ance of the bone to infection, it is necessary to carry out a perfect chain of technique in preparation as well as in the steps of operation, and with our present knowledge of sepsis we are able to show a large per cent of clean cases, and statistics show that our per cent of infections are very low and being reduced each year.

Bartlett of St. Louis in his report of 80 cases shows union of 87 per cent of these by first intention.

Our routine method for preparation is to have part shaved, skin thoroughly scrubbed; washed with ether and iodine applied, the parts protected with sterile dressing. When patient is taken to operating room, remove the dressing, paint limb with iodine again.

Case No. 1A. Showing the spiral fracture of the lower third of the tibia, after it had been reduced and placed in a plaster cast.

2d. If one does not see patient early better put temporary dressing on, have skiagraph made and wait until swelling had receded and bruised tissue has gained its resistance-say ten days. None of our cases were operated on until about ten days after injury.

Because of the low power of resist

No. 1B. Showing the accurate reduction of the fracture of the lower third of the tibia with the splint adjusted with four screws. The line of fracture is almost obliterated.

The method of operation has been very much simplified by inventions of recent years.

Lane by his inventions has done much for bone surgery. With his bone forceps, elevators, drills, screw holders and screw drivers, we are able to handle the most difficult fractures with comparative ease in a very short time. Bartlett of St. Louis has invented a traction apparatus very simple and very useful, description of same can be found in Jour. A. M. A., Oct., 1911.

OPERATION.

Elevating the limb for four or five minutes will cause the veins to empty themselves. Apply turniquet in this way one makes it a bloodless operation. Make long incision through skin, throw that knife aside, protect the wound by bringing towel along margin of skin and holding there by forceps or pins placed through the skin. Go down onto bone, dissect off the periosteum, place forceps on it being careful not to destroy periosteum. If it is the lower limb you have already applied your traction apparatus, this keeps parts taut and prevents ends of bone from puncturing vessels or tissue. Reduce fracture with forceps, bring bones in perfect apposition, and one should not be satisfied with anything short of that, because one's final results depend on good apposition, then apply plate, holding it with clamp, being careful not to touch plate or screws with the hand.

If you suspect much oozing put in rubber tissue drain. Wound is closed, dressing applied and turniquet is removed. It has been our method to remove the turniquet last controlling hemorrhage with sutures and pressure from dressings. Cast is now applied. Some use extension with internal splint, but I see no logical reason for its use. It has been our custom at the General Hospital to get skiagraphs before the operation; one after and one before patient leaves the hospital. In this way we have a good knowledge of splints and apposition or position of bones. The skiagraphs were made by Dr. E. H. Skinner, radiologist to the General Hospital.

Five of these cases I saw with Dr.

Frankenburger on his service at the General Hospital, and it was through his courtesy I operated on them. They were as follows: Two of humerus; one clavical, three femurs and two tibias. Four of these cases healed by first intension, three were open to relieve serum, and one suppurated.

In only one case was it necessary to remove the splint and he was a very poor subject for an operation, an old tabetic with an ununited fracture, but the bones are in good line now and calus in forming.

I am sure there is a great future for the internal splints, especially in well selected cases and cases where they have failed to get results by other methods.

REPORT OF CASES.

Case No. 1.-Name F. R.; address, 5022 E. 15th St.; occupation, paperhanger; admitted, February 4, 1912; age, 51 years. At 2 p. m. on the 3d of February patient injured right leg, while walking on icy walk. Patient was near curb at time of fall, and fell upon the right side. Cannot remember further details of injury. Hands were in overcoat pockets at the time.

When patient was examined, a point of tenderness was discovered on the lateral side of leg, at a point in the upper third side of the fibula. Crepitus was also obtainable here.

There was also a point of tenderness on the median side of the leg at the junction of the lower and middle thirds of the tibia. There was also palpable at this point a decided break in the continuity of the tibia. The skin over this point was ecchymotic, and the bleb was present.

The injured skin was covered with iodine and sterile dressings, and the leg placed in a fracture box. Patient was sent to the X-ray laboratory. Report from radiologist showed oblique fracture at lower and middle third of the tibia with some over-riding and shortening. Also a comminuted fracture of the fibula in the upper third, in fair apposition.

The patient's leg was then placed on double inclined plane after extension. On the ninth the leg was placed in a plaster case by after reduction.

and the foot kept elevated upon return to bed.

The following day patient complained of considerable pain, and the case was trimmed up against the toes and ankle, and a window cut over the wound and the wound dressed. Wound was in good condition. On the 23d the patient was sent to the X-ray laboratory. Report showed fragments in good apposition, and bone place in splendid position. Swelling in leg has

On the 12th he was sent to the Xray laboratory again. The report showed unsatisfactory position, with some over-riding.

On the 16th the patient was sent to the operating-room, and an internal splint applied to the left tibia. The fracture slanted upward and backward at an acute angle with the anterior surface of the bone. The lower end of the upper fragment was wedgeshaped, corresponding to a similarly shaped opening in the lower fragment. It was necessary to rotate the lower fragment to bring the two fragments in good apposition. The plate was applied to the anterior surface. The foot was elevated, plaster cast applied

No. 2B. Shows the apposition of the fragment maintained by a four-screw Lane plate. The comminuted fragment has been removed.

gone down completely, and wound is perfectly clean.

Case No. 2.-Name, R. E.; occupation, schoolboy; admitted January 17, 1912; age, 11 years. Family and previous history of no consequence. Present condition: While coasting ran into another sled and was thrown from his own, thereby fracturing his right femur. X-ray showed it to be a stairstep fracture of the lower one-third with displacement of the lower fragment, upward, inward and backward with consequent over-riding. Shortening about one and one-half inches.

Reduction was attempted and put up on a double incline plane (general anesthetic). The next day X-ray

No. 3B. Shows the application of a six-screw Lane plate to the fracture of the femur after removal of the comminuted wedge. This gap has not been closed, but the normal length of the limb is maintained by the internal splint.

showed gross deformity of fragments with great over-riding. Fracture reduced for the second time under general anesthetic. Buck's extension applied.

Internal splint applied January 1, 1912, got along nicely until January 29. X-ray showed splendid apposition of fragments and good position of screws. Was taken with scarlet fever January 30, 1912.

Four days later stitches became infected. Window cut in cast, abscesses treated. Patient suffering now from a neuritis of the left thigh, along underside of leg.

Case No. 3.-Name, J. C.; Address, 2516 Summit; occupation, livery; admitted January 31, 1912; age, 28 years. Patient was brought to General

showed fracture of the femur just below the middle of the shaft. One large fragment lay behind the upper fragment at the point of the fracture, making the fracture comminuted. The shoulder was a subcoracoid dislocation. In the afternoon the patient was taken to the operating room and the shoulder reduced and the fracture reduced under anesthetic. Upward pres

Case No 4A. Sketch of X-ray negative of the fracture of the middle third of the tibia and the fibula somewhat higher. There is a large comminuted wedge at the site of the tibial fracture,

Hospital at 10 o'clock p.m., January 31st by the police ambulance. He had been struck by an automobile and thrown to the ground. Patient was semi-conscious and further details are not obtainable.

On examination obvious deformity of the left femur was present. Crepitus could be elicited by pressure almost anywhere on the thigh. The point of tenderness was difficult to obtain on account of the condition of the patient. The deformity indicated a fracture in the middle third.

The shortening was not great, not to exceed an inch. The pupils were sluggish, dilated, equal. Patient was bleeding from the nose slightly. There was also a dislocation of the left shoulder.

The next morning the patient was taken to the X-ray room. Report

No. 4B. Showing the application of a long four-screw Lane plate to the fracture of the tibia after the removal of the comminuted wedge of bone. The reduction of the fibular fracture is likewise shown without a Lane plate.

(X-ray negatives by Dr. E. H. Skinner.)