Position and cast as applied by the authors for all fractures, injuries, and diseases of the elbow-joint.

acutely flexed, or a suspension of the flexed arm in a "Thomas wrist-halter," etc. After the surgeon has de

cided this point, then comes the question of mobilization. Some advocate passive motion early-very early, even before ten days; some in ten days; some in two weeks, three weeks, four weeks, six weeks; and we who have thirty cases to report advise no passive motion at all.

Not one of the cases here reported.

Shows the condition of an arm dressed at a right angle for a fracture of the lower end of the humerus.

I. A fragment of the external condyle displaced inward to the front of the elbow, and locking the joint at the angle shown.

II.-Location of the olecranon fossa, which seems to be obliterated by callus.

Our first case was seen in the country, where we found a boy with the following history: May 2, 1891, Harry Robinson, 10 years old, was thrown from a horse,

and sustained a compound comminuted fracture of the lower end of the 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 obliged, much against our will, to dress the arm in this way, using plaster-of-Paris, and extending it from the fingers to the arm-pit (Fig. 1), with the fore-arm 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 re-applied 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 in 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 that we have treated in this way, results are always considered relatively, for it is not easy to follow up the cases, and get an exact report of the present condition.

Nor will we discuss in this paper the position of the parts, or the muscular action on the fragments in the various fractures, as this ground has been thrashed over again and again with no conclusions; but we 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.

CASES

1. May 2, 1891.-Harry Robinson, 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.

2. April 27, 1892.-Willie Thurston, 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.

3. July 2, 1892.-C. W. Hughes, 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.

4. Sept. 16, 1892.-Willie Coleman, 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.

5. October 29, 1892.-Same boy, supracondylar 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.

6. Feb. 23, 1893.-Herbert Cram, 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 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.

7. July 8, 1893.-Frank Glennon, II 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 afterwards.

8. July 12, 1894.-Harry Bock, 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.

9. July 14, 1894.-Dolly Helmle, 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.

10. Nov. 28, 1894.—Clarence Holmes, 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.

11. April 6, 1895.-Arthur Turner, 13 years old, by falling down stairs 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. 12. Sept. 5, 1896.-Same boy, sustained a fracture through neck of right radius.

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

13. Aug. 30, 1897.-Grace Schulz, 4 years old, by a fall fractured the left ulna near the elbow.

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