lead to union in faulty positions more or less frequently.

The result of my inquiries in this respect is that I find the real disability following upon fracture is not so great as one would be led to suppose from recent writings on the subject. It is, for example, distinctly stated by a surgeon who has perhaps a better opportunity for observing badly united fractures and conditions of that kind in sailors of all nations and in all circumstances than perhaps any other, that he has not noticed any particular disability in this class of patient, and that in fact the majority of the seafaring people with whom he has had to deal who have been subjected to fractures, although the union may in the true surgical sense be faulty or even vicious, are able to earn their full pay as ordinary seamen.

The exact words used are as follows: 'We see here a great many cases of old badly united fractures of leg bones, such as those treated at sea, and after careful inquiry I have never yet been assured, excepting, of course, cases of greatly exaggerated deformity needing osteotomy, of serious incapacity or of interference with the full discharge of the onerous and active work of a sailor.'

A surgeon of extensive colliery practice writes that his experience, extending over many years, shows that the diminution in the wage-earning capacity is 'practically nil in fractures of the upper extremities,

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and very little in fractures of the lower extremities," and he believes that diminution of wage-earning capacity is much overstated in text-books.' This,' he says, 'is my experience in a large number of cases occurring in colliery practice, in which I have had the injured under my observation practically all their lives.'

Another colliery surgeon of large experience writes: Have seen no permanent diminution in young men, but in old ones sometimes in compound comminuted fractures of both bones of the leg.'

The fact of the matter is, I believe, as follows. In spite of what may be said to the contrary the disability following upon fracture is much more frequently due to matting of the parts about the fracture and about the joints immediately concerned than to faulty union of the bones themselves; a point which it is especially important to bear in mind in connection with this particular question.

It is quite impossible to judge of the disability or probable disability which has been associated with any fracture by examining bones which have been found accidentally in the dissecting room or at postmortem examinations, evidence to which far too much importance has been given. The amount of disability which the fracture entails can only be estimated by examination of the living subject. And

practically it will be found-I can say this with some assurance, because I have taken much trouble in getting at the truth of the matter--that if a large number of patients be examined, the vast majority of those who suffer great disabilities after fractures which have united badly in the ordinary surgical sense do so in consequence of the want of free mobility about the joint above or below the seat of injury or from pain upon attempt at movement, resulting from adhesions of the parts about the fracture or in the immediate neighbourhood of the injured bones. In other words, I believe that if in cases of fracture early passive movements were methodically used, so that all chance of adhesion of the parts about the fracture is avoided, very much less would be heard about the disabilities in such cases than we hear now. I wish it to be emphatically understood that what I have just said must not be interpreted to mean that I think there is any excuse whatever in the first instance for not taking every possible trouble about the proper adaptation of the bones in fracture. What I decidedly mean fact that the bones of a

to say is that the mere broken limb do not unite symmetrically and quite in the straight line is not of necessity in itself any reason why disability should occur, or why the wage-earning power of the individual should be diminished.

With regard to this part of the subject it has been suggested that the general trend of my remarks is to minimise, or at all events to depreciate, the importance of careful adjustment of the fragments in the first instance. Upon reconsideration of what I have said I cannot admit that such is the case. Absolute accuracy

in 'setting' a fracture must always be of superlative importance, and I am sure that no surgeon now practising is more careful in this respect than I am. There must, however, occur in the experience of all of us cases in which perfect adjustment is for practical purposes impossible; in such cases I repeat that mere want of symmetry in the union of the bones is no necessary bar to perfect utility of the limb, provided that care be taken to prevent the formation of adhesions about the fracture and around the joints concerned.

THE AMBULATORY TREATMENT OF FRACTURES

This is a treatment which, originally recommended in recent fractures about seventy years ago, appears to have received little attention at that time. Recently (see C. D. Lockwood, Illinois Med. Jour.' April 1900) attempts have been made to revive the method. It may, I suppose, be considered to be a modification of the method of massage and early movements, the main element being the application of some form of apparatus which will allow of the upright position being assumed during the healing of the fracture. I do not know that any methodical trial of the method has been made in this country,

although the main object is achieved by those who adopt the immediate use of plaster of Paris and similar plans. It must from the nature of things be practically confined to fracture of the lower limbs. In this connection it is interesting to recall the practice which was in comparatively common use a quarter of a century or so ago, when delayed union and want of union were certainly more common than now, of placing fractures of the lower limbs, in which union was sluggish, in some kind of apparatus which allowed the patient to walk about in order to expedite union by the rubbing of the ends of the bones together, the beneficial effect from the general improvement in the nutrition of the limbs resulting from the movements being entirely overlooked.

Before submitting certain conclusions at which I have been led to arrive by a consideration of the evidence resulting from my inquiries, a summary of which is appended, as well as by an extensive personal experience, the following proposition may be laid down without, I presume, much fear of contradiction:

The general value of a treatment cannot be gauged by the results which can be achieved by it in the hands of a few individuals, but must depend rather upon its adaptability to the circumstances and requirements of the general body of practitioners who use it.