in nearly all the cases after the cessation of the original unconsciousness. There was usually a stage of hallucinations; at and after this a subsidence of all symptoms. The total mortality was 28.31 per cent, whilst before this it had generally been somewhat higher. Meningitis was rare, and this the speaker thought was due to modern treatment (avoidance of washing out, probing, etc.), or the meningitis might be very late after the injury. In fifteen cases there was mental disturbance, in which alcoholism played a considerable part. Symptoms of clot were rare; they showed themselves as aphasia, paragraphia, convulsions, in part of the Jacksonian type. Disturbance of taste was observed twice, flow of fluid from Steno's duct once, associated with facial paralysis. Headache was an almost constant symptom; giddiness was also frequent, especially under certain conditions, as when the head was thrown back. In eleven patients there were labyrinthine symptoms, in seven vomiting, in three mental weakness, the "amnesie retrograde" of the French. There was also occasionally change of character, partly of an irritable, partly of a melancholy type. In twenty cases there was deafness of a nervous kind. The pathological examinations of the brain had shown various changes, mostly of a diffuse kind.-Medical Press. Notes of Societies. AMERICAN ACADEMY OF RAILWAY SURGEONS. The next annual meeting will be held in Chicago, Thursday and Friday, October 1 and 2, 1903. T. B. LACEY, Secretary. ASSOCIATION OF RAILWAY SURGEONS OF THE PACIFIC SLOPE. At the preliminary meeting held in Santa Barbara, Cal., resolutions were passed expressing regret at the death of Dr. Matthew Gardner. The following officers were elected, after which the association adjourned out. of respect to the memory of Dr. Gardner: President, Dr. Walter B. Coffey, San Francisco; vice-presidents, Drs. Norman H. Morrison, Los Angeles; Charles N. Ellinwood, San Francisco, and Kenneth A. J. Mackenzie, Portland, Ore. ; secretary, Dr. James P. Dunn, Oakland, and Dr. Frank K. Ainsworth, Los Angeles, treasurer. The next meeting will be held at San Francisco in August. Notices and Reviews. “A Textbook of Legal Medicine and Toxicology." Edited by Frederick Peterson, M. D., Chief of Clinic, Nervous Department of the College of Physicians and Surgeons, New York; and Walter S. Haines. M. D., Professor of Chemistry, Pharmacy and Toxicology, Rush Medical College. Two imperial octavo volumes, fully illustrated. Philadelphia, New York, London: W. B. Saunders & Co. Chicago: W. T. Keener & Co. Per volume: Cloth, $5.00 net; sheep or half morocco, $6.00 net. Vol. I., 730 pages, 1903. We learn this textbook is planned to occupy a ground midway between manuals and the encyclopedic works, and it seems the attempt has been successful. The present volume is concerned principally with the somatic aspect of the subject. After a short introductory section on expert evidence, there is a full consideration of the technic of recropsies by Hektoen of Chicago. This is formed by sections on Identity, Signs of Death, Wounds, etc. There are two novel features for treatises of this kind, one is a chapter on "Railway Injuries," of 20 pages, by Da Costa of Philadelphia, the other one on "Injuries and Disorders of the Nervous System Following Railway and Allied Accidents," of 45 pages, by Pearce Bailey of New York. The former takes a calm view of spinal concussion and subscribes to the modern belief that most cases are instances of extra spinal injuries associated with traumatic hysteria. The researches of Dr. Bailey on Traumatic Neuroses are too well known to require more than a passing allusion, and this article makes the work invaluable to every railway surgeon. There are 109 text illustrations and 8 plates. "International Clinics." A Quarterly of Illustrated Clinical Lectures and especially prepared Articles on Medicine, Neurology, Surgery, Therapeutics, Obstetrics, Pediatrics, Pathology, Dermatology, Diseases of the Eye, Ear, Nose, and Throat, and other Topics of Interest to Students and Practitioners by leading Members of the Medical Profession throughout the world. Edited by Henry W. Cattell, A. M., M. D., Philadelphia, U. S. A., with the Collaboration of John B. Murphy, M. D., Chicago; Alexander D. Blackader, M. D., Montreal; H. C. Wood, M. D., Philadelphia; T. M. Rotch, M. D., Boston: E. Landolt, M. D., Paris; Thomas G. Morton, M. D., Philadelphia; James J. Walsh, M. D., New York; J. W. Ballantyne, M. D., Edinburgh, and John Harold, M. D., London, with regular correspondents in Montreal, London, Paris, Leipsic, and Vienna. Philadelphia and London: J. B. Lippincott Company. Cloth, $2.00. Vol. IV., Series 12, 1903. One of the noteworthy articles in this volume is the one on "The Blood in Health and Disease," by T. R. Brown, of Johns Hopkins Hospital. This issue closes the year, and the annual series covers over 1,200 pages, with 12 colored plates and 218 text illustrations, illustrating 98 articles, divided into 28 in medicine; 27 in therapeutics; 22 in surgery; 4 in obstetrics and gynecology; 5 on the eye, ear, etc.; 4 on neurology: 5 special articles, and 3 monographs. Vol. I., Series 13. 1903. Dr. A. O. J. Kelly is the editor of the new series. Attention may be called to the articles by Osler on Aneurism of the Descending Thoracic Aorta: Primary Intestinal Tuberculosis, by Frank Billings, and a Review of the Progress of Medicine, Therapeutics and Surgery for 1902, which is very fully illus trated. While there have been many publications attempting to cover the ground occupied by the "Clinics," it is a notable fact that none have lived as long, and that it stands alone, unique in its field. This long life, made possible by the hearty support of the profession, is no doubt due to the very practical nature of the work and its eminent editorial corps. "Progressive Medicine." Volume II., 1903. A Quarterly Digest of Advances, Discoveries and Improvements in the Medical and Surgical Sciences. Edited by Hobart Amory Hare, M. D. Octavo, 427 pages, with 46 illustrations. Per volume, $2.50, by express prepaid. Per annum, in four clothbound volumes, $10.00. Philadelphia and New York: Lea Brothers & Co. Dr. Coley's article on the Surgery of the Abdomen embraces a very full account of hernia, on which he is one of our foremost authorities. The diseases and injuries of the various abdominal viscera are also considered, the article covering 137 pages. Dr. Clark's section. on gynecology commences with a discussion of the various phases of uterine cancer, including etiology, symptoms and treatment. The various affections of the female pelvic viscera are also discussed, as is the relation of appendiceal disease to pathologic conditions of the other organs. In the section by Jackson, on Ophthalmology, is an exceedingly practical albeit short account of the estimation of damage from ocular injury or disease. The entire volume is very interesting, and we were. almost going to say better than its predecessors. CHART OF BACTERIA. Messrs. M. J. Breitenbach Company of New York, the importers of the well-known Gude's Pepto-Mangan, have published a wall chart showing 60 different varieties of micro-organisms magnified 1,000 diameters. They are represented as they appear after appropriate methods of staining, and words cannot do justice to the beauty of the reproductions. Some idea of the labor involved may be gleaned from the following figures: There are 60 separate examinations represented, requiring the services of four skilled artists to make the original drawings from sketches. Time consumed, twelve weeks each; or labor for one man forty-eight weeks. The labor of proving same required the time of three provers five weeks each, or the total time of one man fifteen weeks. Eighty lithographic stones were used for the drawings and proving original designs. The time for transferring and printing of all colors was 61 days. The chart passed through the printing press 16 times. The chart is mounted on linen, and forms an admirable addition to any physician's office. It can be obtained on application to Messrs. M. J. Breitenbach Company, 53 Warren street, New York. PAMPHLETS RECEIVED. Transactions Luzerne. County Medical Society for the year ending Dec. 31, 1902. Vol X. "The Erotoparth in Society," by Charles H. Hughes, M. D., of St. Louis, Mo. "The Treatment of Chronic Diarrhea," by Charles D. Aaron, M. D., of Detroit, Mich. Railway Miscellany. CONTRACTS REQUIRING NOTICE OF EMPLOYES' PERSONAL INJURY SUITS. At the annual session of the Association of Railway Claim Agents at Niagara Falls, N. Y., on June 4, Mr. J. D. M. Hamilton, claims attorney of the Atchison Topeka & Santa Fe system, Topeka, Kan., read an instructive paper on the topic: "Is the contract in the application blank (for employment), requiring the injured employe to give notice in writing of his injury and the facts upon which he bases his claim, binding?" The argument, which was fortified by references to a large number of court decisions in regard to the powers of contracts with common carriers, employers' liability insurance policies, accident insurance policies, etc., was, slightly condensed, as follows: It has been somewhat difficult to prepare a brief or argument on this topic, for the reason that the subject is one, I believe, that has not been solved by any of the higher courts, and to arrive at a correct solution as to the legality of such a clause in the contract of hiring we are forced to rely upon the published decisions enforcing similar stipulations in shipping contracts with common carriers, in employers' liability insurance policies, in accident insurance policies, in decisions declaring constitutional what is known as the "enployer's liability act," and in a similar law applicable to cities, requiring notice after injury as a condition precedent before right of action accrues. These are alike applicable to contracts between master and servant, because they do not, as stated in the opinions, pretend to relieve the defendant from the consequences of his own negligence nor violate any other principle of public policy. In Queen of the Pacific, 180 U. S., 19, it is held: "A stipulation in a bill of lading that all claims against a steamship company, or any of the stockholders of the company, for damage to merchandise, must be presented to the company within 30 days from the date of the bill of lading, applies, though the suit be in rem, against the steamship carrying the property covered by the bill of lading." The court says: "Similar stipulations requiring notices of losses to be given to common carriers, express companies, telegraph and insurance companies have so often been upheld by the courts, when reasonable, that a review of the cases is quite unnecessary. Indeed, this is not the first time that the question has been before this court." In Underwood Veneer Company vs. London Guarantee & Accident Company (Wis.), decided in 1898, it is held: "Where an employer's liability policy was issued and accepted subject to the agreements and conditions indorsed' thereon, and a clause read that 'upon the occurrence of an accident, and also upon receipt of notice of any claim on account of an accident, the assured shall give immediate notice in writing,' such clause was a condition precedent, though there was no forfeiture clause in the policy, and an action could not be maintained thereunder for an injury to an employe when no claim had been made until nine months after the accident, when the company was first notified." The court says: "The reason for requiring such notice is obvious. It was to enable the defendant to investigate the facts and circumstances of the accident while they were fresh in mind, with the view of settling the loss, in case it should be so advised, and, in case of a contest, to be prepared to defend the same as stipulated in the policy. These things made it important for the defendant to be notified, immediately, not only of the occurrence of the accident, but also that a claim for damages had been made by the injured person on account of the accident." And in all the insurance cases it has been held without variation that the stipulation in the policy requiring certain notice and certain proofs within a specified time are binding upon the insured, and unless they are complied with there can be no recovery. If such contracts are good as to insur ance companies, why are they not as to railway companies. especially when railway companies make them as individuals doing things which they are not obliged to do and not as common carriers doing that which they must do without limi•tation of any kind? In Kentzler vs. American Mut. Acc. Assn. (Wis.), it is held: "A policy of accident insurance provided that, in case of death or injury, notice of claim should be given to the secretary of the company immediately after the accident, and positive proof of death should be furnished within six months thereafter, as conditions precedent. Held, that where the insured, a tugboat engineer, disappeared on November 19, 1892, and his body was found in the way near the tugboat on April 19, 1893, and notice of death was furnished on May 26, 1893, and the proofs on July 12, 1893, it showed a reasonable compliance with the terms of the policy." The court says: "What is the object of giving such notice of the accident, injury or death? In case of an injury or disability, not resulting in death, such notice affords the association an opportunity to ascertain the exact condition of the person, and apply the most effectual remedy. But in case of death, there can be no remedy, and the only object of the notice is to secure evidence of the identity." In Healy vs. Blake Manufacturing Company (Mass.), it is held: "The notice required by the employers' liability act (St. 1887, c. 270), providing that no action for injury or death under this act shall be maintained unless notice of the time, place, and cause of injury is given the employer within 30 days from the accident, is a condition precedent to the right of action for such injury." The court says: "This notice is similar to that required in the case of injuries received by reason of defects in highways, and is a condition precedent to the right of action. It is not simply one of the steps in enforcing a right of action already existing, but is the last circumstance necessary to the creation of such right. The liability is not complete until the notice is given. . It emanates from no court. is not dependent for its validity upon the action of any court, and is no part of any proceeding of a court for the purpose of getting jurisdiction over the defendant, or for any other purpose. It is simply a notice in pais, from one party to another, for the purpose of fixing a liability, which otherwise would not arise to the dignity of a cause of action. The statute is not needed, nor was it intended to aid in the creation of rights of action, and its operating force does not begin until the right exists and is to be enforced." Furthermore, it has been held by the courts in a great many cases, wherein the employer has a contract with the employe that in consideration of receiving company's hospital care and attention he will waive all actions for damages, and the courts have, as a general rule, held all such contracts, when not interfering with future liability for negligence, to be valid and enforcible. 20 Am. and Eng. Encl. Law, 2d ed.. 155. And the Supreme Court of the United States, in contracts upon the part of express companies wherein they have employed agents to travel upon the trains and a contract has been entered into by the express company and the agent relieving the railway company from damages while such agent is upon its trains, in a very elaborate opinion in the case of B. & O. S. W. vs. Voight, sustained the same contention and held such a clause to be valid and enforcible. It will then be readily observed that stipulations of railway company by which an attempt is made to escape liability as to negligence as carriers, are in a great many instances enforcible, but as to anything else the employe has a right to contract as to giving notice as well as other persons. Thus, it is not a duty of a common carrier to transport animals, and for this reason a railway makes a contract with a circus company as a private carrier instead of a common carrier, and fixes its own terms as a condition precedent of taking the animals at all. But it is otherwise as to freight which it is bound to receive of anyone that offers it. The carrier cannot dictate terms. Since a railway company is under no obliga tions to employ a certain man, the question of its duty to the public and, therefore, the question of public policy, cannot arise. Of course, the question of public policy would probably appear if a contract were to be made under which a railway company might injure employes with impunity. as the negligence which would result from this would also affect the safety of the traveling public and of the carrying of freight. But even in such cases it has been held by the courts that a contract of employment, by which the employe stipulates to hold the employer harmless in case of negligence, is valid. It must therefore be the result, if the provision that the employe, before bringing suit, shall give 30 days' notice of his intention, is valid in the instances cited, that such a provision in the application made before the employment of the serv ant, if made a part of his contract of employment, would be binding upon the employe, and the giving of such a notice upon the part of the employe would be a condition precedent to his right of recovery. I am fully of the opinion that such a clause in a contract would be as binding as the provisions in bills of lading requiring notice of loss and claim for loss before instituting suit, and such provisions have been generally upheld by the courts in freight as well as in other claim cases. The giving of notice as a condition precedent is also required in the transmission of messages by telegraph companies, and, it has been held, must be given within the date stated therein. As to whether or not the giving of this notice is in contravention of law or of any statute, the parties possessing all the necessary legal requirements, it must certainly be held good unless contrary to public policy. It is settled as a rule of law that the common carrier may relieve himself from the strict liability imposed upon him by the common law by a special contract. He cannot relieve himself from liability for his own negligence, but the notice contemplated does not attempt in any way to do this. I am unable to see how in any way such a condition precedent contravenes public policy. Such contracts are permissible, and have been upheld by the courts in all instances where they were not void on account of unreasonableness or want of consideration. It is in the nature of a regulation for the protection of the company or employer from fraud and imposition in the presentation, adjustment and payment of claims for damages, and the notice required is certainly reasonable, giving an opportunity, while the occurrence of the accident is fresh in the minds of all parties knowing about it, to ascertain the nature of the damage and its cause. I am fully of the opinion that such contracts can be enforced in court when they are not tainted with fraud and are fairly entered into by both parties. A traveling salesman, John C. Lilly, while on a train of the Pennsylvania Railroad going from Philadelphia to Washington, fell from a car platform, sustaining injuries from which he died three days later. He held an accident insurance policy which stipulated that $12,000 was to be paid if death resulted from a railroad accident and $5,000 if it resulted from other causes. The widow sued for $12,000 and a jury in the Kings County, New York, Supreme Court last week decided in her favor, thus classing a fall from a car platform as a railroad accident. During the month of June, 1903, the relief department of the Pennsylvania lines west of Pittsburg paid a total of $34,539.15 in benefits. Of this amount, $3,000 was paid on account of cases of accidental death, $10,250 on account of cases of natural death, $10,702.35 for accidental injury and $10,586.80 for cases of sickness. During the month of May, 1903, the relief department of the Baltimore & Ohio paid a total of $67,850.70 in benefits. Of this amount $25,000 was paid on account of cases of acci dental death; $10,054.77 for cases of accidental injury; $1,488.95 for surgical expenses; $14,991.35 for cases of natural sickness, and $16,315 for cases of natural death. VOL. X. A Nonthly Journal of Traumatic Surgery CHICAGO, AUGUST, 1903. A MODIFICATION OF EXISTING DRESSINGS FOR FRACTURE OF THE PATELLA.* BY C. FRITHIOF LARSON, B. SC., M. D., OF CRYSTAL FALLS, MICHIGAN. Ten years ago a man, who had been severely injured by falling down a mining shaft, came under my care; he had a fracture of the femur about 5 inches above the right knee, a fracture of the tibia and fibula on the left side, and also a fracture of two or three ribs. The man was very despondent over the gloomy prognosis of his case, as he fully expected to be laid up in bed three months, and incapacitated from work for an indefinite time longer. At that time it occurred to me that this case was certainly a good one to try massage in fractures. Accordingly, after a week I removed the dressings, at first every three days, and later on at shorter intervals, and gave the injured limbs massage, with the result that in six weeks. the patient was walking about with the assistance of a cane, and at the expiration of eight weeks started to do No. 3 We will, therefore, leave this procedure out of the question and consider what is to be done in a simple fracture of the patella, where the hope of a fairly good knee joint can be held out to the patient without surgical in tervention in the way of an operation. Shortly after the fractures there will be considerable swelling of the knee-joint and surrounding structure, due to extravasated blood and synovial fluid. This always interferes with the approximation of the fragments and must be gotten rid of, the sooner the better. The next light work. Since then I have always, when possible, thing must be to bring the fragments together and keep used massage in the treatment of fractures and with uniformly good results. When lately a man with a fracture of the patella came under my care I fully determined to use massage in the treatment of this fracture, in addition, of course, to keeping the fragments approximated and immobilized. A fracture of the patella is by all writers considered a serious occurrence. The prognosis as to ultimate result must always be guarded and the time the patient will be incapacitated for work is long. If we briefly consider the development and structure of the patella and the pathologic factors entering into a fracture of this bone, it may be apparent why the prognosis, as to ultimate result, should be guarded, and the time for recovery long. The patella is a sesamoid bone lodged in the tendon of the quadriceps extensor. Its blood supply is scanty, its nutrient arteries coming chiefly from the tendon surrounding it, and as the tendon itself is not a highly developed structure, so the sesamoid bone in its sheath is less developed than other bony structures in the body. The process of repair in injury is, therefore, slower than in other fractures. Then we have the powerful extensor muscle always tending to keep the fragments apart. them so. But I do not think we are justified in stopping here, thinking that all is well if the fragments are in bony contact, and leave them so until the repair has taken place; the joint in the meantime being kept immobilized, a stiffness of the joint is certain to be the result, which it will take many months to overcome, if at all. The dressings suggested for this fracture are manifold: in fact, so many that it plainly shows that the results from their uses have not been satisfactory. The title of my paper may be preposterous because in almost every writing that I have consulted soine new idea has been brought forward, and my access to the literature on this subject has indeed been very limited. There is no absolutely new feature in my dressing, only a combination, perhaps, of old ones. Let us briefly consider the dressings mostly in use. Malgaigne's hooks I have never seen used. There is one objection to them, they puncture the skin, hence strict asepsis must be carried out in their application and maintained during their use, if the consent of the patient to their use can be obtained. Then pads of felt and plaster of Paris are used pressing against the fragments and bringing them together, by means either of Malgaigne's hooks or strips of adhesive plaster placed above and below the knee cap and fastened on the under side of the In all fractures the first principle must be to get the fractured surfaces in as perfect approximation as possible leg after pulling the fragments together. As you are all and keep them so while the process of repair is going on. *Read at the tenth annual meeting C., M. & St. P. Ry, Surgical Association, Chicago, December 18 19, 1902. well acquainted with these different dressings I simply refer to them briefly. The most popular method is, undoubtedly, Agnew's splint and adhesive plaster dressings. Here strips of plaster overlapping each other are placed over and below the fragments; the strips above the kneejoint are fastened around a peg in the splint below the knee-joint and the strips from below the knee-joint are fastened to the peg in the splint above the knee-joint. By turning the pegs the strips are shortened and the fragments brought together. The objection to this dressing, in my opinion, is that it interferes with the circulation. and hence with repair, and if my idea of the massage in the treatment is carried out, a new dressing must be applied every time the joint is treated. I will now briefly describe the dressing and treatment applied by me in the case that recently came under my observation. On October 14, Andrew F, 25 years old, fell about 35 feet in a mine. In striking the bottom he sustained a simple fracture of the left patella, the bone breaking transversely in two near the middle. I saw the patient about twenty-four hours later, another physician having seen him in the meantime and applied a tempo1ary dressing. When I saw the patient the knee-joint was much distended and the fragments separated nearly I inch. His surroundings were very unsatisfactory for successful treatment, so I advised his removal to my hospital ward, which was done the next day, October 16. Here I suggested to him the advantage of wiring the fragments together, telling him also what to expect as a result of his injury. He refused to submit to any operation as long as there was hope of having a useful joint in any other way. ment. Be one-third of an inch space separating them, showing that the pressure within the joint must be less. The nurse had in the meantime prepared pads of gauze and plaster of Paris. Each piece of gauze was 4 inches wide by 7 long. Twelve of these pieces were laid on top of each other with a layer of plaster of Paris between each piece. In the middle a stout 3-inch roller bandage was placed with the ends in the middle so that a loop was slightly extending beyond the gauze at each end. A strip of galvanized tin1⁄2 inch wide by 5 long was also placed in the middle of the pad transversely to the roller bandage and with the free end extending about 3 inches. After being moistened the pad was now with firm and even pressure applied above the knee slightly overlapping the upper fragment, and held so until the plaster had hardened. A similar pad was prepared for the lower fragTwo strips of 2-inch adhesive plaster about 20 inches long were now fastened to the upper pad. ginning on the under side with the adhesive side toward the skin, the strips one on each side of the tin strip, completely circle the plaster-of-Paris pads before extending up the leg. Similar strips, only shorter, were applied to the lower pad. The tin strip was bent up over the pal and again doubled on itself, so as to form a hook. Four rings, one at each corner of the loop, were fastened to each pad. Four screw eyes, two on each side, were fastened to the splint, the two upper ones opposite the upper edge of the upper pad and the two lower ones opposite the lower edge of the lower pad. The dressing was now To overcome the distension of the joint a compression ready to be applied. The two strips of adhesive plaster bandage was applied to the knee. A stout posterior were carried up the leg and applied so that when the splint, well padded, reaching from the gluteal fold to 3 pad was in position against the fragment there was a inches above the heel was first applied and the fragments traction on the muscles and all tension tending to draw brought together as nearly as possible by means of two the fragment upwards was removed. The lower pad was strips of adhesive plaster 2 inches wide applied above and similarly applied. Here there is no muscular tension to below, slightly overlapping the fragments. These were overcome, but the adhesive strips prevent slipping and pulled tight and fastened crossing each other on the keep the pads firmly in place. With tape or stout strings under side of the splint. The nearest I could approximate passed through the rings and the screw eyes the pads are the fragments at this time was within 1⁄2 inch of each now held in place. The two rings farthest away from other. Wool cotton was now well pressed around the the joint and the strings passed through them tend to joint and a tight bandage applied over this. The splint keep the pads down and prevent tilting. By means of was firmly fastened to the leg with a roller bandage above rings nearest the joint we bring the fragments together. and below the knee. On removing this dressing the next For instance, the string is passed from the lower ring in day I was chagrined to find the swelling as bad as ever the upper pad to the screw eyes opposite-the lower edge and the fragments again separated, almost an inch. The of the lower pad. When this is done on both sides and following treatment and dressing was now carried out. traction made, the fragment is carried down and firmly held in place. After the pads are firmly pressed together and the strings tightened, the exposed part of the kneejoint is nicely padded with wool cotton and a bandage applied. Now as an additional means of safety a string is passed through the two hooks on top of the pad and tied firmly. Of course there is a roller bandage above and below the knee fastening the splints to the leg and firmly keeping the adhesive strips in place. The joint was thoroughly massaged to cause absorption and reduce the swelling. And here let me point out that in giving massage, the purpose in view must be the guide in the method employed. Many who prefer to give massage think it is only necessary to knead, rub, pinch or give tapotement to the structure under treatment. Given in a haphazard way massage may be potent for evil as well as good. The anatomy and physiology of the parts under treatment, as well as the pathologic condition present, must be well considered before the movements are applied. It must be clear to everyone that massage should not be given in the same way, if we intend to remove or cause absorption of a pathologic deposit or effusion, as if we wish to increase the nutrition in a wasted muscle. After the massage treatment I could bring the fragments together closer than before, about The further progress of the fracture may be briefly told. Every day the bandage at the joint was removed, the strings untied and the pads turned back on the leg. The whole joint was now free to inspection and massage treatment was persistently carried on throughout. In five days the swelling was so much reduced that new, better fitting pads had to be made and the fragments could be brought together. After this when the pads |