302 CALIFORNIA AND WESTERN MEDICINE Vol. 41, No. 5

dose is increased by 0.05 cc. When a dosage of1 cc. has been reached, treatment with dilutionNo. 2 is started with 0.1 cc., increasing thedosage as before.

In both the intravenous and subcutaneousmethods the interval between doses should befour to five days.A large part of success in vaccine therapy

depends on the persistence with which it is prose-cuted. As a rule, very little benefit can be ex-pected during the first two or three months oftreatment. The injections should therefore becontinued for at least three to four months. Ifimprovement occurs, the treatment is continued.If no improvement occurs, streptococcus vaccina-tion is either discontinued entirely or some newform of vaccine therapy is substituted.Typhoid Vaccines.-In patients who are run-

ning a fever and who have actively inflamedjoints, a series of foreign protein reactions withtyphoid vaccine sometimes works wonderfullywell. In our clinic we start with 50 to 100 milliontyphoid bacilli intravenously, and repeat the in-jection every two to three days until the patienthas had six to eight reactions. If some care istaken in the selection of patients for this form oftherapy, no untoward results will be encountered.The obvious counterindications are old age, weakheart and a history of pulmonary tuberculosis.

Orthopedic Measures.-So far I have saidnothing about orthopedic measures in the treat-ment of rheumatoid arthritis. Orthopedic treat-ment is most important in spondylitis of theMarie-Striimpell type, and in arthritis of the hipand knee. Deformities or ankyloses in any ofthese localities lead to great discomfort on thepart of the patient. For spondylitis, exercisesand some sort of brace or corset are indicated toprevent the extreme kyphosis which often de-velops in these patients as the disease advances.Various orthopedic devices are in use to preventcontractures of the hips, knees and elbows.Drug Therapy.-The drug treatment of arthritis

can be quickly covered. Arsenic in the form ofthe cacodylates or salvarsan is a splendid tonic,and seems to work particularly well in arthriticpatients. Personally I have been disappointed inthe results obtained from the various forms ofsulphur. My experience with the gold salts hasbeen too limited to permit of an opinion, butcertainly the results reported from France andEngland are very encouraging.

IN CONCLUSION

We physicians often speak with frank skepti-cism concerning the various measures employedin the treatment of rheumatoid arthritis, but isn'tthis skepticism due to the fact that too often wehave to treat arthritics in the advanced stages,after the disease has been neglected either by thepatient or by some other physician who took nointerest in the patient's condition? I must confessthat I dislike to treat advanced cases of rheuma-toid arthritis, because I know that comparativelylittle can be done to cure them. I feel quite dif-

ferently, however, about incipient cases. I takeconsiderable satisfaction in attacking early casesof rheumatoid arthritis and watching the patientimprove under the effects of therapy. In otherwords, the situation is not different in arthritisfrom that in tuberculosis or syphilis. The earlycases yield well to treatment. The advanced casesare extremely stubborn. No doubt, as time passesand physicians become more familiar with modernmethods of treatment, advanced cases of rheu-matoid arthritis will not be so numerous, andthere will be fewer invalid chairs in our poor-houses.

33 East Sixty-first Street.

REFERENCES1. Allison, N., and Ghormley, R. K.: Diagnosis in

Joint Disease, p. 139, New York, William Wood & Co.,1931.

2. Rountree, L. G., Adson, A. W., and Hench, P. S.:Preliminary Results of Resection of Sympathetic Gan-glia and Trunks in Seventeen Cases of Chronic "In-fectious" Arthritis, Ann. Int. Med., 4:447 (Nov.), 1930.

3. Fletcher, A. A., and Graham, D.: The LargeBowel in Chronic Arthritis, Am. J. M. Sc., 179:31(Jan.), 1930.

4. Pemberton, R., and Peirce, E. G.: Relation of theIntestinal Tract and Diet in the Treatment of Arthri-tis, Ann. Int. Med., 5:1221 (April), 1932.

5. Richards, J. H.: Bacteriologic Studies on ChronicArthritis and Chorea, J. Bact., 5:511, 1920.

6. Burbank R., and Hadjopoulos, L. G.: SerologicSignificance of Streptococci in Arthritis and AlliedConditions, J. A. M. A., 84:637 (Feb. 28), 1925.

7. Dawson, M. H., Olmstead, M., and Boots, R. H.:Bacteriologic Investigations on the Blood, SynovialFluid and Subcutaneous Nodules in Rheumatoid(Chronic Infectious) Arthritis, Arch. Int. Med., 49:173(Feb.), 1932.

8. Cecil, R. L., Nicholls, E. E., and Stainsby, W. J.:Bacteriology of the Blood and Joints in Chronic In-fectious Arthritis, Arch. Int. Med., 43:571 (May), 1929.

9. Snyder, R. G., and Fineman, S.: A Clinical andRoentgenologic Study of High Colonic Irrigations asUsed in the Therapy of Subacute and Chronic Arthri-tis, Proc. Am. Roentgen Ray Soc., 17:27 (Jan.), 1927.

10. Forestier, Jacques: The Treatment of Rheuma-toid Arthritis with Gold Salts Injections, Lancet, p.441 (Feb. 27), 1932.

11. Slot, G., and Deville, P. M.: Treatment of Arth-ritis and Rheumatism with Gold, Lancet, p. 73 (Jan.13), 1934.

TREATMENT OF FRACTURES-BY THEBOHLER METHODS*

By RALPH KAYSEN, M. D.San Diego

DISCUSSION by Maynard C. Harding, M. D., San Diego;Fraser L. Macpherson, M.D., San Diego; Sterling Bun-nell, M. D., San Francisco.

IN the past few years, increasing major injuriesconsequent upon automobile and industrial acci-

dents have renewed interest in the treatment ofthe frequent fractures occurring as complications.Volumes have recently been written on treatment,apparatus and technique relating to fractures.Lorenz B6hler of Vienna has been credited withhaving pioneered in many of the more radical pro-cedures which are rapidly becoming universallyrecognized in competent fracture treatment.*Read before the San Diego County Medical Society on

April 10, 1934.

TREATMENT OF FRACTURES-KAYSEN

THE BOHLER CLINIC AT VIENNA

The writer has recently had the opportunity ofspending ten months with B6hler at his hospital.During this time he proved very cordial, and pre-sented the freedom of his clinic, his staff, and hisassociates. Attendance at operations, ward walks,staff conferences, and practical participation formthe basis for remarks herewith presented.

His clinic is the Mecca for men from all coun-tries, there being an average gallery of fromtwenty to thirty visiting surgeons. His reputationwith these visitors is that of being somewhat di-dactic and difficult to approach. He explained thatthis reputation was the result of his having beendisappointed by the large majority of his visitorsspending so short a time writh him that they wereunable to grasp the full import of his techniqueand principles.He does not claim originality for his methods.

Having selected certain principles which havestood the test of time, he has evolved an orderlytechnique, with the application of modern appa-ratus, which has resulted in a comparative stand-ardization of treatment and an improvement inend-results.The "Unfallkrankenhaus" is an accident hospi-

tal occupying the two top stories of a modernbuilding owned by an accident insurance companyand operating under the supervision of the state.Patients injured in industry are cared for underState Compensation Insurance regulations. Thedirector of the insurance company supervises allmatters pertaining to compensation and disabilitybenefits. All internal administration in the hospi-tal, and the control of the patients, is under thesupervision of Doctor B6hler, who is the chiefsurgeon. He is in a position to maintain a strictdiscipline over his staff and the patients. The staffconsists of two chief assistants, three to five otherassistants whose services rotate in different de-partments, lay orderlies, and female nurses. Thereare one hundred beds, arranged in from two toten-bed wards, with a few private rooms for themore serious cases. There are two main operatingrooms, a plaster room, a sterilizing and dressingroom, an x-ray room and a service room, all con-nected in series. The equipment is complete butnot elaborate. Close attention is paid to rigideconomy in all departments.

THEORY AND PROCEDURES IN TREATMENTOF FRACTURES

The theory of the treatment of fractures con-sists in early reduction, and restoration of thefragments to a position in which the distal frag-ment is replaced in the same axial plane anddirection as the proximal fragment, followed byimmobilization in traction or fixation in a suit-able splint. Fixation is not interrupted until firmunion of the fragments results. Early activemobilization of the parts contiguous to the frac-ture, for promotion of circulation and preventionof atrophy of the soft parts, is instituted. Thismobilization prevents restriction of motion in thecontiguous joint. The use of massage, passivemotion and moist heat for restoration of function

are occasionally used to hasten the restorationof motion in the joints. Compound, uninfectedfractures are transformed to closed, by primarysuture of the laceration, closed treatment beingfollowed thereafter. Infected compound fracturesare treated in the usual manner, with a window inthe cast for drainage and inspection.

All incised wounds and lacerations have a com-plete debridement, including the skin, soft tissuesand bone, with primary suture of the skin only.No attempt is made to repair tendons, ligamentsor nerves, except in cases in which the incisedwounds are unsoiled or without laceration. Suchrepair as is necessary is done after the originalwound has healed.

After repair, wound areas are exposed to the airwithout dressing of any form. Infected woundswith secretions and crusts, have the latter re-

moved only at long intervals. No medicamentsare applied to the wound areas. Biological prepa-rations, such as vaccines or antitoxins, are notused. Rarely prophylactic doses of anti-tetanusserum are given. Drains are used only if a vacantspace exists in the primarily sutured area.For severe contusions, sprains, and local infec-

tions the affected parts are put completely at restby the use of the airplane for the arm, and theBraun splint for the leg.

In the after-treatment of all fractures of thelower extremity, zinc gelatin dressings are appliedfrom the toes to the knee. If the injury is abovethe knee, elastic bandages are used for the kneejoint.

In bone surgery all sutures under the skin areof non-absorbable materials, such as silk and linen.All burns are primarily debrided, if there is a de-struction of tissue, then painted with tannic acidand kept elevated and at rest until healed.When it is impossible to reduce and maintain

the position of fragments by plaster splints orother apparatus, Steinman pins or Beck wire arepassed through the bones, and traction is thenapplied with the screw traction apparatus. Fore-arm and lower leg fractures are maintained inposition by the pins and wire, incorporated in theplaster of paris. After the removal of the pinsand wire, traction is maintained by incorporatingstraps in zinc gelatin, or adhesive straps attachedto the skin or to the plaster splint.The use of Steinman pins or Beck wire pro-

vides a firm base for the traction apparatus and,in plaster, a firm fixed point for maintaining posi-tion. They do not cause soft tissue damage, andonly temporarily injure the bony structures inwhich they are placed. Infections very seldomoccur.

THE NON-PADDED PLASTER CAST

These casts require specially prepared material.Two sizes only of bandages are used: those forthe extremities are made from a loose mesh gauze15 centimeters wide by 5 meters long; those forthe body and spine cast are 20 centimeters wideand 5 meters long; the plaster of paris used isof the slow-setting variety. The bases of the castsfor the extremities are a posterior splint for theleg, and a splint over the extensor surface of

is scrupulously avoided. Dry heat and diathermy

November, 1934 303

the arm. Fractures of both bones of the forearm

CALIFORNIA AND WESTERN MEDICINE

require an additional short splint over the flexorsurface. These splints are held in position by amoist gauze bandage which in application is neverreversed, over the soft parts, always over thesplint. The splint is carefully smoothed andmoulded to the contour of the part, then a circularplaster bandage is applied and moulded. Casts onthe forearm are commenced at the head of themetacarpals; they allow of complete flexion andextension of the fingers and thumb. Casts on theleg extend to the limit of the toes on the plantarsurface and to the web of the toes on the dorsalsurface, thus allowing free movement of the toeswithout plantar flexion. No padding is used onthe extremities, except over the tibial tubercle, thespine, and the iliac crest.Under the plaster dressing, all wounds are cov-

ered with a thin layer of gauze which is held inplace by mastisol; windows are cut in the cast andthe parts are exposed without dressing. No dress-ings are used on the entrance or exit of the Stein-man pin or Beck wire, the theory being that theplaster of paris is sterile.

GENERAL MATERIAL

Fracture beds are made low for the care of thepatient, and boards are placed between the mat-tress and the springs so that no sagging of theparts may occur. At the head of the bed is at-tached a curved rod with a stirrup, for the useof the patient in moving himself by lifting withhis arms. A balkan frame for femur and pelvicfractures is used, comprising two upright parallelbars with an overhead cross bar; the lower bar isslotted for pulleys.

All fractures and severe injuries of the lowerextremity, including the pelvis, have the injuredleg placed on a Braun frame immediately; thisprovides immobilization and rest with elevation ofthe parts.

All fractures and severe injuries of the upperextremity have the injured arm placed in an air-plane splint to provide immobilization, rest, andelevation of the parts.

Rustless Steinman pins are introduced forskeletal traction of the lower extremity and fre-quently for the upper arm. Beck wire is used inthe forearm, and soft rustless wire for extensionfor the fingers and metacarpals, toes, and meta-tarsals.The Bohler redresseur provides a means for

moulding fragments in fractures involving theos calcis, malleoli, and tibial tuberosities.The screw traction apparatus consists of a gas

pipe frame placed on a table, upon which thepatient may have skeletal traction applied to theextremity. There are provided fixed points ofcountertraction, in the popliteal space and peri-neum for the leg, and in the elbow and axilla forthe arm. Traction is applied by means of a slackscrew and stirrup attached to Steinman pins placedin the bone of the injured extremity. Between thescrew and the stirrup is interposed a spring scalefor measuring the amount of traction. The pullfrom the slack screw is in the long axis of thebone. Angular manipulation is possible by hand.The injured part is placed in plaster, while trac-

tion is maintained. The position of the fragmentis determined by palpation and fluoroscopic in-spection. This apparatus may be disassembled andis portable.

ANESTHESIA

Local infiltration of two per cent novocain isattempted in all fresh fractures. Ten cubic centi-meters are injected with a long needle at the frac-ture site, then the syringe is removed from theneedle; if the solution returns colored with blood,indicating that the hematoma has been reached,15 to 60 cubic centimeters more of novocain areinjected. The pain is thus immediately relieved,the spasmodic muscles are relaxed, and reductioncan proceed. Dislocations and tears of capsule andligaments are freely infiltrated over a wide area.

Regional anesthesia is necessary in surgery orextensive manipulation of the extremity. For theleg, 1 per cent novocain, spinal, is used; 8 cubiccentimeters of the spinal fluid are withdrawn andreplaced with 8 cubic centimeters of fresh novo-cain solution. The patient is then placed flat onthe table, the Trendelenburg position not beingobserved.

Twenty-five cubic centimeters of 2 per centare injected into the brachial plexus for arm an-esthesia; the subclavian artery is palpated anddisplaced medially, and the needle is inserted oneor two centimeters under the skin; the patient isinstructed to announce when a shock is felt in thefingers and elbow, at which time the entire amountis injected.

Should regional or local anesthesia not be effec-tive, ether is given by cone, with ethyl chloridinduction.

GENERAL OUTLINE OF TREATMENT

All reductions are made preferably by the closedmethod and manual manipulation. Skeletal trac-tion is employed when reduction is impossible bythe usual means. The position of the fragmentsis maintained either by weight extension or in-corporation of pins or wire in the plaster cast.Open reduction is resorted to in fractures of theolecranon and patella with separation of frag-ments, also in non-union. Proper reduction ismade in ununited fractures and fractures of theolecranon, the fragments being held in positionwith heavy wire sutures. The patellar fragmentsare replaced in position and the fascia carefullyrepaired by linen sutures.

Fixation is maintained in the original apparatusfor certain definite periods, depending on the loca-tion of the fracture. Fractures of the femur re-quire eight to ten weeks, of the humerus fourto six weeks, of the tibia six to ten weeks, bothbones of the forearm eight to twelve weeks.

Reduction is made immediately in all fractures,except those involving the lower leg, ankle andfoot. In the latter cases, the leg is kept on aBraun frame for one week until the swelling hassubsided.

Active motion of fingers, toes, and all neighbor-ing joints which will not disturb the position ofthe fragments, is commenced immediately andmaintained throughout treatment.

vol. 41, No. s304

TREATMENT OF FRACTURES-KAYSEN

REGIONAL TREATMENT

Spine.-The B6hler theory for prevention ofthe prolonged disability resulting from ordinaryspinal injuries, such as compression fractures ofthe bodies, is that primary reduction must be fol-lowed by early exercising of the spinal and otherbody musculature. Also that, following the periodof immobilization necessary for the repair of theinjured vertebra, no supporting apparatus is neces-sary. If the muscle function has been maintainedby activity, and bony damage has been properlyrepaired, no basis in pathology should exist forphysical disability beyond the time required forrecovery in other similar injuries to bony structure.

Compression fractures, without neurological dis-turbance, are reduced by hyperextending the spineafter the areas affected have been anesthetizedby injecting 50 cubic centimeters of 2 per centnovocain directly against the body of the injuredvertebra. The patient is supported in the positionof hyperextension for thirty minutes; then a bodycast is applied from the axillae to the greater tro-chanters of the femurs.At the end of one week, gymnastics are com-

menced. They consist in raising the body bymeans of trapeze rings, raising the body at thehips over the edge of a bed, raising the legs withweight on the abdomen, and carrying increasinglyheavy weights on the head. The body cast remainsin position three to four months; after its removalno appliance is placed. The gymnastics continuefor two to four months longer.A definite technique has been planned for

almost all forms and combinations of fractures.This technique is meticulously carried out in everycase, and is standardized insofar as individualcases will permit. Several outstanding examplesof treatment have been chosen for exposition,since they differ markedly from the practice gen-erally followed.Femur. Intertrochanteric, trochanteric, and

fractures of the shaft, are treated by weight ex-tension. The patient is placed in a fracture bed,novocain injected in the fracture site, and a Stein-man pin is driven through the tibial tubercle.Twenty pounds of weight is suspended from abalken frame and attached to the pin by meansof a stirrup. The foot of the bed is elevated twelveinches, in which position the weight of the bodyacts in countertraction. The leg is then placed ona Braun frame in a degree of abduction, depend-ing on the location of the fracture. At the end.of three weeks the pin is removed, to preventoverstretching of the knee ligaments, and tenpounds of weight each are attached to the thighand the leg, by means of zinc gelatin with strapsincorporated. The persistent posterior displace-ment of the distal fragment, in the supercondylerregion, is overcome by sliding the Braun frameproximally, until the knee angle of the frame isdirectly beneath the fracture site.Humerus.-Supra- and intracondylar fractures

of this bone have had a high percentage of mal-union, and are frequently complicated with is-chemic contractures of the forearm and hand(Volkman's contracture). Reduction is made by

either manual or screw traction. During reduc-tion, and when placed in plaster, the forearm isheld in extreme pronation. The latter positionrelaxes the spasm of the pronator radii teres,allowing correction of the medial angulation ofthe fragments. The arm is then placed in plasterwith the elbow at right angles, and on an airplanesplint. Extension is applied to the upper arm por-tion of the cast by means of a spring on the air-plane apparatus.Os Calcis.-Fractures in this bone result from

the astragalus being driven into the cancellousbony structure as a wedge. Usually there is acomminution, with longitudinal and transversesplitting, which produces plantar and lateral angu-lation.The normal angle of the superior articulating

plane and the tip of the tuberosity of the os calcisis about 30 degrees. This angle is greatly widenedafter a fracture, and must be corrected to restorenormal function.

Reduction is accomplished by placing Stein-man pins, one through the insertion of the tendoAchilles, the second a handbreadth above the ankle,and through the soft tissues posterior to the tibia;traction on the screw traction apparatus is thenapplied, first in the longitudinal axis of the leg,second at an angle of 45 degrees thereto. Lateraldisplacement is corrected with the redresseur.Plaster is applied, the leg put on a Braun framefor three to five weeks. The patient then becomesambulatory on a walking iron for a period of nineto fourteen weeks additional. Zinc gelatin andarch supports are used after the removal of theplaster.

Carpal and Tarsal Phalanges, Metacarpals andMetatarsals.-Fractures of these bones have pre-viously given uniformly poor results.The Bohler treatment consists of incorporating

a loop-wire splint in a cast on the extremity. Thissplint is at first placed parallel to the digit affected,and on the flexor surface. Through the pulp ofthe distal segment is passed a rustless wire; thisis attached with light tension to the free end ofthe splint; the wire splint, together with the digit,is then flexed to mid-position; the extension ismaintained for three or four weeks. Free move-ment of the remaining fingers or toes, to maintainfunction, is thus possible.The Walking-Iron.-This consists of a piece

of strap iron with small cross pieces at eitherend, which is bent in "U" shape and attachedby plaster bandages over the leg and foot cast,parallel to the long axis of the leg. The free lowerportion extends the width of the heel of the oppo-site shoe, distal to the heel portion of the cast.

Patients with fractures below the knee have thisiron placed and are made to walk immediately, orwithin forty-eight hours after injury. Exceptionsto this rule are fractures of the os calcis andastragalus, in which cases bed treatment on aBohler frame is necessary for the first three tofive weeks, following which the walking-iron isplaced.

It is possible for patients to walk with this iron,for the reason that the non-padded cast preventsany displacement of the fragments. Early union

November, 1934 305

CALIFORNIA AND WESTERN MEDICINE

is stimulated, the limb does not atrophy, fibrousankyloses in neighboring joints are prevented, andthe morale of the patient is greatly improved.

COMMENT

An exposition of the technique covering themany additional fractures and skeletal repair pro-cedures, would require hours for presentation.The few examples here outlined will serve to illus-trate the departure from the older accepted formsof treatment. They include the basic principlesand theories of Bohler's work.The success of the application of Bohler meth-

ods of treatment for fractures and other traumarequires a thoroughly organized staff, a carefulselection of material, and a constantly minute at-tention to details of technique and after-treatment.The principles of reduction and maintenance of

position of the fragments are physiologically andmechanically sound. The practice of early mobili-zation of the soft parts, and joints contiguous tothe fractured member, prevents atrophy, adhesionsand ankylosis.The non-padded plaster cast, if properly ap-

plied, provides perfect immobilization, preventsangular deformity, and is comfortable for thepatient. The danger of pressure disturbances isless than in the use of other constrictive appli-ances.The employment of the walking-iron attached

to leg casts, allows early ambulation, lessens lengthof hospitalization, stimulates the bony repair, andraises the morale of the patient.Treatment of wounds by adequate debridement,

primary skin suture, with complete rest and eleva-tion of the parts, results in few infections andearly repair. Infections treated by immobilizationof the affected parts, free incision and drainagewith complete rest, have a short duration, andresult in the minimum of tissue destruction andcontractures.

Metal pins and wire for skeletal traction pro-vide a most effective method for fracture re-duction and immobilization. The much-fearedinfection or destruction of bone or soft tissuesseldom follows their use.

IN CONCLUSION

In general, in the opinion of the writer, theBohler methods have made possible great advancesin the treatment of fractures and trauma. In someinstances end-results are disappointing and arecomparable to older methods. However, the largemajority of cases observed force the conclusionthat the many years of tireless efforts, concen-trated in his special field, have entitled LorenzBohler to an outstanding position among modernsurgeons.These methods, applied in the treatment of

injuries, result in a lessened disability period, anearlier return to the proper industrial status ofthe patient, a shortened period of hospitalization,and the least possible impairment of function.The morale and physical well-being of the injuredare enhanced, and economy to society ensues.

1301 Medico-Dental Building.

DISCUSSION

MAYNARD C. HARDING, M. D. (861 Sixth Street, SanDiego).-Doctor Kaysen has given a readable resumeof Doctor B6hler's methods. Much of the latter'swork is like our American procedures, but some of itis quite different. Any description of Doctor B6hler'swork would of necessity sound stereotyped, as it couldnot convey the high personal skill which enables himto modify his various standard methods to fit theindividual case.

It must be remembered, in fact, that many of hisoperations, while appearing simple, are really only forthe very skilled and cannot, therefore, be done outsidea well-organized hospital.

In this day of multiplying surgical and mechanicalprocedures, Doctor Kaysen does us a kindness inrecalling to mind the fact that personal skill plussimple apparatus is, after all, an ideal not to be lostsight of.

FRASER L. MACPHERSON, M. D. (610 Medico-DentalBuilding, San Diego).-Doctor Bohler has undoubt-edly made possible great advances in the treatment offractures and trauma, and his experience with certaintypes of fractures is gradually and generally serving asa guide to many practitioners throughout the UnitedStates.In order to carry out the Bohler procedure it is

necessary, of course, to follow his technique, whichhas been so carefully worked out over a period ofyears. In other words, if non-padded casts are to beused, it is essential that the bandages and plaster aremade in accordance with his specifications, as it isimpossible to put on a non-padded cast satisfactorilywith many of the bandages ordinarily used. Not allof his procedures are adaptable to conditions we meetwith in this country.The experience Doctor Bohler has given us in the

use of traction pins for fractures of the extremitieshas undoubtedly eliminated the necessity of manyopen operations and has aided materially in decreas-ing the period of hospitalization, both of which arevery important factors in this present economic crisis.

STERLING BUNNELL, M. D. (516 Sutter Street, SanFrancisco).-In the treatment of fractures the greatestadvance in recent years has been made by Dr. LorenzB64ler, who has compiled and developed a systemrsuperior to that commonly in use. The time of treat-ment and the amount of permanent disability are muchshortened. Total compensation expense, as shown inhis 1930 report of the Accident Hospital in Vienna,was reduced to 41 per cent. The greatest saving inthe order of the amount was in fractures of the lowerleg, forearm, tarsus, femur, and humerus. Since thesefigures were published, his treatment of back injuriesby athletics has further reduced compensation expense.

I have visited Doctor B6hler's clinic, and for fiveyears have used his methods with increasing satis-faction.Among the essential principles are early setting, use

of local anesthesia, and the elevation of limb. Thesetting is accurate by skeletal traction between twofixed points on an apparatus and in the proper direc--tion of pull. With the limbs suspended in this positionthe plaster casing is easily applied. The non-paddedfeature prevents movement. The pins may be em-bedded in the plaster, and if they are kept immobileinfection is extremely rare. Functional treatment, bythe walking cast in the lower extremity and by activeuse in the upper limb, greatly shortens convalescenceand improves the result.The methods when used by those insufficiently

qualified are fraught with danger. When applied, how-ever, by those who have keen comprehension of me-chanics, and have paid the price by thorough studyof the principles, both safety and success are assured.

306 VOl. 41, NO. 5