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..245 Pharmacodynamics..

Microscopy...
Microbes, alarming prevalence of............ .444 Phantom tumor......
Midwifery, practice and legislation.... 94
Middle ear, purulent disease of............484
Mineral waters............

Morphia in uræmic convulsions....
Morbus morbo...

Mortality in the medical profession.
Moral responsibility..

Mountain and sea air............

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Phases of Eclectic medicine............
Phosphorus or fish............

30 Physio-medicalism in Cincinnati...
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.146 Physicians and the liquor question.......... 99
547 Physiological action of hydrastis...............265
219 Pilocarpin in acute alcoholism.................485
.580 Pleasant experiences.

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Salicine causing deafness.

Salicylate of soda......

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.........134 Syphilis, incubation of.........

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51 Syphilis, when constitutional..................... 34

Santonine in amenorrhoea....................................... .217 Syzygirum jambolanum for diabetes......... 87
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Theory, induction and accident............... 18
Therapeuttes of bitter medicines...............385
Therapeutics of diseases of the skin..........313
Thomsen's disease..............................................................582
Tinea capitis..............................................516
Tit for tat............ ............ ......................... 83

Tonga.........

Serpent for fish..........................................................................................................................587 Tonic, female.............................................502
Serous synovitis...
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Sewerage and sewage........................................... ............143
Seventy-seven cases of tracheotomy.
Sexual education..................................

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Sponge and skin grafting.
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State boards of medical examiners.............275 Uterus, removal off.................................. 201
Stigmata maidis in vesical catarrh.............52g Uterus, rupture of.....................................288

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Why does a man commit suicide..............544
..............173 Wine versus water........................................................549

Sympathy with irregular practitioners......284 Yellow fever, treatment of.......................... 29

THE

ECLECTIC MEDICAL JOURNAL.

VOL. XLVI.

JANUARY, 1886.

No. 1.

Art. 1.-Fractures in the Vicinity of the Elbow. By A. J. HOWE, M. D.

Fractures of the shaft of a bone are readily recognized, for the signs are distinct and pronounced; but fractures near the joints present distorted features which may be mistaken for those of dislocation, or for lesions of a mixed or complicated nature, as luxation and fracture in the same injury. In my earlier experiences I was bothered exceedingly, and vexed to the extremes of grace, when an injured elbow was presented for diagnosis and treatment. In diagnosticating the lesion I paid too much attention to the front aspect of the limb, and not enough to the posterior presentment After looking at the general contour of the arm, I flex the fore-arm and throw the elbow away from the thorax, thus bringing the olecranon and the condyles under easy inspection; then I begin to discriminate between the several lesions common to the joint and structares entering or influencing the articulation. As a preliminary consideration, the age of the patient is passed upon. A young subject is extremely liable to the separation of an epiphysis-diastasis. A patient beyond twenty years of age has lost the cartilaginous layer between the shaft and the epiphysis, hence a real fracture takes the place of diastasis. At first I look for fracture of the olecranon.-not that it is a common injury, but I wish to cast the lesion out of the diagnostic problem. Sliding the fingers over the olecranon and the upper half of the ulna, and finding extremity and shaft continuous, fracture of the olecranon process is excluded. Next taking hold of the shaft of the humerus a little above the joint with one hand, and of the upper part of the fore arm with the other hand, make back and forward movements to test the integrity of the humerus at the epiphyseal line and thereabout. If the injury be in an adult and a fracture exist, the separation is usually a little above the epiphyseal line. If there exist no fracture or diastasis of the lower end of the humerus, that lesion is excluded. VOL. XLVI-1

Now examine one of the condyles, then the other, expecting crepitation, mobility of a condyle, and ability to twist the joint into awkward attitudes. The pain elicited by such forced movements is to be estimated. Indent swollen parts with the fingers in order to feel the bones in the manipulating processes. If fracture of either condyle be not made out by either of these methods, then such a lesion is to be excluded. However, it is not to be forgotten that fracture or diastasis of the epitrochlea is a possible lesion, and is quite deceptive in its symptoms. It is to be diagnosticated by exclusion, and by making the separated fragment rock and crepitate on its base.

Dislocation of the radius and ulna backwards is possible, though the injury is apt to involve a fracture of the coronoid process of the ulna; and luxation of the head of the radius from the external trochlea is not uncommon. It will be seen, then, that several distinct lesions of structures entering the elbow are to be carefully considered. Some writers depict and describe fracture of the neck of the radius, but they are likely to be deceived in that respect. When I had enjoyed only limited experience in the diagnostication of fractures, I imagined I had encountered several cases of fracture of the neck of the radius, but am now satisfied I met only one such case. My old cases of fracture of the head and neck of the radius were probably fracture of a condyle of the humerus. Fracture of the coronoid process is not absolutely rare, yet uncommon. The action of the brachialis anticus muscle could never sever the process, for it is inserted at its base, and exerts no displacing force.

Fracture of both condyles of the humerus in a single injury is an occurrence to be suspected in lesions of the elbow. In such a complex event the wedge shaped joint of the shaft of the humerus is forced between the radius and ulna, making the joint altogether too wide.

Anatomically described, the condyles of the humerus terminate at their bases, without embracing articular surface; but, while. surgically considering fractures of the condyles, joint-surface is not to be excluded. In other words, fracture of a humeral condyle means invasion of the articular surfaces rested upon by radius or ulna. Hence, in the healing process osseous material is deposited in the joint, and restrains motion like a nail in a hinge.

One of the dangers of fracture into the elbow joint is a sequential anchylosis, hence the peril is to be spoken of in the presence of friends that damage be not claimed for professional ignorance or negligence. I do not admit much blame on the part of the surgeon for a stiff elbow, unless he has dressed the limb in an extended attitude, thus depriving it of all usefulness. The method of treatment I am about to advise, calls for extreme flexion of the arm during the healing process, or for four weeks. Afterwards passive motion is to be kept up daily till a useful sweep of motion can be secured.

It has been very common for parties coming out of treatment with anchylosis at the elbow, to sue in the courts for an award of damages; and under some circumstances there have been valid reasons for asking recompense. An acquaintance of mine had his arm dressed in a straight

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