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Chapter 8 New Beginnings: The 1780s
MULTIPLE CHOICE
1) American officers encamped at __________ hinted at a military takeover if their demands

were not met.
A) Fishkill
B) Valley Forge
C) Yorktown
D) Newburgh
Answer: D
Learning Objective: Why did the prospect of a Newburgh conspiracy and the creation of the
Society of the Cincinnati upset many Americans?
Topic: 8.1.1 Will the Army Seize Control?
Difficulty Level: Easy
Skill Level: Remember the Facts
2) In 1783, many American soldiers were unhappy that __________.

A) they had not received long-overdue pay
B) Congress intended to extend their tours of duty by three years
C) Congress refused to give them promised land grants
D) they were not seen as heroes by the American people
Answer: A
3) How did Washington respond to the threat of a military takeover of the American
government?
A) He remained neutral and let his officers deal with Congress.
B) He used his personal leverage to force Congress to pay off his officers.
C) He persuaded his officers to work with Congress and secured a reasonable settlement.
D) He had General Gates arrested for treason.
Answer: C
4) How did Robert Morris and his associates respond to the discontent among the soldiers at
Newburgh?
78
Copyright © 2017, 2014, 2011 Pearson Education, Inc. All rights reserved.
A) They openly championed their cause.
B) They quietly encouraged their dissent.
C) They called for the soldiers to be tried for treason.
D) They encouraged them to be patient.
Answer: B
Difficulty Level: Moderate
Skill Level: Understand the Connections
5) With which of the following was the Newburgh conspiracy linked?

A) a proposed tax on imported goods
B) control of the Mississippi River
C) Shays’s Rebellion
D) Dragging Canoe’s uprising
Answer: A
Difficulty Level: Difficult
Skill Level: Analyze It
6) Who was Cincinnatus?

A) a Turkish sultan
B) an Egyptian slave
C) a Roman general
D) a Greek philosopher
Answer: C
Topic: 8.1.2 The Society of the Cincinnati
7) Of all the new American place names, those honoring __________ became the most popular.
A) early colonists
B) figures from Roman history
C) Greek gods
D) individual war heroes
Answer: D
Topic: 8.1.3 Renaming the Landscape
79
8) In contrast to their British counterparts, American political leaders sought to __________.

A) emphasize the superiority of their culture
B) resist efforts to change place names
C) reinforce long-held traditions
D) popularize Christopher Columbus
Answer: D
Topic: 8.1.3 Renaming the Landscape
9) Noah Webster worked to make the American language __________.

A) conform to standard British English
B) more independent and accessible
C) more sophisticated and precise
D) the universal language of business
Answer: B
Topic: 8.1.4 An Independent Culture
10) The Connecticut Wits were known for their __________.

A) nationalistic poetry
B) novels and short stories
C) satires of daily life
D) critiques of American politics
Answer: A
11) Hector St. John de Crevecoeur believed the flourishing of free people in America was
directly linked to what?
A) a temperate climate and fertile land
B) a way of life that nurtured community growth
C) a unique belief in individual liberty
D) a federal system of government
80
Answer: B
12) Who produced An American Dictionary of the English Language?

A) Thomas Jefferson
B) Philip Freneau
C) James Madison
D) Noah Webster
Answer: D
13) The Quaker naturalist __________ drafted a pioneering nature book about his travels
throughout the Southeast.
A) Charles Willson Peale
B) Thomas Jefferson
C) William Bartram
D) Jedidiah Morse
Answer: C
14) In 1785, John Jay and __________ helped form the Society for the Promotion of the
Manumission of Slaves.
A) Thomas Jefferson
B) Alexander Hamilton
C) James Madison
D) George Washington
Answer: B
81
15) The Cumberland Gap was the gateway to the __________.
A) Great Plains
B) Great Lakes region
C) lower Mississippi River Valley
D) Old Northwest
Answer: C
Learning Objective: Why did control of the Mississippi Valley matter so much to Americans
after the revolution?
Topic: 8.2 Competing for Control of the Mississippi Valley
16) In 1763, the Spanish acquired Louisiana from __________.

A) Britain
B) France
C) Portugal
D) the Dutch
Answer: B
Topic: 8.2.1 Disputed Territory: The Old Southwest
17) In the immediate aftermath of the Revolutionary War, Spain claimed __________.
A) much of Canada
B) Georgia and parts of South Carolina
C) ownership of the Great Lakes
D) control of navigation rights on the Mississippi River
Answer: D
18) __________Yazoo claim stretched west from the Chattahoochee River to the Mississippi
River.
A) Georgia’s
B) Virginia’s
C) Alabama’s
D) South Carolina’s
Answer: A
82
Topic: 8.2.2 Southern Claims and Indian Resistance
19) In the 1780s, Georgia, unlike many other states, had not __________.
A) established a state legislature
B) ratified the federal constitution
C) ratified a state constitution
D) relinquished its western lands to the Confederation
Answer: D
20) Native American Southerners found themselves caught between the competing claims of
__________.
A) Spain and the United States
B) Spain and France
C) Britain and the United States
D) France and Britain
Answer: A
21) The mountain state of Franklin was __________.

A) founded by some of North Carolina’s western landholders
B) intended as a refuge for runaway slaves
C) populated by discontented farmers
D) formed by Spanish and French adventurers
Answer: A
22) What approach to the growth of white settlement was favored by Dragging Canoe?
A) violent resistance
83
B) compromise and diplomacy
C) assimilation and acceptance
D) westward migration
Answer: A
23) The Land Ordinance of 1785 laid out a plan for __________.
A) blocking Spanish expansion in North America
B) distributing land to veterans
C) establishing Congressional districts
D) the organization of the United States’ western territory
Answer: D
Topic: 8.2.3 “We Are Now Masters”: The Old Northwest
24) Under Jefferson’s original plan for western land distribution, __________.
A) as many as fourteen new states were envisioned
B) the western lands would become colonies of the thirteen states
C) industry and manufacturing would be encouraged in the West
D) Indian rights would always take precedence
Answer: A
Topic: 8.2.3 “We Are Now Masters”: The Old Northwest
25) The Northwest Ordinance __________.

A) reserved land for Indian tribes
B) accelerated the spread of slavery north of the Ohio River
C) divided the Northwest Territory into ten future states
D) benefited eastern land speculators
Answer: D
Topic: 8.2.4 The Northwest Ordinance of 1787
84
26) The Northwest Ordinance of 1787 __________.

A) prohibited slavery north of the Ohio River
B) granted immediate statehood to four territories
C) was radically democratic
D) distributed land to poor Americans
Answer: A
27) Which of the following benefited most from the Northwest Ordinance?
A) Native Americans
B) eastern land speculators
C) small farmers
D) sailors and shipwrights
Answer: B
28) The end of the Revolutionary War brought _________.

A) financial and commercial stability
B) general prosperity
C) a boom in international commerce
D) widespread economic depression
Answer: D
Learning Objective: Why did large bondholders care so deeply about what forces were in control
of the state and national governments?
Topic: 8.3 Debtor and Creditor, Taxpayer and Bondholder
29) Why did the British government restrict trade with America and the British West Indies?
A) to nurture British trade and punish New England shippers
B) to aid its French and Spanish allies
C) to build an isolationist stance
D) as a warning to potential revolutionaries in India
Answer: A
85
Topic: 8.3.1 New Sources of Wealth
30) Captain Robert Gray took an important first step toward establishing American claims to
__________.
A) Hawaii
B) the Pacific Northwest
C) Cuba
D) California
Answer: A
31) Robert Morris helped pioneer American trade with __________.

A) the Ottoman Empire
B) China
C) Brazil
D) India
Answer: B
32) What important accomplishment was achieved by the Columbia?

A) It crossed the Pacific Ocean in eight days.
B) It was the first American ship to circumnavigate the globe.
C) It located the famed Northwest Passage.
D) It defeated a British man-of-war in battle.
Answer: B
33) The 1786 election in __________ focused on the issue of paper money.
A) Rhode Island
86
B) Massachusetts
C) New Hampshire
D) Connecticut
Answer: A
Topic: 8.3.2 “Tumults in New England”
34) In the years following the Revolutionary War, most Americans wanted their states to
__________.
A) redeem paper securities with hard money
B) issue new paper money
C) clamp down on debtors
D) reduce the money supply
Answer: B
35) Local battles over debt, currency, and credit issues hit which area the hardest?
A) the backcountry
B) the Northeast
C) port cities such as Charleston and Philadelphia
D) South Carolina and Georgia
Answer: B
36) Which of the following sparked Shays’ Rebellion?

A) Indian attacks
B) legal reforms
C) a new tax
D) a military draft
Answer: C
Topic: 8.3.3 Shays’ Rebellion: The Massachusetts Regulation
87
37) At the Constitutional Convention, __________ took the lead in arguing for the separation of
powers.
A) George Washington
B) John Adams
C) Patrick Henry
D) Samuel Adams
Answer: B
Learning Objective: How did nationalist leaders use their political skills to bring about the
Constitutional Convention in Philadelphia?
Topic: 8.4.1 Philadelphia: A Gathering of Like-Minded Men
38) What was the stated purpose of the Annapolis Convention?

A) to discuss Chesapeake trade
B) to discuss state boundary disputes
C) to discuss a new federal constitution
D) to discuss territorial organization in the Old Northwest
Answer: A
39) Which of the following was true of the delegates to the Constitutional Convention?
A) More than half were lawyers.
B) Few delegates had ever met before.
C) They represented a cross-section of American society.
D) They all agreed that the current government was insufficiently democratic.
Answer: A
40) Which of the following best characterizes Alexander Hamilton’s position at the
Constitutional Convention?
A) radically democratic
B) middle of the road
C) moderately democratic
88
D) extremely conservative
Answer: D
Topic: 8.4.2 Compromise and Consensus
41) In determining voting eligibility, convention delegates rejected direct election of

__________.
A) the president
B) members of the House of Representatives
C) state legislatures
D) local mayors
Answer: A
42) Under the Constitution, if no candidate wins a majority in the electoral college, __________
determines the president.
A) the House of Representatives
B) the Senate
C) the Supreme Court
D) a popular vote
Answer: A
43) The Virginia Plan called for a __________.

A) bicameral legislature with representation based on population in both legislative bodies
B) unicameral legislature with representation based on population
C) bicameral legislature with representation divided between population and equality of the
states
D) unicameral legislature with states represented equally
Answer: A
Topic: 8.4.3 Questions of Representation
89
44) George Mason suggested the inclusion of __________ in the Constitution.

A) a third legislative body
B) provisions for a standing army
C) a provision outlawing slavery
D) a bill of rights
Answer: D
Topic: 8.4.4 Slavery: The Deepest Dilemma
45) Supporters of ratification of the Constitution were called __________.

A) Republicans
B) Federalists
C) Democrats
D) Anti-Federalists
Answer: B
Learning Objective: Why was a bill of rights, expected by citizens, omitted by the drafters of the
Constitution and later added?
Topic: 8.5.1 The Campaign for Ratification
46) The strongest advocacy for ratification came from __________ and James Madison.
A) Alexander Hamilton
B) George Washington
C) Patrick Henry
D) George Mason
Answer: A
47) James Madison argued that minority opinions would fare best in which of the following?
A) a monarchy
B) a large nation
C) a small republic
D) a mighty empire
90
Answer: B
48 Leading Anti-Federalists included __________.

A) Alexander Hamilton
B) John Adams
C) James Madison
D) Benjamin Harrison
Answer: D
Topic: 8.5.2 Dividing and Conquering the Anti-Federalists
49) Federalists predominated in __________.

A) coastal commercial centers
B) the backcountry
C) the Lower South
D) small towns and rural areas
Answer: A
Topic: 8.5.2 Dividing and Conquering the Anti-Federalists
50) The Bill of Rights reflected lessons learned during __________.

A) the Glorious Revolution
B) past conflicts between Parliament and the colonies
C) the English Civil War
D) Shays’ Rebellion
Answer: B
Topic: 8.5.3 Adding a Bill of Rights
91
SHORT ANSWER/ESSAY
51) What was the Newburgh conspiracy and why is it important?
Answer: The ideal answer should include:

1. In late 1782, more than 10,000 American troops and 500 officers were encamped at
Newburgh.
2. They were eager to return home, but did not want to do so without receiving overdue pay
and without assurances about promised future payments.
3. In December 1782 disgruntled officers sent a delegation to Philadelphia to press their
claims.
4. Congressional allies, with an agenda of their own, encouraged the military dissidents in
Newburgh.
5. In March 1783, inflammatory petitions circulated among officers at Newburgh, hinting at
a military takeover.
6. George Washington attended a meeting of the officers, using the occasion to dissuade
them from taking aggressive action.
7. Congress then reached a compromise with the officers.
8. The Newburgh conspiracy demonstrated both the fragility of the new nation and the
universal esteem in which Washington was held.
52) Explain the source of the territorial dispute between Spain and the United States in the years
after the Revolutionary War.

1. By 1783, Spain had control of Louisiana, West Florida, and East Florida.
2. Because Spain controlled both banks of the lower Mississippi, the Spanish determined
who could use the river for trade.
3. Since 1763, the Spanish had let British subjects navigate freely on the Mississippi.
4. Nonetheless, Spanish authorities feared American expansion into the Mississippi Valley.
5. A 1783 treaty between Britain and the United States established the thirty-first parallel as
the southern boundary of the United States.
6. The same treaty also gave Americans the right to navigate on the Mississippi.
7. The Spanish believed that West Florida stretched above the thirty-first parallel and that
they alone should grant navigation rights on the Mississippi.
92
53) Describe the key aspects of the postwar economic crisis.

1. The end of the Revolutionary War brought widespread economic depression.
2. The split with Britain disrupted established patterns of commerce.
3. Purchases of foreign goods that were scarce in the United States drained hard currency
away from the states and increased the Confederation’s debt.
4. Citizens everywhere felt the brunt of the postwar slump as prices dropped and the money
supply shrank.
5. Families in debt, especially poor artisans and subsistence farmers, faced the threat of
foreclosure and loss of their property.
6. Violence broke out in state after state as hard-pressed people decried tax and fiscal
policies that favored the wealthy.
Topic: 8.3 Debtor and Creditor, Taxpayer and Bondholder
54) How did the delegates to the Constitutional Convention deal with the issue of slavery?

1. The issue of slavery was among the most difficult to resolve.
2. It revealed the existence of regional divisions within the new nation.
3. Planter delegates from Georgia and South Carolina refused to support any document that
regulated the slave trade or curtailed slavery itself.
4. Rather than force the matter, northern delegates agreed to compromise.
5. For example, the three-fifths clause made every five enslaved people equivalent to three
free people in apportionment matters.
6. Southern delegates dropped their protests against giving Congress the power to regulate
international shipping.
7. In exchange, the importation of slaves was protected for twenty years and a fugitive slave
provision was put into the Constitution.
Topic: 8.4.4 Slavery: The Deepest Dilemma
55) How did James Madison select the amendments that would become the Bill of Rights?

1. In compiling a list of proposed amendments, Madison drew from scores of proposals put
forward by the state ratifying conventions.
2. He selected those, mostly dealing with individual rights, that could pass a Federalist-
dominated Congress and would not dilute any of the proposed new government’s powers.
3. Madison pushed twelve of the less controversial statements through the Congress as
constitutional amendments.
93
4. Ten of these amendments were ratified. These amendments are known as the Bill of
Rights.
5. By securing the freedoms covered under the Bill of Rights, Madison engineered a final
set of compromises that ensured the acceptance and longevity of the Constitution.
Topic: 8.5.3 Adding a Bill of Rights
94
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Fig. 306
A Barton or Smith fracture at wrist. (Beatson.)
Fig. 307
Smith’s fracture; reverse of Colles’. (Beatson.) (Skiagram of case represented in

Fig. 306.)
BENNETT’S FRACTURE.
When considerable force is applied to the distal end of the first
metacarpal, as in striking with the clenched fist, or, as in a fall upon
the outstretched thumb, the first metacarpal is often fractured
transversely at its neck or longitudinally, its interior basal projection
being broken off, both injuries being often associated. This is a
condition lately proved by Russ, of San Francisco, to be more
common than has been generally supposed. It was first described by
Bennett, of Dublin, in 1885, and is known as Bennett’s fracture of
the thumb. Its peculiar features can be best seen in a radiograph. It
produces much pain and swelling of the hand, with tenderness,
especially at the base of the bone involved, i. e., at the root of the
thumb. There may be more or less displacement of fragments. The
injured thumb should be treated by traction and with such
coaptation splints as may be extemporized or prepared for the
purpose, in the position of abduction. If accurate coaptation and
sufficient traction be made to overcome both deformity and muscle
spasm the result obtained will be satisfactory. Otherwise more or
less loss of function and local tenderness may long persist.
PLATE XLI
Skiagram of Fracture of the Proximal Phalanx of the
Ring Finger. (Wharton.)
FRACTURES OF THE WRIST AND HAND.

Fractures of the carpal bones seldom occur, except when the parts
have been crushed. The scaphoid is, however, broken much more
often, and doubtless many cases of so-called severe sprain include
this injury. The use of the x-rays has done more to teach the relative
frequency of carpal fractures than was ever previously appreciated.
The scaphoid ossifies by two centres, which do not appear until the
eighth year. When the bone has been thus cracked the usual signs of
sprain are present, which subside and leave a tender wrist and hand
whose fingers can be normally moved, but whose wrist movements
are reduced one-half, while attempts at motion beyond these limits
produce great muscle spasm and pain. Codman and Chase[40] have
shown that the sheaths of the radial extensor tendons are in close
relation to the periosteum of the bone at this point, as well as to
that of the radius, so that by injury here blood may escape into the
sheath without appearing at other parts; the result being a tense,
fluctuating, triangular swelling over the radial half of the wrist, the
blood being effused so deeply as not to discolor, or at least not at
first. They regard the presence of such an engorged bursa as
diagnostic of fracture either of the radius or the scaphoid.
[40] Annals of Surgery, March, 1905.
While carpal fractures call ordinarily for treatment by absolute

rest, Codman and Chase have advised removal of any loose
fragment, especially of the scaphoid, by incision along the back of
the wrist just to the inner side of the long radial extensor. The
annular ligament is to be divided between it and the long extensors
of the fingers, and without opening tendon sheaths; inasmuch as
this ligament does not retract when divided its borders must be held
apart. In this way the joint may be completely exposed over the
proximal half of the scaphoid. The line of fracture being made out, a
blunt hook is introduced into the fissure and the fragment elevated,
loosened by a tenotome, and removed, its removal seeming nowise
to interfere with the function of the whole bone or the usefulness of
the wrist.
The metacarpal bones are frequently broken, usually as the result
of violence, the distal portions suffering more than the proximal. The
diagnosis is best made with the fingers closed, when any lack of
symmetry in the row of knuckles may be seen or any protrusion of a
fragment noted. Here the x-rays are useful. Such injury should be
treated by placing the hand upon a palmar splint extending well up
the forearm and maintaining rest by suitable pressure, with or
without traction upon the finger of the bone involved. For this
purpose adhesive plaster may be passed up and down the finger and
attached to an elastic band which is fixed to the end of the splint.
The same is true of fractures of the phalanges, which are often
made compound by the injury. Here the danger is not so much to
the bone as to the tendon sheaths or thecæ, along which infection
may easily spread. Widespread and prolonged suppuration might
disable a hand thus injured unless properly and promptly dressed.
Ordinarily adjoining fingers can be utilized for splints, and if the
outstretched hand be fastened upon a palmar splint and the injured
finger kept in position by its neighbors a good result can generally
be obtained. Occasionally distinct splints for one or more fingers are
required, and occasionally also the suggestion made above with
regard to traction may need to be enforced.
FRACTURES OF THE PELVIS.

Fracture of the pelvis may be serious not only in and of itself but
because of frequently accompanying injuries to the various pelvic
viscera. Save in the possible separations that may occur during
parturition it is always the result of direct violence. Such injuries are
usually divided into fractures of the pelvic girdle and those of the
more exposed prominences, such as the iliac crest, the ischiac
tuberosity, the coccyx, etc. Lines of fracture may run at any point,
although it is at the synchondrosis that the pelvis is usually broken
loose from the sacrum. As in the skull and the lower jaw double
fractures or even comminutions may occur. The same considerations
concerning the transmission of serious violence may account for
some of the vagaries seen in these cases. The sacrum is usually
broken as the result of great violence. The pelvic girdle is perhaps
weakest opposite the joints and in the neighborhood of the pubis.
Here there may be a separation of the symphysis, but the break
usually occurs a little to one side of the middle line. In rare instances
the head of the femur has been forced through the acetabulum (Fig.
308).
In a general way fractures of the pelvic girdle can be recognized
not merely by local evidences of injury and shock, but by the
resulting more or less complete loss of function; patients will be
disabled in proportion to the violence and extent of the injury. The
more unilateral the symptoms the easier it is to localize the site of
the injury. Mobility can often be detected upon examination,
sometimes crepitus. This is essentially true of fractures of the pubis.
Occasionally combined manipulation, with a finger in the rectum or
vagina, will permit more accurate localization of the injury. When the
crest of the pelvis is fractured, or any of the parts to which the
abdominal muscles are inserted, then the patient will be still further
disabled in movements of the lower part of the body, while by
palpation the fracture is sometimes easily determined.
Not the least serious features of these injuries are those which
pertain to the viscera. These include not only the ordinary results of
abdominal contusions which may produce all sorts of harm, for
example, ruptures of the kidneys, spleen, or liver, but also more
localized lesions, such as ruptures of the rectum, bladder, or urethra,
or even the pelvic connective tissue. If the urinary passages be torn
there is always opportunity for urinary infiltration and infection. The
same is true of the rectum so far as possibility of infection is
concerned. Therefore one of the earliest maneuvers in dealing with
such a case should be the passage of a catheter, to determine if the
urine be bloody or the urethra obstructed. In such a case, in the
male at least, it will usually be wise to make a perineal section and
to open widely and then drain the bladder. In not a few of these
instances the laceration takes place internally, and a pelvic crushing
injury, which is followed by collapse and abdominal rigidity, without
satisfactory explanation as above, should be promptly explored by
abdominal section, the danger of doing it being considerably less
than the risk of leaving it undone.
Fig. 308
Fracture of pelvis. (Mudd.)
Some of these fractures are conspicuously compound, and the

treatment for the external wound will permit of more careful
exploration of the bone injury, as well perhaps as the insertion of
wire sutures or other means of fixation.
Fig. 309 illustrates a serious Fig. 309
complication that ensued in one
case after multiple fractures of
the pelvis and hip, with
synostosis at the hip, as well as
extensive deformity following
fracture of the shaft of the
femur.
Treatment.—Treatment of
pelvic fractures
should comprise, first, absolute
rest. This means not merely
confinement in bed, with traction
applied to one or both limbs, but
probably fixation of the pelvis
and perhaps the thighs, either in
a compressing bandage or in a
plaster-of-Paris double spica, the
pelvic jacket running as high as
may be necessary upon the trunk
of the body. Cases which seem
to permit of operation and
suturing are entitled to it, but
they will constitute but a small
proportion of the total. While
patients are so rigidly confined
provision should be made for
free elimination, and possibly
conveniences provided for
receiving the evacuations without
possibility of infection. Recovery
is in many instances complete;
occasionally it occurs with
considerable displacement. If the
viscera escape injury much may
be expected in the way of repair Great deformity after multiple
of the bones under suitable fracture of femur, with synostosis.
(From the Buffalo Museum.)
treatment.
The margin of the acetabulum
is occasionally chipped off, sometimes by itself, sometimes as a
complication of dislocation of the hip. The posterior margin of the
brim is the part which usually suffers. Diagnosis should be made by
the ease with which such a dislocation recurs after manual
reduction. Sufficient traction to keep the limb from displacing the
fragment, and snug bandaging with pressure, especially around the
injured hip and above the trochanter, is indicated in such cases.
The coccyx and even the lower portion of the sacrum are
occasionally broken loose, either by external violence or during
parturition. Here the fragment is drawn forward by the levator ani,
displacement is marked, and pain and soreness are great. Should
there be doubt as to the nature of the injury, combined
manipulation, with a finger in the rectum, will make diagnosis
positive. Fibrous union is about all that can be expected in either of
these cases. The fragment may be justifiably removed at any time.
FRACTURES OF THE THIGH.

Fractures at the upper end of the thigh are more common than
those at the lower. At the upper end there may be fractures of the
head, of the neck, those which pass between the trochanters, and
epiphyseal separations. All of these are rare except those of the
neck.
Fractures of the neck of the femur occur most commonly in those
who have passed the fiftieth year of life. They occur, however, during
the middle period and even in children, and, as Whitman has shown,
are by no means so rare in the young as was until recently
supposed.
The shape and structure of this portion of the bone, and the
peculiar changes which occur with advancing years, constitute the
explanation for the frequency of this injury in late life. As the jaw
begins to change in shape, and the teeth to drop out, there occur
also unseen changes within the cancellous structure of the head and
neck of the femur by which the strength of the latter is materially
reduced. It is still further weakened by the change in shape which
the bone also undergoes as it loses its obtuse angle and becomes
set more at a right angle with the shaft. The reduced ability to resist
strain produced by these changes is remarkable, and accounts for
the ease with which fractures occur, even from so apparently trivial
an accident as tripping on the floor. With all the violence directly
transmitted there is usually present an element of twist or torsion by
which fracture is still further favored.
As between so-called intracapsular and extracapsular fractures
surgeons have made distinctions to which unnecessary importance
has been attached. Anteriorly the capsule is attached to the
intertrochanteric line, while posteriorly it does not extend nearly so
far outward; it can thus be seen that many fractures are partly
intracapsular and partly extracapsular. These lines vary in different
individuals, especially that of the posterior insertion; it is not usually
possible to make minute distinctions of this kind. The principal
importance which attaches to them is in the direction of prognosis,
for if the fragment be absolutely intracapsular it can derive its blood
supply only through the ligamentum teres, which is, to say the least,
a precarious method of existence and usually disappointing. In
general it may be assumed that a fracture close to the head is
intracapsular, but that when it occurs well out toward the shaft it
may partake of both characters. In this connection the x-rays will
afford, usually, more satisfactory information than can be obtained
by even extensive or rude manipulation.
Impaction occurs with considerable frequency in these cases, and,
unless accompanied by too much deformity or displacement, is
rather a fortunate occurrence, since by it is afforded an automatic
splint which it should be the surgeon’s endeavor to not break apart.
There can be no doubt, moreover, but that trifling degrees of
impaction with incomplete fracture occur, especially in the aged, in
many injuries to the hip. It would be the greatest misfortune to the
patient in one of these cases to complete the separation, and when
assured of the existence of such a lesion it is best to treat the case
as though it were a fracture. I am sure that many cases which have
gone into court have been due to incomplete fractures with
impaction, where there has been later absorption of bone, by which
the femoral neck has been much shortened, so that recognizable
deformity as well as more or less disability have resulted. Other
changes comprised among those already described in the chapter on
Joints, under the section on Arthritis Deformans, may also occur.
Callus which has been at one time abundant may also undergo too
great absorption.
Fig. 310 Fig. 311
Sections of impacted extracapsular fractures of neck of Extracapsular fracture of

femur, showing the degree of impaction and of thigh.
splintering in different cases. (Erichsen.)
Fig. 311 illustrates extracapsular fracture and comminution. Figs.

312 and 313, also from specimens in the author’s collection, show
some of the changes described above, including impaction,
displacement, and some osteophytic outgrowth.
Fig. 312 Fig. 313
Impacted fractures of necks of femurs.
Signs of fracture of the neck of the femur of special import are

history of injury, pain, loss of function, shortening, rotary
displacement, usually eversion, crepitus, relaxation of the fascia lata,
and disarrangement of the lines of triangulation between the bony
prominences of the pelvis and the trochanter. Diagnosis should be
attempted with as little manipulation as possible lest impaction be
dislodged. The patient should be placed upon a comfortably hard
surface. Anesthesia will sometimes afford important aid. It should be
ascertained, first, that there had been no previous injury which could
produce shortening. If, then, shortening be apparent it is of itself
almost a diagnostic sign. Such a limb is practically helpless, and
unless the neck be so driven in upon itself as to produce impaction
the foot will be usually everted, while the tension of the fascia lata
will be relaxed and there will be fulness in Scarpa’s triangle. Absolute
inability to use the limb implies fracture without impaction. Should
the patient have been able to help himself or work after the injury,
impaction may be safely assumed. The parts are exceedingly tender
and pain is easily produced. Shortening is to be assumed only after
placing the limbs and body in a perfectly symmetrical position (the
pelvis being at right angle with the spine), after which the
measurement most usually made is from the anterior superior spine
to the internal malleolus. Nélaton’s line is the shortest line which can
be made to pass around the hip, in one plane, from the anterior
superior spine to the tuberosity of the ischium. While the line is
curved it should lie in the same plane. Normally this passes just over
the great trochanter. If there be real shortening the trochanter
should rise above this line to an extent corresponding with the
shortening made out by other measurements. Still another method
of measurement is to hold a straight edge opposite to the superior
spine and perpendicular to the surface upon which the patient is
lying; the distance between this edge and the great trochanter
should be as much less than the distance found by similar
measurement on the other side as the amount of shortening
measured by the other methods. This is the easiest way to measure
the lines included in Bryant’s iliofemoral triangle. Both are illustrated
in Fig. 314. Impaction can sometimes be determined by comparing
triangles drawn between three points on either side, these points
being, respectively, the great trochanters, the anterior spine, and the
centre of the pubis, which is common to both. The lower line of the
triangle on the injured side should be shorter than on the other, in
proportion as the head and the end of the shaft have been driven
toward each other.
Fig. 314
Nélaton’s line, dark. Bryant’s iliofemoral triangle, dotted. (Erichsen.)
Crepitus is a sign to be elicited with care and gentleness. Up-and-

down movements of the thigh upon the side of the pelvis or gentle
rotary movements, combined with circumduction of the knee, will
yield it if it is to be easily detected. Every effort of this kind disturbs
the injured bone and should be minimized as much as possible. One
other sign of considerable value is the fact that if the patient be
turned upon his face a fractured femoral neck will permit the leg to
be hyperextended to a degree not permitted by the normal
condition. In making this test the pelvis should be held firmly; it
should be made but once, the intent being to disturb the parts as
little as possible.
Diagnosis.—The diagnosis of fracture is often easy, but in some
cases it is accompanied by many difficulties. It would
be better to give the patient the benefit of a doubt and treat him for
a fracture with rest than to subject him to excessive manipulation.
Such an injury is not likely to be mistaken for anything else save a
dislocation of the hip, although occasionally separation of the margin
of the acetabulum might cause confusion.
Prognosis.—The prognosis depends upon the age and vitality of
the patient, the location and extent of the fracture, the
method of treatment, and upon causes which seem at first foreign to
the subject. Patients with pulmonary or cardiac trouble, who need
frequent change in position, or perhaps absolute rest, are likely to
develop something hurriedly which will disarrange ordinary
calculations. Sometimes they die suddenly or they may develop
pulmonary edema or hypostatic pneumonia. The circulation may be
so poor as to lead to early development of bed-sores, while ordinary
complications in prostatics, or habitual constipation in the aged, may
make care and treatment exceedingly difficult. It should be
emphasized, then, that treatment of the fracture alone is by no
means all that these patients require, and prognosis means
something more than what may merely happen to the bone. In this
last respect, however, the better nourished the fragment the more
likely is bony union to take place if good position can be maintained.
When osseous union has failed patients get fairly useful limbs with
fibrous or ligamentous union, even with one or two inches of
shortening, and such patients may hobble about for years, with a
cane or a crutch, with limbs that are semiserviceable.
Treatment.—Of these cases it may be said that interests of life
are paramount to those of limb, and the treatment
should be directed to that which the patient can tolerate. Reasonably
healthy, muscular people can bear the application of adhesive strips
and traction such as the thin and delicate cannot tolerate. The ideal
method is that by which sufficient traction is made to overcome all
muscle pull which shall produce shortening, the measure of weight
to be used in these cases being the effect thereby produced. Thus if
twenty pounds be sufficient, well and good; if not, it should be
increased to thirty or forty pounds, providing that the patient can
tolerate it. At the same time a broad binder around the pelvis may
afford sufficient support with a tractable patient, while many will
require a long side splint, extending from the axilla to beneath the
foot, to which both body and the injured limb should be fastened, in
order to more perfectly maintain that physiological rest which is so
necessary. This last is the so-called “Physick” splint, which has been
variously modified, while the method of traction has been usually
spoken of as Buck’s extension. It seems well thus to commemorate
the names of the American surgeons who showed the value of these
methods. When a long side splint cannot be borne, sandbags 15 in.
or 20 in. in length and 3 in. in diameter may be used to give
support. Any decided tendency to eversion of the limb should be
corrected as well as the shortening. When the long side splint is
used the foot can be held in place with it and thus the position of
the shaft of the femur controlled. At other times this may be done by
flexing the knee and thus preventing upward rotation. In all methods
of traction it is advisable to keep the heel free from the bed, in order
that the effect of the method may not be lost by the obstruction of
the mattress.
Fig. 315 Fig. 316 Fig. 317
Fracture of upper third of Shortening resulting from Overlapping fracture of

femur. Vicious union. overlapping. femur.
Other methods of treatment of these fractures are common as
well to those of the shaft, and will be considered later. These include
the single and double inclined plane and the method by anterior
suspension. In general the first indication is efficient traction. This
should be made as efficiently as possible. When the patient cannot
tolerate any of the usual methods, then the double-inclined plane
may be used, the knee being hung over its apex, or anterior
suspension may be practised. In severe cases patients should be
simply made comfortable, with such local treatment as they can
bear. It may be even necessary to place them in the semi-upright
position in bed, in order to free the lungs, or to frequently change
their position to avoid the formation of pressure sores.
—Fractures of the shaft of the femur are usually oblique and
accompanied by considerable displacement, because of the powerful
thigh muscles which tend to shorten the limb. These fractures are
often compound, and occasionally the femoral fragment causes
serious damage to important vessels or nerve trunks. When the
fracture is just below the insertion of the psoas into the lesser
trochanter this muscle tends to not only pull up but to externally
rotate the upper fragment. Inasmuch as there is no way of
controlling this muscle or the fragment, the fractured limb should be
dressed upon an inclined plane, or in anterior suspension, in such a
way as to make the axis of the shaft fall into line with that of the
fragment. When the fracture is in the middle of the thigh, or lower,
there is sufficient length of the upper portion so that pressure can be
made upon it, or that psoas activity can be overcome. Fig. 315
illustrates the tremendous deformity that may result from neglect of
these precautions. Fig. 316 illustrates a certain degree of
overlapping without conspicuous other deformity. Fig. 317 shows the
shortening which is often inevitable.
Muscle spasm should be overcome as an essential part of
successful treatment, the most important feature in making traction
being to use force sufficient to tire out and overcome the irritated
muscles.
—Fractures of the lower end of the femur are usually the result of
extreme violence, and may be classified as were those of the lower
end of the humerus. Fig. 318
When there is a
supracondyloid
fracture the two
heads of the
gastrocnemius will
help to displace
backward the upper
end of the lower
fragment to an extent
permitting injury to
the bloodvessels,
while there is always
marked shortening.
Here the patella will
be made unduly
prominent, and there
will be depression
above it. Either
condyle may be
broken loose alone,
or there may be
intercondyloid or T-
fractures which are
serious because the
amount of force
required to produce
them may have
played serious havoc
with the soft tissues. Fracture of lower end of femur, with great
The joint capsule will displacement of condyles.
Fractures of the Shaft of the Femur.probably be filled with

Fractures of the Lower End of the Femur.blood, the
ligaments rent, and
perhaps the blood supply of the limb compromised. In such a case
as this the joint may be opened, the contents turned out, and the
fragments readjusted and wired or fastened in place (Fig. 318).
Epiphyseal separations, which may occur up to the twentieth year,
are not essentially different, although lateral displacement is perhaps
more common, while they are often compound.
Treatment.—Oblique fractures of the femoral shaft can be more
easily adjusted under the influence of powerful and continuous
traction than the transverse, where lateral displacement and
overlapping tend to occur. A more general application can be made
of the method described above when dealing with fractures at the
upper end of the shaft, i. e., when the upper fragment cannot be
controlled the balance of the limb must be adjusted to it in whatever
position it may be required to maintain. By the use of sufficient
traction, combined with molded or other splints, a fair result may
usually be obtained. In stout individuals it is by no means easy to
determine just how the fragments lie, save by the use of the x-rays.
If traction be so adjusted as to maintain the limb at equal length
with the other the surgeon may feel that, with certain coaptation
splints, he is doing the best he can. Application of the same rule
given above would lead him to place the limb on a double inclined
plane, in case of fracture near the knee-joint, in order that in this
position the sural muscles (the calf) may be relaxed and backward
displacement of the lower fragment be adjusted. If the apex of this
plane be arranged sufficiently high, so that the patient’s knee is
practically hung over it, and that the weight of the body makes
sufficient countertraction, then the use of weight and pulley may not
be necessary. Here, however, pressure which will be efficient may
produce numbness, as will any long-continued pressure in the
popliteal space, and after a few days it may be necessary to assume
some other position. Fractures which loosen the condyles will need
lateral pressure, while the position of each condyle may be
controlled by the position of the leg, through the medium of the
corresponding lateral ligament.
Fig. 319
Extension band and foot-piece.
Fig. 320
Same, folded and ready for use.
The standard “Buck’s extension” (for which latter word I prefer to

substitute the term “traction”), by weight and pulley, with the limb in
the extended position, is still the resort of the majority of surgeons,
but combined with other support by long side splints or coaptation
splints as may be needed. Fig. 321 illustrates the method of its use,
except that the ends of the adhesive strips should be extended
upward to a point nearly opposite the site of the fracture. The
amount of weight to be used should be graduated to the effect
produced. From ten to forty pounds, or even more, may be needed.
After the muscles are thoroughly tired the amount of weight may be
somewhat reduced[41] (Figs. 319, 320 and 321).
[41] Before applying the strips of adhesive, the best for the purpose
being that made of moleskin spread with material with which zinc oxide is
incorporated, the limb should be carefully washed and shaved and then
completely dried. A little cotton should be placed over each malleolus, in
order to avoid pressure-sores, while the strip of wood beneath the foot
should be sufficiently wide to prevent or minimize this pressure. The heel
should be kept off the mattress.
Fig. 321
Mode of applying adhesive plaster. (When the dressings are completed the limb
should not be allowed to rest on the bed.)
Continuous and anterior traction was devised by Nathan R. Smith,

in the use of a so-called anterior splint, which was later modified and
improved in device by Hodgen. The method of its use is shown in
Fig. 322. Adhesive strips are used in this method as well, permitting
the leg and foot to be attached to the lower bar of the wire frame.
The position of the frame which contains the limb, swung within it
upon turns or strips of bandage, is then controlled by a suspension
apparatus, as shown, which tends to constantly pull the frame and
its attached lower part of the limb away from the patient, the effect
being to make a constant but gentle traction. If the point of
suspension were placed directly above the limb there would be no
traction whatever. The essential feature of the method, then,
consists in arranging it as shown, so that the pull shall be oblique,
and that, according to the obliquity of the suspension cords, the
amount of traction shall be regulated.
Fig. 322
The Hodgen suspension splint.
In this method of treatment there is no violent attempt made at

reduction or overcoming displacement, but dependence is placed, at
least for two or three days, on the effect of the constant pull and its
overcoming muscular activity. After this such added splints or
expedients may be adopted as the case may require. The knee is
usually flexed at a comfortable angle, the intent being not to lift the
foot too high, so as to avoid being compelled to overcome this
added weight, but to regulate the tension by the obliquity of the
suspending cord.
Fig. 323
Fracture of the femur in a child treated by vertical
extension. (Bryant.)
This method has found favor in the West under the enduring
influence of Hodgen’s teaching. In the East it is not so generally
practised. It has, however, several advantages, as follows: (1)
Equably perfect and comfortable extension; (2) easy adjustment; (3)
easy exposure for inspection; (4) when a fracture is compound it
permits of easy application of dressings; (5) adaptability to nearly all
fractures of the femur. It is peculiarly serviceable for feeble and aged
patients who chafe at restraint. If it be desirable to flex the knee to
a considerable degree this can be done, e. g., in fractures near the
lesser trochanter.
In fractures of the thigh, patients are frequently disturbed by
muscle spasms occurring during sleep. This can usually be obviated
or minimized by suitable doses of sulphonal, given early in the
evening.
Fractures of the femur in children are not uncommon. In those
who still wear diapers, and perhaps in those a little older, these
injuries may be best treated by vertical suspension, with sufficient
weight to overcome all shortening. Here the adhesive strips and the
suspending cords should be attached to both limbs alike, in order to
have sufficient access to the perineum, and in order to judge of the
effect which we are obtaining. Figs. 323 and 324 illustrate this
method.
Plaster-of-Paris dressings for fractures of the thigh appeal
especially to those who are most familiar with the use of the
material. Some patients with fracture of the neck of the femur may
be early put in the erect posture, upon an elevated surface, allowing
the injured limb to hang down while the patient rests upon crutches.
In this upright position, with the down-hanging leg, to which traction
can be made by an assistant, a plaster-of-Paris spica may be applied,
extending from the waist-line down to or below the knee. As a limb
is thus dressed so it will heal, and it is of importance that complete
reduction be effected as a part of the procedure.
Fig. 324
Fracture of the thigh; vertical suspension. The fracture is compound in the patient
on the right. (Stimson).
FRACTURES OF THE PATELLA.

During the active period of middle life the patella is the bone most
frequently broken by muscular violence. In many cases it is
practically cracked over the condyles, as one would crack a piece of
wood over the knee. If direct force be applied, as by a fall, in
connection with the above, the effect is even more marked. In such
cases the fracture is sometimes comminuted (Fig. 325), or the line
of fracture may run more or less perpendicularly rather than
horizontally. Ordinarily, however, these fractures are transverse,
while the upper fragment is pulled upward, sometimes to a
considerable distance, by the powerful extensors of the leg. When
the fracture runs vertically the displacement is very slight.
Occasionally these fractures are compound, a most undesirable
complication, since the knee-joint is thus exposed to infection, from
which it suffers unless first attention be prompt and scientific. There
is usually sufficient hemorrhage to distend the joint cavity, and it
may at first be quite impossible to bring the fragments near enough
to each other to get crepitus, but the loss of the power of extension
and the evident gap between the fragments will serve to make
diagnosis positive, at least in all transverse fractures. A vertical
fracture without much separation is a milder form of injury which
may be regarded in a much more favorable light (Figs. 326, 327 and
328).
In these transverse fractures it is rare that bony union can be
secured by non-operative methods. This is not only because of the
difficulty in maintaining parts in apposition, but because it is notably
the case that fragments of periosteum or other tissue drop in
between bony surfaces and tend to prevent their actual contact, no
matter how firmly they may be pressed toward each other. Osseous
union then may occur without operation, but is rare. The best that
can be expected is fibrous union, the intervening fibrous band being
short or long, according to the success met with in treatment and to
the amount of strain later put upon it by too early use of the limb.
Even with two inches of fibrous tissue intervening patients are not
completely disabled. The usefulness of a limb under these
conditions, however, is seriously impaired. Something will depend,
also, on the extent to which the joint capsule and the aponeurosis
terminating the vasti muscles may have suffered.
Treatment.—The non-operative treatment consists in placing
such a limb upon a single inclined plane, for the
purpose of relaxing the quadriceps extensor group. In this position
the limb should be maintained for at least from ten to fourteen days.
Some expedient should be added, so soon as swelling has subsided,
by which the upper fragment can be coaxed downward toward its
fellow. A neatly molded splint, formed out of gutta-percha or of
plaster of Paris, may be fitted to the thigh above the fragment, held
in position, and then drawn downward by elastic traction on either
side of the leg, the principle of traction being thus given a special
application. Something of this kind should be done if the fragments
are to be approximated to each other.
Fig. 325 Fig. 326 Fig. 327 Fig. 328
Comminuted Stellate fracture of Fracture of patella, Side view of same.

fracture. the patella. united by
(Erichsen.) ligamentous tissue.
(Erichsen.)
The more completely mechanical method, partaking of the

operative, is afforded by the use of certain hooks, whose points are
permitted to pass through the skin above and below the fragments
and to engage in the bone. By a screw mechanism these points are
drawn toward each other, and thus approximation is effected. This
method was first devised by Malgaigne and is usually known under
his name, although his device has been much improved. This is far
from ideal, and yet has given good results in some cases. The
surgeon should constantly guard against infection through the
punctures.
By far the most ideal method, when it can be suitably carried out,
is the open operation, a transverse incision being made across the

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1) American officers encamped at __________ hinted at a military takeover if their demands

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41) In determining voting eligibility, convention delegates rejected direct election of

43) The Virginia Plan called for a __________.

44) George Mason suggested the inclusion of __________ in the Constitution.

45) Supporters of ratification of the Constitution were called __________.

48 Leading Anti-Federalists included __________.

49) Federalists predominated in __________.

50) The Bill of Rights reflected lessons learned during __________.

51) What was the Newburgh conspiracy and why is it important?

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A Barton or Smith fracture at wrist. (Beatson.)

Smith’s fracture; reverse of Colles’. (Beatson.) (Skiagram of case represented in

FRACTURES OF THE WRIST AND HAND.

While carpal fractures call ordinarily for treatment by absolute

FRACTURES OF THE PELVIS.

Fracture of pelvis. (Mudd.)

Some of these fractures are conspicuously compound, and the

FRACTURES OF THE THIGH.

Fig. 310 Fig. 311

Sections of impacted extracapsular fractures of neck of Extracapsular fracture of

Fig. 311 illustrates extracapsular fracture and comminution. Figs.

Impacted fractures of necks of femurs.

Signs of fracture of the neck of the femur of special import are

Nélaton’s line, dark. Bryant’s iliofemoral triangle, dotted. (Erichsen.)

Crepitus is a sign to be elicited with care and gentleness. Up-and-

Fracture of upper third of Shortening resulting from Overlapping fracture of

Fractures of the Shaft of the Femur.probably be filled with

Extension band and foot-piece.

Same, folded and ready for use.