this expectation I think it will be seen that I have not been disappointed.

It is obvious that the treatment of simple fractures at the present time is in a state of transition and, moreover, that the progress of late has tended to rational methods, which contrast favourably with the prolonged splinting and similar plans which held good up to within a very recent period. It is equally clear that the treatment of this class of injury has, until quite lately, been on a stereotyped basis, and that the form of treatment has depended to a great extent upon the practice of the institution in which the cases have come under observation; in other words, in certain institutions certain methods of treatment have held good for many years, having undergone very little change. For example, it will be found that in some hospitals the early application of plaster of Paris as a routine plan is in use. Practitioners educated in such an institution will, as a matter of course, pursue more or less closely that particular line of treatment.

Thus it comes about that it is generally easy to divine the institution at which a practitioner has been educated by observing the method which he adopts in the treatment of fractures of the limbs. In fact, there has until quite recently been practically no change in the method of treatment of these injuries, and such varieties in the treatment as have existed must be

attributed rather to the different traditional plans used in different institutions than to any other cause.

THE USUAL METHOD OF TREATMENT

Setting aside those surgeons-a very small number-who on the one hand consider the majority of fractures of the long bones as suitable for treatment by operation, and those, on the other hand, who under no circumstances see any justification for operation, there is a large intermediate class of practitioners who, whilst under ordinary circumstances adopting non-operative treatment, are open under certain conditions to use the operative treatment, provided that the circumstances of the patient and of the practitioner, and the nature of the case, render it justifiable.

Speaking generally, the routine treatments with this large intermediate class of practitioners consist of three main varieties. The first variety is the immediate application of some immovable splint or apparatus, for example, plaster of Paris, silicate of potash, and the like; in the second variety, splints which are easily removable for the purpose of examination, or for the employment of passive movement or massage, are used; in the third variety there is a tendency to the rejection of splints altogether for any considerable period.

EARLY MOVEMENT IN FRACTURES

Up to a comparatively recent time the use of anything like effective passive or active movement in fractures of the extremities was practically unknown until a period of the case had been arrived at in which the union was so good that splints could be discarded. Recently a change-an extremely advantageous one in my opinion, which I hope I have been in some measure instrumental in bringing about—has come over the face of affairs, and there is a general inclination to begin to discard the use of all splints which make the limb inaccessible, substituting splints of a kind which are easily taken off for the purpose of submitting the limb to certain movements in order to avoid the matting together of parts and other inconveniences which arose under the older method.

From a consideration of the answers which I have obtained in reply to the inquiries already referred to, it appears that at the present time the use of passive movement of some kind in cases of fracture is, in the practice of provincial surgeons, carried out by 64 per cent. In London it is used by 90 per cent., and in Ireland and Scotland by about 85 per cent. of surgeons in large practice in hospital work. Speaking generally, this passive movement may be classified under three heads-the immediate, the intermediate, and the remote. By the immediate I mean that

which is employed within the first two days after the injury; by intermediate that which is commenced in from two to fourteen days or under; and by remote that which is deferred until later periods.

If, as I believe is the case, a great advantage arises from the use of early passive movements in cases of fracture, as opposed to the older-fashioned methods by which fractures were fixed for very long periods in splints, the information which has been forthcoming should show conclusively that those surgeons who use the movements in the early stage are able to report a more rapid recovery of the patients than those who postpone the movements until later periods.1 In point of fact this proves to be the case; for upon analysing the evidence at my disposal I find that, almost without exception, the quickest recoveries are reported by those who use movement the earliest. In this connection it is noteworthy that there is a general tendency to the relinquishing of the use of plaster of Paris, silicate of potash, and other fixed immovable splints of that kind, mainly, it is stated, for the reason that the use of such appliances tends to slow union in the first instance and prolonged disability after their removal.

1 A few surgeons prefer active movements to passive, but they, as a rule, are late in commencing any movements. There is no doubt that as soon as union is sufficiently sound to admit of their employment, active movements are preferable, but in the early stages passive movement is certainly safer, and I think equally efficacious.

There is, therefore, on that account, and for other reasons, a steady inclination to discard all splints of that kind, and to resume the use of movable splints which give easy access to the part.

THE OPERATIVE TREATMENT OF SIMPLE FRACTURES

'Operative treatment' must be held here to mean the open method by which the fragments are cut down upon and exposed, this being the plan adopted by the great majority of surgeons who operate in cases of fracture. A few operators use transfixion pins, passing through or into the upper and lower fragments respectively, no incision beyond that which is necessary to allow of the easy passage of the pins through the skin being made. The projecting ends of the pins are approximated or lashed together by means of silk. It is clear that, although pinning in this way may suffice in cases in which the fragments are easily replaceable in position, it would be quite useless when there is difficulty of reduction—at least if perfect apposition, the crucial point in the initial treatment of fractures, is to be achieved.

It appears that of country practitioners 50 per cent., of London surgeons 35 per cent., of Irish and Scotch surgeons about 25 per cent., have had no experience whatever of the operative treatment of simple fractures of long bones. The number of those who have been good enough to give me information on this subject, who have had experience of the treatment, is sufficient, I think, to enable us to form