seem that the cast encircling the limb would render it much more stable and steady, and possibly secure it more definitely than would be the case if the fracture were manipulated without any support. I am glad to have heard this report, and shall avail myself of the suggestions it contained.

DR. F. G. NIFONG (Columbia, Mo.): I have run the risk of being considered a crank on one subject, and that is the open-wire-cradle type of splint. The doctor's exhibition here of the correction of fractures and the restoration of them especially emphasized certain things which this type of splint does, and his ingenious way of restoring the contour of the bone or the longitudinal continuity of it is very fine indeed. But why should we have all this massive plaster of Paris wrapped around the individual? He well says that the muscles contract, and it is difficult to keep up extension on account of this contraction, even when you have slight flexion, which we should always have, physiologic flexion so-called. Why do not we have an easy method that will keep up extension and counterextension under direct inspection? I think we have through the open-wire splint. This also exemplifies the value of frequent x-ray examinations, a thing that should always be done either in the open or closed method of treatment. The soft parts must be considered as well as the bone in these fractures, whether compounded or not. It is quite as essential. The conservation of these tissues must be considered.

One of the most important principles in the treatment of fractures of long bones, especially of the lower extremity, is extension. Of course, it goes without saying we have immobility, placing the part in absolute surgical rest, and all that. Extension is an indefinite factor. We do not know how much we get in these cases of fracture of the lower extremities in these patients. We do not know until we look and see, and can definitely measure in a Hodgen splint. Extension and inspection are easily obtained by the type of Hodgen splint with which so many of us are familiar. With the open-wire-cradle type of splint we get all the factors that make for immobility, for inspection, for x-ray examination, for general comfort, and for extension.

Why is extension so important? It is not the pressure we make on the soft parts here and there, although we can press the comminuted bone in place or place it at a different angle. That may be done also with the open splint, but extension acts in this way through the long bone, as the femur or humerus. We stretch with our Buck's extension,

plaster, or moleskin, the fascia lata. This is the big sheath which envelops and goes around the separate muscle groups and is attached to the linea aspera posteriorly. Imagine a sheath of canvas with two rings at either end and a stick put through the middle attached to a canvas septum representing the intermuscular septa, and let overlap in this way as this fascia lata would be in the thigh. If you make extension, this bone or this stick would fall back in its normal longitudinal position. That is the way extension works in plaster or any other device. It is through the stretching of the fascia lata, making enough extension to let the bone pull back in its place.

The fracture committee of the British Medical Association found 90 per cent were good physiological results in fractures of long bones that had normal contour. Normal contour is very important, and, if we attain normal contour and then in addition have an x-ray examination, we shall be pretty sure to get a functionally accurate result. That is one of the things that we can so well see in the open-wirecradle type of splint, like the Hodgen splint, because we can inspect both limbs to see if we have a normal contour, which means 90 per cent physiological results.

The character of the soft parts which I mentioned before is most important; and the circulation and the general care of the skin, even in simple fractures, are important. Of course, this pertains more particularly in compound fractures in connection with war wounds that have to be treated, and that is the reason the type of splint I have mentioned, which came from the Civil War, gave facility for drainage and care of wounds in conjunction with the fracture. It is no less important in a simple fracture. The comfort of the patient, the mobility of the patient in bed, the patient being able to sit up, and all that, although he does not get up and out in this splint, are very important factors. But we can hardly get this kind of patient up with any particularly good effect when both thighs are broken. However, this splint facilitates the comfort and well-being of the patient which are important factors in the repair of long bones.

DR. JOHN P. LORD (Omaha, Nebr.): I have lived through the history of the various methods of treatment of fractures. Some years ago we were too much inclined to introduce foreign material in the treatment of fractures, and we had too much infection; and then it was thought desirable to keep away from such methods, if possible.

In connection with the treatment of compound fractures, I fell in the way of using what I call the interrupted adjustable loop plaster splint that enables me to accomplish the same result that is accomplished by Dr. Harsha by his method. It enables one to leave the fractured area exposed, which is desirable in some simple fractures with much traumatism, for it is very desirable to have the parts where they can be watched, because often some of these simple fractures would ultimately become compound if not carefully guarded. This splint was therefore devised. Thumb-screws provide for lengthening or contracting the loop. This splint was made with an adjustable loop because many of these cases were compound fractures and required this sort of interruption. We were in the habit in those days of using bent strap iron or bent heavy telegraph wire for this purpose. There was an advantage in this. This principle is not new, but it does enable one to supervise the part directly and to accomplish readjustment in these cases about as Dr. Harsha cleverly accomplishes it by his method. This enables one to have considerable latitude in the adjustment and handling of fractures in their various forms, as your imagination will tell you.

I have found this device most useful in my experience in handling fractures of the leg especially.

DR. EMIL G. BECK (Chicago, Ill.): Dr. Harsha has shown us that by treating fractures without operation we can accomplish a great deal.

There is one phase of this subject to which I desire to call attention, and that is a false interpretation of the radiograph. I will illustrate with these two cigarettes on a shadow screen, so that you may see how easily we may mistake the position of the fractured bone ends when the röntgenogram is not stereoscopic, or taken in both directions. The stereoscopic picture gives us the dimensions and the angle at which the fractured portions are lying against one another. The single x-ray picture has misled many a surgeon to do unnecessary operations, because the displacement seemed very great, whereas, if the bones had been left in the position as they were, the result would have been better, without running the chance of infection.

Let this cigarette represent one bone (indicating). Now you note that when I change its angle it will show a shadow changed in size and form. If I take two cigarettes and put them at this inclined angle (indicating), their length diminishes. Supposing the two were lying against each other

in this way, you would get a straight shadow, but if you turn it, you can see what a different picture you would obtain.

I have used the stereoscopic method exclusively in all cases, and as soon as the fractured limb is put in the cast I immediately take another stereoröntgenogram to prove its correct position. If the bones are not in correct position, the cast is immediately taken off, and displacements corrected.

We have had many examples of the good results that can be obtained by non-operative treatment of fractures. We have had a young woman who, in the mountains of Colorado, was kicked off a horse. In this condition she was taken from Estes Park on a cot some eighteen miles to the nearest railroad station, and then from there put on a train for Chicago. She arrived with the leg materially shortened, and the fragments displaced. By traction we obtained a perfect result.

DR. HARSHA (Closing): I am very much obliged to the gentlemen for their remarks. I have not had experience with the wire splint that Dr. Nifong referred to, but I know it is a great advantage in having stereos. I tried to check this work up by having two x-ray pictures taken, one anteroposteriorly, and the other laterally; and I quite agree with Dr. Beck that the x-ray picture is misleading because you can get good contour and proper length, yet the x-ray may show a good deal of displacement when the functional result is really good.

I might say, in all these cases, except the femur case, which is not quite through, we have apparently obtained excellent results. One leg is almost perfect in its appearance, and the other one is still in extension but in good position.

FRACTURE OF THE SKULL, DIAGNOSIS, TREATMENT, AND END-RESULTS

W. D. HAINES, M.D., F.A.C.S.

CINCINNATI, OHIO

Surgery of the head prior to the work of Sir Victor Horsley, Keen, and others was a field of uncertainty, in which surgeons in the main did not vie with each other in expressing their zeal for this type of work owing to the disappointing results which so frequently followed surgical intervention for brain abscess, tumor, hemorrhage, and fracture. The incentive lent to the work by these pioneers has attracted numerous surgeons to this field, which today holds an established place in the art and science of surgery. Notwithstanding the enthusiastic assertion of a recently graduated war surgeon that "The entire subject of surgery must be rewritten," it remains our province for the present to apply such knowledge as we possess to the actual working conditions which confront us in our daily rounds in hospitals and industrial centers.

Personal adaptability and dead-room experience are invaluable in acquiring technic in this field, while frequent consultation with the neurological staff will increase accuracy in diagnosis, and the combination will make for the welfare of the patient, betterment of hospital records and advancement in the art of brain surgery. One must early learn, in dealing with skull fractures, that there is no rule of thumb applicable in this field and to recognize in a general and broader sense that each skull fracture will contain certain mechanical problems which are distinctive in their