method takes only a few minutes, accomplishes more than a gastro-enterostomy, and I consider it the method of choice. As to plication of the stomach: I am not in favor of that type of surgery. In the so-called shoe-horn type of stomach, which is narrow and dips away down into the pelvis,—such a stomach will empty in from three to four hours. A stomach in which the greater curvature is close to the lesser curvature is the ideal stomach, and will always empty in normal or less than normal time. The stomach in which the greater curvature is widely separated from the lesser curvature is the one that empties very slowly, and in extreme cases where severe symptoms persist, such as vomiting, in spite of all treatment, a plication may be indicated. I have operated in two such cases by removing an oval-shaped piece of the muscularis from the anterior and posterior wall of the stomach, the incisions running parallel with the greater and lesser curvature. The mucosa was not molested in any way, and the free edges of the muscularis were united by a Lembert suture. This procedure converted a much dilated stomach into a narrow shoe-horn shaped stomach, which functioned perfectly, and all symptoms ceased.

DR. SCHWYZER (closing): I am very glad that I did not get more severely criticized for bringing the subject of plication before you. The operation I have described is intended only for some of the extreme cases when we feel that the stomach really sags too much, and we would like to do something to counteract it.

Dr. Haines discussed the question of suture in gastroenterostomy, and he mentioned that it is important to go with the outer suture far beyond the gastro-enterostomy on both sides. However, if we introduce the sutures in the way I described, we do not go much beyond on the efferent side, and we do not get the folds that otherwise are likely to kink the outlet. That is the principal point I wanted to make.

THE CORRECTION OF FRACTURES AFTER

APPLICATION OF PLASTER CASTS

WILLIAM M. HARSHA, M.D., F.A.C.S.

CHICAGO, ILLINOIS

It seems to me the treatment of fractures with plaster casts has gone very largely into the discard in the last few years. The reason for it is, that probably with the introduction of more accurate methods of approximating fractures with bone plates, wires, pegs, etc., surgeons have paid less attention to the closed method in applying mechanical principles and in seeking for all the devices we have had for the treatment of fractures before operative measures were introduced.

I have not had a large experience in operating for fractures. I have done a moderate number of operations. I have seen a good many fractures treated by different methods, including the use of the Lane plate by Mr. Lane; but in the past year or two the experience and observations I have had have led me to think that in too many cases of fractures we have operated. Of course, we have to admit that there is a need and a place for the operative treatment of fractures. There are cases of ununited fracture in which we have to operate in one way or another. There are other cases in which with our best efforts we are unable to get such an approximation as we would like, so that there will always be a place for the open method of treatment; but my contention is, that the cases of fracture that will not yield to some form of mechanical device in treatment are few.

The cases that I wish to show you are some that have come under my care in the last two or three months in my surgical service at St. Luke's Hospital. I am going to show you some pictures and try to explain them as we go along.

CASE 1.-The first case I show you is a man, aged 40, who was run over by a heavy auto truck, the wheels passing over both thighs producing comminuted fractures of both femurs, involving the middle and lower thirds. This (showing slide) shows the method we employed in putting him up in plaster. (Plate 1.) The Hawley table is a distinct aid to us in getting extension and counter-extension. You will see that these arms are supported by this device which counter-extends at the crotch. There are two arms, one goes to either side, and they suspend the legs at the knees. The plates I show you will enable you to see the involved sites very well, above, or at about the junction of the middle with the upper third, and from that point almost to the knee-joint, as you will see by the x-ray plates. It was out of the question, it seems to me, to plate a fracture of that kind. This man was in profound shock. There was no compound fracture, but both thighs were smashed, so that if you lifted them up you could feel the bones rattle around. We put him up on a Hawley table, with extension on each leg, under the influence of ether, which would permit the handling of the patient in a satisfactory way. We put a cast almost up to the ribs; at any rate, it was well above the hips.

There is one point I should mention in connection with supporting the thighs. Unless you have a great deal of extension upon each leg, with two, three, or four pieces of bone in here (indicating), before the cast gets dry this part will sag unless there is support under the thigh. I have an assistant hold this up (indicating) while the plaster is setting, one on either

side, because at this stage, when it is ready to dry, without that support it would probably sag.

This (showing slide-Plate II) is an anteroposterior view of the left thigh before it was put up in a cast, and the next slide (Plate III) shows you an anteroposterior view after the plaster cast was put on. The next slide gives you a lateral view of the same leg with cast applied. (Plate IV.) The next plate shows a lateral view after cutting and slightly bending the cast. (Plate V.)

Here I want to illustrate the method of making better apposition of these fragments without taking the cast off. If you take the cast off and put it on again, you cannot be sure of a better result at the next trial; with the cast on you have the fragments fixed, and can bend the cast where it is needed. You will see a difference in the alignment and a difference in the tilting of the lower fragments.

The method of correction consists in making a clean circular cut three-quarters of the way around the cast on the concave side. This point here (indicating) is separated from this point. After it is cut three-quarters of the way around I leave enough of the cast to make it fairly firm. That would bend there, but we did not bend it far enough so that it would break. You notice the difference in alignment. This patient has a fine functional result. He entered the hospital on the 9th of October last. This slide shows an anteroposterior view of the right thigh. (Plate VI.) That is the way it looked before it was put up, showing two pieces of bone in the middle. portion. Here is a lateral view (Plate VII) and the other is an anteroposterior view after it was put in the cast. (Plate VIII.)

When should we put a cast on a limb after it has been fractured? In the first place, after a subsidence of the swelling the limb is reduced in size, may be 15

per cent. You also know that after a limb has been up in plaster for a week or two it shrinks nearly 10 per cent from disuse, and then the cast does not fit.

It

In putting this up originally with the Hawley table, I relied on the grasp of the cast, the flexion of the legs at the knees, and the body cast supported by the hips for my extension and counter-extension. worked perfectly on the left side, as the measurements of the leg showed in three weeks. It did not work perfectly on the right side.

When the cast was applied there was a great deal of swelling. In three weeks the swelling subsided, and there was the usual shrinkage of the limb from disuse. The cast, together with the flexion at the knee, did not prevent displacement. The pain increased, which is always an indication that there is mobility or displacement.

We cut away the anterior half of the cast longitudinally up to the hip, applied extension with adhesive plaster, padded the sides of the limb, and reapplied the plaster cast, including the under or posterior half that was left. The leg now shows but half inch shorter than its fellow, and union is taking place, the extension (fifteen pounds) being discontinued.

In a simple fracture with little swelling the cast, plus flexion at the knee, will hold the fragments in position. It may be better in all such cases, however, to provide for extension with moleskin plaster to be used if needed.

CASE 2. This patient is a man, 65 years of age, who entered the hospital about the first part of November. (Plate IX.) He was knocked down by an auto, and sustained a fracture at the surgical neck of the huThis is the photograph after the application of the cast. (Plate X.) It shows the method by which it was put up. This is not new, but I find few surgeons are using it at the present time. I have