rect restoration of the fragments, and in the confirmation of the result in the event of wiring, skiagraphic control is simply indispensable.

In fracture of the leg the difficulties were often insuperable before the discovery of the rays. It is especially in the malleolar type that serious disturbances are observed. Especially in regard to the socalled Pott's fracture, many fresh facts were revealed by the rays, so that, just as in fracture of the lower end of the radius, our former views have been changed completely.

The number of fractures of the ankle treated as sprains and dislocations, to the great disadvantage of the patient as well as of the surgeon, is legion.

Fracture of the foot is also found to be more frequent than was formerly supposed. Individual fractures of the tarsal and metatarsal bones and of the phalanges were often erroneously taken for contusions. Stechow has found that the so-called edema of the foot, so frequently found among the German infantry, is always due to a badly united fracture of a metatarsal bone.

In fracture of the ribs and of the sternum skiagraphy will often prove to be useful from the standpoint of jurisprudence.

In fracture of the vertebra the exact location of the fragments is of great importance in determining the advisability of operating.

In fractures of the skull, those of the face and of the inferior maxilla have derived the most benefit from the rays. Fractures of the base are still with difficulty demonstrated.

In fracture of the larynx the question of differentiation is easily settled by the rays.

PART I.

FRACTURES IN GENERAL.

CLASSIFICATION OF FRACTURES.

A fracture (a word derived from the Latin frangere, "to break ") is a solution in the continuity of a bone. It is either traumatic-that is to say, produced by violence-or spontaneous, caused by disease.

Spontaneous fractures may occur on account of a pathologic fragility of the bones (osteopsathyrosis), which may be due to tumors (enchondroma, sarcoma, metastatic carcinoma, echinococcus cysts, etc.), or to inflammatory processes (caries, osteomyelitic necrosis, osteosarcoma, rachitis, etc.), or to constitutional diseases, such as syphilis and scurvy. Other cases are caused by disturbances of nutrition of the bones. Spinal diseases-syringomyelia, tabes-are also occasional

causes.

In this book the traumatic fractures of healthy bones. will alone be considered.

Traumatic fractures are either direct or indirect. A direct fracture is one occurring at that point of the bone to which a force has been applied. It is obvious that this type bears a more serious character than one caused by indirect violence, since an injury

to the soft tissues covering the point of fracture is added.

An indirect fracture is one that occurs at a point distant from that where the force has been applied. A good example is a fracture of the lower end of the humerus produced by a fall upon the hand.

Sometimes a fracture is caused by muscular contraction. The seats of predilection for this variety are the olecranon, humerus, clavicle, os calcis, tibia, patella, and femur.

Traumatic fractures are also divided into simple and compound.

In simple fractures the bone is broken at one point, and no communication with the external air exists (subcutaneous).

In compound fractures the bone is broken at one or more points and communication with the external air exists.

According to the degree of separation in the continuity of the bone, distinction has also to be made. between complete and incomplete fractures.

According to the direction of the fracture, complete fractures are either transverse, oblique, longitudinal, or spiral.

Thus, according to the displacement taking place after the fracture is sustained, four different types of a complete fracture may be noted: viz.

1. Lateral displacement, characterized by the line of separation being at a right angle to the long axis of the bone (rare in adults). (Fig. 92.)

2. Axial displacement, in which the line of separation is at an acute angle to the long axis. (Fig. 89.)

3. Longitudinal displacement, when the separation

line is parallel to the long axis. If there is axial displacement the so-called riding of the fragments takes place. It is often observed in fractures at the upper third of the femur. (Figs. 112, 114.)

4. Peripheral displacement, in which the fragment is turned around the long axis of the bone (torsion). (This variety may occur when the body is turned while the extremity is fixed.)

If in a complete fracture small bone-fragments are either partly or totally severed from the bone, it is called a comminuted fracture. (Fig. 136.)

If the bone is broken at several points, it becomes a multiple fracture. (Fig. 40.)

If a fragment consisting of compact bone is forced into the substance of a cancellated one, an impacted fracture is produced. (Fig. 107.)

If the fracture is caused by a bullet, it is called a gunshot fracture. The bullet of the army weapon. known as the Kräg-Jörgensen rifle produces extensive splintering of the diaphysis of the long bones up to a distance of 800 yards. (Fig. 136.) This type of fracture may also be incomplete.

Its

In incomplete fractures, which are mostly observed in very flexible bones, the convex corticalis yields and tears, while the concave stratum is only bent. This injury is called infraction (Figs. 92, 137); it may be compared to the bending and partial splintering of a green stick, and is mainly observed in childhood. predilection is for the deformed legs of rachitic children, but it may occur in old individuals, where senile atrophy has caused a diminution of the organic substance of the bones. It is also found, as a result of abnormal uterine contractions, as an intrauterine frac