that it can be inserted into the medullary cavity of the other and larger fragment. (Fig. 13 c.)

Simple fractures may exceptionally be converted into compound fractures on account of great muscular spasm, from necrosis of a small fragment, or from the different sources of infection. The writer has observed three cases of suppuration in simple fractures of the femur, the subjects of which were boys of four, five,

and seven years. They all suffered from tubercular inflammation of the adjacent knee-joint, the suppuration setting in between the second and third week after the accident. Free incision becomes imperative in such cases; after which treatment will be the same. as before advised. (See p. 65.)

Treatment of Disturbances in the Process of Repair. In discussing this subject we shall do best to follow up the instances given under the heading

Disturbances in the Process of Repair (p. 31), where the causes and consequences of these disturbances are discussed.

Pseudarthrosis is sometimes successfully treated by electrolysis. Nailing the bones together with ivory pegs is naturally more effective. But the safest way is resection. The ends of the fragments should be freshened and then sewed together with silver wire (Fig. 13 a) or stout catgut, as described on page 69. If there is much tendency to displacement, the ends may be resected in the form of steps, in order to make them fit closer. (Fig. 13 b.) The insertion of a pointed bone-end into the medullary cavity of the other fragment may also be considered. (Fig. 13 c.) In light cases energetically rubbing the ends of the bones together daily sometimes sets up so much local reaction that callus formation is induced. The production of moderate venous hyperemia by the use of a rubber tourniquet is also recommended. The same procedure may be used in cases of late union.

Gangrene has to be treated after the principles set forth on page 68.

Aneurysm has to be treated after general surgical principles.

Compression of a nerve may be relieved by exposing it freely; a wide incision being necessary if the nerve should be surrounded by much callus proliferation, which latter should be chiseled away. After such interference perfect recovery has been observed in a number of cases. (Figs. 66, 67.)

Embolism has to be treated after general medical principles, stimulation of the heart being the main factor (digitalis, caffein).

Ankylosis offers but poor chances for complete restitution. The bony variety (compare Fig. 118) requires osteotomy, combined with the exsection of a bonewedge. In fibrous ankylosis repeated forcible motion and manual correction of the abnormal position under anesthesia sometimes yield fair results, provided much time has not elapsed since the injury was sustained. Massage treatment is also a potent factor.

But the most good can be done by early prophylaxis. If a fracture is situated in the vicinity of a joint, ankylosis is to be feared, the latter will certainly be avoided, if massage and active and passive motion are employed as soon as the swelling has subsided.

Delirium tremens must be treated mainly by prophylactic measures. Alcohol (wine, whisky) should be given in moderate quantities to such individuals as are accustomed to its use. A light diet should be observed. Opium and chloral in large doses may be freely administered. Patients who give an alcoholic history should be induced to walk about as early as possible. (See p. 42.)

Pneumonia is treated after general medical principles. The main factor in this connection is also prophylaxis. Aged persons especially must walk about as soon as possible. If in bed, their positions must frequently be changed. In fractures of the lower extremity, if walking in a plaster-of-Paris dressing (compare Fig. 6) should prove to be inopportune, extension should be employed when aged people are concerned. When patients of advanced years can not be allowed to walk it is best to let them sit up in bed as much as possible, in order to prevent circulatory stasis and its train of evil consequences.

PECULIARITIES OF FRACTURES IN CHILDREN.

Although fractures in children must practically be considered from the same standpoint as those in adults, they present some characteristic deviations, which deserve a special description.

Among the more marked varieties of infantile fractures the intrauterine and congenital and the rickety and spontaneous types may be mentioned. Almost peculiar to infancy and childhood are separation of the epiphysis and the so-called "greenstick" fracture. (Fig. 90.) It may be added that the scapula, sternum, and pelvis are but seldom fractured in childhood, while the clavicle, humerus, radius, thigh, and leg are more frequently involved than in adults. Fractures of the fingers, the skull, and the maxillas are also much rarer in childhood.

In intrauterine fractures (see Figs. 1, 2, and 93) normal union takes place in a large number of cases. Sometimes there is no union at all, and often a greater or lesser degree of deformity is observed.

Congenital fractures are of moderate frequency. For detailed description see Part II.

True epiphyseal separation-that is to say, a real chondro-epiphyseal division (Fig. 50), where the epiphyseal cartilage is sharply severed from the osseous end of the diaphysis-occurs in infants only, and is extremely rare, while osteo epiphyseal separation (Fig. 49) is frequently observed between the ages of fourteen and seventeen. In these latter cases the fracture line is not limited to the epiphyseal cartilage, but extends to the diaphysis. Traumatic separation has a

marked predilection for the epiphyses of the upper and lower ends of the humerus, the lower end of the radius, and the lower ends of femur and tibia.

The different epiphyses naturally show a tendency to separation at various times. The dates of ossification and union of the epiphyses of the humerus, radius, femur, and tibia are, according to Quain:

In the humerus the nucleus of the head appears in the second, of the capitellum in the third, of the internal condyle in the fifth, of the trochlea in the eleventh, and of the external condyle in the fourteenth year (see Fig. 174), while union between the lower epiphysis and the diaphysis takes place between the sixteenth and eighteenth years, and between the upper epiphysis and the diaphysis in the twentieth year. The lower epiphysis of the humerus consists of four nuclei, which ossify and unite between the eighth and eighteenth years, a fact that is of great importance in the correct interpretation of skiagraphs. In the radius (see Fig. 87) the nucleus of the lower end appears at the end of the second year, while that of the head follows at the fifth. The upper epiphysis and the diaphysis unite between the seventeenth and eighteenth years, and the lower epiphysis and diaphysis join in the twentieth year. The nucleus of the lower end of the femur (see Fig. 138) appears as early as at the ninth month, while that of the head shows at the end of the first year. The head unites with the diaphysis at the eighteenth or nineteenth year, and the lower epiphysis follows after the twentieth year. The upper epiphysis of the tibia (see Fig. 138) appears at the time of birth, while the lower one shows in the second year. The lower tibial epiphysis unites with the diaphysis between the eighteenth and the nineteenth