The same observations apply with equal weight in the case of fracture of the olecranon. It will be found upon examination that in the majority of cases of fracture of the olecranon treated by long-continued immobility in splints the detached fragment of the olecranon is fixed to the humerus. I do not mean that it is always fixed by bony ankylosis, but it is connected to the humerus by such strong adhesions that it is very difficult to move it at all. Further, it will be found that the utility of the limb in such cases is in direct proportion to the mobility of the detached fragment upon the humerus - in fact, the utility of the limb depends more upon this factor than upon the apparent strength of the union. When the fragment is fixed it will be found upon commencing to bend the joint that movement is obtained, not by the gliding downwards of the upper fragment upon the humerus, as should be the case, but by a stretching of the union, the fragment remaining fixed; and in such cases, although flexion may be effected to a great degree, and sometimes completely, extension power is almost, if not entirely, wanting. So much is this sometimes the case in exaggerated instances that although the patient may be able to semiflex the arm or, perhaps, to flex it completely, if the limb is raised above the shoulder or by the side of the head the forearm falls down almost as in a paralysed limb in consequence of the triceps having lost its power from the fixation of the detached olecranon to the lower end of the humerus. If in the treatment of such a case trouble be taken during its early progress to constantly move the detached portion of the olecranon upon the humerus by a little gentle flexion and by lateral manipulation, care being taken that in flexion the detached fragment is made to follow the movements of the forearm, which is easily done by making pressure upon it in a downward direction during passive movement, all adhesion is prevented and the patient probably recovers with a limb which is practically almost as useful as if there had been no fracture at all - the utility of the limb here, as in fracture of the patella, when the union is fibrous, depending upon the freedom of movement of the detached fragment as much as or, indeed, more than upon the actual strength of the uniting medium.

The two cardinal facts to bear in mind in the rational treatment of fracture of the patella and fracture of the olecranon are these: 1. The avoidance under all circumstances of any chance of the upper part of the patella or of the olecranon becoming adherent to the subjacent bone. Such adhesion may be prevented by massage and lateral manipulation combined with gentle flexion and extension, during which the detached fragment is made to move as much as possible with the distal portion of the limb - i.e. with the leg or forearm as the case may be-the lateral movement being the most readily managed and resulting in the least disturbance of the parts generally. 2. All manipulation and passive movement should be preceded by smooth rubbing of the muscles. By this treatment you will in the majority of cases provide the patient with a limb which is useful to an extraordinary degree beyond that which follows when this plan is not used. I am, of course, speaking generally only, because occasionally a case treated by other methods without operation will leave a sound and good limb, but many of the cases so treated are very imperfect both in movement and in power.

When the fracture of an olecranon is treated by wiring, screws, or pegs the same cardinal points must be borne in mind. Massage and passive movement cannot be practised too soon, nor can the patient be encouraged too soon to use gentle voluntary movement at the elbow-joint.

I may perhaps be allowed a moment's digression here to explain, in order to avoid any misunderstanding, that the remarks which I have just made must not be held to imply that I have any wish to substitute in a general way treatment by massage and manipulation for the operative measures now so commonly employed in fractures of the olecranon and patella. I am second to none in my estimation of the value of these measures; but there must always remain a number of cases which, for reasons which it would be foreign to my present purpose to discuss, are not suitable for operation - some in themselves, some because the patient does not desire operation, and some in consequence of the circumstances in which the practitioner finds himself being not such as to justify his undertaking operative measures. In such cases intelligent massage and manipulation will produce a better result than any other plan, and in many instances will restore the limb to a degree of usefulness which cannot even be excelled by operative treatment.