1. Compound fractures resulting from indirect application of force.

2. Compound fractures caused by the direct application of force.

In the former variety the wound is caused by one or more fragments penetrating the skin from within outwards, in which case the wound is usually tamponed by the protruding bone, greatly reducing the danger of infection. In such cases the wound and projecting fragment are carefully disinfected before the fracture is reduced. After reduction has been accomplished the wound is either hermetically sealed with gauze, absorbent cotton and collodion, or a permanent, typical, dry occlusive dressing is applied, thus converting the compound into a simple fracture which is subsequently treated as such.

In the second class of cases the local conditions are entirely different and the treatment is modified to correspond with the nature of the injury. Recent gunshot fractures should be treated on the same principles as fractures caused by indirect application of force. In compound fractures complicated by a large wound of the soft parts, primary disinfection of the wound and that part of the limb which is the seat of the fracture is essential, and is done in the same manner as in the disinfection of a recent wound of the soft tissues uncomplicated by fracture. I wish to enter my protest against the unnecessary removal of detached fragments, if the fracture is comminuted, a procedure which is so often the sole cause of non-union. In a recent fracture the loose fragments should be removed, disinfected, and carefully replaced. If the wound remains aseptic, the reimplanted fragments not only retain their vitality, but take an active part in the subsequent process of repair. Provision for drainage must be made in suturing the external wound. The best drain in such cases is the iodoform gauze tampon. After reducing the fracture, a copious dressing is applied over the wound and the limb immobilized in a fenestrated plaster splint with or without extension, according to the location of the fracture. In the absence of well-founded indications for a change of dressing the limb should not be disturbed for two or three weeks. At that time the fracture, if the wound has remained aseptic, is for all practical purposes a simple fracture. Infected compound fractures require débridement, efficient tubular drainage, immobilization in a fenestrated or bracketed splint, frequent or continuous antiseptic irrigation. For continuous irrigation acetate of aluminum of Thiersch's solution should be employed.

Simple Fractures. The successful treatment of fractures implies mechanical skill and unremitting attention. The surgeon must minimize mature's efforts in the repair of the bone injury by effecting complete reduction and immobilizing the seat of injury with the fragments as nearly as possible in mutual contact for a sufficient length of time to effect restoration of the continuity of the broken bone or bones by the interposition of a bony callus sufficiently firm to render the aid of a mechanical support superfluous. In transverse fractures with considerable displacement of the fragments complete reduction constitutes the most essential part of the treatment. This is particularly ture of Colles's fracture of the radius. It is in such cases that it often becomes necessary to anesthetize the patient to bring the fragments in proper position. The influence of position of the limb in aiding retention of the fragments must be carefully studied and made use of in adding to the efficiency of the mechanical support. In the treatment of fractures nothing is more important in the prevention of unsatisfactory, unlooked-for results than careful supervision of the after-treatment. Many unpleasant litigations have arisen from neglect on the part of the practitioner to give enough time and attention to the after-treatment. Manufactured splints are rapidly disappearing from the clinics and physicians' offices, their place being taken by plastic splints, carefully molded to the surface of the fractured limb. Every fracture should be carefully examined at the end of the second week and malpositions, when found, corrected at that time. If this rule were more generally followed, the number of vicious unions would be much smaller. Another very common mistake in the treatment of fractures is a too early resort to passive motion and too early use of the fractured limb. Passive motion of the joint implicated by the fracture or in close proximity to the fracture must not be made until the union is firm enough to immobilize the fragments, that is, not before the expiration of three or four weeks. Passive motion before that time favors rather than prevents anchylosis. The subject of a fracture should remain under the direct observation of the attending physician until function is restored to perfection or the extent compatible with the nature of the injury, which requires from four weeks to a year or more. I will now refer as briefly as possible to emergency operations which come to the attention of the general practitioner.

Trephining. Trephining for recent injuries of the skull is an important operation in preventing remote complications of fractures of the skull, and not infrequently has to be performed as a life-saving operation in cases of intracranial hemorrhage threatening life from cerebral compression. Operative interference in recent fractures of the cranial vault is indicated: (1) In all compound fractures. (2) In fractures complicated by focal symptoms. (3) In hemorrhage from the meningeal artery and its branches with or without fracture of the skull. In all operations of the skull the whole scalp should be shaved and thorough disinfection. In punctured and gunshot fractures of the skull the perforation in the bone should be exposed by reflecting a flap with the base directed downward, including all the tissues down to the bone. With chisel, rongeur, or De Vilbis forceps the overhanging external table of the bone is removed, all loose fragments looked for and extracted, hemorrhage from meninges and bone carefully arrested, the intracranial wound drained through a buttonhole near the base of the flap, the flap replaced, sutured to the margins of the wound, and a large hygroscopic sterile dressing applied and held in place by a few turns of the plaster of Paris bandage.

In recent comminuted fractures of the skull the seat of fracture is freely exposed by enlarging the wound or by reflecting a flap. Loose fragments of bone are removed, disinfected in a carbolized solution, when they are immersed in a warm saline solution until the wound is ready for their reimplantation.

The sacrifice of fragments of bone that we have reason to believe are aseptic, or can be made so, is unjustifiable. Large cranial defects which follow such a procedure must be guarded against. The wound is disinfected, depressed fragments are elevated, hemorrhage carefully arrested, and the fragments of bone removed, taken from the saline solution, are implanted upon the dura in such a way as to leave no cranial defect after healing of the wound. If the dura is torn the wound should be sutured with fine catgut. Subdural drainage is required in all cases of contusion or laceration of the surface of the brain.

The bone grafts must be covered with periosteum and scalp. Free drainage must be secured and should be continued until the surgeon can satisfy himself that the wound is aseptic. If the wound is found infected or becomes so after the first dressing, it must be opened freely, all loose fragments of bone removed, and, after thorough secondary disinfection, freely drained.

The moist hot antiseptic compress takes the place of dry dressings in all such cases. Opening of the intact or fractured skull becomes an urgent necessity in cases in which life is threatened by hemorrhage from the middle meningeal artery. If the fracture corresponds in location with the focal symptoms, the cranial defect is enlarged sufficiently with chisel or forceps to remove the extravasated blood and secure the bleeding vessel. In hemorrhage from this vessel at a point opposite the seat of frature and laceration of the vessel without fracture, the skull is opened at a point indicated by the focal symptoms by making a temporary resection of the cranial wall according to Wagner's method. When the extravasated blood is removed, the bleeding vessel is tied or otherwise secured, and the flap replaced and sutured.

Tracheotomy.-Tracheotomy is always an emergency operation, and every physician must be able to perform it under the most trying circumstances. No person should be allowed to die of suffocation from mechanical obstruction to the entrance of air into the air passages, caused by a diphtheritic or croupous exudate, laryngeal edema, or a foreign body in the larynx, after other measures have failed, without opening the trachea. Tracheotomy, performed as an emergency operation, can be and should be made without general anesthesia. The patients requiring this operation for the indications enumerated are sufficiently narcotized by the accumulation of carbonic acid in the blood to render the operation comparatively bloodless, besides anesthesia under such circumstances is attended by more than the ordinary risks. If the operator will select the high route and make the incision in the mid