daily; but my experience showed me soon that even that small dose not unfrequently caused salivation in the course of a month or so of daily treatment. I have, therefore, thought it advisable to give a smaller dose than two-thirds of a grain of the proto-iodide of mercury daily, and have, therefore, given latterly one-sixth of a grain of that salt in combination with two grains of extract of henbane in a pill, twice daily, to these young female patients. This dose seems to be well tolerated, and not to produce salivation, even when continued for months. I have given it, with occasional interruptions, for twelve months, without any clear symptoms of mercurial poisoning appearing. Under this treatment, the disease goes on in general in a favorable manner. For the most part, the secondary eruptions are benignant, accompanied, occasionally, by slight alopecia and mucous tubercles, which latter symptoms are amenable to local treatment by means of chlorine lotions and isolation. Iritis has occurred about as often as when I did not use mercury, and has usually been very amenable to belladonna and blisters. One or two cases of rupia have occurred, but have, with one exception, done well. No severe cases of sore throat have been seen. There have been cases of apparent rectal syphilis which have proved obstinate, and in one case the prognosis was bad. As far as I have followed the patients, there have been but few cases of tertiary disease seen; but I am fully aware that it is impossible to foretell when such symptoms may arise, since syphilis arises after twenty years. I conclude 1. The initial lesion requires no mercury. 2. Syphilis, when iodine is used without mercury, is usually mild. 3. Syphilis, when treated with very small doses of iodide of mercury, is usually mild. 4. Iritis supervenes whilst patients are taking courses of mercury, and is usually amenable to blisters and atropine. 5. Tertiary syphilis is rare after iodide of potassium and iodide of mercury. 6. It is best treated by large doses of iodide of potassium, adding mercury when that remedy fails. 7. Cerebro-spinal syphilis supervenes in some cases early in the disease, and we may then give both specifics, or iodide of potassium alone, which holds good also in syphilis of the testis, liver, or lung. 8. Mercury and iodine probably act by their power of destroying the low vegetable organism in the tissues-the yeast of syphilis (Hutchinson). 9. The dose of mercury ought to be very small. TREATMENT OF FRACTURES OF LONG BONES INVOLVING JOINTS. BY JAMES S. GREEN, M D., NEW JERSEY. DURING the winter of 1875 and 1876, it was my privilege to follow closely the private and clinical practice of Professor Lewis A. Sayre, and during that time and afterwards, had the opportunity of witnessing him perform a number of operations for fibrous anchylosis of the knee and hip-joints, from which experience I gathered the principle, which I afterwards applied in the treatment of fractures involving joints. The joints to which I applied this treatment were the elbow and ankle-joints, being the articulations which have suffered more frequently than any other joints from injury, and the mode of treatment laid down in the principal works on surgery with the exception perhaps of the radio-carpal articulation. During the first years of my surgical practice I had, on more than one occasion, realized the truth that the most careful application of the following direction laid down in the text-books for the treatment of a fracture involving the elbow-joint, yielded me an imperfect result. "Bend the forearm at a right angle to the arm, draw it forward until the parts be brought into their proper places, and into apposition, and preserve them in this condition by applying a few turns of roller round the lower part of the arm and upper part of the forearm. An angular splint is then to be applied behind the arm or forearm of wood, leather, or gutta percha, with a smaller straight one in front, fastened by a bandage lightly applied; with evaporating lotions and other antiphlogistic measures to be used as the case demands." "Passive motion is to be commenced in two or three weeks, according to the age of the patient." Notwithstanding my strict observation of the rules above given, and passive motion being commenced within six days, in a case of fracture of both condyles of the humerus, my experience is best expressed in the words of Mr. Wm. H. Flower1 in his article "On Injuries of the Upper Extremity." "The remaining fractures of the lower end of the humerus are of a more serious character, as they are necessarily attended with more or less inflammation of the joint, and are consequently almost always followed by some permanent impairment of the movements of the elbow." Strange as it may seem, and it has appeared passing strange to me, in the standard works on surgery no means have been recommended that will prevent this almost certain "traumatic synovitis," and its consequences of "some permanent impairment in the movements of the elbow." Dr. Sayre's treatment of the joints upon which he had used "brisement force," had so invariably prevented subsequent traumatic synovitis, that I determined to apply it to the first case of fracture involving the elbow-joint which came under my care. But before detailing the cases in which the principle involved was successfully used, I will quote from Dr. Sayre's work on "Orthopaedic Surgery and Diseases of Joints," in which he states the principle alluded to above (page 215). In speaking of the dressing of a knee-joint after "brisement force,” in January, 1854, he writes: "A tight roller was applied from the toes up to near the knee; a large sponge placed in the popliteal space, and strips of adhesive plaster were applied over the sponge and drawn tightly around the joint from the bandage below the knee to some six inches above it. The roller was then continued over the plaster snugly applied to the whole thigh. A piece of sponge about two inches in length and about the size of the forefinger, having been placed over the track of the femoral artery-as is my usual custom in this operationthe roller was carefully applied to cause partial occlusion of the calibre of the artery, and thus diminish the supply of blood to the joint without being so tight as to induce its complete strangulation." "I wish to call especial attention to the principle involved in the dressing in this case, as I think it of cardinal importance, having witnessed its practical benefit in many serious operations. I mean the pressure on the main trunk of an artery leading to any part in danger of inflammation in such 1 Holmes's System of Surgery, vol. ii. p. 544. manner as to diminish the supply of blood, to prevent inflammation by partial starvation. Great caution is of course necessary not to produce gangrene, but little practice and close observation will soon give the necessary tact of knowing how to use pressure without abusing it." In following out this plan in the treatment of fractures involv. ing joints, I determined to incase the whole limb, from its lower extremities to a point at least six inches above the joint involved, in a snugly-fitting plaster-of-Paris bandage (provided the case of fracture was seen before swelling occurred), believing that the plaster bandage properly applied would prevent the swelling in the joint, and influx of blood to the part in sufficient quantity to allow a traumatic synovitis to be set up. CASE I.--On the 26th of June, 1876, the first opportunity presented itself in the person of H. H. I., aged twelve years, who, falling from a high fence, produced a T-shaped fracture of the humerus and a dislocation of the forearm backward. I saw the patient within an hour of the accident, and, having fully anesthetized him, was able to reduce the dislocation and place the bones in perfect apposition. The arm and forearm were fixed at a right angle, and a snug-fitting plaster-of-Paris bandage was applied to the limb, from the fingers to the axilla. This dressing was watched carefully for the first five days, and as there were no indications requiring its removal, it was allowed to remain until the morning of the sixth day, when the mould was cut down along the front of the arm, and the cast carefully removed for the inspection and passive motion of the joint. To my great pleasure I found that the treatment had prevented traumatic synovitis, that the fragments were in proper position, and having moved the joints carefully I returned the arm to the splint. The cast was removed, and passive motion used daily for four weeks, when union was complete and the joint perfect in form and motion. CASE II.-May 25, 1877, C. K., aged fourteen years, fell from a tree, fracturing the external condyle of the humerus, with displacement of the head of the radius. Saw patient immediately after the accident. The same treatment was followed by a perfect result, as in the former case. CASE III.-November 15, 1877. G. K., aged twelve years, fell from the back part of a wagon while in motion, and fractured both condyles of the left humerus, dislocating the forearm |