accomplish the purpose. These depressions are very unsightly. In connection with the subject of fracture of the bones of the face, you should be reminded of the presence of the black or blue stains of the skin, caused by the injuring body, such as a brick in falling from a burning building, or other soiled objects. The causes are numerous. The ugly scars are matters of common observation. In such cases, the black foreign matters are so thoroughly incorporated with the soft parts, particularly with the skin along the edges of the wound, and also with abraded surfaces, that ordinary washing is totally inadequate for their removal. For a number of years, it has been my practice to employ for this purpose, with most satisfactory results, a stiff scrubbing brush, such as is used for the hands. The patient should be under the influence of an anesthetic. No ordinary scrubbing will be sufficient in many of the cases to dislodge the dirt, and the brush should be used in the same manner as it is employed in blacking boots. The curette and incision are often both required.

Perhaps the most unsightly deformity of the face arises from depression or lateral deviations of the broken nasal bones. Often the deformity is masked by swelling. As the bones unite readily, immediate replacement by some blunt instrument introduced into the nose is strongly indicated. Plugging the nose, or the employment of vulcanized supports, if necessary, often aid in preventing re-displacement.

In otherwise unmanageable cases, a suture pin passed from side to side through a drill hole may support the broken bone. A small drill may even be left in situ for two weeks or more. Lateral displacement with broadening of the nose, showing a tendency to redisplacement, may be treated by a button suture composed of silver wire placed in a side to side drill hole and fixed by small lead buttons, over which the ends of the wire are clamped. with shot, while the bones are pressed into position. This suture may not be required after ten days or two weeks. Outside molded splints applied to the bridge of the nose have not been found useful in my practice.

For the past few years I have discarded the usual methods of treatment of fractures of the lower jaw. After noting the practice of some of our dentists, I became convinced that after complete reduction of the fracture, the maintenance of the apposition by well annealed German silver wire, leads to results most satisfactory to surgeon and patient. Overlapping is efficiently prevented; regularity in the line of teeth preserved; apposition of the two rows of teeth maintained; renewal of the dressings rarely necessary; outside and unsightly dressings are avoided; patients go out of doors without inconvenience, and in many instances they can attend to business. First, after the completion of the toilet of the oral cavity, by means of soap, tooth brush and boric acid, or listerine, the fracture should be thoroughly and forcibly reduced, in order to determine the location of the teeth in the upper and lower jaws to be included in the wires.

Second, the wires should be placed around the necks of the teeth and twisted sufficiently tight to prevent slipping.

Third, the surgeon, again satisfying himself of the

complete restoration of the fragments to their normal position, both as to the fragments and the preservation of the normal bearing or apposition of the lower with the upper rows of teeth, proceeds with the twisting of the wires in the upper row with those of the lower row of teeth.

Fourth, the cutting away of the redundant wires, bending or repression of the wire stumps, and the covering of the latter with gutta percha to prevent injury to the lips.

The mouth requires daily attention during the course of the treatment, in order to preserve cleanliness. Much deformity may thus be prevented.

In reference to fractures of the collarbone, three weeks of bed treatment, the patient being on a firm mattress, and the use of a very small pillow for the headnothing whatever being under the shoulders-has for me secured better results than those obtained by the methods generally employed. At the end of three weeks, a sling in some cases, and in others a sling with an axillary

wedge-shaped pad, including a body band encircling the arm immediately above the elbow, may be required for three weeks longer.

Complicated fractures often set at defiance ordinary methods of treatment. What shall we say, for instance, about a simple fracture at the middle third of the ulna, complicated with a forward dislocation of the head of the radius? Flexion and extension are impaired, and later. the head of the bone remaining unreduced, and the malunion of the fractured ulna occurring, there is added marked impairment of pronation and supination. The key to the situation is a reduction of the dislocation of the head of the radius, with enforced flexion of the arm, after the application of splints. The dislocation unreduced, there must be overlapping of the fragments of the broken ulna and an approximation, or even actual contact of the upper end of the ulna with the radius, the upper half of which also occupies a plane anterior to the normal plane. This not only causes pulling of the upper piece of the ulna into the interosseous space, but actually brings this fragment and the radius in actual contact.

tion.) This long splint should reach from a point near the axilla, or as high at least as the nipple, to a few inches below the foot, and be made to press sufficiently on the outside coaptation splint of the thigh to prevent absolutely the bowing in question.

A very serious deformity in fractures of the femur arises from rotation of the body and upper portion of the broken bone, while the lower portion of the leg is held in approximately the normal position. One such case has come to my notice. A table placed by the side of the bed, to the patient's right, contained objects of daily interest to him and he was habitually turned to that side. Moreover, his friends also sat on the same side. His meals were placed on this table. He leaned towards that side when eating. What was the result? Union having taken place, and the patient assuming an upright position, internal rotation of the leg was very marked, the foot, in walking, interfering with the opposite foot and ankle.

Finally, let us not forget the very dangerous fracture of the femur located just above the condyles, which, though simple and uncomplicated, seriously threatens a loss of the circulation by pressure of the lower fragment upon the vessels. Such a fracture has actually resulted in a loss of the leg during enforced extension in treatment. Treatment by extension is is out of the question, as in this position the gastrocnemius and soleus pull the lower fragment backwards against the vessels, cutting off the circulation and thus causing the death of the leg from the knee down. Treatment by flexion and in some cases a tenotomy of the tendo achillis, must be performed. In some extremely bad cases of this fracture, and even where the knee-joint has been involved, wiring of the fragments have been found satisfactory.

DISCUSSION.

Dr. C. H. Mayo of Rochester, Minn.: A few days ago I endeavored to collect such scattered ideas on fractures as I might possess, and on account of delay in the train service I was prevented from imbibing freely of the papers on fractures which have been presented before the Academy, which, I have no doubt, would have been a great additional help to me in treating of this subject, particularly the paper of Dr. Owens, which has been so ably presented.

In thinking over deformities following fractures, it struck me that a good classification would be to divide the subject into those deformities which are purely functional in character, and those which are purely cosmetic. Our ideas have changed in regard to the formation of callus in connection with bone repair. We now look upon callus as occurring in direct ratio to the amount of deviation we secure after a perfect adjustment, that is, a deviation from the true adjustment of the fragments. This may be modified in young people by proximity to joints. Bone repair occurs from the periosteum first, and from bone second, and it would be rare to get non-union of the bone ends in proximity to a joint. The nutrition of the periosteum is in excess, and the cancellated structure of the bone itself is an aid to its repair. In the shaft, sometimes proximity here to the epiphyseal cartilage, at certain ages, may give us an

overgrowth of bone which may produce functional deformity, impair the usefulness of the point afterwards, but healing is almost sure to take place. In the shaft we get overriding of fragments, delayed union, nonunion, and shortening due to such functional deformity. In these days, in addition to our previous clinical knowledge, we have the X-ray, which enables us to determine how far approximately we deviate from a true adjustment of the fragments. Where we feel that we are not going to secure good approximation, where we feel we are not going to get a good result, we now make use of the open incision and replacement of the fracture.

I shall only take a moment of your time in discussing non-union of fractures. There are two varieties of nonunion. Delayed union and non-union occur in the shaft of the bone, usually at some place in its middle third. But I think there is a great difference between the two. We have non-union and delayed union usually from a miss in adjustment of the fragments, and these cases present themselves within a few months, and almost any method of direct incision and replacement of the fragments will secure a good result. It is unnecessary usually to apply some mechanical bone suppʊrt. I wish to say here, that where that is necessary, of all the methods which I have employed the use of the so-called silver splint applied directly to the bone, with silver screws, has, in my hands, proved the most useful, with the least bad after-effects.

There is another variety of non-union due to inherent defects in the patient, possibly through a nerve injury, which Dr. Sneve spoke of this morning. In those cases I have tried almost all methods of fixation, and have sometimes failed after re-operating two or three times. My failures have always been in cases where I secured results of a simple fracture, that is, closure of the wound without drainage, and while I have never seen a nonunion occur, yet there was nothing near the approximation of the bone in a case of suppuration.

In old cases of non-union, if I am quite sure the ends of the bone are separated from the periosteum, I approximate the fragments with something similar to the silver splint, carry a good gauze pack down to the opening, and maintain it as a continuous compound fracture. Healing occurs similar to the healing which takes place in a case of mastoid abscess or of osteomyelitis where we pack the cavity. When I have closed these wounds, using silver wire and catgut, I have failed. But I wish to reiterate, I have never seen a case of non-union with approximation of the bones in the presence of suppuration, or in the presence of continuous and prolonged drainage.

Another subject which has received but little attention in this country, according to its gravity, is separation of the epiphyseal cartilage in young people, usually occuring between the ages of 8 and 20. These injuries have been overlooked primarily. While the separation may not be complete, it produces trouble later, sometimes causing difficulty of growth, and later shortening, as age advances. If the separation is complete, the deformity is sometimes excessive, and such cases are classed in this country with, and treated as, fractures, yet it is one of the most difficult fractures, we might say, to hold in

we are especially concerned in the perfection of results, particularly with regard to deformities following fractures, and not only as to deformities following fractures, but in trying to save all the tissue and all the bone we possibly can. Conservatism in bone injuries is indicated in the paper. The retention of bone fragments in cases of comminuted fracture is a subject of great importance, and one that has been very much neglected, if not overlooked by a great many physicans. The extent to which these fragments can be preserved is little understood and rarely appreciated, especially in youth. In the skull, particularly, and in the nose, which has been referred to by Dr. Mayo, the fragments ought rarely, if ever, to be taken out. In youth they ought never to be taken out. They may be raised up from an inch in the brain, and yet unite to their fellow on the side. This is especially so in youth. A deformity of the bridge of the nose is not appreciated at first, because the soft parts stand out in position. Every sixteenth part of an inch of bone removed from there is a loss, and threatens to increase the sum of damages, because it makes a deformity in the bridge of the nose, the worst cosmetic deformity we have to deal with.

Of course, the whole subject of avoiding deformities in connection with fractures is one in which we all have an interest, and which we are here for, and we were greatly enlightened in this regard by this paper and the other papers that preceded it, dealing, as they have done, with the means to avoid deformities in fractures. Whether we use the Hodgen's splint in cases of frac-. ture of the leg, or a wooden splint, a plaster-of-Paris splint, or a metallic splint, the great thing necessary to success, so far as the ultimate result is concerned, is a knowledge of mechanics. Unless we possess that, we fail.

With regard to the plaster-of-Paris splint, as referred to especially in the first paper on the list, I beg to make a little deviation and difference, although the splint I am to speak of is not new. I learned it under Dr. Hodgen thirty-two years ago. Many of you have gone over the same formation of the plaster-of-Paris splint. But when the plaster roller came out years afterwards, I adopted it. I have tried all forms of splints. Many practitioners still cling to the old splint. I have often seen serious results, such as sloughing, gangrene, deformity, from the use of the plaster-of-Paris cast, as it is called, from shutting up the leg, so to speak, in a room, and locking the door for ten days or two weeks, without opening the cast for the purpose of inspecting the parts. Several cases have come into my town from the country dressed in that way for two or four weeks without the casts having been opened. So often have I seen gangrene about the malleoli and deformity from shutting up the leg in a plaster cast, that I am afraid of it, and do not think I will ever

rub it again, I fold it once more, and then I have 41⁄2 inches wide. If the plaster is well mixed (and it is good dental plaster that I use), it is sufficient in strength for the average leg injury. Sometimes I increase the strength by a little addition, making the plaster strip 14 of an inch thick, by 4 inches wide, and 36 long. I lay it on a table; cover it with a layer of absorbent cotton an inch wider than the strip of plaster; have my assistant grasp the foot and hold it firmly, pulling approximately 15 pounds, while I adjust the bones at the point. of the fracture. I surround the foot with a layer of the plaster, carrying it up each side of the leg to the knee, but not above the knee. I adjust the fragments again and watch them while I put on my bandage. When I apply the bandage, I put a wooden splint at the side of it, a piece of shingle, to be taken off in a day or two. The plaster sets as hard as chinaware in a few hours, and the edges of it near the ankle come within half an inch of each other, but as we go up the leg they are farther apart. I never let a fracture go longer than three days without seeing or inspecting the part. The sine qua non of a perfect result is to watch the fragments. If there is sufficient padding used to guard against gangrene, you can feel safe that gangrene will not develop. We cannot feel safe if the fragments are not moving upon each other, because in three days the leg swells ten or fifteen times its normal size, then the swelling goes down. The splint holds the leg in position as solid as iron; you can draw the strings at the top, when necessary, and you can watch it closely. You can inspect the fracture every three days, and there is no need of getting deformity following a fracture of the leg. A fracture of the humerus is a little harder to manage.

With reference to wiring the fragments, it is so rarely, if ever, necessary; that it is almost out of the question. With proper manipulation and watching the fragments, having a competent assistant from time to time, no matter whether the fracture be a simple or compound one, you can keep the fragments in apposition in almost every case. COMPOUND FRACTURES.*

BY A. L. WRIGHT, M. D., OF CARROLL, IOWA.

When asked by your Committee to participate in a Symposium on Fractures and in the same breath assigned to the most important subject of all, Compound Fractures, I felt like declining at once, as the task seemed like a herculean one and the opportunity to offer anything. new insuperable and beyond the ken of many greater than I. However, realizing that the success of this association depends entirely upon the potentiality of the molecules entering into its conglomerate whole, I consented to contribute my mite to the subject assigned, presenting for your consideration only a few thoughts.

and mix it in a basin with one-half water. For a fracture of both bones of the leg between the knee and ankle, I take a sufficient quantity. It takes a little over a quart of the solution to a yard square of gauze or cloth, and I rub that in every inch of it, the nurse or assistant holding it up by the corners. I fold it once, I rub it again, I fold it a second time, then I have 9 inches wide. I

fractures.

The breaking of bones with a solution of continuity of the soft parts has taken place ever since man took up his abode on this terrestrial sphere. From the days of his primeval existence down to the present the fertile re

Read before the ninth annual meeting of American Academy of Railway Surgeons, held at Kansas City, October 2-3, 1902.