tracheotomy will, I believe, save more cases than intubation,* but the operators seem to be few who can obtain the best results.

Mode of Introduction.-The operator selects the proper tube, attaches the thread, ties the ends together, and adjusts the tube upon the applicator. The child is held upright upon the lap of the nurse, and its feet and hands wrapped firmly in a sheet or blanket. The feet are best held between the knees of the nurse., An assistant behind elevates and firmly holds the child's head with both hands. The gag is inserted well back under the molars, and the handles held in place by the left hand of the assistant. The operator, seated in front, passes the left index finger rapidly into the throat, locates the opening into the larynx and elevates the epiglottis. He then passes in the tube, holding the handle at first near the chest, rapidly elevating it and projecting it forwards until the point of the tube comes in contact with the point of the index finger, carefully slipping the tube between the tip of his finger and the epiglottis, and carrying it down well into the larynx. When it is lodged deeply in the larynx, he transfers the tip of his index finger to the top of the tube to hold it in place; then, releasing the tube from the applicator, he withdraws the plug. Assuring himself, by his finger, that the tube has remained in place during the withdrawal of the plug, he removes his finger and the gag. The relief of the dyspnoea, the peculiar tubular quality of the cough and respiration, assure him that the tube is in the larynx. After a few minutes, when it is certain that all is right, the thread may be removed. It is curious to see the annoyance that this little thread produces; and if the operator be not careful, the child will grasp it and pull out the tube.

The throats of children differ greatly one from another. In some the pharynx is roomy and the larynx placed high. In others, again, there is hardly space enough to operate, and the larynx is very low. In very young children the epiglottis is very soft,

*The author exhibited and described a set of O'Dwyer's instruments for intubation.

and doubles up when the attempt is made to pass the finger under it. In children with severe diphtheria and greatly swollen tonsils the operation is quite difficult. In a case of diphtheria last week I was compelled to perform tracheotomy, because intubation was impossible, as I was unable to reach the epiglottis with my finger without the use of more force than I thought wise. Considerable difficulty is experienced by unskilled operators. The tube passes so easily into the oesophagus that it always enters it in preference to the larnyx. The point to remember is always to keep the tube in front of the guiding finger. Practice upon the cadaver is recommended, but away from the large medical centres this is rarely possible. The operator should at least master the mechanism of the applicator, and be perfectly familiar with the anatomy of the parts before the attempt is made.

The dangers of the operation are apnoea from too prolonged an effort to lodge the tube, the injury to the larynx and contiguous strictures from too violent manipulation, and suffocation from balling up of membrane in the trachea below the tube.

The judgment of the operator will prevent him from making too long an effort to lodge the tube. Repeated trials of short duration, if he do not at first succeed, are better.

The obstructions from the presence of membrane and swelling of larynx does not offer much resistance to the introduction of the tube. Any very great resistance is probably indicative of improper placing of the tube. The pushing of membrane down before the tube does not occur so frequently as would be supposed, and when it does occur, experience shows that it is not attended by much danger. Twice it has happened to me, but with the withdrawal of the tube the membrane was ejected. In one case a perfect cast of the respiratory tract, from the tip of the epiglottis to the fine ramification of one bronchus, was expelled.

This accident is more liable to happen when the membrane is loosely attached.

TREATMENT OF FRACTURES OF THE UPPER AND LOWER EXTREMITIES, WITH NEW DEVICES FOR THE SAME.

WM. H. DE CAMP, M. D.,

Grand Rapids.

Last year, at our meeting, we were told by Prof. Palmer, in his paper on "Inflammation and its Treatment," that to every case of surgical disease treated by the profession, we had to treat at least fifty of some form of inflammatory disease.

I will now venture to say, what appears equally correct, that to every suit brought against a professional man for damages for maltreatment of some inflammatory disease, we have fifty for some surgical disease. The great majority of these are

for the treatment of fractures. With such a state of affairs existing, it leads us to investigate the cause, or causes, which produce them. It is hardly possible that all the poor physicians give their attention to surgery, and all the good ones to treating inflammations; neither is it probable that all persons suffering from inflammatory diseases are so different in disposition as to be willing to accept all kinds of treatment in the former cases, and call it good, and for all surgical, and call it bad.

Again, we cannot believe but most physicians know how to reduce all fractures with a good degree of accuracy. If these assertions be reasonably true, then the bad results in the recoverjes from fractures must come from results or causes existing between the time of their reduction and their final reunion.

These being the facts in the majority of cases, leads us to decide whether it is a thing necessarily unavoidable from the natural laws of reunion, or the result of non-retention.

As early as 1844, Frank H. Hamilton commenced collecting records of all fractures as they existed after recoveries, to see what the general results would show. This resulted in showing that there was a general average of shortening in the femur of about one-half to three-fourths of an inch, and in other bones about the same ratio. This, of course, took in the whole list of good and bad cases.

In 1874, Lewis A. Sayre, M. D., read a paper on the treatment of fractures, at the meeting of the American Medical Association, in which he gave us to understand that extension and counter-extension was all that was required to give good results. In all his reported cases the stucco splint was used to accomplish the work. When you look over his table of cases of femoral fractures treated from April 1st, 1872, to April 1st, 1873, you will find thirty-one cases reported, and the average shortening in them gives a fraction less than one-half inch. This gives us nearly the same result as that of Prof. Hamilton's observations, and leads us to think that we are to look for some shortening as the result in all plans of treatment.

From these reports we are almost forced to expect some shortening; but to prevent this shortening is not all to be accomplished in their treatment, but there is a vast amount of difference in the comfort during the time. To think of a person with frac ture of the femur being confined in bed from six to ten weeks on the straight, or Desault's or Physic's splints, with possibly bed sores and other tortures; or being on their crutches in twelve days on the street, with no apparent shortening, and in ten weeks walking without cane or crutch, is a vast difference. This I have demonstrated in one case by the splints I propose to show you as improvements of my own devising. Within the last six months I have only treated five fractures of the femur, but all of them have resulted remarkably well, with extreme abatement of suffering, compared with former plans.

Sayre, in his report, has given us the true principle of extension and counter-extension as productive of good results, but his

means for accomplishing the same is far from being adequate. The stucco splint has not and will not produce the best possible results.

To devise some means more certain and universal has been my object in preparing the present mechanisms. All the splints of stucco or soda silicate, or felt, or shellac-felted fibre, have proved insufficient. If any change in their form is required, or closer contact, it cannot be done except by renewal of the dressings. Nearly all splints or dressings at present in use require removing from the limb to give them better coaptation, and then they are fixed until the next removal.

To overcome all these objectionable features, I have devised splints capable of being changed at will to nearly any desired form, without disturbing limb or fracture. They are composed of soft, malleable iron, but in the near future there is good reasons to believe that the aluminum metal will be the best of all. Until this comes inot general use, we must rely upon those at present obtainable.

After many tests I found nothing equal to soft and flexible plate iron, of desired thickness, to give strength and retention of desired form; they can be spread out or closed up to the limb at will without removal, and thus admit of any amount of freedom, or by means of suitable pads can confine the limb as closely as desired.

To give good mechanical results to all joint motions in fracture apparatus, they must comply with the motions of each particular joint. In the knee and elbow, they are almost entirely a forward and back movement, which can best be imitated by joint movements that are lateral, and midway from front to rear of limb. In the wrist and ankle, the motions are somewhat universal, and become more difficult of fixation. For the ankle and wrist, it requires three points of fixation to secure the hand and foot in any position desired relatively to the rest of the limb; two of these points have to be lateral to the joint, and one either posterior or anterior; the posterior is the most practicable. By means