if the operation could not be done in a proper and thorough manner. In the operation, after the thorough disinfection of the skin and external wound, the wound should be enlarged, disinfecting as we proceed. In approaching the bone, the greatest care should be taken not to disturb the periosteal attachments of the fragments. Only those fragments should be removed which have no periosteal attachments. In the majority of instances it is better to approximate the fragments with silver wire, disturbing the periosteum as little as possible. If the approximated bone cannot be covered with periosteum nor healthy skin, it should be covered with a muscle-flap. Every effort should be made to cover the bone at the seat of the fracture. If possible, the skin opening should be closed. The indications for drainage-which is best accomplished by rubber tissue, never a drainage-tube-are excessive hemorrhage from the bone and laceration or contusion of the soft parts which threatens their circulation. If this is excessive, the skin wound should be left wide open. In such instances frequent dressings are indicated to prevent or inhibit secondary infection. It is remarkable what excellent results can be obtained in the most grave cases of compound fracture by early and proper operative interference, proper drainage, and the most careful after-treatment.-ED.]

Varieties of Fracture

According to the degree of separation of the fragments, fractures are divided into complete and incomplete. The latter class includes fissures, traversing the bone without producing any alteration in its outward form; infractions ("greenstick" fractures), which occur most commonly in children, particularly in the bow-legs of rachitic children, although occasionally also in the long bones of adults; and depressed fractures, which occur chiefly in flat bones.

In a complete fracture the line may assume various forms; hence we distinguish transverse, oblique, longitud

PLATE 1.

Bending Fractures (Greenstick Fractures).—Fig. 1 a and b. ---Tibia and fibula of the left lower extremity. From a boy, fourteen years old, who was caught between the cogwheels of a threshingmachine. The outer surface of the two bones is shown; the epiphyseal lines are still visible. The fracture of the fibula appears about 2 inches higher than that of the tibia. Both bones are bent at the seat of fracture, forming on the outer surface a projecting, and on the inner surface a receding, angle. The bending first produced a solution of continuity on the convex surface, the fracture being completed by the formation of the characteristic wedge, which, however, has not completely separated, and is still held in place by a bridge of bone, at the lower border in the case of the tibia, at the upper border in the case of the fibula. (From the author's collection.)

Fig. 2 a and b.-Tibia and fibula from the skeleton of an adult after a fracture had been produced artificially with the aid of Rizzoli's osteoclast. It is seen at a glance that the fracture was produced by bending the bone. The tibia shows an excellent sample of oblique fracture. (From the author's collection.)

inal, and spiral fractures. If the bone is broken into a number of small fragments, which may or may not be held together by periosteum, we speak of a comminuted or splintered fracture. There may be multiple fracture of the same bone, as fracture through the upper, lower, and intermediate portions; and simultaneous fractures of several bones, as, for example, fracture of both bones of the forearm or leg, or of various bones situated at some distance from one another.

It is not without importance to determine whether a fracture is direct or indirect. These terms are used to indicate the seat of fracture in relation to the point of impact of the breaking force. If the seat of fracture corresponds with that of the injury,—as, for example, fracture of the ulna sustained in warding off a blow ("parrying fracture"),-the fracture is said to be direct. But when a child falls on its outstretched hand and sustains a fracture of the clavicle or of the lower end of the humerus,

it is called an indirect fracture. Since the effects of the insult, consisting in contusion and subcutaneous hemorrhage, occupy the seat of the fracture itself in direct fractures, the latter are generally considered more serious than indirect fractures.

Another important point is the incidence of certain forms of fracture according to age. That the greatest number of fractures occur among adults is easily understood, since this class is most engaged in heavy labor, and accordingly exposed to the dangers and accidents incident. thereto. To obtain a correct idea of the significance of statistics it is necessary, however, to remember the relation of the total number of inhabitants to the different periods of life. Keeping this in mind, it is found that fractures are most frequent between the ages of thirty and forty (15.4%); fractures are more common in old persons than in children, the latter up to the age of ten representing the minimum of incidence. The frequency of fractures in old age is partly explained by the increased brittleness of the bones due to senile atrophy of the bony tissue (diminution of organic constituents in the bones). In youth the presence of a cartilaginous joint between diaphysis and epiphysis plays an important rôle in the etiology; instead of actual fracture of the long bones, epiphyseal separations are more likely to take place, similar to those which occur spontaneously in inflammatory processes, such as syphilis and, especially, acute osteomyelitis.

The degree of force necessary to produce a fracture varies greatly. As has been said, a comparatively slight force suffices in the case of children (epiphyseal separation) and old persons (senile atrophy). In a healthy adult the resistance of individual bones varies; thus, the following widely differing results were obtained by actual tests:

Female clavicle.
Female humerus

Male radius

Neck of femur in a man

Tibia

126 kg.
600

334 "

815 "

450-650"