apparatus the wheel-crutch, which was of much service in enabling him to regain the use of his limb. The first of May he again came to the city and spent two weeks in my house, during which massage and movements of the limb were cautiously employed, but the contraction was still very great and the abscess discharging somewhat. By the 10th of June "he began to walk a little without the wheelcrutch, went out riding every day, and could sit up straight in a chair." June 20th, his father writes, "Dick can walk up and down stairs without assistance;" and September 1, "His leg has healed up, his back has grown very strong and quite straight, and he is only the least particle lame. We can hardly realize that it is the same Dick. He still uses all of his swings regularly."

He continued to improve without further interruption. His father writes, May 16, 1877, "I wish very much that you could see Dick. He is now stronger than he ever was, in perfect health; his back entirely straight; never complains of the least pain, weakness, or soreness; takes the most violent exercise, and joins in the roughest kind of play. We were always very careful to follow out your instructions to the letter and to have him use his swings regularly."

This result I consider sufficiently bears out the statement with which this paper opened, that the case possesses an intrinsic interest as indicating the value of mechanical treatment, and especially, I may add, of suspension in spinal affections.

1503 SPRUCE STREET, PHILADELPHIA, June 11, 1877.

FRACTURE IN THE UPPER THIRD OF THE ULNA, ACCOMPANIED BY DISLOCATION FORWARD OF THE HEAD OF THE RADIUS.

BY OSCAR H. ALLIS, M.D.,

SURGEON TO THE PRESBYTERIAN HOSPITAL.

THERE is an injury of the elbow-joint that I am forced to believe is frequent from the fact that I have, in quite a brief space of time, observed it in two recent cases, and in four others where it had escaped notice at the time of the injury, and had passed beyond surgical repair. The injury to which I allude is a dislocation of the head of the radius, resulting from a fracture in the upper third of the ulna. As this injury is the result of an unusual force—and must theoretically if not practically always follow fracture of the ulna in the upper third—I shall direct special attention to it at this time.

First, let me allude to the manner in which the ordinary injuries of the elbow-joint occur.

Let a person fall forward upon the hands. In this instance the force is conveyed to the joint mainly through the radius (see Fig. 1, arrow); and as this force acts directly, and squarely through the cupped head of the bone accurately adjusted to the outer condyle, a dislocation is not likely to result. If any injury follows, it will probably be a fracture, at or below the elbow or in the clavicle.

In these two diagrams the ulna is not represented in order to more clearly illustrate my point.

Again, when the arm is bent (at right angles) and the vulnerating force takes the direction of the radius (see arrow, Fig. 2), we have

still the strong probability left, that fracture (somewhere in the line of the radius) will follow, rather than a dislocation at this articulation. But, when the force takes a direction at right angles to the radius, as when we fall upon the bent arm or elbow (Fig. 3, arrow), then it will be noticed that the head of the radius does not offer any material protection to the joint (for its head is at right angles to the articulation, Fig. 3), and the whole force of the injury explodes upon the ulna, and if this breaks (Fig. 4) the unexpended force will drive the head of the radius forward.

I call, then, special attention to this point; viz., that when a fracture in the upper third of the ulna is present, always look for a forward dislocation of the head of the radius.

Even if there is great swelling at the time of the first visit, a fracture in the upper third of the ulna can be detected, though with inordinate swelling it would be very difficult to detect positively the malposition of the head of the radius.

The first and only procedure in such a case is to promptly allay the inflammation by quiet, anodynes, loose dressings, with the arm in a position to favor rapid subsidence of effused fluids. In a week or ten days (the time of course varying with the degree of the swelling) this can be effected, and an accurate diagnosis made. If there is not much swelling at the time of the first visit, the only positive diagnostic feature is the absence of the head of the radius from the outer articular surface of the humerus.

I saw both the cases above referred to within twenty-four hours of the reception of the injury. There was no unusual swelling, and the diagnosis was made out on finding the head of the radius absent from its natural articular situation.

It was easily restored; and to satisfy myself that there had been no mistake, I redislocated it, which I found was so readily done that I had some fear that it would not remain in its normal situation during repair.

In case the head of the bone is not properly restored it is some consolation to know that the usual motions of the forearm, flexion, pronation, and supination, will not be materially interfered with; but when an attempt is made, after the cure is complete, to bend the forearm upon the arm beyond a right angle, the head of the radius will offer a barrier (Fig. 4), and this may be regarded as diagnostic, viz., that in old anterior dislocations of the radius the forearm cannot be bent upon the arm much if any beyond the right angle. In this, as in most surgical operations, the patient has a witness more eloquent than his tongue against his doctor.

Little can be said in regard to treatment, nothing in fact dogmatically. Every fracture should be a distinct study and merit special attention. That position and that dressing that will bring good results is the proper one. One thing only I will say-if you find the extended position the best, use it without fear of anchylosis. I bent the arm in both cases at a right angle. Then, to obviate a tendency to displacement, I placed a compress of cotton in the bend of the arm, and over this, the arm and forearm, applied a starch dressing. This was removed in the fifth week, and with the happiest results. Passive motion should not be instituted earlier than in the fourth week, and not then if the swelling is great and the joint sore.

1328 SPRUCE STREET, PHILADELPHIA.

URETHRAL FISTULA,

TREATED BY MEANS OF THE ELASTIC LIGATURE.

BY JOHN H. PACKARD, M.D.,

OF PHILADELPHIA.

MR. PRESIDENT:

I BEG to occupy the time of the Society for a few moments with an account of a case in which a very difficult condition of things was remedied by the employment of a method which, although not old, has been already somewhat extensively used, but which, in this application, I believe to be new.

The lesion was a perineal fistula at the peno-scrotal angle; the remedy was the elastic ligature.

The patient, Edward B., was a boy 14 years of age, stunted, small, and delicate looking, who had had urinary trouble for seven years. Neither he nor his friends could give any accurate history of his case; but on his admission to the Episcopal Hospital, Oct. 7, 1876, he had some narrowing of the urethral canal, and three fistulous openings communicating with it. One, at the peno-scrotal angle, had existed ever since an attack of sickness when he was about seven years of age. The other two were situated, one on either side, about half way between the anus and the tuber ischii, and were said to have been first noticed in the autumn of 1875.

There was no history of injury so far as known.

Until within the last year he had been unable to control the evacuations from his bladder, day or night; and his clothes had been constantly saturated with urine. He now, by passing water frequently, could avoid this. The stream was of fair size. The urine was loaded with a heavy yellow deposit, consisting of pus, mucus, and vesical epithelium, with some black granular amorphous matter, probably broken-down blood.

Latterly there had been some dribbling of urine from the left perineal opening.

Oct. 10, 1876. He was etherized, and perineal section performed on a small staff. In introducing the staff a slight roughness was felt, as of a calcareous deposit. A free incision was made in the median line. Probes introduced at the fistulous orifices were